Every finding on record at Duncanville Healthcare and Rehabilitation Center

Based on interview and record review, the facility failed to ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider for one of four residents (Resident #1) reviewed for hospital transfers. 1. The facility failed to give EMTs Resident #1's discharge documents when she complained of muscle spasms and was sent to hospital per her calling 911 on 07/17/26. 2. The facility failed to notify local hospital of Resident #1's transfer on 07/21/26 when Resident #1 complained of muscle spasms and called 911 to be sent to hospital. 3. The facility failed to document reason for transfer to hospital for Resident #1, document notification to physician and give report to receiving hospital on [DATE] for Resident #1 when family member called 911 for hospital transfer. 4. The facility failed to follow their discharge policy in completing a hospital transfer on 07/17/26, 07/21/26 and 08/03/26 when Resident #1 went to the hospital. This failure could place residents at risk of discharge services being uncoordinated at time of discharge, not receiving proper treatment at the hospital and continuity of care issues. Findings included: Record review of Resident #1's face sheet undated reflected Resident #1 was discharged to the hospital on [DATE]. The face sheet reflected the hospital Resident #1 was sent to was documented incorrectly. Record review of Resident #1's quarterly MDS dated [DATE] reflected Resident #1 was a [AGE] year-old female admitted to 04/13/26 and readmitted to the facility on [DATE] with diagnoses of type 2 diabetes (chronic medical condition where the body cannot use insulin properly and/or does not make enough insulin), hypertension (high blood pressure) and seizures (abnormal electrical activity in your brain that temporarily affects your consciousness, muscle control and behavior). Record review of Resident #1 electronic medical record revealed no hospital transfer form was completed for 07/17/26, 07/21/26 and 08/03/26. Record review of Resident Progress Notes for Resident #1 reflected the following:-dated 07/17/26 22:42 completed by LVN A Resident c/o having muscle spasms. medication was administered as per prn order. About an hour later, resident was yelling, demanding to go out side. Staff advised resident to be patient, we would get her up but resident had already called 911,. the police officerarrived. Police officer asked this writer if she had the muscle spasm medication. CN told the officer it had already been administered. The ambulance arrived, resident then left with EMT's to XXX (sic) Hospital. DON notified.-dated 07/21/26 15:50 completed by LVN A Upon shift changed. Resident had been out side at smoking patio. Resident returned to room around 1430 (2:30 PM) . Resident then started yelling of having muscle spasms in her legs. Resident medication for spasms is routine and was [administered]. Resident [complaint of] pain to legs. Pain medication Hydrocodone was given as per PRN order. Resident then called 911 herself again. EMT's arrived. CN told EMT's when medications were given.-dated 08/03/26 11:30 AM completed by LVN B reflected Resident #1 sent to Hospital per family request. Family member called EMT and never notified nurse or any staff member that she was going to have resident taken to hospital. Staff knew EMT had been called when they came in and went down to resident room and a family member started talking to them. ADM notified of situation. Interview on 08/05/26 at 1:50 PM with LVN B stated on 08/03/26 Resident #1's Responsible Party came up to her asking her for the address of the facility, so she gave it to her and did not realize this was Resident #1's Responsible Party since she had only talked to them on the phone. She stated then EMS arrived at facility she did not know why Resident #1's Responsible Party had called 911. She stated she did not speak with EMS since they were busy with Resident #1's responsible party. LVN B stated she did provide EMS with continuity of care form which has medication list and last vitals. She stated she did not notify the local hospital of Resident #1's transfer since she did not call 911. She stated she notified the physician of Resident #1's transfer to hospital per family request. Interview on 08/05/26 at 3:10 PM with ADON C stated the expectation for the charge nurse is to ensure the CCD form is printed which has medication list and vital signs along with diagnoses and given to EMS. She stated the charge nurse should document the reason resident is transferred to hospital but do not need to notify the local hospital of transfer unless the charge nurse called 911 for transfer for report. Interview on 08/05/26 at 3:55 PM with DON stated she expected charge nurse to find out reason resident wants to be transferred to hospital even if the resident calls 911 themselves and documents it on nurse progress note. She stated she expected physician notification to be documented in the progress note when transferred to hospital. She stated she was not aware of hospital transfer forms needing to be completed when resident goes to hospital, but EMS should be given a verbal report by charge nurse. Interview on 08/12/26 at 2:45 PM with LVN A stated on 07/21/26 she did not know until EMS arrived that Resident #1 had called 911. She stated she notified Resident #1's responsible party and physician of Resident #1 request to be sent to hospital on [DATE]. She stated she should have documented the physician notification on 07/21/26. She stated she did not notify the local hospital of incoming hospital transfer of Resident #1 on 07/21/26 since she did not call 911. She stated she did not know about hospital transfer forms and if charge nurse calls 911 to send them out to hospital, then we call the admitting local hospital to give report on resident. Interview on 08/13/2026 at 12:18 PM with DON stated she expected charge nurse to give EMS the CCD which has the medication list and last vital signs when resident sent out to hospital via EMS. She stated she expected facility nurse to document resident's condition and assess resident. She stated it is important for local hospital notification of transfer and EMS verbal report and documents given to EMS when sent to hospital for continuity of care and to prevent any delays in receiving proper care at hospital. Review of facility's policy Transfer or Discharge, Emergency last revised 03/03/26 reflected Emergency transfers or discharges may be necessary to protect the health and/or well-being of the resident(s).4. Should it be necessary to make an emergency transfer or discharge to a hospital.our facility will implement the following procedures: b. Notify the receiving facility that the transfer is being made; c. prepare the resident for transfer; d. prepare a transfer form to send with resident. Review of facility's policy Transfer or Discharge Notice last revised 03/03/26 reflected .8.The reasons for the transfer or discharge are documented in the resident's medical record. Review of facility's policy Transfer or Discharge Documentation and Notice revised 03/03/26 reflected When a resident is transferred or discharged , details of the transfer or discharge will be documented in the medical record and appropriate information will be communicated to the receiving health care facility or provider.4. When a resident is transferred or discharged from the facility, the following information will be documented in the medical record: a. the basis for the transfer or discharge b.That an appropriate notice was provided to the resident and/or legal representative; c. The date and time of the transfer or discharge; d. The new location of the resident.f. A summary of the resident's overall medical, physical and mental condition.7. Should the resident be transferred or discharged for any reason, the following information will be communicated to the receiving facility or provider: a. The basis for the transfer or discharge.

Based on interviews and record reviews, the facility failed to ensure professional staff were licensed, certified, or registered in accordance with applicable State laws for 1 or 4 CNAs (CNA A) reviewed for CNA certification. The facility failed to ensure CNA A's certification was current before allowing her to care for residents. CNA A worked in the facility providing resident care, on a full-time basis, with an expired certification for 8 days between [DATE], and [DATE]. This failure could result in residents being provided care by staff who were not currently qualified per state laws. The findings included:Record review of CNA A's personnel file reflected CNA A's certification expired on [DATE].Record review of the time sheet and staff schedule reflected CNA A worked on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE].During an interview on [DATE] at 12:35 p.m., the Human Resources Director stated she was not aware CNA A's certification expired and she only became aware of its expiration during this investigation. She stated employees were responsible for ensuring their nurse aide certification was current and she was responsible for tracking the certifications to ensure they were not expired. She stated there was not a system in place to track nurse aides' certification expiration. She stated it was important for nurse aides to have current certifications to ensure there were no issues or violations attached to it. She stated nurse aides that worked, with expired nurse aide registry status, placed residents at risk for potential abuse and neglect.During an interview on [DATE] at 1:01 p.m., the Staffing Coordinator stated she became aware of CNA A's expired certification during this investigation and removed CNA A from the schedule until the license was renewed. She stated CNA A was scheduled and worked on [DATE], [DATE], [DATE], and [DATE] from 10pm-6am. She stated Human Resources was responsible for checking the nurse aide registry for verification after employees were hired. She stated the risk associated with nurse aides that worked with an expired certification could include conduct issues, lack of safety and care updates and lack of training.During an interview on [DATE] at 1:13 p.m., CNA A stated she was unaware her certification expired. She stated she was informed by the Staffing Coordinator that she was unable to work until the certification is renewed.During an interview on [DATE] at 1:51 p.m., the Administrator revealed the HR Director was responsible for checking nurse aide certifications monthly to ensure current validation. He stated the expectation was for nurse aide certifications to be checked monthly after date of hire. He stated it was important to ensure CNAs have the skills, competencies, and were compliant to provide quality of care. He said the risk to residents was possible adverse effects in their care including abuse.Record review of the Background Checks Prohibition policy revised [DATE] reflected, .Human Resources will execute some or all of the following steps: Verify professional licenses, certifications, and education.

Based on observation, interview and record review the facility failed to ensure that a resident with urinary incontinence, based on the resident's comprehensive assessment, received the appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for one (Resident #1) of 6 residents reviewed for incontinent care. The facility failed to ensure Resident #1 was assisted with incontinence care and toileting in a timely manner on 05/20/26. This failure could place residents at risk of skin breakdown, infection and a diminished quality of life by not receiving care and services to meet their toileting needs. Record review of Resident #1's annual MDS assessment, dated 01/10/26, reflected a [AGE] year-old-male admitted to the facility on [DATE]. Resident #1's diagnoses included hypertension (elevated blood pressure), cerebral palsy (a group of lifelong neurological disorders that affect movement, muscle tone, and posture), non-Alzheimer's dementia (many other progressive neurodegenerative diseases and medical conditions cause dementia without involving Alzheimer's pathology) and muscle weakness, atrophy, neck, multiple sites. His BIMs score of 11/15 indicating moderate cognition impairment. His functional status reflected substantial/maximal assistance for personal hygiene. He was frequently incontinent of bowel and bladder. Record review of Resident #1's comprehensive plan of care dated 04/30/26 reflected,*Focus: The resident has potential for an ADL self-care performance deficit related to Cerebral Palsy. Goals: The resident will maintain current level of function through the review date. Intervention: toilet use: the resident requires total assistance by 1 staff for toileting. He is incontinent of bowel and bladder. personal hygiene/oral care: The resident requires extensive assistance by 1 staff with personal hygiene and oral care. *Skin-Focus: I have a Skin Tear of the (right lower leg, wound #1) related to Fragile skin, History of skin trauma. Observation and interview on 05/20/26 at 10:53 AM, Resident #1 was sitting up in wheelchair in his room by the foot of the bed , wearing hospital gown. There was a strong smell of urine in Resident #1's room. Resident#1 hospital gown was wet in the front area up to the pocket in the right-side upper chest. Resident #1 stated he was wet and waiting to be changed. CNA A came into Resident #1's room to answer his call light. CNA A stated she had not changed the resident since the start of her shift at 6:30 AM this morning during her first round. CNA A shift started at 6:00 AM. CNA A did not provide any explanation for the delay in providing incontinent care to Resident #1. CNA A took Resident#1 to shower room stating it was his shower day today, and she was going to provide him a shower. Interview on 05/20/26 at 2:45 PM the DON stated the charge nurses and CNAs supposed to do rounds room to room at least every 2 hours to check residents and change them if they were wet. The DON stated the risk of incontinent care not being provided on time would be skin breakdown, infection, and resident dignity. A record review of the facility's policy Resident Rights, revised February 2021, reflected Employees shall treat all the residents with kindness.dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents' right to a. a dignified existence .

Based on observation, interview, and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 6 residents (Resident #2) reviewed for ADL care.The facility failed to provide Resident #2 assistance with timely incontinence care for at least 5 hours.This failure could place the residents at risk for decreased feelings of self-worth, skin breakdown, and infection.Findings included:Record review of Resident #2's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with medical diagnoses of Dementia (a decline in mental ability), Muscle Wasting and Atrophy (loss of muscle mass), Unspecified Protein-Caloric Malnutrition (deficient protein and caloric intake), Type 2 Diabetes (the body resists insulin), and Benign Paroxysmal Vertigo, Bilateral (calcium crystals are dislodged in both inner ears). Record review of Resident #2's quarterly MDS assessment, dated 02/13/2026, reflected a BIMS score of 99, which indicated the resident was unable to complete the interview. Section GG0103-Functional Abilities revealed Resident #2 was dependent on staff for toileting.Record review of Resident #2's care plan revealed Resident #2 had an ADL Self Care Performance Deficit. Interventions/Task: Toilet Use: The resident is totally dependent on 1 staff for toilet use. Record review of the posted Meal Service reflected, Breakfast: Hall Trays-7am; Dining Room-7:30am. During an interview on 04/30/26 at 2:45 p.m., Resident #2 stated (via the Account Manager who translated) she was unsure, but she thought she was not changed today and no one asked if she needed to be changed. During an interview on 04/30/26 at 1:20 p.m., the CNA stated she was assigned to Resident #2. The CNA stated incontinent care was provided every 2 hours or when needed. The CNA stated Resident #2 was last changed before breakfast. The CNA stated she gave other residents bed baths and got them up and she didn't get around to changing Resident #2 again. The CNA stated delayed incontinence care placed residents at risk for skin breakdown. During an interview on 04/30/26 at 2:23 p.m. the RN stated incontinent care was provided every 2 hours and PRN. She stated that a delay placed residents at risk of skin breakdown. She stated that charge nurses were responsible for checking residents every 2 hours to ensure they were provided with incontinent care. She stated the nurse would go specifically to the patient to check on them. She stated she was busy and didn't check Resident #2 for incontinent care. During an interview on 04/30/26 at 4:10 p.m., the DON stated the expectation was for CNAs to check if residents were incontinent and change when needed every 2 hours. She stated charge nurses were responsible for ensuring residents were changed by rounding every 2 hours. She stated delayed incontinence care placed residents at risk for infection, skin breakdown, dignity issues, and pain from sitting. Review of the facility's Activities of Daily Living (ADL) Policy, revised March 2018, reflected, Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care including appropriate support and assistance with: elimination (toileting).

Based on interviews and record reviews, the facility failed to send a copy of the residents' discharge notice to the representative of the Office of the State Long-Term Care (LTC) Ombudsman for 1 of 3 residents (Resident #1) reviewed for discharge planning. The facility failed to send a copy of the discharge notice to the facility's Ombudsman when Resident #1 received a discharge notice on 03/19/26 and 04/22/2026. This failure could place residents at risk of being discharged without alternative placement, discharge options, their rights to appeal and access to advocacy services.Findings included: Record review of Resident #1's face sheet dated 04/30/26 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease (a lung condition caused by damage to the lungs), Attention-Deficit Hyperactivity Disorder (persistent inattention, hyperactivity, and impulsivity), Insomnia (persistent difficulty falling asleep), Type 2 Diabetes (the body fails to produce enough insulin), and Bipolar Disorder (intense, fluctuating mood shifts). Record review of Resident #1's Quarterly MDS, dated [DATE], reflected a BIMS score of 14, which indicated intact cognitive response.Record review of Resident #1's Progress Notes, from 03/19/26 to 04/30/26, reflected there were no notes related to a written notice of discharge and reasons for the move given to the facility's Ombudsman. Record review of Resident #1's Electronic Health Record on 04/30/26, reflected there were no written notice of discharge and reasons for the move given to the facility's Ombudsman. During an interview on 04/30/26 at 8:45 a.m., the Ombudsman stated there wasn't notification from the facility regarding discharges. She stated Resident #1 received an involuntary 30-day discharge notice in March 2026 and because it was past the 30-day window to appeal, she was unable to help. She stated she was not notified of the second discharge notice given to Resident #1. She stated notification was important because residents have a right to appeal and the Ombudsman educated and assisted residents on discharge options. During an interview on 04/30/26 at 9:20 a.m., the Social Worker stated she was unaware the Ombudsman was notified prior to resident discharge. She stated she was responsible for notifying the residents, responsible parties, and the physician regarding discharges. She stated the Ombudsman's role was to advocate for residents and ensure discharges were safe and legal. During an interview on 4/30/26 at 3:35 p.m., the Regional [NAME] President of Operations stated discharge notices were given to residents, who are their own responsible party, and if not, to their responsible party, and notification to the Ombudsman. The Regional [NAME] President stated the expectation was for the Ombudsman to receive a copy of the discharge notice in case the resident decided to appeal. During an interview on 4/30/26 at 4:37 p.m., the Business Office Manager stated she contacted the Ombudsman 4/29/2026 because Resident #1 was issued two discharge notices. She stated the first discharge notice was 3/19/26 and the second notice on 4/22/26. She stated the Ombudsman was not notified when both discharge notices were issued to Resident #1. She stated she was aware the Ombudsman should have been notified in case the resident wanted to appeal, to be involved in the discharge process, and advocate for the resident. She stated the Ombudsman was not notified in error on her part. She stated the Business Office Manager was responsible for notifying the Ombudsman. Surveyor attempted to interview the Administrator 4/30/26 but he was unavailable throughout the investigation. A record review of the facility's Transfer or Discharge Notice reviewed and revised 03/03/26, revealed, A copy of the notice is sent to the office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative.

Based on interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet the resident's medical, nursing, and mental and psychosocial needs and described the services that were to be furnished to attain, or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 6 residents (Resident #1) reviewed for care plans in that:The facility failed to include interventions for ADLs in Resident #1's care plan.This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs.Record review of Resident #1's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with medical diagnoses of Hemiplegia (paralysis of one side of the body), Cerebral Infarction (a type of ischemic stroke caused by disrupted blood supply and restricted oxygen supply), Type 2 diabetes (the body resists insulin causing high blood sugar levels), Muscle Weakness (the loss of strength in one or more muscles) and Muscle Wasting and Atrophy (loss of muscle mass). Record review of Resident #1's quarterly MDS assessment, dated 03/29/2026, reflected a BIMS score of 7, which indicated severe cognitive impairment. Section GG0103-Functional Abilities revealed substantial/maximal assistance for oral, toileting, and personal hygiene, lower body dressing, and putting on/taking off footwear. Section GG0103 also revealed Resident #1 was dependent on showers/baths, required partial/moderate assistance for upper body dressing, and setup or clean-up assistance for eating.Record review of Resident #1's Comprehensive Care Plan reviewed 04/07/2026 revealed it did not address ADLs as a focus of care.During an interview on 04/07/26 at 12:28 p.m., the MDS Coordinator stated MDS was responsible for care plans. She stated care plans were reviewed quarterly and as needed by the IDT team. She stated ADLs were important for staff to know how to care for residents. She stated she was unaware the care plan excluded ADLs.During an interview on 04/07/26 at 3:44 p.m., the DON stated the nurse management team, that included the ADON, MDS Coordinator and nurses, created and carried out the care plan. She stated ADLs were important to guide staff on what the residents' care needs were. She stated care plans were reviewed quarterly and as needed. She stated she didn't know why ADLs were missed in the care plan.During an interview on 04/08/26 at 8:49 a.m., the Administrator stated care plans were updated as residents progressed and there were changes in condition. He stated ADLs were reflected in the care plan after 21 days. The Administrator stated care plans were updated quarterly and at any time. He stated the MDS Coordinator and DON were responsible for updated care plans.Review of the facility policy titled Care Plans, Comprehensive Person-Centered, dated 06/02/25, revealed on page 1, The comprehensive, person-centered care plan will: a) Include measurable objectives and timeframes. b) Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 1 (Resident #1) of 6 residents reviewed for ADLs. The facility failed to ensure Resident#1 had his fingernails trimmed.This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections, and a decreased quality of life. Record review of Resident #1's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with medical diagnoses of Hemiplegia (paralysis of one side of the body), Cerebral Infarction (a type of ischemic stroke caused by disrupted blood supply and restricted oxygen supply), Type 2 diabetes (the body resists insulin causing high blood sugar levels), Muscle Weakness (the loss of strength in one or more muscles) and Muscle Wasting and Atrophy (loss of muscle mass).Record review of Resident #1's quarterly MDS assessment, dated 03/29/2026, reflected a BIMS score of 7, which indicated severe cognitive impairment. Section GG0103-Functional Abilities revealed substantial/maximal assistance (a functional level where a helper provides more than 50% up to 75% of the effort) for personal hygiene.Record review of Resident #1's Comprehensive Care Plan reviewed 04/07/2026 revealed ADLs were not addressed as a focus of care.During an observation and interview on 04/07/26 at 10:28 a.m., Resident #1 was in his room sitting in his wheelchair. Resident #1 was observed with long fingernails, approximately 1/8 of an inch, on his right hand. Resident #1 stated he wanted his fingernails cut, but no one would cut them.During an interview on 04/07/26 at 10:47 a.m., CNA revealed residents' nails were cut during their designated shower days unless they were diabetic. She stated nurses were responsible for nail care of diabetic residents. She stated nail care was important to prevent residents from scratching themselves or harming others.During an interview on 04/07/26 at 12:34 p.m., the Shower Aide revealed residents' nails were cut on shower days. She stated nail care was important for prevention of buildup underneath nails and prevention of residents scratching themselves or others. She stated nurses were responsible for cutting the nails of diabetic residents.During an interview on 04/07/26 at 3:25 p.m., RN revealed nurses were responsible for cutting the fingernails of residents who were diabetic. She said she was unaware Resident #1 was diabetic. She stated she observed her assigned residents, which included Resident #1, daily for skin care versus nail care. She stated trimmed fingernails were important to avoid infection, prevention of residents hurting themselves, and safety reasons.During an interview on 04/07/26 at 3:44 p.m., the DON stated nurses were responsible for trimming the nails of diabetic residents as needed. She stated the expectation was for nurses to know which residents were diabetic and provide necessary care, once the residents' needs were identified, as part of their daily care. The DON stated nail care was important for good skin care, for injury prevention, and dignity.During an interview on 04/08/26 at 8:23 a.m., LVN stated nurses were responsible for cutting the nails of residents who were diabetic on their shower days and at least weekly. She stated residents with untrimmed nails were at risk of infection and could scratch themselves. She stated nailcare was important for hygiene and to prevent injury.Record review of facility's policy, Activities of Daily Living (ADL), Nursing Policy & Procedure Manual for Long Term Care, revealed Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently.including appropriate support and assistance with: hygiene (bathing, dressing, grooming, and oral care).

Based on observation, interview, and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 1 of 8 residents (Resident #1) observed for infection control. The facility failed to ensure CNA A performed hand hygiene, and proper use of gloves, while providing incontinent care to Resident # 1 on 03/25/2026. These failures could place residents at risk for development of infection.Findings include: Record review of Resident #1's Quarterly MDS, dated [DATE], reflected he was a [AGE] year-old male admitted to the facility on [DATE], and readmitted [DATE] with the diagnoses of acute kidney failure (a sudden decrease in kidney function occurring over hours or days, causing waste buildup, fluid retention, and electrolyte imbalances), Chronic obstructive pulmonary disease with exacerbation (a sudden worsening of symptoms-increased dyspnea, cough, and mucus-beyond normal daily variations, often triggered by respiratory infections or pollution), and muscles weakness. Resident #1 had a BIMS score of 07, which indicated severe cognition impairment. Further review revealed urinary continence/ bowel continence were coded as frequently incontinent. Observation on 03/25/26 at 10:13 AM, reflected CNA A entered Resident #1's room and washed her hands, put on clean gloves and helped Resident#1 transfer from wheelchair to the bed. CNA A positioned the resident and unfastened his brief, then proceeded to clean the resident. Resident#1's brief was soaked with urine and had a small bowel movement. CNA A cleaned Resident #1 front area. CNA A helped Resident #1 turn to his right side. CNA A cleaned Resident#1's buttocks area, then removed the dirty brief and put in the plastic bag. CNA A removed her gloves and pulled a pair of clean gloves from her uniform pants pocket. CNA A put on the clean gloves without performing any form of hands hygiene (Sanitizing/washing). CNA A applied the clean brief on Resident#1 and covered him. CNA A removed her gloves completed hand hygiene and exited the room. In an interview on 03/25/26 at 10:42 AM, CNA A stated she was to complete hand hygiene before and after taking off Resident #1's dirty brief. CNA A stated she was supposed to change her gloves with hand hygiene after she cleaned the resident before applying the clean brief. CNA A stated she was supposed to sanitize her hands each time she removed the dirty gloves before putting on the clean gloves, but she forgot to bring a sanitized hand with her. CNA A stated she was not supposed to carry gloves in her pocket and get the clean gloves from the gloves box in the room. CNA A stated not following proper hands hygiene and infection control policy could lead to cross contamination and development of infection for residents. In an interview on 03/25/26 at 2:47 PM, the RN B stated infection control was important during care. She stated during care the staff was to use hand sanitizer or wash hands if they were physically soiled. The RN B stated the staff was expected to complete hand hygiene before care and after care, she also stated during incontinent care the staff was supposed to change gloves and use hand sanitizer when taking off the dirty brief before applying the clean one. The RN B stated the facility had boxes of gloves in each resident's room, and the staff were not supposed to carry gloves in their uniform pockets. The RN B stated proper hands hygiene and following proper infection control policy was to be followed to prevent the development of infections for residents and staff. Review of the facility policy dated 20-2020 and titled Handwashing-Hands Hygiene reflected, The facility considers hand hygiene the primary means to prevent the spread of infections. h. before moving from contaminated body site to a clean body site during resident care.9. The use of gloves does not replace hand washing/hands hygiene. 1. Perform hand hygiene before and after applying non-sterile gloves.2. When applying, remove one glove from the disposing box at a time, touching only the top of the cuff.

Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 4 of 10 residents (Resident #1, Resident #4, and Resident #5 and Resident #6 ) reviewed for rights. The facility failed to ensure the staff in the main dining room served Resident #4, and Resident #5, at the same time Resident #1 was served his lunch meal. The facility failed to ensure CNA B made up Resident #6's bed in her room before lunch as she had requested. These failures could place residents at risk of feeling like their dignity was being invaded or the facility was not their home. Findings included: Record review of Resident #1's admission MDS assessment, dated 09/23/2025, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnosis which included: heart failure (weakened heart), hypertension (increased blood pressure), and diabetes (increased sugar levels). Resident #1 had severe cognitive impairment and required assistance of one staff for activities of daily living.Record review of Resident #4's quarterly MDS assessment, dated 07/17/2025, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #4 had diagnosis which included: heart failure (weakened heart), hypertension (increased blood pressure), and diabetes (increased sugar levels). Resident #4 had moderate cognitive impairment and required assistance of one staff for activities of daily living.Record review of Resident #5's quarterly MDS assessment, dated 09/03/2025, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #5 had diagnosis which included: hypertension (increased blood pressure), Aphasia (talking is difficult), Cerebrovascular Accident (stroke) and depression (mental illness). Resident #5 had moderate cognitive impairment and required assistance of one staff for activities of daily living.Record review of Resident #6's quarterly MDS assessment, dated 10/06/2025, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #6 had diagnosis which included: Quadriplegia (paralyzed), neurogenic bladder (bladder muscle does not work), and depression (mental illness). Resident #6 had no cognitive impairment and required assistance of two staff for activities of daily living.Observation of 100 hall on 10/21/2025 at 9:55 a.m., revealed Resident #6's bed had not been made. The mattress had been stripped of all linens and there was a bare mattress noted. There were pillows piled up on the top of the dresser in the room.In an interview on 10/21/2025 with Resident #6 at 10:30 a.m. revealed that this was the way it was on most days, and some days the bed was not made until 6:00 p.m. Resident #6 stated she had told the nurse and the CNA in charge of the hallway, but the bed was still not made. Resident #6 stated that she liked to go to bed around 6:00 pm after she ate her dinner, but last night (10/20/2025) she did not get to go to bed until 8:00 p.m. because the CNA did not make the bed until around that time. Resident #6 stated she complained to the charge, nurse and called the resident complaint line for residents to the cooperation, but the bed was not made this morning either. Resident # 6 stated on most days she admits she does not get out of bed until after 10:00 a.m. but the bed is still not made by lunch time, and it was embarrassing if she had visitors.Observation of Hall 100 on 10/21/2025 at 11:30 a.m. revealed Resident #6's bed had not been made.Observation on 10/21/2025 at 12:05 p.m. revealed Resident #1 was served his lunch meal at a tab [NAME] table where he was sitting with two other residents. Resident #1 proceeded to eat his lunch.In an interview on 10/21/2025 at 12:10 p.m. with Resident #5 revealed they were served at the table all the time like this. Resident #5 stated she did not like sitting at the table watching someone else eat their food and Resident #5 stated, think it is rude for him to even start to eat until we are served. Resident #5 stated she wished that if they going to serve him first serve them also. Resident # 4 could not speak but when ask if she was disturbed by the food being served to the other resident first and she not getting to eat at the same time, she nodded yes. Resident #4 pointed her finger at Resident #5 and Resident #5 stated that is what shedoes if she agrees with what I am talking about. Observation on 10/21/2025 at 12:15 p.m. Resident #1 was also served an additional grill cheese sandwich that he had requested when his original lunch had been served, Residents #4 and Resident #5 had not been served at this time.Observation on 10/21/2025 at 12:22 p.m. revealed the staff serving Resident #4 and Resident #5 their lunch meal.In an interview on 10/21/2025 with LVN C at 12:30 p.m. it was revealed that all residents at the same table should be served at one time. This prevents other residents from sitting watching the other residents eat their meal. LVN C stated that sometimes that does not happen because the kitchen does not serve the trays out that way. LVN C stated that it is the resident's right. LVN C stated she did not know how it was monitored.In an interview on 10/21/2025 at 12:45 p.m. with CNA D revealed that all residents at the same table should be served their meals at the same time, but the kitchen does not send them out to the tables that way. We can ask for the trays, the kitchen sends out the trays as they serve each ticket. The CNA stated she did not know if there was any organization to the process. CNA D stated it is the right of the residents to not have to sit and watch another resident eat, we have been trained about that.Observation of Hall 100 at 1:00 p.m., revealed Resident #6's bed had not been made.An interview with the Administrator on 10/21/2025 at 1:11 p.m., revealed that he and staff had been trained on resident rights. He stated the policy was to treat the residents all equally and to uphold the residents' rights. He stated that staff should make sure the residents' needs are met and the beds should be clean and changed on the hallway by lunchtime. When the meals are served in the dining room all the residents at one table should be served at the same time. In an interview on 10/21/2025 at 1:30 pm with CNA B revealed that all the beds on her assigned hall should be made before lunch time. The CNA stated she did not know why she had not made Resident #6's bed she guessed she thought she had and just did not check. Resident #6 is up out of bed all day and does not go to bed until after dinner time, so I just do not check sometimes, because the evening staff could also make the bed before she goes to bed. The CNA stated that the residents have rights to have their rooms to the way they want them.In an interview on 10/21/2025 at 4:45 p.m. with the DON revealed she was upset because Resident #6's bed had not been made this morning after she got up. The DON said she had received a phone call last night about how Resident #6 was upset because her bed had not been made until 8:00 pm. The DON stated she had told one of the staff members to make sure the bed was made before lunch time, but she did not follow up to see that the bed had been made. The DON stated that when servicing meals in the dining room all tables should be served at the same time, even if another resident joined the table later the tray should be brought to that resident when they joined the table. It is the right of the residents to not have to sit at the table and watch someone else eat, when they have nothing to eat themselves. Record review of Resident Rights Policy revised dated July 2025 reflected the right to be treated with dignity and respect. right to a safe , clean, and comfortable living environment

Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of five (MA A) staff members reviewed for infection control procedures.Medication Aide A failed to perform hand hygiene after direct contact with residents while serving meals in the main dining room.This failure could place residents at risk for healthcare associated cross contamination and infections. Findings included:Record review of Resident #1's admission MDS assessment, dated 09/23/2025, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnosis which included: heart failure (weakened heart), hypertension (increased blood pressure), and diabetes (increased sugar levels). Resident #1 had severe cognitive impairment and required assistance of one staff for activities of daily living.Record review of Resident #2's quarterly MDS Assessment, dated 08/08/2025, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2 had diagnosis which included: atrial fib (abnormal heart rhythm), hypertension (increased blood pressure), and cerebral vascular disease (stroke). Resident #2 had severe cognitive impairment and required two staff for assistance with activities of daily living. Record review of Resident #3's annual MDS Assessment, dated 09/22/2025, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3 had diagnosis which included: Cerebral infarction (stroke), diabetes (increased blood sugar), bipolar disorder (mental illness), and hypertension (increased blood pressure). Resident #3 was moderately impaired for cognition and required one staff for assistance with activities of daily living.Observation on 10/21/2025 beginning at 12:00 p.m. revealed MA A had washed her hands, adjusted her clothing, did not use hand sanitizer, and served a lunch tray to Resident #1. MA A touched the hand and shoulder of Resident #1 and prepared the meal tray for the resident to eat his lunch. MA A did not have on gloves. MA A was observed not to wash her hands or use hand sanitizer, available in the dining room. MA A walked over the serving cart that had lunch trays on the cart and took another tray off the cart serving the lunch meal to Resident #2. MA A touched Resident 2's edge of the dining table, unwrapped the eating utensils, and then took the lid off the dessert bowl. MA A left the resident's table without using hand sanitizer. MA A walked over and laid a dirty place on the dish cart, walked to the serving cart and took another tray, serving the tray to Resident #3, assisting her to open her utensils.An interview on 10/22/2025 at 1:45 p.m., MA A stated she did not complete hand hygiene after having direct contact with residents. MA A stated she was supposed to use the hand sanitizer in between serving each tray from the cart. She stated she washed her hands in the sink in the dining area prior to serving trays MA A said she had been educated on completing hand hygiene, by the DON. MA A stated she did not sanitize her hands, because she was trying to get the lunch trays served.An interview with the DON on 10/22/2025 at 4:45 p.m. revealed that all staff must complete hygiene after having contact with residents. She stated all staff should have been trained to use hand sanitizer between each tray that was served. The DON stated there was alcohol gel available at the door of the kitchen to use for all staff. The DON stated if the staff do not use appropriate hygiene, they can spread germs to the residents and themselves. The DON clarified she did not have any in-services that she had completed with the staff on hand hygiene, since she had only been at the facility for two months. Today would be the first in-services given to the staff since she had been working at the facility, the ADON was in the dining room giving the in-service right now.Review of the facility's policy titled Infection Control dated revised January 2020 reflected, An infection prevention and control program is established and maintained to provide a safe sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. 11. Prevention of infection a. Important facts of infection prevention included . 3. Educating staff and ensuring that they adhere to proper technique as and procedures.Review of the facility's policy tilted Handwashing-Hand Hygiene Policy and Procedure dated revised October 2020 reflected, This facility considers hand hygiene the primary means to prevent the spread of infections. Polciy interpretation and implementation 1. All personnel shall be trained and regularly in-service on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 3. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub.) shall be readily accessible and convenient for staff to encourage compliance with hand hygiene policies.7. Use an alcohol-based hand rub. b. before and after direct contact with residents. p. before and after assisting a resident with meals.10 hand hygiene is recognized as the best practice for preventing healthcare-associated infections.

Based on observation, interview and record review, the facility failed to ensure that resident who require colostomy, urostomy, or ileostomy services, receive such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for one (Resident #1) of five residents.The facility failed to change Resident #1 colostomy bag upon request.These failures placed residents at risk of embarrassment, at risk of loss of dignity and a decrease in quality of life.The findings include:During a review of the Face Sheet for Resident #1 reflected a [AGE] year old male admitted to the facility on [DATE] with the following diagnoses: unspecified intestinal obstruction (food or stool cannot pass through the small or large intestine, but the specific cause is not yet known or categorized), unspecified as to partial versus complete obstruction; dysphagia (difficulty swallowing, where food or liquids cannot move easily from the mouth to the stomach), cognitive communication deficit (difficulty in communication that arises from an underlying cognitive impairment, affecting mental processes like attention, memory, problem-solving, and executive function), , gastrostomy status (presence of a gastrostomy (G-tube), which is a surgically created opening in the stomach to allow for feeding or to relieve air and fluid pressure). During a review of Resident #1's Minimum Data Set (MDS) assessment, dated 10/31/25, did not reflect a Brief Interview for Mental Status (BIMS) score for Resident #1 and did not reflect colostomy bag.During a review of Resident #1's Care Plan undated, reflected Resident #1 is on antibiotic therapy Ciprofloxacin 500 milligrams twice a day times five related to urinary tract infection initiated 10/30/25.During an observation and interview on 11/08/17 at 10:30 a.m., Resident #1 was in bed covered up, no odor noted, no distress noted. Resident #1 reported to the state surveyor he wanted his colostomy bag changed. Resident #1 pressed his call light; a facility aide came and checked Resident #1 request and informed Resident #1 they would get the nurse. The state surveyor observed the staff member inform the nurse that Resident #1 wanted his bag changed. Resident #1 stated the bag had not been emptied since last night and that the bag had started to lift and that is why he wanted it changed because he did not want it to leak on him again. Resident #1 stated the bag had leaked on his clothes before but could not recall when or how long it took. Resident #1 stated that he had only been here a few weeks so not that long ago.During an interview on 11/08/25 at 10:50 a.m., the complainant she stated that on 10/26/25 she was in the facility and had observed Resident #1's in bed and his colostomy bag required changing as it had leaked onto his clothing. The complainant stated she witnessed the aide inform the nurse that Resident #1 bag needed to be changed and it took over two hours for the nurse to come change the colotomy bag and then the aide cleaned him up. She stated she was not sure how long he had been like that prior to her arrival but took a picture and stated she would provide the picture. During a record review of complainant photo received on 11/08/25 of Resident # 1. Resident #1 was lying in bed in a blue crewneck sweater and blue pants with noted brown and yellowish stains on outside or sweater and pants near Resident #1 right side of the mid-section.During an interview on 11/08/25 at 11:06 a.m., CNA A revealed that only nurses can burp (to expel air through the drainable end or filter opening. Done to manage any odor or splashing), [empty or change colostomy bags. CNA A stated that Resident #1 is the only resident that had a hard time getting his colostomy bag changed. She stated she could tell the nurse, and it could take an entire shift for the nurse to change Resident #1 colostomy bag. CNA A stated if the bag is not changed it could cause resident distress, there was the potential for it to leak on to the skin and cause breakdown and the dignity of the resident, and if not emptied or changed the colostomy bag can have a blowout.During an interview on 11/08/25 at 11:42 a.m., CNA B revealed that aides could not change colostomy bags they were to inform their nurse on duty if resident requested or required their colostomy bag changed. CNA B stated that there had been occasions where a resident requested for their bag to be changed and had to ask the nurse to change the bag multiple times during a shift an entire shift and had witnessed the nurse take all shift before they would change the bag out. CNA B stated when the nurses did not change the bag that the bag would lift and leak onto the resident, which was a dignity issue and could have led to possible skin irritation or breakdown.During an interview on 11/08/25 at 12:25 p.m., LVN C revealed that nurses were the only staff members who could burp/empty/change colostomy bags. LVN C stated that she had one resident on her hall who had a colostomy bag. LNV C stated that Resident #1 had requested it to be changed today on/or before 11 a.m. The LVN stated she had not changed the bag but had burped the bag and would change it after Resident #1 ate lunch. LVN C stated that she asked Resident #1 if he wanted to wait until after lunch for his colostomy bag to be changed and Resident #1 agreed. LVN C stated that residents have the right to have their bag changed upon request. LVN C stated Resident #1 bag was not full so no risk to Resident #1 if bag was not changed.During an interview on 11/08/25 at 1:14 p.m., the DON stated she expects nurses to burp/empty/change colostomy bags as soon as they are able once a resident request. The DON stated the harm of not changing the colostomy bag would be dignity issues at the least and to prevent bag from leaking on the skin which could be causative to the resident's skin and there is potential for infection.During an interview on 11/08/25 at 1:24 p.m., the ADM stated that the resident has the right to have his or her colotomy bag emptied changed at any time it was their right. The ADM stated that the harm of not emptying the colostomy bag when requested would cause resident dignity issues and prevent leaking on the skin. The ADM stated that his expectation of his staff was for staff to change upon request as soon as possible.During a record Review of facility document titled, Rights of the Elderly dated 7/21/18 reflected An elderly individual has all the rights, benefits, responsibilities and privileges granted by the constitution and laws of this stat and the United States, except where lawfully restricted. The elderly individual has the right to be free of interference, coercion, discrimination, and reprisal in exercising these civil rights.(1) Has the right to make the individual's own choices regarding the individual's personal affairs, care, benefits and servicesRequested a policy on colostomy care from the DON on 11/08/25 it was not provided prior to exit.

Based on interview and record review, the facility failed to ensure that all allegations involving abuse, neglect, and misappropriation were reported immediately, but no later than 2 hours after the allegation was made to the State Survey Agency for 1 of 6 residents (Resident #1) reviewed for abuse and neglect.The facility did not report to the State Survey Agency (HHSC) an incident in which Resident #1 tied the call light cord around his neck.This failure could place residents at risk for abuse/neglect and could lead to a diminished quality of life and psychosocial harm. The findings included: Record review of Resident #1's face sheet, dated 09/18/2025, reflected an [AGE] year-old male with an initial admission date of 08/15/2025. Resident #1 had diagnoses which included chronic diastolic heart failure (a condition where the heart becomes stiff and cannot relax properly, making it difficult for the heart to fill with blood), severe intellectual disabilities (a condition characterized by significant limitations in cognitive functioning), and cognitive communication deficit (Communication difficulty stemming from an underlying problem with a person's thinking processes). Record review of Resident #1's admission MDS Assessment, dated 08/22/2025, reflected a BIMS score of 11, which indicated the resident was moderately impaired (a condition with a serious limitation in a specific area of functioning, requiring significant support or assistance to carry out daily tasks).Record review of Hospice Agreement dated and signed 09/09/25 reflected Resident #1 had been admitted to hospice. Record review of Resident #1's Progress Notes, dated 09/09/2025 written by the ADON, reflected, hospice mattress arrived res was very lethargic and very difficult to arouse for most of this shift. Family members arrived and expressed that it was [Resident #1's] wish to not eat - he is tired. family wants to keep meds on board to ease his discomfort [sic]. Record review of Resident #1's Care Plan, updated 09/09/25, reflected, [Resident #1] was admitted to Hospice with Terminal DX: CHF, DC all routine labs and radiological studies. Do not call 911 or send resident to hospital without calling Hospice. Call with any falls, occurrences or any change in condition. An interview on 09/18/25 at 2:37 PM with ADON revealed she had just talked to Resident #1 and his family prior to him tying the call light cord around his neck. She stated the family stated they had accepted that the resident was not going to get better and had placed him on hospice. She stated Resident #1 had not informed her of any suicidal plans and she had not seen any suicidal ideations when she visited his room that day or she would have reported it to the DON, the administrator, social services, and hospice. She stated the hospice representative was still in the building on 09/10/25 when Resident #1 tied the cord around his neck because she had just finished talking to him and his family.In a telephone interview on 09/18/25 at 3:13 PM with the NP revealed Resident #1 had never expressed to her that he wanted to harm himself. She stated she met with the dietitian, the family, and the previous DON regarding Resident #1 refusing to eat. She suggested Resident #1 received a feeding tube for nutrition, but the family refused. She stated hospice was suggested, and the family wanted to think about it for a few days. She stated after a few days the family decided to place Resident #1 on hospice on 09/07/25. In a telephone interview on 09/18/25 at 3:19 PM with previous DON revealed she and the dietitian met with the family of Resident #1 regarding him not eating. She stated she could not remember the exact date of the meeting but that it was around the beginning of the month. She stated the family stated Resident #1 was not eating because of recent dental work and he wanted to give up because of his sickness. She stated Resident #1 never stated he had suicidal ideations. She stated when the family stated he was giving up and not eating was not an indication to her that he would attempt suicide. She stated he had not attempted suicide prior to being admitted to the facility. She stated her assessments prior to admission nor during admission revealed any thoughts of suicide. An interview on 09/18/25 at 6:23 PM, the ADM stated Resident #1 tying the call light cord around his neck was not reported to the State Survey Agency because there was no indication in the Provider Letter that the incident should have been reported. He stated Resident #1 was found by one of the Medication Aides. He stated Resident #1 had not shown any evidence of suicidal ideations in any assessment completed during admission or when there was a change in condition when he was placed on hospice. He stated the only time Resident #1 made a statement that he wanted to harm himself was after he was found with the cord around his neck on 09/10/25. He stated the resident had no documented history of suicide attempts or wanted to harm himself. He stated when the statement was made by the resident that he wanted to kill himself, he was placed one to one until he was taken to the hospital for psychological evaluation, his family and hospice were notified. He stated Resident #1 passed away from his heart condition prior to the evaluation being completed. He stated the hospice staff were still in the building they had just finished talking to Resident #1. He stated he would have been responsible for reporting incidents to HHSC and conducting facility investigations. He stated there was no incident report completed and there was no investigation done. He stated not completing an incident report and investigation could have placed residents at harm if signs are not recognized and acted upon timely.In a telephone interview on 09/19/25at 8:40 AM, with the Administrator of Hospice, she stated Resident #1was placed with hospice on 09/07/25. She stated Mr. [NAME] was declining due to his heart condition and he was not wanting to eat, and the NP had suggested tube feeding but the family had refused and that was when hospice had been suggested. She stated the nurse, and social worker had gone to the facility to complete the assessment on 09/10/25. She stated they were leaving the building when they were notified of the incident.Attempted to contact Medication Aide who found Resident #1 on 9/181925 at 5:43 PM and again on 9/19/25 a message was left both times with no return phone call. Record review of TULIP did not reflect a facility reported incident that corresponded to the allegations in the incident described above.Record review of the facility policy's titled, Abuse Prohibition Policy, dated 5/01/01 and last reviewed 6/2/25, reflected, 2. The facility will conduct an investigation of alleged or suspected abuse, neglect, or misappropriation of property, and will provide notification of information to the proper authorities according to state and federal regulations.

Based on interview and record review, the facility failed to promptly notify the physician of laboratory results in accordance with facility policy and procedures for notification for 1 of 5 residents (Resident #306) reviewed for laboratory services.The facility failed to send Resident #306's weekly labs to the infectious disease doctor while the resident resided at the facility from 11/27/24 to 12/20/24.This deficient practice placed the residents at high risk of not receiving treatment, and/or developing complications.Findings included:Review of Resident 306's MDS dated [DATE] reflected the resident was [AGE] year-old female admitted to the facility on [DATE] and discharged on 12/20/24. Her diagnoses included diabetes and anxiety disorder. Resident #306 had a BIMS of 6 indicating her cognition was severely impaired. The MDS also reflected the resident had a stage 4 pressure ulcer.Review of Resident #306's care plan effective on 11/28/24 reflected the resident had pressure ulcers to her right heel, unstageable to right hip, and stage 4 to the left lateral ankle. Interventions included to obtain labs per physician orders.Review of Resident #306's discharge hospital records dated 11/27/24 reflected the following: Labs to be followed: weekly CRP (a blood test that measures the level of CRP, a protein produced by the liver in response to inflammation)/BMP (measures eight different substances in your blood and it provides important information about your body's fluid balance, your metabolism and how well your kidneys are working)/CBC (group of blood tests that measure the number and size of the different cells in your blood) faxed to the office of [Doctor] Review of Resident #306's facility clinical record revealed labs were obtained on 12/02/24, 12/09/24, and on 12/16/24.Interview on 05/15/25 at 12:13 PM with Resident #306's family revealed the resident was discharged from the facility on 12/20/24. The family said the infectious disease doctor had ordered for the resident to have weekly labs drawn and faxed over to his office and the doctor's clinic said they had never received any of the lab requested.Interview on 05/15/25 at 11:47 AM with the Infectious Disease Doctor's clinic revealed they had called the facility on 12/02/24, 12/18/25 and on 12/31/24 to try and obtain Resident #306's labs copies. The clinic said that on 12/31/24 the facility finally sent one set of labs that were dated for 12/02/24. The Infectious Disease Clinic further stated the doctor would have wanted to keep up with the resident's infection treatment.Interview on 05/15/25 at 2:42 with ADON N revealed he will send or fax labs when he was asked but he could not specifically recall if he had sent Resident #306's labs to the infectious disease clinic.Interview on 05/15/25 at 2:55 PM with the DON revealed she thought she was sure she had asked ADON N to fax Resident #306's labs results to the infectious disease clinic. The DON further stated she did not know what else could have happened with the labs during that time.Review of the facility's policy titled Lab and Diagnostic Test Results - Clinical Protocol revised on 09/2012 reflected the following:Assessment and Recognition1. The physician will identify and order diagnostic lab testing on diagnostic and monitoring needs.2. The staff will process test requisitions and arrange for tests.3. The laboratory, diagnostic radiology provider, or other testing source will report test results to the facility 1. A physician can be notified by phone, fax, voicemail, e-mail, mail, pager, or a telephone message to another person acting as the physician's agent a. Facility staff should document information about when, how, and to whom the information was provided and the response

Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve foods in accordance with the professional standards for food service safety in the facility's kitchen. 1. The facility failed to ensure food items in the refrigerator, freezer and dry storage room were labeled and stored in accordance with the professional standards for food service.2. The facility failed to ensure stored canned goods, had an uncompromised seal, free from dents.3. The facility failed to discard items stored in refrigerator, freezers or dry storage that were not properly labeled or past the 'best buy', consume by or expiration dates.These failures could place residents at risk for food-borne illness and cross contamination. Findings Included:Observation of the walk-in food storage room on 08/12/2025 at 5:15 a.m., revealed the following:- 1 Box of graham cracker crumbs in unsealed zip top bag. 5 lbs., date was written by facility 5.13.2025.- 12 slices of white bread in an unsealed, unlabeled bag.- 1 opened 24oz ketchup bottle, 1/2 full, BB date: 9.28.2026. date written by facility 8.8.2025. Manufacture label states, Refrigerate after opening.- 1 bag of cake mix - Icing in an unsealed manufacturers bag, 5 lbs. in an unsealed zip top bag, not dated.- 2 cans of Chunk Light skip jack tuna, 66.5 oz, facility dated both cans 7.25.2025. First can has 2 dents on upper seal, 1 dent approximately 2, the other dent is approximately 1. There is no best buy date or use by date on either can. 2nd can of Chunk Light skip jack tuna, 66.5 oz, dented on the bottom seal approximately 1. - 1 Can of pinto beans vegetarian 110 oz approximately 2 dent on bottom seal, dated by facility 8.5.2025. BB date June 2027.- 1 can Salad Sliced Beets 6 lbs. 8 oz, facility dated 10.01.2024. Rust around top and bottom of the seal, there is no BB date or expiration date. Observation of the walk-in refrigerator on 08/12/2025 at 6:20 a.m., revealed the following:- 3 large produce boxes were noted without any dates. One box contained approximately 15 cucumbers, the second box contained approximately 10 cantaloupes, and the third contained approximately 20 zucchinis. The produce in all three boxes was observed to be collapsing in areas, slimy to the touch, and exhibiting wrinkled and discolored skin with visible fuzzy mold growth. The boxes were noted to be soggy, stained, and wet from decomposing juices, with dark spots spreading across the cardboard. Observation of the walk-in freezer on 08/13/2025 at 11:46 a.m., revealed the following:- 1 large bag of meat patties, no label, and no date. - 1 box of chicken thighs was observed stored in a plastic bag that was opened and exposed to air, the bag was dated July 22nd. In in an interview with the DM on 08/12/2025 5:31 a.m., she said the dented cans go in her office and all staff is responsible for removing dented cans if they notice a dent. She said if there is no date on the can there is a code on the can that she can look up to see what the date is. DM said that residents could become ill if their food that is expired or improperly stored is consumed.Interview with DM on 08/12/2025 5:51 a.m., she said all kitchen staff who removes food items from the freezer, refrigerator or dry storage are responsible for putting the food item back labeled with open date and properly sealed.Record review of the facility's Refrigerator and Freezer Storage policy undated, states, 2. All items must be dated with the date that the food was delivered. 3. If a food is taken out of the original container what the manufacturer placed the product in it must be labeled and dated. 4. All left over foods should be labeled and dated with the date in and the date out (date the food is to be discarded) this date can be no more than 72 hours after it was put in the refrigerator. 9. If an item is opened, the food must be tightly sealed. It should be dated with the date that it was opened. If the product was removed from its original container, then the product should also have the name of the product. If using large bags to seal open items in their original packaging, the bag may be reused but needs to be re-dated. If the food is directly in the bag, the bag must be labeled and dated, and when the bag is emptied, it should be discarded. Bags must be sealed.Record review of the facility's Dry Storage policy undated, states, .3. Items must be dated with the date that the food was delivered. 4. If a food is taken out of the original container (what the manufacturer placed the product in) it must be labeled and dated. 5. Iron foods must be removed from the storeroom. 6. All dented cans must be removed from the storeroom or marked do not use until it is picked up. 9. If an eye opened, the food must be tightly sealed. It should be dated with the date that it was opened. If the product was removed from its original container, then the product should also have the name of the product. If using large bags to seal open items in their original packaging, the bag may be reused but needs to be redated. If the food is directly in the bag, the bag must be labeled and dated, and when the bag is emptied, it should be discarded. Bags must be sealed. 11. Bags of bread products should be closed and dated with the date that it was opened. Use the open product first.Review of the U.S. FDA Food Code 2022 reflected: Definitions 3. Food Receiving and Storage - When food, food products or beverages are delivered to the nursing home, facility staff must inspect these items for safe transport and quality upon receipt and ensure their proper storage, keeping track of when to discard perishable foods and covering, labeling, and dating all PHF/TCS foods stored in the refrigerator or freezer as indicated. Review of the U.S. FDA Food Code 2022, Chapter 3, 3-201.11 Compliance with Food Law FDA considers food in hermetically sealed containers that are swelled or leaking to be adulterated and actionable under the Federal Food, Drug, and Cosmetic Act. Depending on the circumstances, rusted and pitted or dented cans may also present a serious potential hazard.

Based on observation, interview and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for five (Resident #74, #46,#5, #73, and #29) of eight residents observed for infection control in that: CNA C failed to wear a gown, change her soiled gloves and wash hands during incontinent care to Resident #74. LVN D failed to clean off the overbed table prior to and after usage, while replacing tubing on Resident #46' G-tube. LVN E failed to disinfect the blood pressure cuff, in between vital sign checks for Resident #5, and Resident #73. LVN E failed to disinfect the glucometer (machine used to check blood sugar) in between usage on Resident # 29 and Resident #5. LVN E failed to change her soiled gloves and wash hands during tracheostomy care to Resident #5Findings included:1.Review of Resident #74's quarterly MDS assessment, dated 05/22/2025, reflected he was a [AGE] year-old male admitted to the facility on [DATE], with the following diagnoses: dependence on renal dialysis (the need of a machine to make kidneys clean the blood), and end stage renal failure (kidneys do not work well). Resident #74 BIMs score of 11 indicated the resident had moderate cognitive impairment and required assistance from one staff for activities of daily living. Review of Resident #74's Care Plan dated 08/11/2025 reflected, Focus: Resident requires Enhanced Barrier Precautions. dialysis catheter.Goal: to reduce the potential spread of Multidrug-resistant organism, (infections).interventions planned. Enhanced Barrier Precautions used during high-contact resident care activities. such as: dressing, transferring, changing briefs or assisting to toilet. Observation on 08/12/2025 at 4:45 a.m. revealed a sign outside of Resident #74's door: the sign gave instructions to the staff concerning EBP (Enhanced Barrier Precautions) the sign instructed the staff what type of PPE (Person Protection Equipment) to use when assisting the resident. There was a three drawer container holding gowns, gloves, and mask, with a face shield outside the doorway. Observation of incontinence care on 08/12/2025 at 4:50 a.m., revealed CNA C did not use hand gel or wash her hands she did not don a gown in the hallway before entering the room. Resident #74 was lying on his back. CNA C placed on gloves and unfastened the resident's brief tabs and wiped the pubic area with a disposable wipe, discarding the wipe in the trash bag. CNA C wiped the genitals, discarding the wipe in the trash bag. CNA C wiped the shaft of the penis and discarding the wipe in the trash bag, and then cleaned the head of the penis and discarded the wipe in the trash bag. CNA C positioned Resident #74 on his right side with the help of the resident. CNA C wiped the rectal area that was soiled with bowel movement and discarded the wipe, using another wipe CNA C completed cleaning the rectal area of bowel movement, and discarded the wipe. CNA C wiped the right buttocks, which was soiled with urine, discarded the wipe. CNA C repositioned Resident #74 with her soiled gloves to his left side, CNA C cleaned the left buttocks, which was soiled with urine, discarded the wipe. CNA C assisted, with her soiled gloves, with the help of the resident to reposition Resident #74 on his back. CNA C took off her soiled gloves, did not wash her hands or use hand sanitizer, left the room and obtained a clean brief. CNA C returned to the room placed on another pair of gloves, without washing her hands or using hand sanitizer, placed and pulled the clean brief up underneath him and fastened the brief, removing the soiled brief placing it in the trash. CNA C then pulled the pants up on the resident. CNA C removed her dirty gloves did not wash her hands or use hand sanitizer, placed on new gloves, and continued to assist the resident to adjust clothing. CNA C removed her gloves in the room and assisted Resident #74 into his wheelchair. CNA C stated the resident had to be ready for pick-up between 5:00 and 6:00 a.m. for dialysis pick-up. CNA C left the room, not washing her hands or using hand sanitizer. CNA C entered another resident's room, closing the door. During an interview on 08/12/2025 at 5:00 a.m., CNA C revealed she was in a hurry because he has the non-emergency pick-up for dialysis between 5:00 a.m. and 6:00 a.m. and if he is not ready the transport people get upset. CNA C stated she was supposed to place on a gown outside the doorway because he had a tube in his arm, where he receives dialysis. CNA C stated that anyone with a tube of any kind, or wounds, has a set of drawers outside their door and a sign on the door, explaining what you must wear, according to what you have to do for the resident. CNA C said this was more the protection of us and the resident. I just got in a hurry and forgot, the same with the washing of my hands and changing my gloves, I got into a hurry, because you came into the room with me and it made me nervous. CNA C said not washing her hands when changed her gloves could cause the spread of infection, she said she had recently had the in-service for infection control. 2.Review of Resident #46's quarterly MDS assessment, dated 05/14/2025, reflected she was a [AGE] year-old female admitted to the facility on [DATE], with the following diagnoses: hypertension (high blood pressure), peripheral vascular disease (poor blood circulation), diabetes (high blood sugar), and cardiovascular accident (stroke). Resident #46 BIMs score of 6 indicated the resident had severe cognitive impairment and required assistance from two staff for activities of daily living. Further review reflected Resident #46 had a feeding tube (nutritional tube placed in the stomach) that was present upon admission. The resident receives 51%vor more of nutrition and fluid delivered through the feeding tube. Observation on 08/12/2025 at 5:38 a.m., LVN D entered Resident #46's room to replace the tubing for the resident's tube feeding. LVN D washed her hands and placed on gloves, she laid all her supplies on the overbed table, she did not clean the table prior to laying supplies on it. The overbed table had dried dark sticky substance on it. LVN D completed the replacement of the tubing turned the pump back on after priming the tubing for the G-Tube (feeding tube), spilling formula on top of the overbed table. LVN D cleaned up the remaining old tubing, removed her gloves washed her hands and left the room taking her trash with her, but not cleaning the overbed tabletop. In an interview on 08/12/2025 at 5:45 a.m., LVN D said she knew the overbed tabletop should have been cleaned before placing clean supplies on the overbed tabletop. LVN D stated she noticed it was sticky, but thought it was dried formula, she said if the surface was not clean then it could cause the spread of germs to the new supplies. LVN D stated she had infection control in-service in the past couple of months. 3.Review of Resident #5's 30-day MDS assessment, dated 07/30/2025, reflected she was a [AGE] year-old female admitted to the facility on [DATE], with the following diagnoses: hypertension (high blood pressure), seizures (abnormal brain waves), diabetes (high blood sugar), and acute respiratory failure with hypoxia (unable to breath loss of oxygen). Resident #5 BIMs score of 99 indicated the resident had severe cognitive impairment and required assistance from two staff for activities of daily living. Review of Resident #5's the consolidated physician orders dated August 2025 reflected: order dated 08/13/2025, Keppra (for seizures) oral solution 100 mg/ml via G-tube two times a day one tab by mouth two times a day, Furosemide oral tablet (for increased fluid & swelling) 20mg give 20mg via G-tube two times a day, and metoprolol tartrate (for high blood pressure) tablet give 12.5mg [NAME] G-tube daily. Further review revealed physician orders to check blood pressure, every shift and to check blood sugar three times a day and inject Humalog (for diabetes) 100units/ml per sliding scale. Observation on 08/12/2025 at 6:52 a.m. revealed LVN E performed morning medication pass, during which time she checked the blood pressure of Resident #5. LVN E failed to sanitize the blood pressure cuff before or after using it on Resident #5. Observation on 08/12/2025 at 11:30 a.m. revealed LVN E performed a blood sugar test on Resident #5. LVN E failed to sanitize the glucometer machine (an instrument for measuring the concentration of glucose in the blood) before or after using it on Resident #5. Observation on 08/12/2025 at 11:35 a.m., revealed LVN E performed Tracheostomy Care (tube opening in the throat at the neck allowing resident to breath) LVN E entered the room with her supplies, placing on gloves without washing her hands or using hand sanitizer. LVN E cleaned the overbed table with Sani Wipes and then placed her supplies on the overbed table after the cleanser had dried. LVN E changed her gloves to the sterile gloves in the trach kit, not washing her hands or using hand sanitizer. LVN E performed [NAME] care, suctioning, and cannula replacement, removed her sterile gloves, placed on another pair of non-sterile gloves, without washing her hands or using hand sanitizer. LVN E adjusted the humidifier over the trach opening, made sure the blankets were strait on the bed, then performed mouth care for Resident #5. LVN E took off her gloves washed her hands and then left the room. 4.Review of Resident #73's 5-day MDS assessment, dated 07/31/2025, reflected he was a [AGE] year-old male admitted to the facility on [DATE], with the following diagnoses: hypertension (high blood pressure), end stage renal disease (kidneys do not work right), malnutrition (poor food intake), and infection of cardiovascular graph (heart surgery). Resident #73 BIMs score of 13 indicated the resident was cognitively intact and required assistance from one staff for activities of daily living. Review of Resident #73's the consolidated physician orders dated August 2025 reflected: order dated 08/08/2025, hydralazine (high blood pressure) tablet 100mg one tab by mouth three times a day, nifedipine ER (high blood pressure) 60mg by mouth two times a day, and coreg oral tab (high blood pressure) 60mg give one tablet by mouth two times a day. Further review revealed physician orders to check blood pressure, every shift. Observation on 08/12/2025 at 7:15 a.m. revealed LVN E performing morning medication pass, during which time she checked the blood pressure of Resident #73. LVN E failed to sanitize the blood pressure cuff before or after using it on Resident #73. 5.Review of Resident #29's quarterly MDS assessment, dated 06/26/2025, reflected she was a [AGE] year-old female admitted to the facility on [DATE], with the diagnosis of: diabetes (high blood sugar). Resident #73 BIMs score of 13 indicated the resident was cognitively intact and required assistance from one staff for activities of daily living. Review of Resident #29's the consolidated physician orders dated August 2025 reflected: order dated 08/08/2025, blood sugar checked three times a day prior to meals. Further review revealed physician orders to administer Humalog Kwik pen (for diabetes) 100units/ml per the sliding scale following blood sugar checks. Observation on 08/12/2025 at 11:15 a.m., revealed LVN E performed a blood sugar test on Resident #29. LVN E failed to sanitize the glucometer machine (an instrument for measuring the concentration of glucose in the blood) before or after using it on Resident #29. In an interview on 08/12/2025 at 11:55 a.m., LVN E said she thought that washing hands, then placing on gloves was the only time, she had forgotten you should wash your hands or use hand sanitizer between each glove change. LVN E stated the equipment such as the blood pressure cuff and the glucometers were the same, both should be cleaned with sanitizing wipes before and after each use and allowed to dry. She used hand sanitizer before using the equipment, but that was not enough. LVN E stated she had just gotten in a hurry and had not followed the infection control protocol. LVN E stated that by doing that she could be spreading infections to others, including herself. In an interview on 08/13/2025 at 9:30 a.m., the Administrator revealed in-services had been completed monthly since June and infection control had been discussed with all the staff, by himself after the recertification had begun on 08/12/2025. The staff should know what to do and the Administrator said he was surprised they had made mistakes. Interview on 08/14/2025 at 10:00, a.m. the interim DON revealed she expected all staff to use hand sanitizer, or wash their hands, prior to placing on gloves and between glove changes, when conducting any direct resident care. The DON stated the staff should also follow the EBP protocols that are placed outside the doorway, when caring for the residents. The interim DON stated the staff has had in-services on infection control for cleaning equipment, incontinent care, EBP, and tach care about changing gloves, handwashing and using hand sanitizer. Review of the in-services given in the past three months reflected an in-service dated June19th, 2025, July 7th, 2025, and August 12, 2025, for infection control and cleaning of equipment. CNA C, LVN D, and LVN E had attended the meetings. Review of the facility's policy Infection Control Plan revised dated June 2025, reflected, An infection prevention and control program is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infections. Policy interpretations and Implementation. 3. The infection prevention and control program isa a facility-wide effort involving all disciplines and individual . ensure that reusable equipment is appropriately cleaned, disinfected, or reprocessed . 6. Resident care equipment. 3. Non-invasive resident care equipment is cleaned . as need between use. all reusable items and equipment requiring special cleaning, disinfection . shall be cleaned in accordance with our current procedures governing the cleaning. Review of the facility's policy Enhanced Barrier Precautions reviewed June 2025, reflected, Enhanced Barrier Precautions . designed to reduce transmission of multidrug-resistant organisms that monotargeted gown and glove use during high contact resident care activities. used in conjunction with standard precautions and donning of gloves and gown and gloves during high-contact resident care activities that provide opportunities for transfer of organisms to staff hands and clothing.EBP are indicated for residents with any of the following: .wounds and/or indwelling medical devices.Donning PPE for Residents on EBP based on activity provided/assistance while in resident room.changing briefs or assisting with toilting. Review of the facility's policy Handwashing-hand Hygiene revised dated October 2020 reflected, This facility considers hand hygiene the primary means to prevent the spread of infections. policy interpretation and implementation.6. Wash hands a. when hands are visible soiled. 7. Use alcohol-based hand rub.b. before and after direct contact with residents.f. before donning sterile gloves. m. after removing gloves. 9. The use of gloves does not replace hand washing/hand hygiene. 10. Hand hygiene is recognized as the best practice for preventing healthcare associated infections.Applying an Removing Gloves 1. Perform hand hygiene before and after applying non-sterile gloves.

Based on observation, interviews, and record review the facility failed to ensure that medications were secure and inaccessible to unauthorized staff and residents for three (one medication cart for Hall 400 and one medication cart for Hall 200, one medication cart for Hall 300) of seven medication carts reviewed for medication storage. The facility failed to ensure medication supplies were all stored in locked compartments and permit only authorized personnel to have keys, when LVN A's one medication cart for Hall 400 were left unlocked and unattended by LVN A. The facility failed to ensure medication supplies were all stored in locked compartments and permit only authorized personnel to have keys when LVN B's two medication carts for Hall 200 and one medication carts for Hall 300 were left unlocked and unattended by LVN B. This failure could result in resident access and ingestion of medications leading to a risk for harm and possible drug diversion. Findings included: An observation on 08/12/2025 at 4:30 a.m., revealed LVN B's one medication cart were left at the nursing station unlocked for Hall 400. LVN B was in the breakroom on Hall 300, and no other staff was at the nurse's station. The lock on the medication cart were popped out showing the red bottom indicating the carts were unlocked. An observation on 08/12/2025 at 4:30 a.m., revealed LVN A's two medication carts were left at the nursing station unlocked for Hall 200 and Hall 300. LVN A's whereabouts was unknown at this time and no other staff was at the nurse's station. The lock on the medication cart were popped out showing the red bottom indicating the carts were unlocked. An observation and interview on 08/12/2025 at 4:45 a.m., revealed LVN A coming back to the nurse's station and speaking with the investigator and then calling her supervisor on the phone. LVN A was leaning against one of the unlocked medication carts. LVN A stated she had been at the nurse's station the entire time, until the front doorbell rang and she left her carts unlocked. LVN A stated she was at the nurse's station, and she could see everything. LVN A walked the survey team down Hall 400 to the conference room out of the site of the nurse's station, with the medication cart unlocked at the nurse station and no one was at the nurse's station, except the surveyor. An observation on 08/12/2025 at 5:00 a.m., revealed no staff at the nurse's station, with one resident sitting in wheelchair around the nurse's station. One nursing medications cart for Hall 400 remained unlocked and not in direct site of the LVNs. In an interview on 08/18/2025 at 5:10 a.m., LVN B revealed she never left the medication cart unlocked, for Hall 400. LVN B stated she did not know how it was unlocked and wanted to know how the surveyor had gotten the drawers open to the cart. LVN B said she knew the cart was supposed to be locked each time. LVN B stated if the medication cart was left unlocked a resident or a staff member could get the medications, this could lead to medications being stolen or a resident taking something they should not have. In an interview on 08/12/2025 at 5:20 a.m., LVN A revealed she had her medication carts locked and showed the investigator that they were. LVN A was told the medication carts was observed earlier unlocked and the LVN just shrugged and stated, they were locked now. LVN A stated the medication carts that were unlocked were in her direct site. LVN A stated that if the medication carts were left unlocked and unattended the medications could be stolen or taken by a resident that could harm them. In an observation on 08/12/2025 at 9:00 a.m., with LVN D of the medication cart for Hall 200 revealed: Medications that could have been taken by staff or another resident for Resident #73 Multivitamin-minerals oral tablet (Supplement), Ascorbic Acid 500mg (Vitamin C), Diltiazem HCL 30mg tablet (Blood pressures med), and Coreg oral tablet 6.25mg (blood pressure). LVN D confirmed these were Resident #73's ordered medications and could have caused harm if taken by unauthorized person. In an observation on 08/12/2025 at 7:00 a.m. with LVN E of the medication cart for Hall 300 revealed: Medications that could have been taken by staff or another resident for Resident #5 Keppra oral solution 100mg (seizures), Insulin Glargine Solution 100 unit (diabetes), syringes, Robinul oral tablet 1mg (secretions), Furosemide oral tablet 20mg (edema), and metoprolol tartrate tablet 12.5mg (blood pressure). LVN E confirmed these were Resident #5's medications and could have caused harmed if taken by unauthorized person. In an observation and interview on 08/12/2025 at 11:15 a.m., with LVN E of the medication cart for Hall 400 revealed: for Resident #29 Mounjaro Subcutaneous Solution injector 5mg/0.5ml (diabetes), melatonin oral tablet 10mg (insomnia), apixaban oral tab 5mg (blood thinner), and protoxin tablet delayed release 40mg (for gastric acid reflux). LVN E confirmed that these were Resident #29's ordered medications. LVN E stated the medication carts should never be left unlocked, except when in use. LVN E stated this could be unsafe as medications could be taken form the cart by the residents or staff, which could result in harm. In an interview on 08/13/2025 at 3:00 p.m., the interim DON stated it was her expectation that medication carts should be locked when not in use. The interim DON said that the nurses were responsible to keep the medication carts locked when not in use. She stated if they were not locked, residents and unauthorized staff could get into the cart and there would be opportunities for harm and medication diversion. When the interim DON was asked who was responsible to monitor the carts to ensure they were locked she said that would be the staff that was using the carts. Review of the Policy and Procedure Medication Administration dated April 2019, reflected, Medications are administered in a safe and timely manner. 19. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide.

Based on record reviews and interviews the facility failed to send a copy of the residents' discharge notice, prior to discharge, to the representative of the Office of the State Long-Term Care (LTC) Ombudsman of the residents' transfer or discharge and the reasons for the move, for 1 of 5 residents (Resident #8) reviewed for notifying the LTC Ombudsman of the residents' discharge.Resident #8 was discharged on 07/01/2025 without a notice to the LTC state ombudsman.This failure could place residents at risk of not knowing their rights or receiving the services of the state LTC Ombudsman.The findings included:A record review of Resident #8's admission record dated 7/3/2025 revealed diagnoses which included Secondary Parkinsonism (similar to Parkinson disease caused by certain medicines, a different nervous system disorder or another illness), Muscle Weakness, Unspecified Lack of Coordination, Calculus of Ureter (kidney stone that has traveled into the ureter, the tube connecting the kidney to the bladder), Calculus in Bladder (bladder stones), Unsteadiness on Feet, Abnormal Weight Loss, Post-Traumatic Stress Disorder (mental health condition), Protein-Calorie Malnutrition, Quadriplegia (paralysis of all four limbs and the torso).A record review of Resident #8's MDS quarterly assessment, dated 07/13/25, reflected a BIMS score of 15 which indicated cognitively intactA record review of Resident #8's medical record revealed no evidence of a discharge notice to the LTC ombudsman.During an interview on 8/13/2025 at 3:19 PM, the LTC Ombudsman stated she had no evidence the facility had notified her of Resident #8's discharge. The LTC Ombudsman stated she visited the facility and had not received discharge notice from the facility.During an interview on 8/14/2025 at 1:45 PM, the SW revealed she was not aware of any reports for discharges of residents were sent to the LTC Ombudsman. The SW stated a review of Resident #8's records could not evidence a notice to the LTC Ombudsman for Resident #8's discharge to hospital.During an interview on 8/14/2025 at 2:20 PM the Administrator stated he was unaware of the rule to notify the LTC Ombudsman of any resident discharges.A record review of the facility's Transfer or discharged Notices Policy Statement dated March 2025, revealed, Notice of Transfer or Discharge (Anticipated).4. A copy of the notice is sent to the Office of the State Long Term Care Ombudsman at the same time the notice of transfer of discharge is provided to the resident and representative. Notice of Transfer or Discharge (Emergency)'.2. Notice of Transfer is provided to the resident and representative as soon as practicable before the transfer and to the Long-Term Care (LTC) ombudsman when practicable (e.g., in a monthly list of residents that includes all notice content requirements).

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs residents for one (Resident #5) of three residents reviewed for medication review. LVN E failed to ensure Keppra (a medication given to prevent seizures) was administered to Resident #5 appropriately. LVN E did not hold the G-tube feeding an hour before and one hour after the medication was given. This failure could place residents at risk for not receiving medications as ordered by their physician and not receiving the intended therapeutic benefit of the medications.Findings included:Review of Resident #5's 30-day MDS assessment, dated 07/30/2025, reflected she was a [AGE] year-old female admitted to the facility on [DATE], with the following diagnoses: hypertension (high blood pressure), seizures (abnormal brain waves), diabetes (high blood sugar), and acute respiratory failure with hypoxia (unable to breath loss of oxygen). Resident #5 BIMs score of 99 indicated the resident had severe cognitive impairment and required assistance from two staff for activities of daily living. Review of Resident #5's the consolidated physician orders dated August 2025 reflected: order dated 08/13/2025, Keppra (for seizures) oral solution 100 mg/ml via G-tube two times a day one tab by mouth two times a day. Record review of Resident #5's care plan revised on 7/06/2025 revealed Resident #5 had a seizure disorder and medications should have been administered as ordered. Record review of Resident #5's August 2025 MAR revealed Keppra oral solution 100mg/ml give 10ml via G-tube two times a day for seizures was signed as administered each day from 08/01/205 until 08/12/2025. There was no guidance to the nurse to hold the G-tube feeding for one hour before or one hour after administering the medication. In an interview and observation on 8/12/2025 at 06:52 a.m., LVN E during a medication pass prepared to administer the Keppra, as well as other medications to Resident #5. LVN E entered the room and turned off the running G-tube pump, checked the tube for placement and administered eight medications, including the Keppra. Following each medication, LVN E administered 5mls of water. LVN E provided a flush before and after completion of the medications that were given, then the LVN restarted the feeding pump and left the. In an interview on 08/12/2025 at 7:15 a.m., LVN E stated she did not turn the pump off before or after the administering the Keppra because she did not recall that she was supposed to do that. LVN E said when she thinks about it she did recall something about that in nursing school but that had been a long time ago. LVN E stated after looking it up on the phone, that it was about an absorption problem, and she would have to start doing that so the resident received all the medication appropriately. LVN E thought maybe that should be added to the MAR, so other nurses would do the same thing. In an interview on 08/13/2025 at 2:00 p.m., the DON said the G-tube should be stopped for one hour before giving the Keppra and on hour after, that was basic nursing 101 and she was shocked the nurse did not know this and practice best practices. This could affect the absorption of the medication causing the levels to not be correct and the resident could have seizures form not having the medication absorbed correctly. In an interview on 08/13/2025 at 2:45 p.m., with the Medical Director revealed he did not know about the specifics of the administration of the Keppra in a G-tube, he just wanted his resident to have the right amount, at the right times, and the medication to have the best potential to work. If this was the recommendation of the research that had been done the nursing facility nurses should be giving it this way. Record review of facility policy titled Medication Administration, with a revision date of April 2019, revealed Medications are administered in a safe and timely manner, and as prescribed . Policy interpretation and Implementation. 4. Medications are administered as in accordance with prescribed orders. 5. Medication administration times are determined by resident need and benefit, not staff convenience, factors that are considered include: a. optimal therapeutic effect of the medication. 31. Each Nurses' station has a current Physician's Desk Reference (PDR) and/or other medication references.Record review of reference, Developing guidance for feeding tube administration of oral medications https://www.ncbi.nlm.nih.gov/ revealed: When administering Keppra (levetiracetam), it is generally recommended to hold the enteral nutrition (EN) infusion for one to two hours before and after the administration of the medication. This practice is aimed at minimizing the potential for interactions between the medication and the EN, which can affect the drug's absorption and efficacy.The exact timing and duration of EN withholding may vary depending on the specific drug and the patient's individual circumstances. It is crucial to consult with a healthcare provider to determine the best approach for each patient.

Based on observation, interview, and record review the facility failed to ensure Nurse Staffing Information was posted daily for one of one building. The facility did not post and maintain the required staffing information on August 12, 2025.This failure could place residents and visitors at risk of not knowing how many nursing staff were on duty and the actual hours worked per shift daily.findings included:During an observation on 08/12/25 at 04:35 AM, there was no Nursing Staffing Information posted up in the facility in an area visible to all residents and visitors.In an interview on 08/12/25 at 11:42 AM, The Staffing Coordinator state that she places the staffing sheets every morning when she arrives. She stated that she will adjust if there is a call out but the sheets are placed in the holder at on the wall near the Director of Nursing's office. She state that she also does the weekend sheets and they are accessible for the weekend supervisor or charge nurse to place and or update if needed. She stated that she placed it this morning but does not know who removed it. She stated that she has the actual sheet and brings it to the surveyor for proof. She stated some weekend s she may come in for other matters and she will make sure the information is posted.In an interview on 8/14/25 at 1:09 PM The Administrator stated they always have the information posted and the staffing coordinator updates that information. He reported he would provide a copy of the policy for posting staffing. Record review of facility policy Posting Direct Care Daily Staffing Numbers. Review 3-2023Page 1 Policy Statement: Our facility will post on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents. Within two (2) hours of the beginning of each shift, the number of licensed nurses (RNs, LPNs and LVNs) and the number of unlicensed nursing personnel (CNAs) directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format.

Based on observation, interview, and record review, the facility failed to ensure personnel provided basic life support, which included CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 1 of 7 residents (Resident #1) reviewed for cardio-pulmonary resuscitation. RN E failed initiate CPR when FM C told him Resident #1 was unresponsive on [DATE]. A Past Non-Compliance Immediate Jeopardy (PNC IJ) was identified and presented to the Administrator and DON on [DATE] at 4:04 PM at exit. The noncompliance began on [DATE] and ended on [DATE]. The facility corrected the noncompliance before the investigation began. This failure could place residents at risk of not receiving life-saving measures, medical complications, distress, and up to and including death. Findings included: Record review of Resident #1's face sheet dated [DATE] reflected she was an [AGE] year-old female that was admitted on [DATE]. DX (diagnosis) included: Unspecified Dementia (memory loss), Mood Disturbance (disruption in emotional state), Anxiety (feeling of worry), Other Symbolic Dysfunctions (affecting speech and memory). The face sheet did not reflect Resident #1's advance directive as it was left blank. Record review of Resident #1's quarterly MDS dated [DATE] reflected she had a Bims score of 3, indicating severe cognitive impairment; Section GG resident functional abilities reflected she required extensive assistance for bed mobility, transfers, eating, toilet, she was a hospice patient, and all medications and DX were addressed. Record review of Resident #1's care plan dated [DATE] reflected the staff and/or responsible party have been provided the information explaining the Advanced Directive process and following Date Initiated: [DATE]. interventions .Obtain a copy of my [full code] status physician order Family and staff are aware of my Full code status .Send the copy of my [full code] status with me on all transfer to physician appointments or hospital .Upon admission my family or I have received a copy of the Advanced Directive and Resident Rights. ADL care reflected Resident #1 required extensive assistance from staff with self-care, transfer, ADL, hygiene .The resident has a terminal prognosis r/t Alzheimer's Disease. (disease causing a decline in cognitive function) Record review of Resident #1's MD orders dated [DATE] reflected resident was a full code .Hospice to evaluate and treat as Indicated, [DATE] .Resident/Responsible Party is aware of Diagnosis: Yes. Record review of Resident #1's progress notes reflected the following: On [DATE] at 3:56 PM, by RN E This nurse was called into room [room number] at 1505 (3:05 PM) resident was not breathing, this nurse (RN E) assessed pulse and respiration and initiated [code blue] and CPR started on the resident and 911 EMS was called, Nurses were doing CPR on the patient when EMS staff arrived by 3:09 PM [EMS] started working on the resident till 4:00 PM. Pulse and BP noted on the resident and EMS staff took her to [hospital.] Resident left the facility with EMS exactly 4:00 PM signed [RN E] Nursing - Registered Nurse (RN) [e-signed.] RN E's note did not mention that the family was present in the room not that the family as the initial notification to him when Resident #1 became unresponsive. Record review of Resident #1's progress notes dated [DATE] at 9:17 PM by ADON reflected the following: Resident expired. An observation of Resident #1 was not conducted as she expired on [DATE] at the hospital. During an interview with ADM on [DATE] at 11:00 AM stated that he was notified by the ADON on of the incident [DATE] at 3:10 PM. ADM said he proceeded to the facility to meet with the corporate staff to investigate the incident. ADM stated that upon his arrival the investigation was initiated. ADM said that his investigation revealed that FM C notified RN E that Resident #1 was nonresponsive. ADM said the resident was a full code. ADM said the hospice nurse was contacted to ensure advance directive due to HLV leaving DNR documents for the family to sign on [DATE] at 10:00 AM. HLVN and ADON both confirmed that Resident #1 was a full code. ADM said a code blue was initiated by RN E. ADM said that RN A immediately assisted with the code blue on Resident #1 in her room until EMS arrived. ADM said there were family members present in the room. The family members were later identified as (FM C and FM T). ADM said he had not interviewed the family that was present, only the POA. ADM said on [DATE] and [DATE] all active staff were in-serviced on CPR protocol, Code Blue, and DNR protocol. After the education, the staff were required to take a test on their knowledge of the incident. All staff passed. ADM said the training and monitoring was ongoing and this was an isolated incident. He stated that RN E was immediately suspended pending investigation findings and terminated on [DATE]. During an interview with DON on [DATE] at 11:10 AM stated she was not working the day of the incident ([DATE]). The DON stated that she was in-service on [DATE] and she has been a monitoring, auditing, and educating staff on CPR (task conducted to save a life during cardiac arrest), code Blue (procedures of the facility), and DNR protocol. The DON stated that (RN E) failed to check code status for Resident #1 and follow administrative and MD orders to initiate CPR and call 911 when she was found unresponsive. The DON expects all nursing staff to review advance directives on assigned residents, know where to locate the information in the electronical files, initiate CPR, and call 911 immediately for residents that have an advanced code of full code. The DON said it was her expectation that the staff continue CPR until EMS arrived and take over. The DON stated the risk to residents when the advance directive was not followed included: failure to honor the resident's wishes and death if no CPR was initiated. DON said the facility initiated corrective actions immediately to ensure other resident's safety and this was an isolated incident. The DON said RN E was terminated on [DATE] at 9:22 AM via phone. During an interview with ED on [DATE] at 11:20 AM stated that he was notified of the incident with Resident #1. ADM said other corporate staff and ADM reported to the facility and investigated. ED said RN E failed to follow the care guidelines for all residents advance directives, initiate CPR immediately for residents that were full code, and notify 911 when a resident was fund non-responsive. The ED expects all staff to follow MD orders and leadership directives quickly to alleviate any delay in care or services for residents. The ED stated that he assisted with the investigation and training along with other corporate staff to ensure staff were trained immediately and residents were safe. The ED stated that RN E was immediately suspended on [DATE] pending the investigation findings, then terminated on [DATE] at 9:22 AM via phone. ED stated that he will be referring RN E nursing license. The ED stated the risk to residents when the advance directives for CPR/full code were not followed included failure to honor the resident's wishes and death if no CPR (task conducted to save a life during cardiac arrest) was initiated. During an interview with ADON on [DATE] at 11:25 AM who stated she received a call from the HLVN and CNA B at 2:45 PM stating that RN E was asked to conduct CPR (task conducted to save a life during cardiac arrest) for Resident #1, and he had not initiated the lifesaving actions for Resident #1. HLVN told the ADON that Resident #1's DNR form had not been signed by the POA or MD, so CPR should be the first course of action for the resident to save her life. ADON notified RN E and CNA B to activate a code blue and initiate CPR and call 911. The ADON headed to the facility along with ADM, ED, and other corporate staff to investigate, educate, monitor, audit staff knowledge and competency on trainings on CPR and code blue protocol. The ADON said all active staff were trained and evaluated on training protocol's and they all passed the test. The ADON said Resident #1 was sent out via ambulance and RN E was suspended pending investigation findings. The ADON said RN E was terminated on [DATE] after the investigation determined he did not follow advance directive protocol for Resident #1. ADON said she did not know if the facility ADM referred RN E to the BON. The ADON stated she expected all staff to be knowledgeable on resident's advance directive and act immediately by calling a code blue, initiating CPR, and notifying 911. The ADON said she expects the nursing staff to continue CPR until EMS arrive and take over care. The ADON said the risk to residents included failure to honor the resident's and families wishes and death if no CPR was initiated. During an interview with CNA B on [DATE] at 11:30 AM revealed she observed FM C telling RN E on [DATE] at 2:40 PM that Resident #1 was full code and he needed to conduct CPR. CNA B overheard FM C talking to RN E at the nursing station. CNA B said she intervened and spoke with FM C to address concerns that Resident #1 was full code and RN E had not initiated CPR. CNA B immediately checked the chart and notified the ADON via phone to report Resident #1's advance directive (full code). The ADON reviewed Resident #1's file and confirmed that Resident #1 was a full code requiring CPR. The ADON told RN E to initiate CPR immediately, call a code blue, and notify 911. CNA B observed RN E take the Crash Cart and head to resident room. CNA B stated she notified RN A of the code blue at the nursing station and LVN T to notify 911 and get Resident #1's files prepared for transport via EMS. CNA B was seeking additional staff to assist with the code blue. CNA B said RN E headed to the resident room with the crash cart to initiate CPR. CNA B stated that she told RN A to go and assist RN E with a code blue. CNA B said she then asked LVN T to contact 911 and gather medical documents for the transport with EMS. CNA B stated she did not enter the room, nor did she observe RN E initiate CPR. CNA B said the risk to residents included failure to honor the resident's and families rights and death if no CPR was initiated. CNA B said all nursing staff were required to know resident advance directive status and immediately conduct CPR for full code to residents until EMS arrives. CNA B said she was not in the room with RN E and RN A to confirm that CPR was initiated immediately. CNA B said she told RN A and LVN T of the code blue verbally at the nurse's station. CNA B said she did not make an announcement on the PA system notifying staff of a code blue on [DATE]. CNA B said that several family members were resident in the room with Resident #1. During an interview with [NAME] on [DATE] at 11:59 AM stated Resident #1 was on hospice and her advance directive on [DATE] at the time of the incident was full code. [NAME] said FM C called HLVN concerned that RN E had not initiated CPR on Resident #1. [NAME] said FM C told RN E several times that Resident #1 was full code, and he ignored her request for 10 to 15 minutes and returned to the nursing station. During an interview with HLVN G on [DATE] at 12:25 PM stated she visited the facility at 10:45 AM. HLVN G stated she received a call from a family member name (later identified as FM C) unknown inquiring about Resident #1's advance directive. HLVN G stated she spoke with RN E time unknown to confirm that the resident did not have a DNR for AD and he (RN E) should proceed with CPR. HLVN then contacted the ADON to report FM C's concerns about RN E not initiating CPR. HLVN told ADON that Resident #1 was full code indicating that the staff would administer CPR and call 911. During an interview with LVN T on [DATE] at 1:25 PM who stated that CNA B called her over to the nursing station on [DATE] at 3:00 PM and asked her to contact EMS for a code blue of a resident, and to gather face sheet, Medication list, and care plan to provide to the EMS when they arrive to transport Resident #1. LVN T said she called 911 at 3:00 PM and they arrived at 3:20 PM. LVN T said she waited at the front door for EMS and escorted them to the Resident #1's room and provided the transfer documents. LVN T said she did not enter the room and could not confirm if CPR was in progress on Resident #1 by RN E or RN A. LVN T family in the room and observed the EMS taking Resident #1 out on a stretcher (tall bed with wheels) while continuing to provide breathing support. LVN T stated she was trained on CPR protocol and code blue on [DATE]. She completed the testing was knew the location in the electronic files to access resident's advance Directives. LVN T stated that risk to residents included failure to honor the resident's choices and death if no CPR was initiated. LVN T did not remember if an announcement was conducted over the PA system notifying all staff of a code blue. During an interview with RN A on [DATE] at 1:57 PM revealed she was notified by CNA B on [DATE] at 3:00 PM that a code blue was activated and to go and assist RN E on the three hundred Hall with CPR protocol. RN A said upon arrival to Resident #1's room, she observed the facilities crash cart outside of Resident #1's room in the hallway. RN A entered Resident #1's room and observed RN E standing in the room talking with family and he had not initiated CPR on Resident #1. RN A said she had observed Resident #1 lying down on the bed unresponsive, assessed her pulse, and then RN E asked if the Resident #1 was a full code, and he (RN A) said yes and 911 had been called. RN A proceed to position Resident #1 and initiated CPR. RN A said the facility staff did not announce a code blue over the PA system. RN A stated she was notified by CNA B verbally at the nursing station. RN A said after she initiated CPR RN E left the room before EMS arrived, therefore he was not available to communicate with the EMS staff on specifics about the patient (Resident #1) and care. During an interview with the Administrator on [DATE] at 5:00 PM, he stated the IJ occurred on [DATE] after the charge nurse (RN E) failed to check code status, initiate code blue, call 911, and initiate CPR protocol for Resident #1 when she was found unresponsive. He stated the hospice company provided the DNR form, however despite directions from family member, hospice nurse, and the ADON he failed to ensure the POA and Resident #1's rights were represented. Resident #1's POA expressed her desire for a DNR order earlier in the day with HLVN. ADM stated the risk to residents not receiving immediate actions for full code status and CPR included failure to honor the resident's wishes, distress, and death if CPR was not initiated. ADM said the facility initiated corrective actions immediately on [DATE] when the failure was identified to ensure other resident's safety, and this was an isolated incident. A phone interview was attempted with RN E on [DATE] at 1:39 PM and a voicemail was left requesting a return call for an interview was left. RN E did not return the call, and he was not interviewed prior to exit on [DATE]. During an interview with Residents #1's POA on [DATE] at 3:32 PM, who stated that she was not present when Resident #1 became non-responsive on [DATE]. POA said she left to allow other family members (FM C and FM T) and others to visit the resident after she was notified by hospice HLVN G that Resident #1 was declining. POA stated that the HLVN discussed changing Resident #1's advance directive to a DNR early that morning and ordered morphine to keep Resident #1 comfortable. POA stated Resident #1 was declining in health and she did not want Resident #1 to be resuscitated. The POA said she had not signed the DNR documents for Resident #1 at the time of the incident ([DATE]). POA stated that the resident passed away before she could return to the facility and sign the DNR. The POA provided contact information for FM H who was present with others in the room when Resident #1 died. She did not have the phone number for FM C and others that were present on [DATE]. Review of RN E personnel file reflected a disciplinary action dated [DATE] reflecting Recommended Action: termination. Rule Infracted (violation): Failure to Follow [Facility] Policy .facts regarding incident: On [DATE], a [Resident #1] went into full code. The resident, although on hospice, did not have a DNR in place. At the time of the full code, you failed to perform CPR at that moment which is against [Facility] Policy and CPR had to be initiated by another nurse. This failure to follow policy which requires CPR with no DNR in place Expectations for [facility] associate's behavior: The follow [facility] Policy at all times when it comes to the health and welfare of our residents. Solutions & corrective action to be taken: Immediate termination of employment Associate's statement: was blank Note to Associate: Continued performance problems will result in further disciplinary action, up to and including termination. Associate's Signature verifies that (1) This Disciplinary Action has been presented to me; (2) the Associate does not necessarily agree with its content; and (3) the Associate has had an opportunity to respond to the counseling. Associate signature and date reflected Delivered by phone 9:22 AM. Supervisors signature and date [ED] [DATE] Copy to: Associate's Personnel file Witness (in the event Associate refuses to sign) Associate HR if suspend/terminated. An attempted phone interview with FM H on [DATE] at 3:47 PM a voicemail was left requesting a return call for an interview. FM H did not return call and the interview was not conducted. Record review of the facility's Inservice dated [DATE] policy titled CPR-AED Policy revised [DATE] reflected the following: Full Code/DNR by ADON and [facility) dated [DATE], titled QAPI reflected Immediately on [DATE] nurse who was responsible for resident was suspended pending investigation. Review of in-services on [DATE] reflected, corporate staff in-serviced Administrator and DON on CPR policy that included education on full code status and when to initiate a full code. In serviced on if verbal consent also given however if the DR has not signed the DNR form the resident will remain a full code until DNR paperwork has been signed and facility has copy. Competency was verified via quiz. Review of in-services dated [DATE] DON/Designee initiated in-services with the nursing staff on CPR policy that included education on full code status and when to initiate a full code. In serviced on if verbal consent also given to nursing staff however, if the DNR has not been signed the resident will remain a full code until DNR paperwork has been signed and facility has copy. Competency was verified via quiz. Nursing staff was not allowed to work until in servicing had been completed. the above content was incorporated into new hire orientation by Administrator effective [DATE]. Review of audit on [DATE], an audit was completed of all resident code status by DON/Designee. Medical Director was notified on [DATE] In order to monitor current residents for potential risk, SW/designee will audit the code status of all residents weekly x 4 weeks and monthly thereafter to ensure accuracy. Any negative findings will be corrected and reported to the QAPI committee to ensure continued compliance. The facility QA Committee will meet weekly for the next eight weeks to review compliance with the plan of action. If no further concerns are noted, will continue to monitor as per routine facility QA Committee. Record review of the facility's Full Code/DNR Quiz for staff dated [DATE] reflected the following information questions .1. An RP/POA for a resident communicates verbally that they would like the residents code status changed from CPR to a DNR. Prior to completion of DNR form and physicians order the resident codes you must .Initiate CPR Do nothing until the form is back 2. A patient is listed as a Full Code and becomes pulseless. What should you do first? Begin CPR immediately and call for help .3. A patient becomes unresponsive and pulseless. You are unsure of their code status. What is the first action you should take? Start CPR immediately Call the provider for clarification. Double check the medical record .4. Who is responsible for knowing a resident's code status? All members of the care team. Monitoring of the facility's Plan included record review of Resident #1, #2, #3, #4, #5, #6, and #7's medical charts for compliance with advance directives orders, and notifications. All resident's charts reflected active Advance Directives on the face sheet, MD orders, Care plan with specific interventions and communication with RP. Interviews were conducted with facility staff across all three shifts on [DATE] from 11:00 AM through 2:55 PM. The staff included, ADM, ADON, CNA B, CNA L, DON, ED, HR, LVN T, MA G, MA R, RN A, RN T, and SW. The interviews revealed they had all received in-service training and could accurately describe how to determine the resident's code status, how to determine whether DNR documentation was complete, how and when to initiate CPR, code blue, and how long they should continue CPR. Record review of facility policy titled CPR dated [DATE] reflected In the event of cardiopulmonary arrest of a resident/patient without DNR status, life support measures will be initiated according to either the American Heart Association/American Red Cross guidelines or per State Guidelines. According to the 2001 American Heart Association, BLS (Basic Life Support) for Healthcare Providers, prompt initiation of CPR remains the standard of care .Rescuers who initiate BLS should continue until one of the following occurs: Restoration of effective spontaneous circulation and ventilation; Transfer of care to emergency medical responders or other trained personnel who continue BLS or initiate advanced life support; Transfer of care to a physician who determines that resuscitation should be discontinued; Inability to continue resuscitation because of exhaustion, because environmental hazards endanger the rescuer, or because continued resuscitation would jeopardize the lives of others; Recognition of reliable criteria for determination of death; or Presentation of a valid no-CPR order to the rescuers. At least one person at the scene of the arrest will remain with the victim and initiate the Code Blue procedure Any clinical employee trained in Basic Life Support may initiate CPR .The Emergency Medical System (911 or local number) will be activated immediately. Advanced Life Support functions will be instituted by paramedics with the EMS system EMS will transport resident/patient to the emergency room of the transfer agreement hospital .Guidelines: Person Responsible in a Code Blue Situation: Person Responsible in a Code Blue Situation: Any physician in the facility, becomes Team Leader for directing a code This facility is not currently equipped with defibrillator or cardiac drugs to conduct ACLS measures. In the event a physician is in the facility at the time of the code and gives specific order for the treatment of the resident/patient within the capabilities of the facilities equipment and supplies, such orders will be carried out .Nurse manager/charge nurse - delegated code responsibility as part of shift assignment for nursing staff present person to record, persons to do CPR, person to call 911, (or appropriate local number) physician and family if social workers not present Resident's/Patient's assigned nurse - available to give report Director of Nursing if in facility - Dismisses unnecessary personnel .Assures the EMS has been contacted of transport if physician not present, supervises code activities, Observes performance of Code Team and makes recommendations on code review, Delegates contacting and providing emotional support to resident's/patient's family to administrative representative, social worker or recreational therapy Social Services, if in facility, to support family members Person who discovers arrest: Calls for help while placing resident/patient in flat position on back C. Nurses Responding: Establish a patent airway .Use lift, jaw lift technique, or nasal airway. Do not hyperextend neck of any resident/patient .remove dentures if they are obstructing the airway .Begin CPR - one person rate in accordance with current American Heart Association/American Red Cross standards use single use resuscitation mask mouth-to-mouth or mouth to nose until [NAME] bag is obtained . Documentation: Time arrest called, date and location-information must be complete on every Record .Ventilation-Note time started and stopped, types of ventilation and by whom .External massage-Chart time started and stopped and each person involved .Persons responding-Record names of people responding to the Code Blue .- if possible, give department name also .Time, Pulse, Pupils, Skin - The patient's/resident's condition at intervals should be recorded with regard to BP, pulse, pupils, and skin Pulse -weak, thready, slow, unobtainable, bounding, femoral only, etc. (further, similar). Pupils - pinpoint, dilated fixed, non-reactive, unequal, etc. (further, similar) . Skin - warm, dry, cold, clammy, cyanotic, pale, etc. (further, similar) . Time EMS called, arrived, and departed with resident/patient Condition of resident/patient on departure.

Based on observation, interviews, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident #6) of 5 residents reviewed for quality of care in that:. 1) Resident #6 was observed to have moisture-related skin breakdown and chafing which had not been addressed by the nursing staff; and 2) The facility failed to conduct weekly skin assessments and ensure Resident #6 was accurately assessed and treated for her skin breakdown. This failure placed residents at risk of having unidentified skin conditions leading to delays in treatment and worsening of conditions. Findings included: Record review of Resident #6's Admission Record dated 02/23/24 reflected she was a [AGE] year-old female originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including acute respiratory failure (lungs cannot release enough oxygen into the blood to allow organs to function properly); unspecified open wound of abdominal wall; Type 2 diabetes; pressure ulcer of right heel, Stage 4; pain in right shoulder, pain in left shoulder, lack of coordination and obesity. Record review of Resident #6's Annual MDS dated [DATE] revealed she had a BIMS score of 15 indicating she was cognitively intact; she required a wheelchair for mobility; she was dependent on staff for toileting, extensive assistance for bed mobility and transfers, and was incontinent of bowel and bladder; she was at risk for developing pressure ulcers and had 1 Stage 4 pressure ulcer Record review of Resident #6's Care Plan revealed a focus, initiated on 12/29/21 and last revised on 05//22/23, which indicated Resident #6 had an ADL self-care performance deficit with interventions to include: BED MOBILITY: [Resident #6] required extensive assistance by 2 staff to turn and reposition in bed as necessary. TOILETING: [Resident #6] required extensive assistance by 1-2 staff for toilet use. Record review of Resident #6's Care Plan revealed the following: A focus, initiated on 02/22/23 and last revised on 05/16/23, which indicated Resident #6 had a pressure ulcer on her right heel related to peripheral arterial disease wound and refusal to wear heel protection boots. Interventions included: Follow facility policies/protocols for the prevention/treatment of skin breakdown. A focus initiated on 07/18/23 which indicated Resident #6 had a behavior problem r/t hoarding and non-compliance with medication administration (self-administering OTC meds and ordering from online pharmacies). Interventions included, Anticipate and meet the residents needs; educate the resident/family/caregivers on successful coping and interaction strategies such as using the call light when she needs assistance, notifying the nurse of medical needs .If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident . Record review of Resident #6's Weekly Body Skin Check dates 02/01/24 revealed she had no skin issues. Record review of Resident #6's electronic medical record revealed the Evaluations screen included an area titled Next Evaluation Due: and included a list of evaluations along with due dates. The area included an entry that reflected: Nex.Weekly Body Skin Check Due Date: 2/8/2024. The same Evaluations screen on the electronic medical record revealed a list of completed evaluations which reflected her weekly wound assessments were being completed. Record review of Resident #6's Wound Weekly Observation Tool dated 2/22/24 at 11:39 AM reflected it contained only an assessment of her right great toe. Record review of Resident #6's monthly MAR/TAR for February 2024 reflected the following entries: Micatin cream 2% apply to vaginal area topically two times a day for vaginal irritation apply cream to vulva. Order date 0 9/21/23-Discontinued 02/18/24. The entries reflected she refused the cream 13 times between 02/01/24 and 02/17/24. Apply Triad paste in between incontinence care every shift for wound care prevent. Order date 08/02/23. The entry was signed as administered every shift from 02/01/24 through 02/23/24. Hydroxyzine HCL oral tablet 25 mg. Give one tablet my mouth every 8 hours as needed for itching. Order date 01/14/14. The entry reflected only 2 doses had been administered for the month: one dose on 02/06/24 and one dose on 02/21/24. Micatin cream 2% apply to labia topically as needed for irritation. Order date 02/18/24. No doses had been signed as administered. Record review of Resident #6's nursing progress notes dated 02/02/24 through 02/21/24 reflected no entries were made describing the condition of Resident #6's skin. Record review of Resident #6's Documentation Survey Report (reflecting the entries made by CNAs for ADL care) dated February 2024 reflected the following: Toileting Hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement: No codes were entered to reflect resident refused the activity during any shift from 02-01022 through 02/22/24. Shower/Bathe Self M-W-F [Monday-Wednesday-Friday]: No codes were entered to reflect resident refused the activity during any shift from 02/01/24 through 02/22/24. Record review of an entry dated 02/22/24 at 1:14 PM (after surveyor inquiry) reflected the following: Skin assessment completed on patient, pt has a very large abdominal hernia to LLQ [left lower quadrant], multiple areas of scab/dry skin noted to area. No open areas noted. Right heel has a dry scab to area, surrounding skin wnl [within normal limits]. Moisture-associated skin damage noted to abdominal folds, peri area and left upper back/flank area with broken skin. Pt states, it itches, so I scratch all the time. Blanchable redness noted to ischial area and coccyx. Notified [NP B] of the above. New order obtained for air mattress, increase miconazole to twice a day and have wound MD assess on his next visit. Orders entered at this time. An observation and interview with Resident #6 on 02/22/24 at 7:40 AM revealed she was lying in bed on a large mattress. She was laying on a chux pad but had no sheet covering her bed. She stated they never put a sheet on her bed, and she did not know why. She stated she did not like to get out of bed due to multiple health conditions, issues with her back and both shoulders. She stated she was terribly itchy all over, all the time and was not sure why . She pointed out a shelf and her bedside table where she had multiple types of body washes, shampoos, and lotions she had tried . Resident #6 stated she bought them herself. She stated she had occasionally complained to staff about her itching and they use a cream on her or give her some medicine for itching. She was unable to say when she last complained to nursing staff. She stated she was wet at that time but wanted to wait until after breakfast to be changed. She described her history of bowel surgery that left her with a huge hernia that was inoperable. She lifted her gown and revealed a large mass protruding from her lower left abdomen. The area was noted to have multiple scabbed sores. Resident #6 stated, Those are my fault, I pick and scratch at it. In an interview on 02/22/24 at 9:18 AM, LVN C identified herself as Resident #6's charge nurse. She stated Resident #6 had wounds to her right foot that were being treated by the wound doctor. She stated the resident's bottom became red at times, but she had no other current skin conditions at that time. An observation on 02/22/24 at 9:40 AM revealed Resident #6 was lying in bed; she had no fitted sheet and was on a chux pad and wearing a brief. CNA K and CNA L entered and brought linens and supplies to provide incontinent care. No fitted sheet was observed among the supplies. When asked about the missing sheet, CNA K stated resident #6 had requested no sheets some time ago and told them they stick to her skin. Resident #6 stated that was when she had Shingles on her back several months ago but had since healed. CNA K offered to get her a sheet and she declined. During care, Resident #6's groin and perineal area was red, there was a red streak observed along the areas where her groin met her upper thighs that was approximately an inch wide. Resident #6 stated she thought that was chafing from her brief. Her buttocks area was also red and had a red streak on her upper left thigh beneath her left buttock. She stated it was sore when touched. The red areas on her buttocks blanched when touched. Resident #6 had a large area on her left back that was reddish/purple in color. There were small open areas observed in the area. Resident #6 stated that was where she previously had shingles and was still itchy at times, so she scratched a lot. A back scratcher was observed on her bedside table. A barrier cream was applied to all affected areas. When the CNAs moved on to clean her skin folds, the areas under her left abdominal fold and under her left breast were noted to be red. Resident #6 stated she got frequent yeast infections in her skin folds that came and went. CNA K stated the nurses were aware of the red areas. Resident #6's R foot was observed in a heel protector. She had two wounds to her right great toe and a healed wound to her left heel. She stated she was seen and treated by the wound care physician for her foot wounds but did not recall him assessing her other areas. Following care, CNAs K and L stated Resident #6 had a habit of clawing and scratching down there. She refused showers and only wanted bed baths. They stated they would go in and offer to clean her, she would tell them to come back later then complain she wasn't cleaned. The CNAs stated they reported any refusals to whatever charge nurse was on duty at the time. During an interview on 02/22/24 at 2:20 PM, CNA N stated he cared for Resident #6. He stated she never wanted sheets on her bed, he stated, she wants a brief, chux and a draw sheet, that's it. He stated he did not report her skin to the nurses after every care because the nurses already knew about her red skin and she was getting treatment. He stated she refused incontinent care at times and refused to get out of bed. He stated her bed and skin will never dry out if she doesn't get out of it. During an interview on 02/22/24 at 12:21 PM, the CCS stated the DON was home ill and she was covering the building. The observation of Resident #6's skin condition was discussed as well as the inability to locate any recent skin assessments in her electronic record other than the wound assessments for her foot. A request was made for any additional documentation that may have been missed. During an interview on 02/22/24 at 1:55 PM, LVN I stated weekly head-to-toe assessments should be completed by the nurses. She stated they were important because skin issues could get missed and become worse. She stated she could not recall when the last one was done for Resident #6 because she no longer worked on her hall. During an interview on 02/22/24 at 2:49 PM, LVN G stated he had been caring for Resident #6 and had cared for her the evening of 02/21/24. He stated the only skin conditions affecting Resident were her foot and abdomen. When asked about her weekly head-to-toe skin assessments, he stated, as a nurse, I can do it. He stated he had not done a skin assessment on her and was not sure when her last one was done. When asked if specific shifts were assigned to perform the head-to-toe assessment and how he knew if one was due, LVN G stated he was not aware if certain shifts were assigned. He stated the computer would indicate whether an assessment was due and any nurse could do them. During a follow-up interview with the CCS on 02/23/24 at 1:03 PM, she stated she had not located any other weekly head-to-toe assessments for Resident #6 in her record since 02/01/24 but would also need to check her nurses progress notes. She stated she assessed Resident #6, and felt the areas were due to tight briefs and moisture. She had staff place her on hourly checks overnight to make sure she was dry. She stated she ordered an air mattress for her that would be delivered that day that would hopefully allow more airflow for her and made sure she had larger briefs available. She stated she noted Resident #6 had frequent yeast infections and had creams ordered. She stated the charge nurses were responsible for completing the weekly head-to-toe skin assessments and should have known they were due because an alert pops up in the electronic record indicating the date when they are due . She stated the assessments could have been completed by any nurse on any shift. She stated the risk for failing to complete the assessments were missed skin breakdown. During a follow-up interview with CNA K on 02/23/24 at 1:33 PM, she stated she had previously informed LVN C and LVN I about Resident #6's skin condition but could not recall when she told them. She stated she was not sure about any treatments she was getting. She stated it was important to tell the nurses what she sees because resident'ss skin can get worse. She stated the nurses were usually very good at following-up when she reported issues to them. During an interview on 02/23/24 at 4:39 PM, CNA O and CNA P stated they both assisted with care for Resident #6. CNA O stated reporting skin conditions to the nurses was important because residents could develop pressure sores. CNA P stated Resident #6 was on her shower schedule but usually refused showers. She stated bed baths were offered but she would refuse those as well at times. CNA O stated her skin was always red in her creases and stated, she digs down there, always scratching herself. They said she never wanted sheets because she said they made her itch. She stated they tried to clean her and use creams, but she refused a lot. CNA P stated the resident was really nice but would sometimes refuse incontinent care on her shift then tell the night shift, 'no one touched me all day'. Both CNAs stated they reported it to the nurses including LVN G and RN F but were unsure when. CNA O stated they previously had a treatment nurse who would work with her. She used to say she thought it was the creams and lotions the resident would buy. She also worried about the different types of body wash she used including using her family member's. During a follow-up interview with LVN G on 02/23/24 at 5:29 PM, he stated he did not recall the CNAs telling him anything about Resident #6's skin condition. He stated the resident usually told him when she had issues such as under her abdomen and breast, and he applied her cream. He stated she had not complained to him about anything recently. He stated the risk of missing head-to-toe assessments was possibly missing skin conditions that needed to be addressed. When asked about the creams he had signed as administered on her TAR, he stated those were applied to her abdomen and under her breast. He stated he had not administered her medication for itching because she did not complain to him about it. During an interview with RN F on 02/23/24 at 5:34 PM, he stated he occasionally cared for Resident #6 and stated she had skin issues off and on. He stated she would refuse care for her at times, depending on her mood. He stated he last cared for Resident #6 on 02/19/24 and did not recall her having any skin issues. During an interview on 02/25/24 at 11:50 AM, the ADON stated she was new to the facility and had been there less than 2 weeks. She stated head-to-toe skin assessments should have been done once per week by the nurses and documented in the electronic medical record. She stated they were important to catch any skin conditions early. She stated she and the DON were responsible for monitoring the assessments to ensure they were completed. She stated she was still getting the facility's systems figured out and had not begun monitoring the assessments yet During a telephone interview on 02/25/24 at 12:31 PM, the DON stated head-to-toe skin assessments should have been conducted weekly by the nurses in order to detect any new skin conditions that may have developed. They were important to prevent skin conditions from worsening. She stated it was her responsibility to ensure the assessments were completed. She stated they recently had a treatment nurse that had been overseeing them, but she had left the facility. She stated she was interviewing for a new one and had been working on getting her new ADON trained to assist. She stated she had been unaware Resident #6 had not had her weekly skin assessments completed on time. During a follow-up interview with RN F on 02/25/24 at 3:02 PM, he stated head-to-toe skin assessments should be done weekly and he tried to do his on the residents' shower days. He stated he could check in the electronic medical record and tell when they were due. He stated, if any issues were found, they should call the physician and get orders. He stated skin assessments were important because they could have missed a new area of skin breakdown, for example a resident may have a stage 1 pressure area and worsen to a stage 3 if not caught. He did not know why he missed the skin assessment due for Resident #6. Record review of the facility's policy titled, Perineal Care dated Revised 7/21/18 and reviewed 10/09/2020 reflected the following: Purpose: The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. Preparation: 1. Review the resident's care plan to assess for any special needs of the resident .Steps in the procedure .15. Report any red or open areas to the nurse .Reporting: 1. Any discharge, odor, bleeding, skin care problems or irritation, complaints of pain or discomfort must be reported to the nurse .3. Notify the nurse if the resident refused the procedure, the reason(s) why and the intervention taken. 4. Report any other information I accordance with the facility policy and professional standards of practice. Record review of the facility's policy titled The [company name] Skin Integrity Prevention and Treatment Program dated Revised 2-2022 and Reviewed January 2023 reflected the following: [Company name] Skin Essentials Staff Education is completed via orientation in various methods such as but not limited to in person, virtual live and virtual recorded sessions . Weekly Skin Integrity Checks a. Weekly assessment looking for new wounds-completed by a licensed nurse. B. Document in/on Treatment Record. C. If new area found-if pressure injury-complete new wound evaluation/assessment-if non-pressure area-complete new wound evaluation/assessment. D. Notify MD-obtain treatment orders .g. update care plan

Based on interview and record review, the facility failed to protect a resident's right to be free from deprivation of goods for 1 of 5 residents (Resident #1) reviewed for abuse. 1. The facility failed to provide Resident #1 with goods necessary to avoid physical harm, when the nurses did not report to the resident's MD/NP change of conditions including her coughing up blood on [DATE], her blood sugar reaching a level of 52 mg/dl on [DATE]. 2. LVN B failed to take Resident #1's vitals when her BS dropped to 52 mg/dl. Resident #1 was found approximately 40 minutes later unresponsive with no pulse, which led to her being hospitalized on [DATE]. Resident #1 expired on [DATE]. An Immediate Jeopardy (IJ) was identified on [DATE] at 2:25 PM. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility still monitoring the effectiveness of their Plan of Removal. This deficient practice could place residents at risks of not obtaining the care that was needed, which could lead to worsening of their condition, hospitalization , or death. Findings included: Record review of Resident #1's electronic Face Sheet, dated [DATE], revealed a [AGE] year-old female who originally admitted to the facility on [DATE] and last readmitted on [DATE]. Resident #1 had diagnoses which included the following: diabetes, end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), hypertension (blood pressure that is higher than normal), acute respiratory failure (often caused by a disease or injury that affects your breathing), acute kidney failure, gastro-esophageal reflux disease (a common condition in which the stomach contents move up into the esophagus), heart failure, and unspecified convulsions (rapid, involuntary muscle contractions that cause uncontrollable shaking and limb movement). Record review of Resident #1's Quarterly MDS, dated [DATE], revealed a BIMS score of 15, which indicated Resident #1's cognition was intact. The MDS revealed Resident #1 was diabetic but did not require insulin injections. Further review reflected Resident #1 required moderate to substantial assistance with mobility in rolling left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair to bed transfer, toilet transfer, and shower transfer. Further review of the MDS revealed Resident #1 was occasionally incontinent of urine, and always incontinent of bowel. Record review of Resident #1's Care Plan, initiated on [DATE], reflected Resident #1 had congestive heart failure and the interventions included monitor vital signs every shift and notify MD of significant abnormalities, inform physician of any insomnia or anxiety, monitor/document/report PRN any s/sx of Congestive Heart Failure: . dry cough . wheezes upon auscultation (listening to sounds) of the lungs .lethargy. The Care Plan reflected Resident #1 had diabetes and the interventions included Notify MD if BS <60 or >300. The Care Plan reflected Resident #1 needed dialysis due to end stage renal disease and one of the interventions included monitor/document/report PRN for s/sx of the following: Bleeding, Hemorrhage, Bacteremia, septic shock. Further review reflected Resident #1 needed oxygen therapy and one of the interventions included Monitor for s/sx of respiratory distress and report to MD PRN: Respirations, Pulse oximetry, Increased heart rate (Tachycardia), Restlessness, Diaphoresis, Headaches, Lethargy, Confusion, Atelectasis, Hemoptysis (coughing up blood from some part of the lungs (respiratory tract)), Cough . Record review of Resident #1's electronic clinical record revealed a progress note by LVN A, dated [DATE] at 12:09 AM, reflected Patient c/o hemoptysis (coughing up blood from some part of the lungs (respiratory tract)) and needing additional breathing treatment. Patient lung sound with some congestion. Patient noted to be laying supine at the foot of the bed without elevation of the head. Suggestion made to have her moved to head of bed so she could be elevated but patient declined. Assisted patient with propping her head up with a pillow and advised her that her next breathing treatment was due at 0200. Also advised that if the coughing persisted with blood tinged mucous, we would need to elevate her head more. Patient voiced agreement and understanding. Record review of Resident #1's electronic clinical record revealed a progress note by LVN B, dated [DATE] at 11:20 PM, reflected Resident blood sugar checked on or around 2050 (8:50 PM) resident reading 52, resident awake and responding to this nurse, gave resident snack and juice before also administering glucose gel, brought resident a sandwich and advised her to eat, rechecked blood sugar and received a reading of 72, resident refused to continue eating and this nurse to leave, gave the resident more juice and crackers and told her I would be back to check her reading gain shortly. Arrived back in residents room on or around 2130 (9:30 PM), resident awake but no longer verbalizing with the nurse, resident coughed at nurse, took finger stick and got a reading of 56, resident, left room to get glucagon inject, other hall nurses stepped in to assist this nurse, When arrived back in room resident was given glucagon. Assisting nurse unable to palpate pulse, code blue, CPR started on or around 2145 (9:45 PM). 911 called, 12 rounds of CPR performed, before EMS arrived approx. (approximately) 5 mins later and took over CPS (CPR). Resident transported to hospital by EMS. RP notified, NP notified, DON notified. Record review of Resident #1's hospital records, dated [DATE], reflected Resident #1 admitted into theER on [DATE] at 10:18 PM. The records reflected Resident #1 was discharged from the ER and into Intensive Care unit on [DATE] at 1:05 AM. The ER notes dated [DATE], reflected [Resident #1] is a 68 y.o. female who present to the ED in cardiac arrest with CPR in progress. History is obtained from EMS personnel. Per report, the patient is a resident of a nursing facility, she was last seen around an hour prior to arrival where she was treated for hypoglycemia with glucagon. Around 40 minutes prior to arrival nursing staff stated they went to check on the patient and she was found unresponsive in bed, CPR was initiated at bedside and EMS was called. At the time of EMS arrival she was found to be in asystole. A king airway was placed and CPR was continued per ACLS protocols. EMS reports at least 30 minutes of CPR prior to arrival. She was persistently hypoglycemic and received 250cc D10 bolus (a single, large dose of insulin) prior to arrival. Resident #1's diagnosis included cardiac arrest, hypoglycemia, and end stage renal disease. The hospital records indicated Resident expired on [DATE] at 4:55 PM. In an interview on [DATE] at 11:59 AM, LVN A stated she worked on [DATE] from 10PM to 6AM and was assigned to Resident #1. LVN A stated Resident #1 had a breathing treatment scheduled per the MAR, so she went into her room to provide it. She stated Resident #1 was laying at the foot of the bed, and when she asked her why, Resident #1 said the mattress was more comfortable at the foot of the bed. LVN A stated Resident #1 did not have her nasal cannula in, so her O2 was low but not dangerously low. She stated she could not remember the exact number. LVN A stated she put the nasal cannula back in, and her vitals went back to normal. LVN A stated she provided Resident #1 her breathing treatment and she tolerated it well. LVN A stated Resident #1 said she was coughing up blood and showed her the tissue which had blood on it. LVN A stated she did not think to notify the MD because Resident #1 said she was coughing up blood at the hospital and they had just released her the same day ([DATE]), so she thought Resident #1 was ok. LVN A stated she was supposed to notify the MD if there were changes of condition, but she checked Resident #1's lungs and it was a little congested but was not severe. LVN A stated she did not notify Resident #1's family nor the DON. LVN A stated she told Resident #1 if she continued to cough up blood, then she would need to move her to the head of the bed and prop up her head, which would help with the congestion. LVN A stated she checked on Resident #1 a little later and saw she was at the top of the bed and was sleeping. She stated she notified LVN B of Resident #1's condition when she arrived to relieve her on [DATE] at 6:00 AM. In an interview on [DATE] at 1:35 PM, LVN B stated she worked a double on [DATE] from 6AM to 10PM and was assigned to Resident #1. LVN B stated when she started her shift at 6AM, LVN A told her that Resident #1 had been spitting up blood. She stated she was familiar with Resident #1 and that was not normal. LVN B stated she did not contact the MD or Resident #1's family. She stated she did not contact the MD because when she gave her, the breathing treatments, everything seemed fine, and she did not ever see Resident #1 coughing or spitting up blood. LVN B stated in hindsight, that was a change of condition, and she should have contacted the MD and Resident #1's family. LVN B stated she was doing evening BS and when she checked Resident #1's BS it was in the low 50's. She stated she could not recall the exact number. LVN B stated she gave Resident #1 food and glucose gel to ger her BS back up. LVN B stated she did not take Resident #1's vitals, so she was unaware of her BP or O2 level. She stated after applying the glucose gel and Resident #1 eating her BS was back up to the 70's. LVN B stated she was not for sure what a normal BS range was, but she believed it was between ,d+[DATE]. LVN B stated she told Resident #1 to continue to eat the sandwich while she finished getting the other resident's BS. LVN B stated she did not contact the MD about the low BS because the normal procedures were to try interventions before contacting the MD. She stated she was able to get Resident #1's BS back to normal range after her interventions. LVN B stated a drop in BS was considered a change of condition, and even after getting the BS back to normal range, she did not notify the MD. LVN B stated once she finished getting the rest of the resident's evening BS, she returned to check on Resident #1. She stated Resident #1 she was not verbally responding but was coughing. LVN B stated she checked Resident #1's BS and it was back in the 50's. LVN B stated she got help from LVN C and gave Resident #1 a glucagon injection. She stated Resident #1 was not responding, so they started CPR and called EMS. LVN B stated when EMS arrived, they continued to give Resident #1 CPR and took her to the hospital. In an interview on [DATE] at 2:01 PM, the DON stated she had only been working at the facility for two weeks, so she was getting to know the residents. The DON stated she did not know a lot about Resident #1 or the situation that happened because LVN B did not contact her and called the ADMN instead. The DON stated the ADMN notified her that Resident #1 was found unresponsive by LVN B, who did CPR and called EMS. She stated Resident #1 was sent to the hospital. She stated she had not spoken to LVN B about the incident. The DON stated she had never heard that Resident #1 was spitting up blood. She stated that should have been reported to the MD right away, because it was considered a change of condition. The DON stated even if the resident reported to the nurse that she was spitting up blood in the hospital, she should have still contacted the MD. The DON stated she was not aware of the issue with Resident #1's BS. She stated when the BS drops, the expectation was to first take care of the resident. The DON stated the facility had standing orders for glucose gel and glucagon inject depending on if the resident was responsive. She stated after attending the to the resident with one of those interventions, then staff should notify the MD, DON, and family because there was a change of condition. In an interview on [DATE] at 10:50 AM, the ADMN stated on Sunday night ([DATE]) he received a call from LVN B that Resident #1 was found unresponsive. He stated LVN B told him that Resident #1's BS was low like 50 and she gave her glucose gel and was able to get it back up to 70. The ADMN stated LVN B reported when she went back into Resident #1's room to check on her, she was unresponsive. He stated LVN B reported she had performed CPR and called EMS, who transported Resident #1 to the hospital. The ADMN stated he was aware the previous night that LVN A reported Resident #1 was coughing up blood-tinged sputum. He stated LVN A reported it was pinkish in color and was not a lot. The ADMN stated both situations were a change of condition and should have been reported to the MD/NP. He stated they had started in-servicing the nurses on change of condition. An attempt to interview the MD was completed via phone on [DATE] at 11:51 AM and on [DATE] on 10:47 AM. The facility's MD had not returned the call. In an interview on [DATE] at 1:07 PM, the NP stated he was not notified about any issues with Resident #1, until [DATE], when they found her unresponsive. He stated he was on-call for the MD and the staff were supposed to call him if residents had change of conditions. The NP stated on [DATE] he received a text from LVN C that LVN B found Resident #1 unresponsive, and she was sent to the hospital. He stated he immediately called LVN C back, and it was informed that Resident #1 had been coughing up blood and her BS had dropped to 52. The NP stated those are considered critical conditions and staff should have notified him. He stated he would have ordered Resident #1 to be sent back to the hospital. In a phone interview on [DATE] at 10:36 AM, LVN C stated on [DATE] she was at the nurse's station and overheard LVN B telling Med Aide D that she did not know what to do because Resident #1's BS was 50 and she would not eat. LVN C stated she asked LVN B did she give Resident #1 glucose gel and she said no, she did not have any. LVN C stated she gave LVN B glucose gel, which LVN B administered to Resident #1. LVN C stated when she went to room to assess Resident #1, she was cold to touch and was not responding. She stated she started sternal rubs, while she was checking Resident #1's pulse. LVN C stated she could not get a pulse on Resident #1, so they started CPR and called EMS. She stated they did CPR for about ten minutes until EMS arrived. She stated while she was in the room with Resident #1, she was never able to get a pulse. LVN C stated once EMS arrived, they took over and continued CPR. LVN C stated she contacted the NP. She stated Resident #1 was transported to the hospital. LVN C stated she did not know if LVN B took Resident #1's vitals, but she should have when her BS dropped to 50. She stated they had standing orders for BS. LVN C stated when BS drops below 60, they were supposed to give glucose gel, but if the resident was unresponsive, they were supposed to give glucagon inject. LVN C stated once they have provided the gel or inject, they were supposed to notify MD/NP, DON, and family, and then check the BS again in 15 minutes after administering the gel/inject. LVN C stated LVN B told her the overnight nurse reported that Resident #1 had been spitting up blood. She stated they were supposed to notify the MD/NP right away for that. LVN C stated when the overnight nurse provided LVN B with that information, she should have told her she needed to contact the MD/NP. In a phone interview on [DATE] at 10:56 AM, Med Aide D stated about ,d+[DATE] PM she was at the nurse's station and LVN B told her that Resident #1's BS was like 50, she could not get her to eat, and did not know what to do. Med Aide D stated LVN C heard them talking and jumped in to help. She stated LVN C told LVN B to give Resident #1 the gel to get her BS up. She stated LVN B and LVN C went to Resident #1's room. Med Aide D stated she later went to Resident #1's room and heard LVN B and LVN C saying Resident #1 was not responding. She stated they were doing CPR on the resident. She stated they called EMS and Resident #1 was sent to the hospital. In a phone interview on [DATE] at 2:14 PM, RN E stated she worked the overnight shift on [DATE] but was not assigned to Resident #1. RN E stated she and LVN A were at the nurses' station and CNA F said Resident #1 was coughing up blood. She stated LVN A asked her what she should do, should she call EMS. RN E stated she told her to go assess Resident #1. She stated LVN A headed towards Resident #1's room. RN E stated she assumed Resident #1 was ok because she did not get sent the hospital. RN E stated she did not know if LVN A contacted the MD, but she assumed she did. She stated coughing up blood is a change of condition, so they were supposed to notify the MD/NP. In a phone interview on [DATE] at 6:01 PM, CNA F stated she worked overnight on [DATE] and was assigned to Resident #1. CNA F stated she got to work a little early and started doing rounds. She stated she saw Resident #1 was laying at the foot of the bed and was coughing. CNA F stated she asked Resident #1 if she was ok, and Resident #1 said she was coughing up blood and to get the nurse. She stated as Resident #1 pulled the tissue away from her mouth she saw the blood on the tissue. CNA F stated LVN A was at the nurse's station, and she told her that Resident #1 was coughing up blood. She stated LVN A asked RN E what was she supposed to do. She said RN E told her to go assess Resident #1. CNA F stated she walked away from the nurse's station and continued to do rounds. CNA F stated about 15 minutes later she passed by Resident #1's room and saw LVN A was checking Resident #1's chest with a stethoscope. CNA F stated throughout the night Resident #1 kept pressing her call light to be repositioned from the top to bottom of bed. She stated Resident #1 was coughing throughout the night and was spitting into tissues. CNA F stated it seemed as if she could not get comfortable and was restless, which was not normal for Resident #1. She stated she did report these things to LVN A, and she was surprised that Resident #1 was not sent back to the hospital. In a phone interview on [DATE] at 2:03 PM, Resident #1's FM stated she received a call from the facility on Sunday night ([DATE]) that Resident #1 was found unresponsive, the facility did CPR, and she was sent to the hospital. Resident #1's FM stated she was not notified that Resident #1's BS had dropped low, nor was she notified that Resident #1 was coughing up blood the previous night. The FM stated if the facility would have called her about Resident #1 coughing up blood, she would have told them to send her back to the hospital. A record review of the facility's policy titled Nursing Care of the Older Adult with Diabetes Mellitus, dated [DATE], reflected Purpose: To provide an overview of diabetes in the older adult, its symptoms and complications and principles of glucose monitoring . Glycemic Targets: 5. Manage hypoglycemia according to protocols and provider orders. 6. Establish provider notification protocols, for example: a. Call provider and DON/Designee immediately if resident is hypoglycemic (<70 mg/dl) . A record review of the facility's policy titled Change of Condition and Physician/Family Notification, dated [DATE], reflected Purpose: To ensure that resident's family and/or legal representative and physician are notified of resident changes that fall under the following categories: . A significant change in resident's physical, mental, or psychosocial status. (See below for examples). A need to significantly alter treatment. Transfer of the resident from the facility. Procedures: When any of the above situations exist, the licensed nurse will contact the resident's family and their physician . Each attempt will be charged as to time the call was made, who was spoken to, and what information was given to the physician . Examples of Significant Changes: . a sudden change in mental status including agitation, lethargy, sudden lack of responsiveness or manic behavior, bleeding .emesis . A record review of the facility's policy titled Abuse Prohibition Policy, dated [DATE], reflected Intent: This protocol was intended to assist in the prevention of abuse, neglect and misappropriation of property. Each resident has the right to be free from abuse, mistreatment, neglect . Policy: The facility will prohibit neglect, mental or physical abuse, including involuntary seclusion and the misappropriation of property or finances of residents . Definitions: Neglect is defined as the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, mental anguish, or emotional distress. Neglect occurs when the facility is aware of, or should have been aware of, good or services that a resident(s) requires but the facility fails to provide them to the resident(s), that has resulted in or may result in physical harm, pain, mental anguish, or emotional distress. Neglect incudes cases where the facility's indifference or disregard for resident care, comfort or safety, resulted in or could have resulted in physical harm, pain, mental anguish, or emotional distress. This failure resulted in an identification of an Immediate Jeopardy on [DATE] at 2:25 PM. The Administrator was informed and provided the IJ template on [DATE] at 2:26 PM and a Plan of Removal (POR) was requested. The Plan of Removal reflected: Immediately on [DATE], CCS inserviced Administrator and DON on change of condition policy and procedure to include comprehensive assessments and notification of Physician/NP. Competency was verified via quiz. Immediately on [DATE], CCS2024, CCS inserviced Administrator and DON on diabetic policy and procedures, and abuse and neglect policy and procedures in regards to change of condition. Competency was verified via quiz. On [DATE], Administrator and DON initiated inservices with the licensed nurses on change of condition policy and procedure to include comprehensive assessments and notification of Physician/NP, diabetic policy and procedures, and abuse and neglect policy and procedures in regards to change of condition. Competency was verified via quiz. Nursing staff will not be allowed to work until inservicing has been completed. On [DATE], Administrator and DON initiated inservices with staff on change of condition, abuse and neglect policy and procedures in regards to change of condition. Competency was verified via quiz. Staff will not be allowed to work until inservicing has been completed. On [DATE] an audit was conducted by DON/Designee to identify other residents with potential change of condition. Via direct observation, staff interviews, and record review, no other residents were identified as having a change of condition. Medical Director was notified on [DATE], by Administrator. Medical Director was notified on [DATE] of the IJ situation by Administrator. On [DATE] Social Services completed life satisfaction rounds with residents in regards to change of condition. In order to monitor current residents for potential risk, DON, and CCS will monitor residents for change of condition to include diabetic changes in blood sugar daily beginning [DATE], for 30 days on all residents via Triage Log. The purpose of this log is to monitor residents with acute changes in condition. DON compliance will be monitored weekly by CCS for 90 days. Social Services/Designee will complete life satisfaction rounds weekly with residents in regards to change of condition for 90 days. Administrator will monitor compliance of Social Services Director/Designee. Thereafter, QA will monitor quarterly up to a year for compliance of change of condition, quality of care and abuse and neglect. If any issues are identified, the physician will be contacted for further medical management and family/POA of the same. The facility QA Committee will meet weekly for the next eight weeks to review compliance with the plan of action. If no further concerns are noted, will continue to monitor as per routine facility QA Committee. Monitoring of the plan of removal included: Interviews were conducted on [DATE] from 12:25 to 3:10 PM with 2 RNs, 7 LVN, 3 CMAs, 11 CNAs, 2 HK, the Staffing Coordinator, Activity Director, SW, ADON, DON and ADMN, who worked multiple shifts, revealed they had all been in-serviced on Abuse & Neglect policy, Change of Conditions policy, and nurses on Diabetes Mellitus policy. The staff were able to identify examples of abuse & neglect and changes in condition and were knowledgeable on who they should report to. The nursing staff were able to identify the ranges in BS levels that were not normal, and they were knowledgeable on protocols to follow and who they needed to report to. The staff reported verifying their competency via a quiz. In an interview on [DATE] at 2:37 PM, the CCS stated she had in serviced the ADMN and DON on the change of condition policy, abuse & neglect policy, and the diabetic policy. She stated their competency was verified via quizzes. The CCS stated for the next 30 days she and the DON would be monitoring BS levels for any changes of condition. She stated this would be documented on their log. The CSS stated if they identified any changes, they would contact the MD and family/POA immediately. A record review of the facility's documented titled Personnel Action Form, dated [DATE], reflected LVN A began suspension on [DATE]. A record review of the facility's documented titled Personnel Action Form, dated [DATE], reflected LVN B began suspension on [DATE]. A record review of in-services titled Change of Condition, Abuse & Neglect and Nursing Care of older Adult with Diabetes Mellitus, dated from [DATE] to [DATE], conducted by the ADON and DON, reflected all staff were educated on policy and procedures including assessments and notification to MD/NP regarding change of condition. All staff were in-serviced on policy and procedures regarding abuse and neglect including who to report to. The nursing staff were educated on diabetic policy and procedures which included parameters of BS levels and when to call the MD/NP. The records reflected the staff were quizzed on the competency of these policies. A record review of Life Satisfaction Rounds, dated [DATE] reflected the SW completed safety rounds with no negative responses on 20 residents from multiple halls asking 1. Do you feel you receive quality care from your nurse? 2. Are the nurses responsive to your care needs? 3. Do you feel safe at [facility]? 4. If you have a concern regarding the care you receive from a nurse, who would you speak with?. The Administrator were informed the Immediate Jeopardy was removed on [DATE] at 3:45 PM. The facility remained out of compliance at a severity level of no actual harm and a scope of isolated, due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interview and record review the facility failed to consult with the resident's physician and notify the resident's representative when there was a significant change in the resident's physical, mental, or psychosocial status for 1 of 5 residents (Resident #1) reviewed for notification of changes. The facility failed to notify and consult with the Resident #1's physician and notify the resident's representative when Resident #1 was coughing up blood on [DATE] and her blood sugar level dropped to 52 mg/dl on [DATE]. Resident #1 was hospitalized on [DATE] and expired on [DATE]. An Immediate Jeopardy (IJ) was identified on [DATE] at 2:25 PM. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility still monitoring the effectiveness of their Plan of Removal. This deficient practice could place residents at risks of a delay in medical treatment, which could lead to worsening of their condition, hospitalization , or death. Findings included: Record review of Resident #1's electronic Face Sheet, dated [DATE], revealed a [AGE] year-old female who originally admitted to the facility on [DATE] and last readmitted on [DATE]. Resident #1 had diagnoses which included the following: diabetes, end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), hypertension (blood pressure that is higher than normal), acute respiratory failure (often caused by a disease or injury that affects your breathing), acute kidney failure, gastro-esophageal reflux disease (a common condition in which the stomach contents move up into the esophagus), heart failure, and unspecified convulsions (rapid, involuntary muscle contractions that cause uncontrollable shaking and limb movement). Record review of Resident #1's Quarterly MDS, dated [DATE], revealed a BIMS score of 15, which indicated Resident #1's cognition was intact. The MDS revealed Resident #1 was diabetic but did not require insulin injections. Further review reflected Resident #1 required moderate to substantial assistance with mobility in rolling left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair to bed transfer, toilet transfer, and shower transfer. Further review of the MDS revealed Resident #1 was occasionally incontinent of urine, and always incontinent of bowel. Record review of Resident #1's Care Plan, initiated on [DATE], reflected Resident #1 had congestive heart failure and the interventions included monitor vital signs every shift and notify MD of significant abnormalities, inform physician of any insomnia or anxiety, monitor/document/report PRN any s/sx of Congestive Heart Failure: . dry cough . wheezes upon auscultation (listening to sounds) of the lungs .lethargy. The Care Plan reflected Resident #1 had diabetes and the interventions included Notify MD if BS <60 or >300. The Care Plan reflected Resident #1 needed dialysis due to end stage renal disease and one of the interventions included monitor/document/report PRN for s/sx of the following: Bleeding, Hemorrhage, Bacteremia, septic shock. Further review reflected Resident #1 needed oxygen therapy and one of the interventions included Monitor for s/sx of respiratory distress and report to MD PRN: Respirations, Pulse oximetry, Increased heart rate (Tachycardia), Restlessness, Diaphoresis, Headaches, Lethargy, Confusion, Atelectasis, Hemoptysis (coughing up blood from some part of the lungs (respiratory tract)), Cough . Record review of Resident #1's electronic clinical record revealed a progress note by LVN A, dated [DATE] at 12:09 AM, reflected Patient c/o hemoptysis (coughing up blood from some part of the lungs (respiratory tract) and needing additional breathing treatment. Patient lung sound with some congestion. Patient noted to be laying supine at the foot of the bed without elevation of the head. Suggestion made to have her moved to head of bed so she could be elevated but patient declined. Assisted patient with propping her head up with a pillow and advised her that her next breathing treatment was due at 0200. Also advised that if the coughing persisted with blood tinged mucous, we would need to elevate her head more. Patient voiced agreement and understanding. Record review of Resident #1's electronic clinical record revealed a progress note by LVN B, dated [DATE] at 11:20 PM, reflected Resident blood sugar checked on or around 2050 (8:50 PM) resident reading 52, resident awake and responding to this nurse, gave resident snack and juice before also administering glucose gel, brought resident a sandwich and advised her to eat, rechecked blood sugar and received a reading of 72, resident refused to continue eating and this nurse to leave, gave the resident more juice and crackers and told her I would be back to check her reading gain shortly. Arrived back in residents room on or around 2130 (9:30 PM), resident awake but no longer verbalizing with the nurse, resident coughed at nurse, took finger stick and got a reading of 56, resident, left room to get glucagon inject, other hall nurses stepped in to assist this nurse, When arrived back in room resident was given glucagon. Assisting nurse unable to palpate pulse, code blue, CPR started on or around 2145 (9:45 PM). 911 called, 12 rounds of CPR performed, before EMS arrived approx. (approximately) 5 mins later and took over CPS (CPR). Resident transported to hospital by EMS. RP notified, NP notified, DON notified. Record review of Resident #1's hospital records, dated [DATE], reflected Resident #1 admitted into theER on [DATE] at 10:18 PM. The records reflected Resident #1 was discharged from the ER and into Intensive Care unit on [DATE] at 1:05 AM. The ER notes dated [DATE], reflected [Resident #1] is a 68 y.o. female who present to the ED in cardiac arrest with CPR in progress. History is obtained from EMS personnel. Per report, the patient is a resident of a nursing facility, she was last seen around an hour prior to arrival where she was treated for hypoglycemia with glucagon. Around 40 minutes prior to arrival nursing staff stated they went to check on the patient and she was found unresponsive in bed, CPR was initiated at bedside and EMS was called. At the time of EMS arrival she was found to be in asystole. A king airway was placed and CPR was continued per ACLS protocols. EMS reports at least 30 minutes of CPR prior to arrival. She was persistently hypoglycemic and received 250cc D10 bolus (a single, large dose of insulin) prior to arrival. Resident #1's diagnosis included cardiac arrest, hypoglycemia, and end stage renal disease. The hospital records indicated Resident expired on [DATE] at 4:55 PM. In an interview on [DATE] at 11:59 AM, LVN A stated she worked on [DATE] from 10PM to 6AM and was assigned to Resident #1. LVN A stated Resident #1 had a breathing treatment scheduled per the MAR, so she went into her room to provide it. She stated Resident #1 was laying at the foot of the bed, and when she asked her why, Resident #1 said the mattress was more comfortable at the foot of the bed. LVN A stated Resident #1 did not have her nasal cannula in, so her O2 was low but not dangerously low. She stated she could not remember the exact number. LVN A stated she put the nasal cannula back in, and her vitals went back to normal. LVN A stated she provided Resident #1 her breathing treatment and she tolerated it well. LVN A stated Resident #1 said she was coughing up blood and showed her the tissue which had blood on it. LVN A stated she did not think to notify the MD because Resident #1 said she was coughing up blood at the hospital and they had just released her the same day ([DATE]), so she thought Resident #1 was ok. LVN A stated she was supposed to notify the MD if there were changes of condition, but she checked Resident #1's lungs and it was a little congested but was not severe. LVN A stated she did not notify Resident #1's family nor the DON. LVN A stated she told Resident #1 if she continued to cough up blood, then she would need to move her to the head of the bed and prop up her head, which would help with the congestion. LVN A stated she checked on Resident #1 a little later and saw she was at the top of the bed and was sleeping. She stated she notified LVN B of Resident #1's condition when she arrived to relieve her on [DATE] at 6:00 AM. In an interview on [DATE] at 1:35 PM, LVN B stated she worked a double on [DATE] from 6AM to 10PM and was assigned to Resident #1. LVN B stated when she started her shift at 6AM, LVN A told her that Resident #1 had been spitting up blood. She stated she was familiar with Resident #1 and that was not normal. LVN B stated she did not contact the MD or Resident #1's family. She stated she did not contact the MD because when she gave her, the breathing treatments, everything seemed fine, and she did not ever see Resident #1 coughing or spitting up blood. LVN B stated in hindsight, that was a change of condition, and she should have contacted the MD and Resident #1's family. LVN B stated she was doing evening BS and when she checked Resident #1's BS it was in the low 50's. She stated she could not recall the exact number. LVN B stated she gave Resident #1 food and glucose gel to ger her BS back up. LVN B stated she did not take Resident #1's vitals, so she was unaware of her BP or O2 level. She stated after applying the glucose gel and Resident #1 eating her BS was back up to the 70's. LVN B stated she was not for sure what a normal BS range was, but she believed it was between ,d+[DATE]. LVN B stated she told Resident #1 to continue to eat the sandwich while she finished getting the other resident's BS. LVN B stated she did not contact the MD about the low BS because the normal procedures were to try interventions before contacting the MD. She stated she was able to get Resident #1's BS back to normal range after her interventions. LVN B stated a drop in BS was considered a change of condition, and even after getting the BS back to normal range, she did not notify the MD. LVN B stated once she finished getting the rest of the resident's evening BS, she returned to check on Resident #1. She stated Resident #1 she was not verbally responding but was coughing. LVN B stated she checked Resident #1's BS and it was back in the 50's. LVN B stated she got help from LVN C and gave Resident #1 a glucagon injection. She stated Resident #1 was not responding, so they started CPR and called EMS. LVN B stated when EMS arrived, they continued to give Resident #1 CPR and took her to the hospital. In an interview on [DATE] at 2:01 PM, the DON stated she had only been working at the facility for two weeks, so she was getting to know the residents. The DON stated she did not know a lot about Resident #1 or the situation that happened because LVN B did not contact her and called the ADMN instead. The DON stated the ADMN notified her that Resident #1 was found unresponsive by LVN B, who did CPR and called EMS. She stated Resident #1 was sent to the hospital. She stated she had not spoken to LVN B about the incident. The DON stated she had never heard that Resident #1 was spitting up blood. She stated that should have been reported to the MD right away, because it was considered a change of condition. The DON stated even if the resident reported to the nurse that she was spitting up blood in the hospital, she should have still contacted the MD. The DON stated she was not aware of the issue with Resident #1's BS. She stated when the BS drops, the expectation was to first take care of the resident. The DON stated the facility had standing orders for glucose gel and glucagon inject depending on if the resident was responsive. She stated after attending the to the resident with one of those interventions, then staff should notify the MD, DON, and family because there was a change of condition. In an interview on [DATE] at 10:50 AM, the ADMN stated on Sunday night ([DATE]) he received a call from LVN B that Resident #1 was found unresponsive. He stated LVN B told him that Resident #1's BS was low like 50 and she gave her glucose gel and was able to get it back up to 70. The ADMN stated LVN B reported when she went back into Resident #1's room to check on her, she was unresponsive. He stated LVN B reported she had performed CPR and called EMS, who transported Resident #1 to the hospital. The ADMN stated he was aware the previous night that LVN A reported Resident #1 was coughing up blood-tinged sputum. He stated LVN A reported it was pinkish in color and was not a lot. The ADMN stated both situations were a change of condition and should have been reported to the MD/NP. He stated they had started in-servicing the nurses on change of condition. An attempt to interview the MD was completed via phone on [DATE] at 11:51 AM and on [DATE] on 10:47 AM. The facility's MD had not returned the call. In an interview on [DATE] at 1:07 PM, the NP stated he was not notified about any issues with Resident #1, until [DATE], when they found her unresponsive. He stated he was on-call for the MD and the staff were supposed to call him if residents had change of conditions. The NP stated on [DATE] he received a text from LVN C that LVN B found Resident #1 unresponsive, and she was sent to the hospital. He stated he immediately called LVN C back, and it was informed that Resident #1 had been coughing up blood and her BS had dropped to 52. The NP stated those are considered critical conditions and staff should have notified him. He stated he would have ordered Resident #1 to be sent back to the hospital. In a phone interview on [DATE] at 10:36 AM, LVN C stated on [DATE] she was at the nurse's station and overheard LVN B telling Med Aide D that she did not know what to do because Resident #1's BS was 50 and she would not eat. LVN C stated she asked LVN B did she give Resident #1 glucose gel and she said no, she did not have any. LVN C stated she gave LVN B glucose gel, which LVN B administered to Resident #1. LVN C stated when she went to room to assess Resident #1, she was cold to touch and was not responding. She stated she started sternal rubs, while she was checking Resident #1's pulse. LVN C stated she could not get a pulse on Resident #1, so they started CPR and called EMS. She stated they did CPR for about ten minutes until EMS arrived. She stated while she was in the room with Resident #1, she was never able to get a pulse. LVN C stated once EMS arrived, they took over and continued CPR. LVN C stated she contacted the NP. She stated Resident #1 was transported to the hospital. LVN C stated she did not know if LVN B took Resident #1's vitals, but she should have when her BS dropped to 50. She stated they had standing orders for BS. LVN C stated when BS drops below 60, they were supposed to give glucose gel, but if the resident was unresponsive, they were supposed to give glucagon inject. LVN C stated once they have provided the gel or inject, they were supposed to notify MD/NP, DON, and family, and then check the BS again in 15 minutes after administering the gel/inject. LVN C stated LVN B told her the overnight nurse reported that Resident #1 had been spitting up blood. She stated they were supposed to notify the MD/NP right away for that. LVN C stated when the overnight nurse provided LVN B with that information, she should have told her she needed to contact the MD/NP. In a phone interview on [DATE] at 10:56 AM, Med Aide D stated about ,d+[DATE] PM she was at the nurse's station and LVN B told her that Resident #1's BS was like 50, she could not get her to eat, and did not know what to do. Med Aide D stated LVN C heard them talking and jumped in to help. She stated LVN C told LVN B to give Resident #1 the gel to get her BS up. She stated LVN B and LVN C went to Resident #1's room. Med Aide D stated she later went to Resident #1's room and heard LVN B and LVN C saying Resident #1 was not responding. She stated they were doing CPR on the resident. She stated they called EMS and Resident #1 was sent to the hospital. In a phone interview on [DATE] at 2:14 PM, RN E stated she worked the overnight shift on [DATE] but was not assigned to Resident #1. RN E stated she and LVN A were at the nurses' station and CNA F said Resident #1 was coughing up blood. She stated LVN A asked her what she should do, should she call EMS. RN E stated she told her to go assess Resident #1. She stated LVN A headed towards Resident #1's room. RN E stated she assumed Resident #1 was ok because she did not get sent the hospital. RN E stated she did not know if LVN A contacted the MD, but she assumed she did. She stated coughing up blood is a change of condition, so they were supposed to notify the MD/NP. In a phone interview on [DATE] at 6:01 PM, CNA F stated she worked overnight on [DATE] and was assigned to Resident #1. CNA F stated she got to work a little early and started doing rounds. She stated she saw Resident #1 was laying at the foot of the bed and was coughing. CNA F stated she asked Resident #1 if she was ok, and Resident #1 said she was coughing up blood and to get the nurse. She stated as Resident #1 pulled the tissue away from her mouth she saw the blood on the tissue. CNA F stated LVN A was at the nurse's station, and she told her that Resident #1 was coughing up blood. She stated LVN A asked RN E what was she supposed to do. She said RN E told her to go assess Resident #1. CNA F stated she walked away from the nurse's station and continued to do rounds. CNA F stated about 15 minutes later she passed by Resident #1's room and saw LVN A was checking Resident #1's chest with a stethoscope. CNA F stated throughout the night Resident #1 kept pressing her call light to be repositioned from the top to bottom of bed. She stated Resident #1 was coughing throughout the night and was spitting into tissues. CNA F stated it seemed as if she could not get comfortable and was restless, which was not normal for Resident #1. She stated she did report these things to LVN A, and she was surprised that Resident #1 was not sent back to the hospital. In a phone interview on [DATE] at 2:03 PM, Resident #1's FM stated she received a call from the facility on Sunday night ([DATE]) that Resident #1 was found unresponsive, the facility did CPR, and she was sent to the hospital. Resident #1's FM stated she was not notified that Resident #1's BS had dropped low, nor was she notified that Resident #1 was coughing up blood the previous night. The FM stated if the facility would have called her about Resident #1 coughing up blood, she would have told them to send her back to the hospital. A record review of the facility's policy titled Nursing Care of the Older Adult with Diabetes Mellitus, dated [DATE], reflected Purpose: To provide an overview of diabetes in the older adult, its symptoms and complications and principles of glucose monitoring . Glycemic Targets: 5. Manage hypoglycemia according to protocols and provider orders. 6. Establish provider notification protocols, for example: a. Call provider and DON/Designee immediately if resident is hypoglycemic (<70 mg/dl) . A record review of the facility's policy titled Change of Condition and Physician/Family Notification, dated [DATE], reflected Purpose: To ensure that resident's family and/or legal representative and physician are notified of resident changes that fall under the following categories: . A significant change in resident's physical, mental, or psychosocial status. (See below for examples). A need to significantly alter treatment. Transfer of the resident from the facility. Procedures: When any of the above situations exist, the licensed nurse will contact the resident's family and their physician . Each attempt will be charged as to time the call was made, who was spoken to, and what information was given to the physician . Examples of Significant Changes: . a sudden change in mental status including agitation, lethargy, sudden lack of responsiveness or manic behavior, bleeding .emesis . This failure resulted in an identification of an Immediate Jeopardy on [DATE] at 2:25 PM. The Administrator was informed and provided the IJ template on [DATE] at 2:26 PM and a Plan of Removal (POR) was requested. The Plan of Removal reflected: Immediately on [DATE], CCS inserviced Administrator and DON on change of condition policy and procedure to include comprehensive assessments and notification of Physician/NP. Competency was verified via quiz. Immediately on [DATE], CCS2024, CCS inserviced Administrator and DON on diabetic policy and procedures, and abuse and neglect policy and procedures in regards to change of condition. Competency was verified via quiz. On [DATE], Administrator and DON initiated inservices with the licensed nurses on change of condition policy and procedure to include comprehensive assessments and notification of Physician/NP, diabetic policy and procedures, and abuse and neglect policy and procedures in regards to change of condition. Competency was verified via quiz. Nursing staff will not be allowed to work until inservicing has been completed. On [DATE], Administrator and DON initiated inservices with staff on change of condition, abuse and neglect policy and procedures in regards to change of condition. Competency was verified via quiz. Staff will not be allowed to work until inservicing has been completed. On [DATE] an audit was conducted by DON/Designee to identify other residents with potential change of condition. Via direct observation, staff interviews, and record review, no other residents were identified as having a change of condition. Medical Director was notified on [DATE], by Administrator. Medical Director was notified on [DATE] of the IJ situation by Administrator. On [DATE] Social Services completed life satisfaction rounds with residents in regards to change of condition. In order to monitor current residents for potential risk, DON, and CCS will monitor residents for change of condition to include diabetic changes in blood sugar daily beginning [DATE], for 30 days on all residents via Triage Log. The purpose of this log is to monitor residents with acute changes in condition. DON compliance will be monitored weekly by CCS for 90 days. Social Services/Designee will complete life satisfaction rounds weekly with residents in regards to change of condition for 90 days. Administrator will monitor compliance of Social Services Director/Designee. Thereafter, QA will monitor quarterly up to a year for compliance of change of condition, quality of care and abuse and neglect. If any issues are identified, the physician will be contacted for further medical management and family/POA of the same. The facility QA Committee will meet weekly for the next eight weeks to review compliance with the plan of action. If no further concerns are noted, will continue to monitor as per routine facility QA Committee. Monitoring of the plan of removal included: Interviews were conducted on [DATE] from 12:25 to 3:10 PM with 2 RNs, 7 LVN, 3 CMAs, 11 CNAs, 2 HK, the Staffing Coordinator, Activity Director, SW, ADON, DON and ADMN, who worked multiple shifts, revealed they had all been in-serviced on Abuse & Neglect policy, Change of Conditions policy, and nurses on Diabetes Mellitus policy. The staff were able to identify examples of abuse & neglect and changes in condition and were knowledgeable on who they should report to. The nursing staff were able to identify the ranges in BS levels that were not normal, and they were knowledgeable on protocols to follow and who they needed to report to. The staff reported verifying their competency via a quiz. In an interview on [DATE] at 2:37 PM, the CCS stated she had in serviced the ADMN and DON on the change of condition policy, abuse & neglect policy, and the diabetic policy. She stated their competency was verified via quizzes. The CCS stated for the next 30 days she and the DON would be monitoring BS levels for any changes of condition. She stated this would be documented on their log. The CSS stated if they identified any changes, they would contact the MD and family/POA immediately. A record review of the facility's documented titled Personnel Action Form, dated [DATE], reflected LVN A began suspension on [DATE]. A record review of the facility's documented titled Personnel Action Form, dated [DATE], reflected LVN B began suspension on [DATE]. A record review of in-services titled Change of Condition, Abuse & Neglect and Nursing Care of older Adult with Diabetes Mellitus, dated from [DATE] to [DATE], conducted by the ADON and DON, reflected all staff were educated on policy and procedures including assessments and notification to MD/NP regarding change of condition. All staff were in-serviced on policy and procedures regarding abuse and neglect including who to report to. The nursing staff were educated on diabetic policy and procedures which included parameters of BS levels and when to call the MD/NP. The records reflected the staff were quizzed on the competency of these policies. A record review of Life Satisfaction Rounds, dated [DATE] reflected the SW completed safety rounds with no negative responses on 20 residents from multiple halls asking 1. Do you feel you receive quality care from your nurse? 2. Are the nurses responsive to your care needs? 3. Do you feel safe at [facility]? 4. If you have a concern regarding the care you receive from a nurse, who would you speak with?. The Administrator were informed the Immediate Jeopardy was removed on [DATE] at 3:45 PM. The facility remained out of compliance at a severity level of no actual harm and a scope of isolated, due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 5 residents (Resident #1) reviewed for quality of care. The facility nurses failed to identify and report to Resident #1's MD/NP change of conditions, including her coughing up blood on [DATE] and her blood sugar reaching a level of 52 mg/dl on [DATE], which led to her not being provided with needed care and services. Resident #1 was hospitalized on [DATE] and expired on [DATE]. An Immediate Jeopardy (IJ) was identified on [DATE] at 2:25 PM. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility still monitoring the effectiveness of their Plan of Removal. This deficient practice could place residents at risks of not obtaining the care that was needed, which could lead to worsening of their condition, hospitalization , or death. Findings included: Record review of Resident #1's electronic Face Sheet, dated [DATE], revealed a [AGE] year-old female who originally admitted to the facility on [DATE] and last readmitted on [DATE]. Resident #1 had diagnoses which included the following: diabetes, end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), hypertension (blood pressure that is higher than normal), acute respiratory failure (often caused by a disease or injury that affects your breathing), acute kidney failure, gastro-esophageal reflux disease (a common condition in which the stomach contents move up into the esophagus), heart failure, and unspecified convulsions (rapid, involuntary muscle contractions that cause uncontrollable shaking and limb movement). Record review of Resident #1's Quarterly MDS, dated [DATE], revealed a BIMS score of 15, which indicated Resident #1's cognition was intact. The MDS revealed Resident #1 was diabetic but did not require insulin injections. Further review reflected Resident #1 required moderate to substantial assistance with mobility in rolling left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair to bed transfer, toilet transfer, and shower transfer. Further review of the MDS revealed Resident #1 was occasionally incontinent of urine, and always incontinent of bowel. Record review of Resident #1's Care Plan, initiated on [DATE], reflected Resident #1 had congestive heart failure and the interventions included monitor vital signs every shift and notify MD of significant abnormalities, inform physician of any insomnia or anxiety, monitor/document/report PRN any s/sx of Congestive Heart Failure: . dry cough . wheezes upon auscultation (listening to sounds) of the lungs .lethargy. The Care Plan reflected Resident #1 had diabetes and the interventions included Notify MD if BS <60 or >300. The Care Plan reflected Resident #1 needed dialysis due to end stage renal disease and one of the interventions included monitor/document/report PRN for s/sx of the following: Bleeding, Hemorrhage, Bacteremia, septic shock. Further review reflected Resident #1 needed oxygen therapy and one of the interventions included Monitor for s/sx of respiratory distress and report to MD PRN: Respirations, Pulse oximetry, Increased heart rate (Tachycardia), Restlessness, Diaphoresis, Headaches, Lethargy, Confusion, Atelectasis, Hemoptysis (coughing up blood from some part of the lungs (respiratory tract)), Cough . Record review of Resident #1's electronic clinical record revealed a progress note by LVN A, dated [DATE] at 12:09 AM, reflected Patient c/o hemoptysis (coughing up blood from some part of the lungs (respiratory tract) and needing additional breathing treatment. Patient lung sound with some congestion. Patient noted to be laying supine at the foot of the bed without elevation of the head. Suggestion made to have her moved to head of bed so she could be elevated but patient declined. Assisted patient with propping her head up with a pillow and advised her that her next breathing treatment was due at 0200. Also advised that if the coughing persisted with blood tinged mucous, we would need to elevate her head more. Patient voiced agreement and understanding. Record review of Resident #1's electronic clinical record revealed a progress note by LVN B, dated [DATE] at 11:20 PM, reflected Resident blood sugar checked on or around 2050 (8:50 PM) resident reading 52, resident awake and responding to this nurse, gave resident snack and juice before also administering glucose gel, brought resident a sandwich and advised her to eat, rechecked blood sugar and received a reading of 72, resident refused to continue eating and this nurse to leave, gave the resident more juice and crackers and told her I would be back to check her reading gain shortly. Arrived back in residents room on or around 2130 (9:30 PM), resident awake but no longer verbalizing with the nurse, resident coughed at nurse, took finger stick and got a reading of 56, resident, left room to get glucagon inject, other hall nurses stepped in to assist this nurse, When arrived back in room resident was given glucagon. Assisting nurse unable to palpate pulse, code blue, CPR started on or around 2145 (9:45 PM). 911 called, 12 rounds of CPR performed, before EMS arrived approx. (approximately) 5 mins later and took over CPS (CPR). Resident transported to hospital by EMS. RP notified, NP notified, DON notified. Record review of Resident #1's hospital records, dated [DATE], reflected Resident #1 admitted into theER on [DATE] at 10:18 PM. The records reflected Resident #1 was discharged from the ER and into Intensive Care unit on [DATE] at 1:05 AM. The ER notes dated [DATE], reflected [Resident #1] is a 68 y.o. female who present to the ED in cardiac arrest with CPR in progress. History is obtained from EMS personnel. Per report, the patient is a resident of a nursing facility, she was last seen around an hour prior to arrival where she was treated for hypoglycemia with glucagon. Around 40 minutes prior to arrival nursing staff stated they went to check on the patient and she was found unresponsive in bed, CPR was initiated at bedside and EMS was called. At the time of EMS arrival she was found to be in asystole. A king airway was placed and CPR was continued per ACLS protocols. EMS reports at least 30 minutes of CPR prior to arrival. She was persistently hypoglycemic and received 250cc D10 bolus (a single, large dose of insulin) prior to arrival. Resident #1's diagnosis included cardiac arrest, hypoglycemia, and end stage renal disease. The hospital records indicated Resident expired on [DATE] at 4:55 PM. In an interview on [DATE] at 11:59 AM, LVN A stated she worked on [DATE] from 10PM to 6AM and was assigned to Resident #1. LVN A stated Resident #1 had a breathing treatment scheduled per the MAR, so she went into her room to provide it. She stated Resident #1 was laying at the foot of the bed, and when she asked her why, Resident #1 said the mattress was more comfortable at the foot of the bed. LVN A stated Resident #1 did not have her nasal cannula in, so her O2 was low but not dangerously low. She stated she could not remember the exact number. LVN A stated she put the nasal cannula back in, and her vitals went back to normal. LVN A stated she provided Resident #1 her breathing treatment and she tolerated it well. LVN A stated Resident #1 said she was coughing up blood and showed her the tissue which had blood on it. LVN A stated she did not think to notify the MD because Resident #1 said she was coughing up blood at the hospital and they had just released her the same day ([DATE]), so she thought Resident #1 was ok. LVN A stated she was supposed to notify the MD if there were changes of condition, but she checked Resident #1's lungs and it was a little congested but was not severe. LVN A stated she did not notify Resident #1's family nor the DON. LVN A stated she told Resident #1 if she continued to cough up blood, then she would need to move her to the head of the bed and prop up her head, which would help with the congestion. LVN A stated she checked on Resident #1 a little later and saw she was at the top of the bed and was sleeping. She stated she notified LVN B of Resident #1's condition when she arrived to relieve her on [DATE] at 6:00 AM. In an interview on [DATE] at 1:35 PM, LVN B stated she worked a double on [DATE] from 6AM to 10PM and was assigned to Resident #1. LVN B stated when she started her shift at 6AM, LVN A told her that Resident #1 had been spitting up blood. She stated she was familiar with Resident #1 and that was not normal. LVN B stated she did not contact the MD or Resident #1's family. She stated she did not contact the MD because when she gave her, the breathing treatments, everything seemed fine, and she did not ever see Resident #1 coughing or spitting up blood. LVN B stated in hindsight, that was a change of condition, and she should have contacted the MD and Resident #1's family. LVN B stated she was doing evening BS and when she checked Resident #1's BS it was in the low 50's. She stated she could not recall the exact number. LVN B stated she gave Resident #1 food and glucose gel to ger her BS back up. LVN B stated she did not take Resident #1's vitals, so she was unaware of her BP or O2 level. She stated after applying the glucose gel and Resident #1 eating her BS was back up to the 70's. LVN B stated she was not for sure what a normal BS range was, but she believed it was between ,d+[DATE]. LVN B stated she told Resident #1 to continue to eat the sandwich while she finished getting the other resident's BS. LVN B stated she did not contact the MD about the low BS because the normal procedures were to try interventions before contacting the MD. She stated she was able to get Resident #1's BS back to normal range after her interventions. LVN B stated a drop in BS was considered a change of condition, and even after getting the BS back to normal range, she did not notify the MD. LVN B stated once she finished getting the rest of the resident's evening BS, she returned to check on Resident #1. She stated Resident #1 she was not verbally responding but was coughing. LVN B stated she checked Resident #1's BS and it was back in the 50's. LVN B stated she got help from LVN C and gave Resident #1 a glucagon injection. She stated Resident #1 was not responding, so they started CPR and called EMS. LVN B stated when EMS arrived, they continued to give Resident #1 CPR and took her to the hospital. In an interview on [DATE] at 2:01 PM, the DON stated she had only been working at the facility for two weeks, so she was getting to know the residents. The DON stated she did not know a lot about Resident #1 or the situation that happened because LVN B did not contact her and called the ADMN instead. The DON stated the ADMN notified her that Resident #1 was found unresponsive by LVN B, who did CPR and called EMS. She stated Resident #1 was sent to the hospital. She stated she had not spoken to LVN B about the incident. The DON stated she had never heard that Resident #1 was spitting up blood. She stated that should have been reported to the MD right away, because it was considered a change of condition. The DON stated even if the resident reported to the nurse that she was spitting up blood in the hospital, she should have still contacted the MD. The DON stated she was not aware of the issue with Resident #1's BS. She stated when the BS drops, the expectation was to first take care of the resident. The DON stated the facility had standing orders for glucose gel and glucagon inject depending on if the resident was responsive. She stated after attending the to the resident with one of those interventions, then staff should notify the MD, DON, and family because there was a change of condition. In an interview on [DATE] at 10:50 AM, the ADMN stated on Sunday night ([DATE]) he received a call from LVN B that Resident #1 was found unresponsive. He stated LVN B told him that Resident #1's BS was low like 50 and she gave her glucose gel and was able to get it back up to 70. The ADMN stated LVN B reported when she went back into Resident #1's room to check on her, she was unresponsive. He stated LVN B reported she had performed CPR and called EMS, who transported Resident #1 to the hospital. The ADMN stated he was aware the previous night that LVN A reported Resident #1 was coughing up blood-tinged sputum. He stated LVN A reported it was pinkish in color and was not a lot. The ADMN stated both situations were a change of condition and should have been reported to the MD/NP. He stated they had started in-servicing the nurses on change of condition. An attempt to interview the MD was completed via phone on [DATE] at 11:51 AM and on [DATE] on 10:47 AM. The facility's MD had not returned the call. In an interview on [DATE] at 1:07 PM, the NP stated he was not notified about any issues with Resident #1, until [DATE], when they found her unresponsive. He stated he was on-call for the MD and the staff were supposed to call him if residents had change of conditions. The NP stated on [DATE] he received a text from LVN C that LVN B found Resident #1 unresponsive, and she was sent to the hospital. He stated he immediately called LVN C back, and it was informed that Resident #1 had been coughing up blood and her BS had dropped to 52. The NP stated those are considered critical conditions and staff should have notified him. He stated he would have ordered Resident #1 to be sent back to the hospital. In a phone interview on [DATE] at 10:36 AM, LVN C stated on [DATE] she was at the nurse's station and overheard LVN B telling Med Aide D that she did not know what to do because Resident #1's BS was 50 and she would not eat. LVN C stated she asked LVN B did she give Resident #1 glucose gel and she said no, she did not have any. LVN C stated she gave LVN B glucose gel, which LVN B administered to Resident #1. LVN C stated when she went to room to assess Resident #1, she was cold to touch and was not responding. She stated she started sternal rubs, while she was checking Resident #1's pulse. LVN C stated she could not get a pulse on Resident #1, so they started CPR and called EMS. She stated they did CPR for about ten minutes until EMS arrived. She stated while she was in the room with Resident #1, she was never able to get a pulse. LVN C stated once EMS arrived, they took over and continued CPR. LVN C stated she contacted the NP. She stated Resident #1 was transported to the hospital. LVN C stated she did not know if LVN B took Resident #1's vitals, but she should have when her BS dropped to 50. She stated they had standing orders for BS. LVN C stated when BS drops below 60, they were supposed to give glucose gel, but if the resident was unresponsive, they were supposed to give glucagon inject. LVN C stated once they have provided the gel or inject, they were supposed to notify MD/NP, DON, and family, and then check the BS again in 15 minutes after administering the gel/inject. LVN C stated LVN B told her the overnight nurse reported that Resident #1 had been spitting up blood. She stated they were supposed to notify the MD/NP right away for that. LVN C stated when the overnight nurse provided LVN B with that information, she should have told her she needed to contact the MD/NP. In a phone interview on [DATE] at 10:56 AM, Med Aide D stated about ,d+[DATE] PM she was at the nurse's station and LVN B told her that Resident #1's BS was like 50, she could not get her to eat, and did not know what to do. Med Aide D stated LVN C heard them talking and jumped in to help. She stated LVN C told LVN B to give Resident #1 the gel to get her BS up. She stated LVN B and LVN C went to Resident #1's room. Med Aide D stated she later went to Resident #1's room and heard LVN B and LVN C saying Resident #1 was not responding. She stated they were doing CPR on the resident. She stated they called EMS and Resident #1 was sent to the hospital. In a phone interview on [DATE] at 2:14 PM, RN E stated she worked the overnight shift on [DATE] but was not assigned to Resident #1. RN E stated she and LVN A were at the nurses' station and CNA F said Resident #1 was coughing up blood. She stated LVN A asked her what she should do, should she call EMS. RN E stated she told her to go assess Resident #1. She stated LVN A headed towards Resident #1's room. RN E stated she assumed Resident #1 was ok because she did not get sent the hospital. RN E stated she did not know if LVN A contacted the MD, but she assumed she did. She stated coughing up blood is a change of condition, so they were supposed to notify the MD/NP. In a phone interview on [DATE] at 6:01 PM, CNA F stated she worked overnight on [DATE] and was assigned to Resident #1. CNA F stated she got to work a little early and started doing rounds. She stated she saw Resident #1 was laying at the foot of the bed and was coughing. CNA F stated she asked Resident #1 if she was ok, and Resident #1 said she was coughing up blood and to get the nurse. She stated as Resident #1 pulled the tissue away from her mouth she saw the blood on the tissue. CNA F stated LVN A was at the nurse's station, and she told her that Resident #1 was coughing up blood. She stated LVN A asked RN E what was she supposed to do. She said RN E told her to go assess Resident #1. CNA F stated she walked away from the nurse's station and continued to do rounds. CNA F stated about 15 minutes later she passed by Resident #1's room and saw LVN A was checking Resident #1's chest with a stethoscope. CNA F stated throughout the night Resident #1 kept pressing her call light to be repositioned from the top to bottom of bed. She stated Resident #1 was coughing throughout the night and was spitting into tissues. CNA F stated it seemed as if she could not get comfortable and was restless, which was not normal for Resident #1. She stated she did report these things to LVN A, and she was surprised that Resident #1 was not sent back to the hospital. In a phone interview on [DATE] at 2:03 PM, Resident #1's FM stated she received a call from the facility on Sunday night ([DATE]) that Resident #1 was found unresponsive, the facility did CPR, and she was sent to the hospital. Resident #1's FM stated she was not notified that Resident #1's BS had dropped low, nor was she notified that Resident #1 was coughing up blood the previous night. The FM stated if the facility would have called her about Resident #1 coughing up blood, she would have told them to send her back to the hospital. A record review of the facility's policy titled Nursing Care of the Older Adult with Diabetes Mellitus, dated [DATE], reflected Purpose: To provide an overview of diabetes in the older adult, its symptoms and complications and principles of glucose monitoring . Glycemic Targets: 5. Manage hypoglycemia according to protocols and provider orders. 6. Establish provider notification protocols, for example: a. Call provider and DON/Designee immediately if resident is hypoglycemic (<70 mg/dl) . A record review of the facility's policy titled Change of Condition and Physician/Family Notification, dated [DATE], reflected Purpose: To ensure that resident's family and/or legal representative and physician are notified of resident changes that fall under the following categories: . A significant change in resident's physical, mental, or psychosocial status. (See below for examples). A need to significantly alter treatment. Transfer of the resident from the facility. Procedures: When any of the above situations exist, the licensed nurse will contact the resident's family and their physician . Each attempt will be charged as to time the call was made, who was spoken to, and what information was given to the physician . Examples of Significant Changes: . a sudden change in mental status including agitation, lethargy, sudden lack of responsiveness or manic behavior, bleeding .emesis . This failure resulted in an identification of an Immediate Jeopardy on [DATE] at 2:25 PM. The Administrator was informed and provided the IJ template on [DATE] at 2:26 PM and a Plan of Removal (POR) was requested. The Plan of Removal reflected: Immediately on [DATE], CCS inserviced Administrator and DON on change of condition policy and procedure to include comprehensive assessments and notification of Physician/NP. Competency was verified via quiz. Immediately on [DATE], CCS2024, CCS inserviced Administrator and DON on diabetic policy and procedures, and abuse and neglect policy and procedures in regards to change of condition. Competency was verified via quiz. On [DATE], Administrator and DON initiated inservices with the licensed nurses on change of condition policy and procedure to include comprehensive assessments and notification of Physician/NP, diabetic policy and procedures, and abuse and neglect policy and procedures in regards to change of condition. Competency was verified via quiz. Nursing staff will not be allowed to work until inservicing has been completed. On [DATE], Administrator and DON initiated inservices with staff on change of condition, abuse and neglect policy and procedures in regards to change of condition. Competency was verified via quiz. Staff will not be allowed to work until inservicing has been completed. On [DATE] an audit was conducted by DON/Designee to identify other residents with potential change of condition. Via direct observation, staff interviews, and record review, no other residents were identified as having a change of condition. Medical Director was notified on [DATE], by Administrator. Medical Director was notified on [DATE] of the IJ situation by Administrator. On [DATE] Social Services completed life satisfaction rounds with residents in regards to change of condition. In order to monitor current residents for potential risk, DON, and CCS will monitor residents for change of condition to include diabetic changes in blood sugar daily beginning [DATE], for 30 days on all residents via Triage Log. The purpose of this log is to monitor residents with acute changes in condition. DON compliance will be monitored weekly by CCS for 90 days. Social Services/Designee will complete life satisfaction rounds weekly with residents in regards to change of condition for 90 days. Administrator will monitor compliance of Social Services Director/Designee. Thereafter, QA will monitor quarterly up to a year for compliance of change of condition, quality of care and abuse and neglect. If any issues are identified, the physician will be contacted for further medical management and family/POA of the same. The facility QA Committee will meet weekly for the next eight weeks to review compliance with the plan of action. If no further concerns are noted, will continue to monitor as per routine facility QA Committee. Monitoring of the plan of removal included: Interviews were conducted on [DATE] from 12:25 to 3:10 PM with 2 RNs, 7 LVN, 3 CMAs, 11 CNAs, 2 HK, the Staffing Coordinator, Activity Director, SW, ADON, DON and ADMN, who worked multiple shifts, revealed they had all been in-serviced on Abuse & Neglect policy, Change of Conditions policy, and nurses on Diabetes Mellitus policy. The staff were able to identify examples of abuse & neglect and changes in condition and were knowledgeable on who they should report to. The nursing staff were able to identify the ranges in BS levels that were not normal, and they were knowledgeable on protocols to follow and who they needed to report to. The staff reported verifying their competency via a quiz. In an interview on [DATE] at 2:37 PM, the CCS stated she had in serviced the ADMN and DON on the change of condition policy, abuse & neglect policy, and the diabetic policy. She stated their competency was verified via quizzes. The CCS stated for the next 30 days she and the DON would be monitoring BS levels for any changes of condition. She stated this would be documented on their log. The CSS stated if they identified any changes, they would contact the MD and family/POA immediately. A record review of the facility's documented titled Personnel Action Form, dated [DATE], reflected LVN A began suspension on [DATE]. A record review of the facility's documented titled Personnel Action Form, dated [DATE], reflected LVN B began suspension on [DATE]. A record review of in-services titled Change of Condition, Abuse & Neglect and Nursing Care of older Adult with Diabetes Mellitus, dated from [DATE] to [DATE], conducted by the ADON and DON, reflected all staff were educated on policy and procedures including assessments and notification to MD/NP regarding change of condition. All staff were in-serviced on policy and procedures regarding abuse and neglect including who to report to. The nursing staff were educated on diabetic policy and procedures which included parameters of BS levels and when to call the MD/NP. The records reflected the staff were quizzed on the competency of these policies. A record review of Life Satisfaction Rounds, dated [DATE] reflected the SW completed safety rounds with no negative responses on 20 residents from multiple halls asking 1. Do you feel you receive quality care from your nurse? 2. Are the nurses responsive to your care needs? 3. Do you feel safe at [facility]? 4. If you have a concern regarding the care you receive from a nurse, who would you speak with?. The Administrator were informed the Immediate Jeopardy was removed on [DATE] at 3:45 PM. The facility remained out of compliance at a severity level of no actual harm and a scope of isolated, due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Resident #1) reviewed for adequate supervision. The facility failed to supervise and implement a wander guard device when Resident #1 set off the alarm on the door near the laundry area, in an attempt to exit the facility. Resident #1 was later successful in exiting the same door, because the RN Supervisor did not reset the alarm after the first attempt. The the outside temperature was approximately 100 degrees and Resident #1 was located on the facility's property near the gazebo. The noncompliance was identified as PNC. The IJ began on 07/30/23 and ended on 07/31/23. The facility had corrected the noncompliance before the survey began. This failure could place the residents with exit seeking behaviors at risk for injury. Findings included: Record review of Resident #1's electronic Face Sheet, dated 08/01/23, revealed a [AGE] year-old female who last admitted to the facility on [DATE]. Resident #1 had diagnoses which included the following: history of falling, schizoaffective disorder bipolar type (is a mental illness that can affect your thoughts, mood and behavior), muscle weakness, unspecified lack of coordination, unsteadiness on feet, and dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain). Record review of Resident #1's Comprehensive MDS, dated [DATE], revealed a BIMS score of 3, which indicated Resident #1's cognition was severely impaired. The MDS revealed Resident #1 exhibited the behavior of wandering daily, which placed the resident at significant risk of getting to a potentially dangerous pace (e.g., stairs, outside of the facility). Further review of the MDS revealed Resident #1 required extensive assistance by one-person for the following ADLs: bed mobility, locomotion on/off unit, dressing, eating, toilet use, and personal hygiene and extensive assistance by two-persons for transfers. Record review of Resident #1's care plan, last reviewed on 07/31/23, revealed Resident #1 had been evaluated as a wandering risk due to decreased safety awareness, confusion, wandering behavior (trying to exit building) saying she wants to go home date initiated on 02/16/23. The care plan reflected and updated on 07/30/23- Resident noted with increased exit seeking behaviors. Wander guard placed on resident. Physician and RP notified. Resident placed on 1:1 (one to one) monitoring. The interventions included check my location frequently, observe me for S/S of agitation, repetitive verbalizations of wanting to leave/go home, restlessness, report increased behaviors to nurses for further intervention, provide me re-orientation as needed, wandering alert bracelet to be checked by nurse for placement and function every shift and PRN, if bracelet is removed please replace or place on increase monitoring of my whereabouts. Record review of Resident #1's Wander Data Assessment, dated 07/27/23, reflected she scored a 23. The assessment reflected Wander Data Total Score: I. Total Score: 0-6-Low 7-11=Moderate 12 and above =High, and since Resident #1 scored a 23 she was categorized as High Risk for Wandering A record review of Resident #1's Progress Note, dated 07/30/23 at 3:04 PM, written by the RN Supervisor, reflected This Nurse was at the nurses desk and the alarm went off when it was dictated that it was the alarm for the laundry area, it was checked, and patient [Resident #1] was observed in that direction, and she was redirected. A record review of Resident #1's Progress Note, dated 07/30/23 at 4:26 PM, written by the RN Supervisor, reflected patient Physician notified of wander guard placement, Patient observed at the laundry exit door location. Patient [family member] informed. A record review of the Resident #1's Progress Note labeled Late Entry, dated 07/31/23 at 3:53 PM, written by LVN A, reflected Exited seeking noted with resident. Resident noted outdoors in grassy area toward the gazebo. Resident stated that she was just wanted to be outside. Resident assessed no injuries noted. Resident on monitoring system. Notified DON. Notified responsible party/ [family member]. Notified Nurse Practitioner. In an interview on 08/01/23 at 2:19 PM, LVN A stated on 07/30/23 she had exited a resident's room on the 200-hall and was headed towards the nurse's station. LVN A stated as she approached the nurse's station, Resident #2 came from the exit door near the laundry area, rushing towards her frantically saying Resident #1 was outside in the heat. LVN A stated she believed it was around 2:30 PM, because she remembered looking at the clock when she entered the resident's room on the 200-hall, and it was 1:35 PM. She stated she remembered looking at the clock again and it was a little after 2:00 PM, and she thought to herself that she had been in the resident's room for a long time. LVN A stated she left the room about 20-30 minutes after she last looked at the clock. LVN A stated she never heard an alarm going off while she was in the resident's room or as she was walking down the hall towards the nurse's station. She stated the RN Supervisor was sitting at the nurse's station when Resident #2 notified them that Resident #1 was outside. LVN A stated they went to get Resident #1 from outside. LVN A stated Resident #1 was in the grass area near the gazebo. She stated she did a head-to-toe assessment on Resident #1, and she did not have any injuries. LVN A stated she did not know how Resident #1 got out of the building because she did not think Resident #1 was strong enough to push open the exit door. She stated the wander guard device was put back on the resident after she exited the facility. When LVN A was asked about the RN Supervisor's documentation dated 07/30/23 at 3:04 PM, LVN A stated as she and the RN Supervisor was heading to get Resident #1, the RN Supervisor told her Resident #1 had set the alarm off earlier by that door and she had to tell her to get away from the door. In an interview on 08/01/23 at 3:39 PM, ADON C stated she completed Resident #1's Wander Data assessment on 07/27/23 after she readmitted from the hospital to the facility on [DATE]. She stated Resident #1 was a high risk for wandering, but she was not exit seeking. ADON C stated some behaviors that were exit seeking included residents going to the exit doors and trying to get out or verbalizing they wanted to leave he facility. She stated at the time Resident #1 readmitted on [DATE] she did not exhibit any of those behaviors, so she was not requried to put the wander guard device on her. In a phone interview on 08/02/23 at 9:39 AM, the Investigator read the RN Supervisor's Progress Note dated 07/30/23 at 3:04 PM and asked the RN Supervisor where was Resident #1 observed when she went to respond to the alarm. The RN Supervisor stated Resident #1 was found in front of the vending machines by the door, but she had not exited. The RN Supervisor stated she redirected Resident #1 back into the hallway. She stated later Resident #2 came to the nurse's station and stated Resident #1 was outside. The RN Supervisor stated the alarm did not go off. She stated she and LVN A went to get Resident #1 from outside. She stated she was in the grass area near the exit door. The RN Supervisor stated she did not document the second incident because LVN A was the nurse for Resident #1, so she assessed her and documented that incident. The RN Supervisor stated Resident #1 had a wander guard device before she went to the hospital, but it was not put back on after she readmitted on [DATE]. The RN Supervisor stated she placed the wander guard device back on Resident #1 after she exited the facility. When the RN Supervisor was asked why didn't she put it on when she was found the first time by the door, she stated she intervened by re-directing her away from the door. During an observation and interview on 08/02/23 at 10:40 AM, the Maintenance Director (MD) stated with the door by the laundry area, if someone pressed on the door for a few seconds the alarm would go off for 15 seconds and the door would unlock. The MD stated the door would not lock again, unless someone resets it by putting in the code. He stated the door had an emergency release to allow everyone to evacuate for fire hazards. The Investigator pressed on the door for approximately 3 to 4 seconds, and the alarm went off for approximately 15 seconds. After setting off the alarm, the Investigator observed the door was unlocked and would not latch on to the door frame. The door was partially opened and when the Investigator lightly touched the door, it completely opened. The MD was observed putting in the code and then the door latched back to the doorframe and locked. In a follow up phone interview on 08/02/23 at 10:54 AM, LVN A stated the RN Supervisor told her that Resident #1 was by that door earlier and had set the alarm off. She stated she did not specify what time this happened, she only stated it was earlier that day. LVN A stated she was not notified of this incident until they were on their way to get Resident #1 from outside. LVN A stated she did not hear the alarm go off earlier that day, but she was in and out of resident's room providing care. LVN A stated if the RN Supervisor would have told her that Resident #1 attempted to leave out of the door earlier, then she would have had the wander guard put back on. In an interview on 08/02/23 at 11:58 AM, the ADON B stated on 07/30/23 she was at the nurse's station with the RN Supervisor, and they heard the alarm going off . She stated they looked at the panel and saw it was coming from the 200 hall. The ADON B stated she told the RN Supervisor to be on the safe side she would check halls 100 and 400. She stated the RN Supervisor headed towards the 200 Hall. The ADON B stated she checked halls 100 and 400 and saw no issues, so she headed to the 300 Hall, where she was assigned because she had to do a resident's tube feeding. The ADON B said she did not know anything after that. She stated the RN Supervisor never reported to her that she found Resident #1 by the door. The ADON B said she did not witness Resident #2 coming to the nurse's station to let the RN Supervisor know Resident #1 was outside. The ADON B stated she did not see LVN A coming towards the nurse's station from the direction of the 200 hall. The ADON B stated this happened about 1pm on 07/30/23. She stated she knew it was about 1pm because it happened about one hour before shift change, which was at 2pm. In an interview on 08/02/23 at 12:29 PM, Resident #2 stated she did witness the incident with Resident #1 exiting the facility. Resident #2 stated she was coming into the building from outside, and she saw Resident #1 kick the door and it opened. She stated the door was not locked, so it just swung open, and the alarm did not go off. Resident #2 stated when she went outside the door was unlocked. Resident #2 stated Resident #1 did not have that thing on her leg to set off the alarm. Resident #2 stated she told Resident #1 that it was hot outside, and she shouldn't be outside. She said Resident #1 went around her and still went outside. Resident #2 stated she knew Resident #1 wore that thing on her leg, and should not be outside by herself, so she went inside to the nurse's station and told them that Resident #1 was outside. Resident #2 stated LVN A was standing in front of the nurse's station, and the RN Supervisor was sitting at the nurse's station. She stated they went outside to get Resident #1. She stated she knew who the ADON was, and she was not at the nurse's station. In an interview on 08/01/23 at 2:50 PM, the DON stated she was not working at the building on 07/30/23, when Resident #1 got out of the building. She stated she was filling in at a sister facility. The DON stated she was told that Resident #1 pushed the door open and got out of the facility. The DON stated Resident #1 had a wander guard device prior to her going to the hospital and when she readmitted it was not put back on. She stated she believed the admitting nurse did not put the device back on because the resident wandered but was not exit seeking. The DON stated after this incident, they changed their policy, which required the wander guard device to be put on if residents were high risk for wandering or eloping, even if they were not exit seeking. She stated on 07/31/23 the staff was in-serviced regarding the elopement situation and monitoring the doors. A record review of the facility's policy titled Wanderer Management, Monitoring System & Resident Elopement Protocol, last reviewed date 01/2023 , reflected Purpose: To provide a system to alert staff that a resident may be attempting leave the facility. Policy: It is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible . Procedures: 4. Residents identified as risk for elopement shall be provided one of the following: a. Door alarms on exit doors. b. A personal safety device that alerts staff of resident effort to leave the facility. c. Signaling device to the arm or angle or as permitted by the manufacturer . An Immediate Jeopardy (IJ) was identified to have existed from 07/30/23 through 07/31/23 on 08/02/23. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the investigation. The facility took the following actions to correct the non-compliance prior to the investigation: An observation on 08/01/23 at 11:22 AM revealed Resident #1 had a wander guard device in place upon entrance to the facility. In interviews with the RN Supervisor on 08/02/23 at 9:39 AM and LVN A on 08/01/23 at 2:19 PM they stated the wander guard was put on Resident #1 on 07/30/23 after she exited the facility. A record review on 08/01/23 of Resident #1's progress notes revealed a wander guard device was put on Resident #1 when she exited the facility on 07/30/23. A record review of the facility's in-services dated 07/31/23 conducted by the DON, reflected all nursing staff were educated on wander guard devices and monitoring wandering behaviors. All staff were in-serviced that they should be doing rounds to ensure exit doors are closed and locked, in-putting codes to ensure doors had been reset after the alarm had gone off, and monitoring wandering residents and reporting if they witness exit seeking behaviors. Interviews were conducted from 08/01/23 to 08/04/23 at various times, with five nurses, six CNAs, three Med Aides, and two ADONs, from various shifts. The nursing staff were able to identify procedures of assessing and applying the wander guards to residents who were elopement risk. The staff were able to identify wandering and exit seeking behaviors and were knowledgeable on who exit seeking behaviors should be reported to. The staff were knowledgeable that exit doors required resetting by entering the code once the alarm had been activated.

Based on interview, and record review, the facility failed to ensure the resident was free from abuse for 1 (Residents #1) of 3 residents reviewed for abuse. 1. The facility failed to protect Resident #1 from continued abuse. Resident #1 was verbally abused twice by MA B. MA B told Resident #1 you need to shut up, CNA A witnessed the incident did not act, and MA B worked another 7 days and verbally abused Resident #1 again. An Immediate Jeopardy was identified on 05/18/23. The IJ Template was provided to the facility on [DATE] at 6:48 p.m. While the Immediate Jeopardy was removed on 05/19/22, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy, due to the facility's need of continuation of in-servicing and monitoring the plan of removal. This failure could cause actual harm and place all residents in the facility at risk for severe negative psychosocial outcomes which could prevent them from achieving their highest practicable physical, mental, and psychosocial well-being. Findings included: Review of Resident #1's face sheet, dated 05/19/23, revealed she was a [AGE] year-old-female admitted to the facility on [DATE] with diagnoses that included: quadriplegia, seizures, depression, and anxiety. Review of Resident #1's quarterly MDS assessment, dated 05/09/23, revealed she had a BIMs score of 12: mildly impaired for decision making. The resident had the ability to understand, with clear speech, with no documented behaviors and required extensive assistance of two staff members to complete ADLs. Review of Resdient#1's Plan of Care dated 05/17/23 reflected, 1. [Resident #1] had potential to be verbally aggressive (screams at and uses vulgarity on staff) and refuses, care. Interventions included: if resident is agitated, let her know you will be back or ask another staff to take over to deescalate the situation. Assess resident's coping skills and support system. For her to call if she needs to. 2. [Resident #1] has a mood problems Anxiety D/O, resident lashes out at staff and kicks them out of the room refuses care. The Resident has been provided the phone numbers of both the Administrator and the assistant administrator. [Resident # 1] has told staff I will make everyone miserable because I am miserable Offered Psych services, declined. Interventions included: administer medications, monitor mood to determine if problems seem to be related to external causes medications, treatments, concern over diagnosis. [Resident #1] alleged staff said to her I can walk .you can't, I can wipe myself .you can't Also she does not like rounding in the hall in the morning-she alleged another resident was verbally abuse and the other resident denied allegation. Interventions included: Investigation initiated by Abuse Coordinator. Review of MA B punch detail report reflected the MA B worked on 05/01/23 on the 6:00 a.m. to 2:00 p.m. shift (when incident occurred), then worked the 6:00 p.m. to 2:00 p.m. shift on the following dates: 05/02/23, 05/03/23, 05/08/23, 05/09/23, 05/10/23, 05/11/23, and on 05/12 23 from 6:00 a.m. to 9:52 a.m., when he was suspended. Review of the daily schedules reflected MA B worked on Hall 100 on 05/01/23, 05/02/23, 05/03/23, 05/08/23, 05/09/23, 05/10/23, 05/11/23, and 05/12/23. Interview on 05/18/23 at 12:00 p.m. with Resident #1 revealed she had reported that she had been verbally abused by MA B. Resident #1 said the first time it happened, on 05/01/23, she did not report to the Administrator, because she was tired that the previous administration did not listen to her and the day it happened a new administrator was supposed to come. During this interview the resident provided a name of a witness (CNA A) to the incident that occurred and then became upset and did not want to talk anymore. Interview on 05/18/23 at 12:35 p.m. with CNA A revealed she had been off the day (05/12/23) the second time the allegation of abuse was made by Resident #1. CNA A said there had been another time before that on 05/01/23. CNA A said she was on the hallway right by Resident #1's room around 7:00 a.m. in the morning and MA B came down the hallway talking loudly. CNA A said she told him to lower his voice, that residents were still sleeping, when Resident #1 said from her room, You need to be quiet; you are too loud. I am still trying to sleep. CNA A said MA B said to Resident #1 You need to shut your door then. CNA A said Resident #1 said This is my house and if I want my door open, I can have it. CNA A said she observed MA B to the doorway of Resident #1's room, tell her you need to shut up and then left her room. The CNA stated she knew she was supposed to report to the Administrator, but she did not report it to anyone because she was afraid of the previous administration retaliating against her and she would lose her job. The CNA said the previous administration did not seem to take concerns seriously. CNA A stated there was no other staff around and there were no other residents that were awake that said anything at that time. In a confidential interview on 05/18/23 at 12:45 p.m. with five residents revealed they did not have any problems with MA B. In an interview on 05/18/23 at 1:15 p.m. with Resident #1 revealed she was asleep around 7:00 a.m., and she heard someone talking loudly. She said she heard CNA A tell the person to lower their voice, I yelled out of my room that they I was trying to sleep and be quiet. [MA B] stood in my doorway and said you need to shut your door. Resident #1 stated, this is my house, and I can have my door open if I want. The resident said MA B came into her room and said then you need to shut up and he left her room When the resident was asked who she reported it to, she stated, I called the state because I got tired of telling the previous administration about my concerns and they never listened. Then when it happened again [MA B telling me to shut up], I told the new Administrator on the 12th of this month. In a later interview on 05/18/23 at 1:45 p.m. Resident #1 identified the day that this incident occurred was on 05/01/23. Resident #1 stated that [MA B] continued to work on her hallway, until he was suspended. Interview on 05/18/23 at 3:00 p.m. with the Administrator revealed she was the abuse prevention coordinator and was the person responsible for investigating and reporting incidents. She stated allegations of abuse were reported if there was injury within two hours. She stated if the cognitive level of the involved resident was low (BIMs) the incident was reported within eight hours, and if there was no injury it was reported within 24 hours. She stated she followed the provider letter related to reporting incidents to guide her when reporting. The Administrator stated she picked a sample of staff and residents when she was investigating. She stated she would try to interview the staff and the residents in the area where the incident was reported to occur. She stated that way she could get a random selection of what the residents and staff understanding was of the incident that may have occurred. She stated she did not interview all the staff. The Administrator said when Resident #1 reported the allegation of abuse on 05/12/23 of [MA B] telling her to shut up and [MA B] B told her to shut up the week before, she started her investigation, interviewing the staff members that were at the facility that day and suspending the staff that was alleged to be involved. She said she did not recall if she asked Resident #1 about any witnesses. The Administrator stated she had completed her investigation and was awaiting the state's visit before she decided concerning the staff, which had been suspended. Interview on 05/18/23 at 5:55 p.m. with the Administrator revealed she used the facility's policy and procedure for abuse investigations. She stated she went by the information that was provided to her by Resident #1. She stated, I placed everything she told me in the investigation report and then I begin my investigation. I start my investigation on the day the allegation occurred and then I start my in-service and in-service the staff that requires training. The Administrator stated she was not aware there was a witness to verbal abuse related Resident #1's allegation. Interview on 05/18/23 at 7:10 p.m. with the Administrator revealed the previous investigation for allegation on 05/12/23 had been completed, with the five-day period allowed, when the investigator had made her aware of the witness, she had found she started interviewing all the staff and had kept the two pervious employees [MA B and CNA MM] suspended and she would be suspending the employee [CNA A] that did not report the abuse. The Administrator stated the facility had a corporate hotline to call and Resident #1 had been previously provided the personal cell phone number of the Administrator, Regional [NAME] President, and Regional Nurse Consultant. Resident #1 had been instructed she could call those numbers any time of the day or night. The Administrator stated Resident #1 had not hesitated to call those numbers in the past. Interview on 05/19/23 at 1:52 p.m. with MA B revealed on 05/12/23 at 7:30 a.m. she was passing medications on the hallway that Resident #1 lived on. MA B stated Resident #1 started yelling and screaming at him, some horrible things. I have never had any problems with [Resident #1], we got along fine, until 05/12/23 when she started yelling and cussing me. In fact, she told me she was glad I was working here, it really hurt my feelings the things that she said to me. MA B said that was not the first time he had ever had any problems with [Resident #1], she had gotten upset with me the week before (MA B could not identify what day) saying [MA B] was too loud, [MA B] just gave [Resident #1] her space and she was fine. MA B stated he knew better then to tell any resident to shut up because that could be considered abuse. MA B said there was no other staff or residents on the hallway when the incident 05/12/23, occurred. MA B stated he was suspended on 05/12/23, after providing a statement to the Administrator and has not returned to work yet. Interview on 05/18/23 at 7:20 p.m. with the DON revealed staff to resident verbal abuse should be treated as an allegation of abuse and should be reported immediately. Review of the facility's Provider Investigation Report, incident date 05/12/23 at 7:30 a.m. and reported to HHSC on 05/12/23 at 4:45 p.m., reflected an incident category of abuse, staff to resident verbal altercation. The report's description of the allegation revealed, On last week, [Resident #1] alleged [MA B] told her to shut up. The report's description of injury revealed there were no injuries. The report's description of assessment revealed, .the ADON performed Head to Toe Assessment. No injuries or adv [adverse] reaction, no changes in resident behaviors noted. The report's provider response revealed upon investigation Resident #1 alleged that on 05/12/23 staff member MA B verbally abused her telling her to shut up. The Physician and Ombudsman were notified. Abuse/Neglect/Exploitation In-service. Employee interviews and statements were completed. Employees were in-serviced on Resident Abuse. Staff statements noted no further concerns or further witnesses to allegations made. The report indicated the findings were unconfirmed. Further review reflected the investigations focused on the allegation made on 05/12/23, not the previous week (05/01/23). Review of the in-service training reported dated 05/12/23-05/16/23 reflected Abuse/Neglect comments: -resident to resident, -Verbal abuse, -mental, --forms of abuse -misappropriation, -report immediately. CNA A was not listed on the training and MA B had been suspended. Review of the employee file for CNA A reflected in-service training dated 12/08/22 for abuse prohibition (prevention). Review of the employee file for MA B reflected in-service training dated 04/20/23 for abuse prohibition (prevention). Review of the facility Abuse Prohibition policy, revised dated 03/2023, reflected each resident has the right to be free from abuse, mistreatment . the facility will prohibit neglect, mental or physical abuse . the facility will conduct an investigation of alleged or suspected abuse, neglect, or misappropriation of property, and will provide notification of information to the proper authorities according to state and federal regulations . the policy definition of verbal abuse includes as the use of oral, written, or gestured language that willfully includes disparaging or derogatory terms to residents . or within their hearing distance regardless of their age, ability to comprehend, of disability .Investigation: The facility will thoroughly investigate all alleged violations and take appropriate actions . The Administrator and DON were notified of the Immediate Jeopardy on 05/18/23 at 6:48 p.m. The IJ template was provided. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 05/19/23 at 4:56 p.m. and reflected the following: Immediately on May 18, 2023, at 5:30pm, [CNA A] was suspended for failure to report an allegation of abuse. Immediately on May 18, 2023, RN, CCS, RVP, and COO in serviced, Administrator and DON/RN on the policy and procedures of abuse policies and procedures to include reporting procedures on what to report, how to conduct a thorough investigation with the importance of interviewing all witnesses and development of a timeline of events. The Administrator and DON were able to verbalize the training material back to, RN, CCS, RVP, and COO and deemed competent in their knowledge. Training initiated on May 18, 2023 and completed on May 18, 2023. On 5/18/2023, the Administrator, DON, CCS' initiated in servicing of department heads and staff on the policy and procedures of abuse to include reporting any and all allegations of abuse/neglect, reporting if they witness any issues with abuse/neglect and/or customer service, to whom to report and in what timeframe to report, and location of posting that is available with numbers for whom to report. Comprehension of training will be validated by successful responses to verbal scenarios presented to each employee. Training initiated on May 18, 2023, and will be completed on May 19, 2023. (See attached Policy and Procedure regarding reporting). Staff will not be allowed to work their next scheduled shift until in servicing has been completed. This will be monitored by Administrator. Grievances will be audited by Administrator/Designee and completed on 5/19/2023. Life Satisfaction rounds will be completed by Social Services/Designee and completed on 5/19/2023. Medical Director was notified of IJ by, Administrator. The above training material will be incorporated into the new hire orientation by, Administrator/, RN, DON/designee effective May 19, 2023, and ongoing. Monthly quizzes will be completed with staff for 3 months. After 3 months, quarterly for 3 quarters. In order to monitor current residents for potential risk, IDT team will review and discuss all grievances and allegations daily for 30 days. The IDT team consists of Administrator, DON, ADONs, and Social Worker. RN, CCS and RVP will review all allegations and investigations for 30 days. After 30 days, the IDT will follow the above process monthly. Thereafter, QA will monitor quarterly up to a year. The facility QA Committee will meet weekly for the next eight weeks to review compliance with the plan of action. If no further concerns noted, will continue to monitor as per routine facility QA Committee. Monitoring of the facility's Plan of Removal to confirm the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) included the following: Interviews were conducted on 05/19/23 starting at 5:00 p.m. and continued through 05/19/23 at 8:00 p.m. with 10 nurses, and 15 CNAs, 2 housekeepers, 3 kitchen staff, one van driver, and 4 MAs from various shifts regarding in-services with policy and procedures of abuse to include reporting any and all allegations of abuse/neglect, reporting if they witness any issues with abuse/neglect and/or customer service, to whom to report and in what timeframe to report, and location of postings that were available with numbers for whom to report. Comprehension of training would be validated by: The staff members were able to: Describe the correct process for reporting abuse and neglect. Describe the process for reporting if they witness abuse. Describe the process of customer service. Describe the process of whom to report to and timeframe to report. Describe the location of posting that are available with numbers for whom to report. Interviewed staff members and shifts were: LVN C -worked 10:00 p.m. to 6:00 a.m. LVN D-worked 6:00 a.m. to 2:00 p.m. LVN E- worked 6:00 a.m. to 2:00 p.m. LVN F- worked 6:00 a.m. to 2:00 p.m. RN G- worked 6:00 a.m. to 2:00 p.m. and 2:00 p.m. to 10:00 p.m. LVN H- worked all shifts ADON I- worked all shifts LVN J- worked 6:00 am to 2:00 p.m. LVN H - worked 10:00 p.m. to 2:00 p.m. RN I - worked 10:00 a.m. to 2:00 p.m. LVN J - worked 6:00 a.m. to 2:00 p.m. LVN K - worked 2:00 p.m. to 10:00 p.m. LVN L - worked 2:00 p.m. to 10:00 p.m. LVN M- worked the 10:00 p.m. to 6:00 a.m. MA N- worked 6:00 a.m. to 2:00 p.m. MA O- worked 2:00 p.m. to 10:00 p.m. MA P- worked 6:00 a.m. to 2:00 p.m. MA Q-worked 2:00 p.m. to 10:00 p.m. CNA R-worked 6:00 a.m. to 2:00 p.m. CNA S-worked 6:00 a.m. to 2:00 p.m. CNA T-worked 6:00 a.m. to 2:00 p.m. CNA U-worked 6:00 a.m. to 2:00 p.m. CNA V- worked 2:00 p.m. to 10:00 p.m. CNA W- worked 2:00 p.m. to 10:00 p.m. and 10:00 p.m. to 6:00 a.m. CNA X - worked 2:00 p.m. to 10:00 p.m. CNA Y - worked 2:00 p.m. to 10:00 p.m. CNA Z - worked 2:00 p.m. to 10:00 p.m. CNA AA -worked- 10:00 p.m. to 6:00 a.m. CNA BB - worked 10:00 p.m. to 6:00 a.m. CNA CC - worked all shifts CNA DD - worked 10:00 p.m. to 6:00 a.m. CNA EE - worked 6:00 a.m. to 2:00 p.m. CNA FF - worked 6:00 a.m. to 2:00 p.m. Housekeeper GG- worked 7: 00 a.m. to 3:00 p.m. Housekeeper HH - worked 7:00 a.m. to 3:00 p.m. KA II - worked 12:00 p.m. to 7: 00 p.m. Cook JJ - worked 6:00 p.m. to 2:00 p.m. KA KK- worked 11:00 a.m. to 7:00 p.m. VD LL - worked 8:00 a.m. to 5:00 p.m. An interview with the DON on 05/19/23 at 1:30 p.m. revealed going forward the facility would be following the policy and procedure for reporting abuse and neglect. She stated the staff would be monitored by the compliance testing that would be given on a month-by-month basis An interview with the Administrator on 05/19/23 at 2:00 p.m. revealed going forward the facility would be following the policy and procedure for reporting and investigating neglect. She stated she would ensure the facility completed and continued the proficiency training and testing for abuse and neglect. The Administrator was notified on 05/19/23 at 4:56 p.m., the Immediate Jeopardy was removed. While the immediacy was removed on 05/19/23, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy, due to the facility continuing in-servicing and monitoring the plan of removal.

Based on interview and record review the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, which included injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours to the administrator or the facility and to other officials, which included the State Survey Agency, in accordance with State law through established procedures for one of 1 resident (Resident #1) reviewed for reporting incident allegations. 1. CNA A failed to report an observation on 05/01/23 of verbal abuse involving Resident #1 and MA B, who told Resident #1 to you need to shut up to the abuse coordinator (Administrator). MA B worked another 7 days before Resident #1 reported to the abuse coordinator on 05/12/23 that MA B had verbally abused her again. 2. CNA A witnessed MA B verbally abuse Resident #1. CNA A was aware she should have reported it and due to fear of retaliation did not report it, therefore; exposing the resident to another incident of verbal abuse by MA A. CNA A had multiple opportunities and days to tell the Administrator but did not. The Administrator was informed that CNA A was a witness per surveyor intervention during the investigation. CNA A's failure to report to the Administrator exposed Resident #1 to a repeated incident of verbal abuse. 3. The Administrator investigated the allegations made by Resident #1 on 05/12/23 but did not investigate the first allegation of abuse 05/01/23 provided by Resident #1 at the time she reported the abuse allegation that occurred on 05/01/23. The Administrator and did not discover CNA A had observed the verbal abuse by MA B, allowing MA B to be able to work another 7 days, which provided the potential for further abuse to Resident #1 as well as other residents. An Immediate Jeopardy was identified on 05/18/23. The IJ Template was provided to the facility on [DATE] at 6:48 p.m. While the Immediate Jeopardy was removed on 05/19/22, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy, due to the facility's need of continuation of in-servicing and monitoring the plan of removal. This failure could place residents at risk for abuse. Findings included: Review of Resident #1's face sheet, dated 05/19/23, revealed she was a [AGE] year-old-female admitted to the facility on [DATE] with diagnoses that included: quadriplegia, seizures, depression, and anxiety. Review of Resident #1's quarterly MDS assessment, dated 05/09/23, revealed she had a BIMs score of 12: mildly impaired for decision making. The resident had the ability to understand, with clear speech, with no documented behaviors and required extensive assistance of two staff members to complete ADLs. Review of Resdient#1's Plan of Care dated 05/17/23 reflected, 1. [Resident #1] had potential to be verbally aggressive (screams at and uses vulgarity on staff) and refuses, care. Interventions included: if resident is agitated, let her know you will be back or ask another staff to take over to deescalate the situation. Assess resident's coping skills and support system. For her to call if she needs to. 2. [Resident #1] has a mood problems Anxiety D/O, resident lashes out at staff and kicks them out of the room refuses care. The Resident has been provided the phone numbers of both the Administrator and the assistant administrator. [Resident # 1] has told staff I will make everyone miserable because I am miserable Offered Psych services, declined. Interventions included: administer medications, monitor mood to determine if problems seem to be related to external causes medications, treatments, concern over diagnosis. [Resident #1] alleged staff said to her I can walk .you can't, I can wipe myself .you can't Also she does not like rounding in the hall in the morning-she alleged another resident was verbally abuse and the other resident denied allegation. Interventions included: Investigation initiated by Abuse Coordinator. Review of MA B punch detail report reflected the MA B worked on 05/01/23 on the 6:00 a.m. to 2:00 p.m. shift (when incident occurred), then worked the 6:00 p.m. to 2:00 p.m. shift on the following dates: 05/02/23, 05/03/23, 05/08/23, 05/09/23, 05/10/23, 05/11/23, and on 05/12 23 from 6:00 a.m. to 9:52 a.m., when he was suspended. Review of the daily schedules reflected MA B worked on Hall 100 on 05/01/23, 05/02/23, 05/03/23, 05/08/23, 05/09/23, 05/10/23, 05/11/23, and 05/12/23. Interview on 05/18/23 at 12:00 p.m. with Resident #1 revealed she had reported that she had been verbally abused by MA B. Resident #1 said the first time it happened, on 05/01/23, she did not report to the Administrator, because she was tired that the previous administration did not listen to her and the day it happened a new administrator was supposed to come. During this interview, the resident provided a name of a witness (CNA A) to the incident that occurred and then became upset and did not want to talk anymore. Interview on 05/18/23 at 12:35 p.m. with CNA A revealed she had been off the day (05/12/23) the second time the allegation of abuse was made by Resident #1. CNA A said there had been another time before that on 05/01/23. CNA A said she was on the hallway right by Resident #1's room around 7:00 a.m. in the morning and MA B came down the hallway talking loudly. CNA A said she told him to lower his voice, that residents were still sleeping, when Resident #1 said from her room, You need to be quiet; you are too loud. I am still trying to sleep. CNA A said MA B said to Resident #1 You need to shut your door then. CNA A said Resident #1 said This is my house and if I want my door open, I can have it. CNA A said she observed MA B to the doorway of Resident #1's room, telling her you need to shut up and then left her room. The CNA stated she knew she was supposed to report to the Administrator, but she did not report it to anyone because she was afraid of the previous administration retaliating against her and she would lose her job. The CNA said the previous administration did not seem to take concerns seriously. CNA A stated there was no other staff around and there were no other residents that were awake that said anything at that time. In a confidential interview on 05/18/23 at 12:45 p.m. with five residents revealed they did not have any problems with MA B. In an interview on 05/18/23 at 1:15 p.m. with Resident #1 revealed she was asleep around 7:00 a.m., and she heard someone talking loudly. She said she heard CNA A tell the person to lower their voice, I yelled out of my room that they I was trying to sleep and be quiet. [MA B] stood in my doorway and said you need to shut your door. Resident #1 stated, this is my house, and I can have my door open if I want. The resident said MA B came into her room and said then you need to shut up and he left her room When the resident was asked who she reported it to, she stated, I called the state because I got tired of telling the previous administration about my concerns and they never listened. Then when it happened again [MA B telling me to shut up], I told the new Administrator on the 12th of this month. In a later interview on 05/18/23 at 1:45 p.m. Resident #1 identified the day that this incident occurred was on 05/01/23. Resident #1 stated that [MA B] continued to work on her hallway, until he was suspended. Interview on 05/18/23 at 3:00 p.m. with the Administrator revealed she was the abuse prevention coordinator and was the person responsible for investigating and reporting incidents. She stated allegations of abuse were reported if there was injury within two hours. She stated if the cognitive level of the involved resident was low (BIMs) the incident was reported within eight hours, and if there was no injury it was reported within 24 hours. She stated she followed the provider letter related to reporting incidents to guide her when reporting. The Administrator stated she picked a sample of staff and residents when she was investigating. She stated she would try to interview the staff and the residents in the area where the incident was reported to occur. She stated that way she could get a random selection of what the residents and staff understanding was of the incident that may have occurred. She stated she did not interview all the staff. The Administrator said when Resident #1 reported the allegation of abuse on 05/12/23 of [MA B] telling her to shut up and [MA B] B told her to shut up the week before, she started her investigation, interviewing the staff members that were at the facility that day and suspending the staff that was alleged to be involved. She said she did not recall if she asked Resident #1 about any witnesses. The Administrator stated she had completed her investigation and was awaiting the state's visit before she decided concerning the staff, which had been suspended. Interview on 05/18/23 at 5:55 p.m. with the Administrator revealed she used the facility's policy and procedure for abuse investigations. She stated she went by the information that was provided to her by Resident #1. She stated, I placed everything she told me in the investigation report and then I begin my investigation. I start my investigation on the day the allegation occurred and then I start my in-service and in-service the staff that requires training. The Administrator stated she was not aware there was a witness to verbal abuse related Resident #1's allegation. Interview on 05/18/23 at 7:10 p.m. with the Administrator revealed the previous investigation for allegation on 05/12/23 had been completed, with the five-day period allowed, when the investigator had made her aware of the witness, she had found she started interviewing all the staff and had kept the two pervious employees [MA B and CNA MM] suspended and she would be suspending the employee [CNA A] that did not report the abuse. The Administrator stated the facility had a corporate hotline to call and Resident #1 had been previously provided the personal cell phone number of the Administrator, Regional [NAME] President, and Regional Nurse Consultant. Resident #1 had been instructed she could call those numbers any time of the day or night. The Administrator stated Resident #1 had not hesitated to call those numbers in the past. Interview on 05/19/23 at 1:52 p.m. with MA B revealed on 05/12/23 at 7:30 a.m. she was passing medications on the hallway that Resident #1 lived on. MA B stated Resident #1 started yelling and screaming at him, some horrible things. I have never had any problems with [Resident #1], we got along fine, until 05/12/23 when she started yelling and cussing me. In fact, she told me she was glad I was working here, it really hurt my feelings the things that she said to me. MA B said that was not the first time he had ever had any problems with [Resident #1], she had gotten upset with me the week before (MA B could not identify what day) saying [MA B] was too loud, [MA B] just gave [Resident #1] her space and she was fine. MA B stated he knew better then to tell any resident to shut up because that could be considered abuse. MA B said there was no other staff or residents on the hallway when the incident 05/12/23, occurred. MA B stated he was suspended on 05/12/23, after providing a statement to the Administrator and has not returned to work yet. Interview on 05/18/23 at 7:20 p.m. with the DON revealed staff to resident verbal abuse should be treated as an allegation of abuse and should be reported immediately. Review of the facility's Provider Investigation Report, incident date 05/12/23 at 7:30 a.m. and reported to HHSC on 05/12/23 at 4:45 p.m., reflected an incident category of abuse, staff to resident verbal altercation. The report's description of the allegation revealed, On last week, [Resident #1] alleged [MA B] told her to shut up. The report's description of injury revealed there were no injuries. The report's description of assessment revealed, .the ADON performed Head to Toe Assessment. No injuries or adv [adverse] reaction, no changes in resident behaviors noted. The report's provider response revealed upon investigation Resident #1 alleged that on 05/12/23 staff member MA B verbally abused her telling her to shut up. The Physician and Ombudsman were notified. Abuse/Neglect/Exploitation In-service. Employee interviews and statements were completed. Employees were in-serviced on Resident Abuse. Staff statements noted no further concerns or further witnesses to allegations made. The report indicated the findings were unconfirmed. Further review reflected the investigations focused on the allegation made on 05/12/23, not the previous week (05/01/23). Review of the in-service training reported dated 05/12/23-05/16/23 reflected Abuse/Neglect comments: -resident to resident, -Verbal abuse, -mental, --forms of abuse -misappropriation, -report immediately. CNA A was not listed on the training and MA B had been suspended. Review of the employee file for CNA A reflected in-service training dated 12/08/22 for abuse prohibition (prevention). Review of the employee file for MA B reflected in-service training dated 04/20/23 for abuse prohibition (prevention). Review of the facility Abuse Prohibition policy, revised dated 03/2023, reflected each resident has the right to be free from abuse, mistreatment . the facility will prohibit neglect, mental or physical abuse . the facility will conduct an investigation of alleged or suspected abuse, neglect, or misappropriation of property, and will provide notification of information to the proper authorities according to state and federal regulations . the policy definition of verbal abuse includes as the use of oral, written, or gestured language that willfully includes disparaging or derogatory terms to residents . or within their hearing distance regardless of their age, ability to comprehend, of disability .Investigation: The facility will thoroughly investigate all alleged violations and take appropriate actions . The Administrator and DON were notified of the Immediate Jeopardy on 05/18/23 at 6:48 p.m. The IJ template was provided. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 05/19/23 at 4:56 p.m. and reflected the following: Immediately on May 18, 2023, at 5:30pm, [CNA A] was suspended for failure to report an allegation of abuse. Immediately on May 18, 2023, RN, CCS, RVP, and COO in serviced, Administrator and DON/RN on the policy and procedures of abuse policies and procedures to include reporting procedures on what to report, how to conduct a thorough investigation with the importance of interviewing all witnesses and development of a timeline of events. The Administrator and DON were able to verbalize the training material back to, RN, CCS, RVP, and COO and deemed competent in their knowledge. Training initiated on May 18, 2023, and completed on May 18, 2023. On 5/18/2023, the Administrator, DON, CCS' initiated in servicing of department heads and staff on the policy and procedures of abuse to include reporting any and all allegations of abuse/neglect, reporting if they witness any issues with abuse/neglect and/or customer service, to whom to report and in what timeframe to report, and location of posting that is available with numbers for whom to report. Comprehension of training will be validated by successful responses to verbal scenarios presented to each employee. Training initiated on May 18, 2023 and will be completed on May 19, 2023. (See attached Policy and Procedure regarding reporting). Staff will not be allowed to work their next scheduled shift until in servicing has been completed. This will be monitored by Administrator. Grievances will be audited by Administrator/Designee and completed on 5/19/2023. Life Satisfaction rounds will be completed by Social Services/Designee and completed on 5/19/2023. Medical Director was notified of IJ by, Administrator. The above training material will be incorporated into the new hire orientation by, Administrator/, RN, DON/designee effective May 19, 2023, and ongoing. Monthly quizzes will be completed with staff for 3 months. After 3 months, quarterly for 3 quarters. In order to monitor current residents for potential risk, IDT team will review and discuss all grievances and allegations daily for 30 days. The IDT team consists of Administrator, DON, ADONs, and Social Worker. RN, CCS and RVP will review all allegations and investigations for 30 days. After 30 days, the IDT will follow the above process monthly. Thereafter, QA will monitor quarterly up to a year. The facility QA Committee will meet weekly for the next eight weeks to review compliance with the plan of action. If no further concerns noted, will continue to monitor as per routine facility QA Committee. Monitoring of the facility's Plan of Removal to confirm the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) included the following: Interviews were conducted on 05/19/23 starting at 5:00 p.m. and continued through 05/19/23 at 8:00 p.m. with 10 nurses, and 15 CNAs, 2 housekeepers, 3 kitchen staff, one van driver, and 4 MAs from various shifts regarding in-services with policy and procedures of abuse to include reporting any and all allegations of abuse/neglect, reporting if they witness any issues with abuse/neglect and/or customer service, to whom to report and in what timeframe to report, and location of postings that were available with numbers for whom to report. Comprehension of training would be validated by: The staff members were able to: Describe the correct process for reporting abuse and neglect. Describe the process for reporting if they witness abuse. Describe the process of customer service. Describe the process of whom to report to and timeframe to report. Describe the location of posting that are available with numbers for whom to report. Interviewed staff members and shifts were: LVN C -worked 10:00 p.m. to 6:00 a.m. LVN D-worked 6:00 a.m. to 2:00 p.m. LVN E- worked 6:00 a.m. to 2:00 p.m. LVN F- worked 6:00 a.m. to 2:00 p.m. RN G- worked 6:00 a.m. to 2:00 p.m. and 2:00 p.m. to 10:00 p.m. LVN H- worked all shifts ADON I- worked all shifts LVN J- worked 6:00 am to 2:00 p.m. LVN H - worked 10:00 p.m. to 2:00 p.m. RN I - worked 10:00 a.m. to 2:00 p.m. LVN J - worked 6:00 a.m. to 2:00 p.m. LVN K - worked 2:00 p.m. to 10:00 p.m. LVN L - worked 2:00 p.m. to 10:00 p.m. LVN M- worked the 10:00 p.m. to 6:00 a.m. MA N- worked 6:00 a.m. to 2:00 p.m. MA O- worked 2:00 p.m. to 10:00 p.m. MA P- worked 6:00 a.m. to 2:00 p.m. MA Q-worked 2:00 p.m. to 10:00 p.m. CNA R-worked 6:00 a.m. to 2:00 p.m. CNA S-worked 6:00 a.m. to 2:00 p.m. CNA T-worked 6:00 a.m. to 2:00 p.m. CNA U-worked 6:00 a.m. to 2:00 p.m. CNA V- worked 2:00 p.m. to 10:00 p.m. CNA W- worked 2:00 p.m. to 10:00 p.m. and 10:00 p.m. to 6:00 a.m. CNA X - worked 2:00 p.m. to 10:00 p.m. CNA Y - worked 2:00 p.m. to 10:00 p.m. CNA Z - worked 2:00 p.m. to 10:00 p.m. CNA AA -worked- 10:00 p.m. to 6:00 a.m. CNA BB - worked 10:00 p.m. to 6:00 a.m. CNA CC - worked all shifts CNA DD - worked 10:00 p.m. to 6:00 a.m. CNA EE - worked 6:00 a.m. to 2:00 p.m. CNA FF - worked 6:00 a.m. to 2:00 p.m. Housekeeper GG- worked 7: 00 a.m. to 3:00 p.m. Housekeeper HH - worked 7:00 a.m. to 3:00 p.m. KA II - worked 12:00 p.m. to 7: 00 p.m. Cook JJ - worked 6:00 p.m. to 2:00 p.m. KA KK- worked 11:00 a.m. to 7:00 p.m. VD LL - worked 8:00 a.m. to 5:00 p.m. An interview with the DON on 05/19/23 at 1:30 p.m. revealed going forward the facility would be following the policy and procedure for reporting abuse and neglect. She stated the staff would be monitored by the compliance testing that would be given on a month-by-month basis An interview with the Administrator on 05/19/23 at 2:00 p.m. revealed going forward the facility would be following the policy and procedure for reporting and investigating neglect. She stated she would ensure the facility completed and continued the proficiency training and testing for abuse and neglect. The Administrator was notified on 05/19/23 at 4:56 p.m., the Immediate Jeopardy was removed. While the immediacy was removed on 05/19/23, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy, due to the facility continuing in-servicing and monitoring the plan of removal.

Based on observation, interview, and record review the facility failed to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #1) of five residents reviewed for pain medication. 1. The facility failed to reorder Resident #1's hydrocodone-acetaminophen 10-325 mg medication from the pharmacy in a timely fashion or after the last dose was administered on 03/27/23, causing Resident #1 to not receive PRN pain medications of choice on 03/28/23. 2. The facility failed to administer Resident #1 's hydrocodone-acetaminophen 10-325 mg medication that was in accordance with the resident's comprehensive care plan, and the resident's preference to manage Resident #1's pain level of 7 on 03/28/23 during the day and evening shifts. This failure placed residents at risk of not receiving timely pain management care. Findings included: A record review of Resident #1's Admission MDS assessment dated [DATE] revealed an [AGE] year-old female admitted on [DATE]. Resident #1 had diagnoses of HF {when the heart cannot pump enough blood and oxygen to support other organs in your body}, HTN {High blood pressure that is higher than normal}, DM {a group of diseases that result in too much sugar in the blood}, CVA {a loss of blood flow caused by blood clots and broken blood vessels, which damages brain tissue in the brain}, CAD {a heart disease caused by plaque buildup in the wall of the arteries that supply blood to the heart}, hyperlipidemia (high cholesterol) {an excess of lipids or fats in the blood} and Bilateral {Right and Left} leg pain. Resident #1's BIMS score was 07, which suggested severe impairment. Resident #1 required one-person physical assist with ADLs, two persons assist with bed mobility and transfer, and used a wheelchair as a mobility device. A pain assessment interview indicated Resident #1 did not have pain or hurting at any time in the last 5 days during the Admission MDS assessment. A record review of Resident #1's active physician orders indicated: Start date 02/17/23: Is this resident in pain? 0=no pain; 1-3=mild pain; 4-6=moderate pain; 7-10=severe pain every shift. Follow MD orders. Start date 02/17/23: Hydrocodone-Acetaminophen Oral Tablet 10-325 MG (Hydrocodone-Acetaminophen) every eight hours as needed for moderate pain. Give 1 tablet by mouth every six hours as needed for moderate pain. [Discontinued: 03/20/23 at 2:43 PM] Start date 03/20/23 at 2:43 PM: Hydrocodone-Acetaminophen Oral Tablet 10-325 MG (Hydrocodone-Acetaminophen). Give 1 tablet by mouth every six hours as needed for moderate pain. [Discontinued: 03/27/23 at 12:32 PM] Start date 03/27/23 at 12:32 PM: Hydrocodone-Acetaminophen Oral Tablet 10-325 MG (Hydrocodone-Acetaminophen). Give 1 tablet by mouth every six hours as needed for moderate pain. Start date 03/27/23: Biofreeze External Gel 4% (Menthol Topical Analgesic). Apply to lower spine/sacral area topically three times a day for pain. Start date 03/27/23: Lumbar/Sacral/Spine X-ray d/t pain Start date 03/29/23: Acetaminophen Oral Tablet 325 MG (Acetaminophen). Give 2 tablets by mouth every six hours as needed for mild pain. A record review of Resident #1's comprehensive care plan, initiated 03/29/23, entered by the MDS, reflected medical, nursing, mental, psychosocial needs as identified in the physician orders and problems/risks identified in the MDS admission assessment. Areas of focus in Resident #1's comprehensive care plan reflected: Allergy to Penicillin; Advanced Directives [Full Code]; ADL self-care performance deficit; altered cardiovascular status; HF; HTN; chest pain; CAD; DM; moderate Risk for Falls; risk of Constipation; hypnotic/sedative therapy - Melatonin; anticoagulant therapy - ASA (aspirin); pain medication therapy - Hydrocodone/Acetaminophen; Therapeutic Diet - CC/RCS; hemiplegia/hemiparesis; Chronic Pain; functional bladder incontinence; and altered respiratory status. An observation and interview on 03/29/23 at 12:50 PM revealed Resident #1 sitting up in bed received oxygen at 2L via NC by concentrator with call light in hand. Resident #1 was alert and oriented to self and surrounding; to time of day with prompts/cues. Resident #1 stated a pain level of 10 in her lower back and was tearful. Resident #1 was observed, guarding lower back, and attempting to reposition for comfort. Resident #1 said there are some things she may or may not remember, but she was sure she did not receive her pain pill today (03/29/23). When the MA entered the room to administer Resident #1's 1:00 PM medication, Resident #1 stated she needed something for pain. The MA returned after notifying the nurse and informed Resident #1 that the nurse [LVN F] said that pain medicine was given at 11:00 AM and it is too soon for more pain medicine. Resident #1 said that she had not received her pain medicine (hydrocodone-acetaminophen) and if she . would only receive Tylenol, she could have her family bring it from home Review of Resident #1's March 2023 MAR revealed she did not receive Hydrocodone-Acetaminophen 10-325 mg, 1 tablet Q6H, PRN for moderate pain on 03/28/23. The last tablet was administered on 03/27/23 at 9:41 PM. The pain level on 03/28/23 was documented at 7 (severe) on the day and evening shift. The pain level was documented at 0 on 03/28/23 during the 10PM - 6 AM (03/29/23) shift. The March 2023 MAR reflected no other pain medications were administered until 03/29/23. On 03/29/23 at 10:53 AM, LVN F charted Resident #1's pain level as a '5'. According to the physician's orders [start date: 02/17/23] and as indicated on the MAR, a pain level from four to six is considered moderate pain. LVN F administered Acetaminophen 325 mg, two tablets, that was ordered for mild pain to Resident #1 instead of Hydrocodone-Acetaminophen 10-325 mg, one tablet, as written PRN for moderate pain. The Hydrocodone-Acetaminophen (HC-APAP) was scheduled every six hours (last dose 03/27/23 at 9:41 PM) as needed. Between 03/28/23 at 3:41 AM to 03/29/23 at 9:41 AM, there were six opportunities to receive HC-APAP every 6 hours as needed. Based on Resident #1's last HC-APAP dose, she could receive HC-APAP on 03/29/23 at 12:50 PM when she told the MA she needed something for pain. The MAR did not reflect orders not to exceed a certain amount of acetaminophen within 4-, 6-, 8-, 12-, or 24 hrs. It is not likely Resident #1 would have exceeded the acetaminophen recommended dose between 650 mg - 1,000 mg within 6 hours or 3000 mg from all sources within 24 hours. LVN F administered Hydrocodone-Acetaminophen 10-325 mg, 1 tablet at 1:57 PM [verified by e-kit access and drug count]. Review of the 300 Hall narcotic book revealed Resident #1's narcotic count sheet for Hydrocodone-Acetaminophen 10-325 mg, 1 tablet Q6H, PRN for moderate pain folded in half. ADON A administered the two previous tablets on 03/27/23 at 7:58 AM and 2:06 PM. The last tablet was administered on 03/27/23 at 9:41 PM. An interview on 03/29/23 at 2:40 PM, LVN F stated she administered Tylenol 325 mg two tablets to Resident #1 around 10:45 AM. LVN F said that she saw the order for hydrocodone-acetaminophen 10-325 mg when the MA informed around 1 PM that Resident #1 was asking for pain medication. LVN F stated there were no hydrocodone-acetaminophen 10-325 mg tablets available for Resident #1. LVN F said that she called the pharmacy to notify that Resident #1 did not have hydrocodone-acetaminophen 10-325 mg tablets available. LVN F stated that the pharmacy staff told her that a triplicate prescription was needed to send the medication. LVN F said that she obtained an access code from the pharmacy to retrieve a Hydrocodone-Acetaminophen 10-325 mg tablet from the e-kit to administer to Resident #1 at approximately 1:50 PM on 03/29/23. An interview on 03/29/23 at 2:46 PM, ADON A said that she was the nurse assigned to Resident #1 on 03/27/23 from 6A - 2P. ADON A said that Resident #1 requested pain medication for a pain level of 10 during the morning start of shift rounds. ADON A stated that she administered a hydrocodone-acetaminophen 10-325 mg tablet per the MAR at 7:58 AM. ADON A said that when medication run low, 7 days before the last dose, the nurse is required to contact the pharmacy, write a note, and communicate on the 24-hour report. ADON A stated when narcotics require refill, the ADON or DON must be notified to contact the pharmacy for refills. An alternative to administer medications that have not been delivered yet is to call the pharmacy as a representative and obtain a code to access the medication from the e-kit. ADON A said that she was not informed that Resident #1's hydrocodone-acetaminophen 10-325 mg tablets needed to be refilled and that the ADON [ADON B] for the 300 Hall would have more information. An interview on 03/29/23 at 2:48 PM, ADON B said that the protocol is to notify leadership (ADON or DON) if a narcotic refill is needed. ADON B stated she was not informed on 03/27/23 that Resident #1 had only three hydrocodone-acetaminophen 10-325 mg tablets remaining and was not informed prior to 03/27/23 that a refill was needed. ADON B said that she did not come to work on 03/28/23 and was unaware that Resident #1 had no tablets available. An interview on 03/29/23 at 3:31 PM, the DON said if a Resident had seven or less days' worth of PRN controlled medications left or no tablets available, she would expect to be notified. The DON stated she was not aware Resident #1 had run out of Hydrocodone-Acetaminophen tablets. The DON said that she received the new order from the MD on 03/27/23 to increase the frequency of Hydrocodone-Acetaminophen 10-325 mg from Q8H to Q6H. The DON stated once the MD signed the triplicate and forwarded to the pharmacy the pharmacy would deliver the medication. The DON said when a narcotic needed to be reordered, the nurse would notify the ADON or DON and the ADON or DON would call the pharmacy for refill. Review of the facility's Pain Management Program Policy revised 01/2023, indicated the facility will ensure that residents receive the treatment and care in accordance with professional management. The Nurse will assess the resident q shift for pain, depending on the type of resident being assessed, using the PAINAD or Wong Baker Pain Evaluation Scale as indicated on the MAR. If a resident is assessed as experiencing pain during that shift, then pain medication and or alternative therapies should be administered as ordered. Effectiveness of the intervention should be documented to determine if pain is reduced or alleviated appropriately.

Based on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one (Resident #1) of five residents reviewed for pain medication. 1. The facility failed to reorder Resident #1's hydrocodone-acetaminophen 10-325 mg medication from the pharmacy in a timely fashion or after the last dose was administered on 03/27/23, causing Resident #1 to not receive PRN pain medications of choice on 03/28/23. 2. The facility failed to administer Resident #1 's hydrocodone-acetaminophen 10-325 mg medication that was in accordance with the resident's comprehensive care plan, and the resident's preference to manage Resident #1's pain level of 7 on 03/28/23 during the day and evening shifts. This failure placed residents at risk of not receiving timely pain management care. Findings included: A record review of Resident #1's Admission MDS assessment dated [DATE] revealed an [AGE] year-old female admitted on [DATE]. Resident #1 had diagnoses of HF {when the heart cannot pump enough blood and oxygen to support other organs in your body}, HTN {High blood pressure that is higher than normal}, DM {a group of diseases that result in too much sugar in the blood}, CVA {a loss of blood flow caused by blood clots and broken blood vessels, which damages brain tissue in the brain}, CAD {a heart disease caused by plaque buildup in the wall of the arteries that supply blood to the heart}, hyperlipidemia (high cholesterol) {an excess of lipids or fats in the blood} and Bilateral {Right and Left} leg pain. Resident #1's BIMS score was 07, which suggested severe impairment. Resident #1 required one-person physical assist with ADLs, two persons assist with bed mobility and transfer, and used a wheelchair as a mobility device. A pain assessment interview indicated Resident #1 did not have pain or hurting at any time in the last 5 days during the Admission MDS assessment. A record review of Resident #1's active physician orders indicated: Start date 02/17/23: Is this resident in pain? 0=no pain; 1-3=mild pain; 4-6=moderate pain; 7-10=severe pain every shift. Follow MD orders. Start date 02/17/23: Hydrocodone-Acetaminophen Oral Tablet 10-325 MG (Hydrocodone-Acetaminophen) every eight hours as needed for moderate pain. Give 1 tablet by mouth every six hours as needed for moderate pain. [Discontinued: 03/20/23 at 2:43 PM] Start date 03/20/23 at 2:43 PM: Hydrocodone-Acetaminophen Oral Tablet 10-325 MG (Hydrocodone-Acetaminophen). Give 1 tablet by mouth every six hours as needed for moderate pain. [Discontinued: 03/27/23 at 12:32 PM] Start date 03/27/23 at 12:32 PM: Hydrocodone-Acetaminophen Oral Tablet 10-325 MG (Hydrocodone-Acetaminophen). Give 1 tablet by mouth every six hours as needed for moderate pain. Start date 03/27/23: Biofreeze External Gel 4% (Menthol Topical Analgesic). Apply to lower spine/sacral area topically three times a day for pain. Start date 03/27/23: Lumbar/Sacral/Spine X-ray d/t pain Start date 03/29/23: Acetaminophen Oral Tablet 325 MG (Acetaminophen). Give 2 tablets by mouth every six hours as needed for mild pain. A record review of Resident #1's comprehensive care plan, initiated 03/29/23, entered by the MDS, reflected medical, nursing, mental, psychosocial needs as identified in the physician orders and problems/risks identified in the MDS admission assessment. Areas of focus in Resident #1's comprehensive care plan reflected: Allergy to Penicillin; Advanced Directives [Full Code]; ADL self-care performance deficit; altered cardiovascular status; HF; HTN; chest pain; CAD; DM; moderate Risk for Falls; risk of Constipation; hypnotic/sedative therapy - Melatonin; anticoagulant therapy - ASA (aspirin); pain medication therapy - Hydrocodone/Acetaminophen; Therapeutic Diet - CC/RCS; hemiplegia/hemiparesis; Chronic Pain; functional bladder incontinence; and altered respiratory status. An observation and interview on 03/29/23 at 12:50 PM revealed Resident #1 sitting up in bed received oxygen at 2L via NC by concentrator with call light in hand. Resident #1 was alert and oriented to self and surrounding; to time of day with prompts/cues. Resident #1 stated a pain level of 10 in her lower back and was tearful. Resident #1 was observed, guarding lower back, and attempting to reposition for comfort. Resident #1 said there are some things she may or may not remember, but she was sure she did not receive her pain pill today (03/29/23). When the MA entered the room to administer Resident #1's 1:00 PM medication, Resident #1 stated she needed something for pain. The MA returned after notifying the nurse and informed Resident #1 that the nurse [LVN F] said that pain medicine was given at 11:00 AM and it is too soon for more pain medicine. Resident #1 said that she had not received her pain medicine (hydrocodone-acetaminophen) and if she . would only receive Tylenol, she could have her family bring it from home Review of Resident #1's March 2023 MAR revealed she did not receive Hydrocodone-Acetaminophen 10-325 mg, 1 tablet Q6H, PRN for moderate pain on 03/28/23. The last tablet was administered on 03/27/23 at 9:41 PM. The pain level on 03/28/23 was documented at 7 (severe) on the day and evening shift. The pain level was documented at 0 on 03/28/23 during the 10PM - 6 AM (03/29/23) shift. The March 2023 MAR reflected no other pain medications were administered until 03/29/23. On 03/29/23 at 10:53 AM, LVN F charted Resident #1's pain level as a '5'. According to the physician's orders [start date: 02/17/23] and as indicated on the MAR, a pain level from four to six is considered moderate pain. LVN F administered Acetaminophen 325 mg, two tablets, that was ordered for mild pain to Resident #1 instead of Hydrocodone-Acetaminophen 10-325 mg, one tablet, as written PRN for moderate pain. The Hydrocodone-Acetaminophen (HC-APAP) was scheduled every six hours (last dose 03/27/23 at 9:41 PM) as needed. Between 03/28/23 at 3:41 AM to 03/29/23 at 9:41 AM, there were six opportunities to receive HC-APAP every 6 hours as needed. Based on Resident #1's last HC-APAP dose, she could receive HC-APAP on 03/29/23 at 12:50 PM when she told the MA she needed something for pain. The MAR did not reflect orders not to exceed a certain amount of acetaminophen within 4-, 6-, 8-, 12-, or 24 hrs. It is not likely Resident #1 would have exceeded the acetaminophen recommended dose between 650 mg - 1,000 mg within 6 hours or 3000 mg from all sources within 24 hours. LVN F administered Hydrocodone-Acetaminophen 10-325 mg, 1 tablet at 1:57 PM [verified by e-kit access and drug count]. Review of the 300 Hall narcotic book revealed Resident #1's narcotic count sheet for Hydrocodone-Acetaminophen 10-325 mg, 1 tablet Q6H, PRN for moderate pain folded in half. ADON A administered the two previous tablets on 03/27/23 at 7:58 AM and 2:06 PM. The last tablet was administered on 03/27/23 at 9:41 PM. An interview on 03/29/23 at 2:40 PM, LVN F stated she administered Tylenol 325 mg two tablets to Resident #1 around 10:45 AM. LVN F said that she saw the order for hydrocodone-acetaminophen 10-325 mg when the MA informed around 1 PM that Resident #1 was asking for pain medication. LVN F stated there were no hydrocodone-acetaminophen 10-325 mg tablets available for Resident #1. LVN F said that she called the pharmacy to notify that Resident #1 did not have hydrocodone-acetaminophen 10-325 mg tablets available. LVN F stated that the pharmacy staff told her that a triplicate prescription was needed to send the medication. LVN F said that she obtained an access code from the pharmacy to retrieve a Hydrocodone-Acetaminophen 10-325 mg tablet from the e-kit to administer to Resident #1 at approximately 1:50 PM on 03/29/23. An interview on 03/29/23 at 2:46 PM, ADON A said that she was the nurse assigned to Resident #1 on 03/27/23 from 6A - 2P. ADON A said that Resident #1 requested pain medication for a pain level of 10 during the morning start of shift rounds. ADON A stated that she administered a hydrocodone-acetaminophen 10-325 mg tablet per the MAR at 7:58 AM. ADON A said that when medication run low, 7 days before the last dose, the nurse is required to contact the pharmacy, write a note, and communicate on the 24-hour report. ADON A stated when narcotics require refill, the ADON or DON must be notified to contact the pharmacy for refills. An alternative to administer medications that have not been delivered yet is to call the pharmacy as a representative and obtain a code to access the medication from the e-kit. ADON A said that she was not informed that Resident #1's hydrocodone-acetaminophen 10-325 mg tablets needed to be refilled and that the ADON [ADON B] for the 300 Hall would have more information. An interview on 03/29/23 at 2:48 PM, ADON B said that the protocol is to notify leadership (ADON or DON) if a narcotic refill is needed. ADON B stated she was not informed on 03/27/23 that Resident #1 had only three hydrocodone-acetaminophen 10-325 mg tablets remaining and was not informed prior to 03/27/23 that a refill was needed. ADON B said that she did not come to work on 03/28/23 and was unaware that Resident #1 had no tablets available. An interview on 03/29/23 at 3:31 PM, the DON said if a Resident had seven or less days' worth of PRN controlled medications left or no tablets available, she would expect to be notified. The DON stated she was not aware Resident #1 had run out of Hydrocodone-Acetaminophen tablets. The DON said that she received the new order from the MD on 03/27/23 to increase the frequency of Hydrocodone-Acetaminophen 10-325 mg from Q8H to Q6H. The DON stated once the MD signed the triplicate and forwarded to the pharmacy the pharmacy would deliver the medication. The DON said when a narcotic needed to be reordered, the nurse would notify the ADON or DON and the ADON or DON would call the pharmacy for refill. Review of the facility's Policy for Controlled Substance Prescriptions dated and revised October 1, 2019, revealed, the pharmacy must receive a clear, signed prescription before dispensing a controlled drug and refills must be requested at least five days in advance for CII medications to assure an adequate supply is on hand.

Based on observation, interview, and record review the facility failed to provide adequate supervision and devices to prevent accidents for 1 (Resident #1) of 4 residents reviewed for accidents and supervision. The facility failed to ensure Resident #1 was provided with supervision resulting in him eloping from the facility on 03/18/23. Resident #1 was found approximately 5 miles away at a convenience store by Emergency Medical Services (EMS). The resident was taken to the hospital and required hospitalization for altered mental status and unknown infection. An Immediate Jeopardy IJ)was identified on 03/19/23 at 2:50 PM. While the (IJ) was removed on 03/22/23 at 1:30 PM, the facility remained out of compliance at a severity level of actual harm that was not Immediate Jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed all residents that are an elopement risk at risk for serious injury, harm, and/or death. Findings included: Review of Resident #1's MDS assessment, dated 01/12/23, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His BIMs score was 9 meaning he had moderately impaired cognition. The resident required one staff assist for transferring. The resident required supervision for walking and locomotion on/off the unit. The resident required 1 person assist for toilet use and hygiene. The resident was occasionally incontinent of bowel and bladder. The resident did not have any behaviors. The resident's diagnoses included Wernicke's Encephalopathy (disease that leads to confusion, loss of mental activity, and loss of muscle coordination), Parkinson's Disease (brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), and a seizure disorder . Review of Resident #1's Care Plan reflected the following: 09/26/22 Resident is exhibiting exit seeking behaviors by stating he no longer wants to live at facility. Wander guard placed on right ankle. Facility interventions included: Check resident location frequently, wandering alert bracelet to be checked by nurse every shift. If bracelet is removed, replace or place on increased monitoring of whereabouts. Observe for verbalizations of wanting to leave/go home. Review of Resident #1's Physician Orders reflected the following: 09/26/22 Wander Bracelet related to wandering/exit seeking behaviors. Nurse to check placement and function every shift including skin check under bracelet. Location of bracelet on resident: right ankle Review of Resident #1's progress notes reflected the following: 03/18/23 at 2:25 AM Late Entry: Patient (Resident #1) was not observed in his room, and on investigation, his roommate stated that patient informed him that he would be going to South Dallas to visit a friend. Patient wears an ankle wander guard bracelet, and it was noted that he has taken it off and he wrapped it up and put on top of toilet roll paper and put it in his drawer. The DON, Administrator, Physician, and Police was notified. Staff Immediately did a search of the whole building, rooms and surrounding areas, called the hospital and business, drove the streets. Patient is his own responsible person. - Weekend Supervisor. Review of Risk Elopement Assessment for Resident #1 reflected: 12/19/22 High Risk for Wandering . Review of the Police Report for Resident #1 reflected: [AGE] year-old male diagnosed with Parkinson's left the location. Male listed as missing. Male found. Reported 03/18/23 6:59 PM. Cleared 03/20/23 10:52 AM An interview with the DON on 03/19/23 at 1:00 PM, the DON revealed Resident #1 eloped from the facility on 03/18/23 . She said the resident was oriented x2 and his own responsible party. The DON said the resident was found by EMS at a convenience store approximately 5 miles away from the facility. She said she had spoken to the resident, and he said he left the facility because he needed a break and was still in the hospital. The DON said the facility did not have a secure unit but did have a wander guard system in place. The DON said Resident #1 took off his wander guard bracelet before eloping from the facility. The DON said the resident wore the wander guard because he was at risk for wandering. The DON said a little after 2:00 PM on 03/18/23 the resident left the facility, and the security doors were working at that time. He was found sometime between 5:00-6:00 AM on 03/19/23 by EMS. She said she did not know how he eloped from the facility because all the doors required a security code to exit and enter the facility . An observation on 03/19/23 at 2:25 PM, of Hall 200 with CNA A revealed there were two sets of doors that had to be opened to go to the smoking area. The 2nd door had a security code pad and CNA A entered the code to open the door. The smoking area had sidewalks and a gazebo. There was no fence or barrier to prevent residents from walking to the front of the building. CNA A said on 03/18/23 construction painters were painting the interior area with the vending machines when she arrived for her shift at 2:00 PM. She said later she saw the painters had barricaded the first door with the vending machines to paint behind them. An observation and interview on 03/20/23 at 2:30 PM, with Resident #1 revealed he was still in the hospital. He was in bed awake and alert and was oriented x2. (He knew who he was and where he was, he did not know what day it was or why he was in the hospital.) The resident was unable to recall specific events of his elopement. He did not remember being found. He said he took of his bracelet and left the facility. He said he was able to push the door (on Hall 200) open and go out the door. He said he did not have to enter a security code. He said residents frequently used that door to go outside to smoke. He said when he left the facility he wanted to go to South Dallas, get his government money and get his own place, but did not know how to do it. He said he did not know where he was going when he left the hospital, but did not want to go back to the facility because he did not like it. An interview on 03/20/23 at 2:40 PM, the Hospital RN assigned to Resident #1 reflected the resident was in the hospital for altered mental status and an infection (the nurse did not say what the infection type was). She said she did not know when or where the resident was going to be discharged to. She said the resident was alert and oriented x2. An interview on 03/19/23 at 2:30 PM with Resident #2 revealed he was awake, alert, and oriented x4. He said he saw Resident #1 go out the Hall 200 door on 03/18/23 after lunch while he was sitting outside. He said there were no staff outside and no one let Resident #1 out of the facility and no one followed him out of the facility. He said Resident #1 exited the facility by himself. Resident #2 said he was able to go out of the Hall 200 door by entering a security code to leave and another security code to re-enter. He said he saw Resident #1 with his coat and hat on and knew he was not supposed to be outside. He said he saw him go around the edge of the facility in his wheelchair. Resident #2 said he was seated in the smoking area at the gazebo in front of the laundry department . Resident #2 said he did not tell anyone he saw the resident. An interview on 03/22/23 at 12:50 PM, CNA A revealed she was assigned to Resident #1 on the 2:00 PM - 10:00 PM shift on 03/18/23. She said she did rounds after starting her shift at 2:00 PM, but she did not see him. She said she thought the resident was in the front room of the facility. She said at dinner time (approximately 4:30 PM-5:00 PM), she put his tray in his room as she did every day. She said she went to pick up the tray and realized he had not eaten it. She notified LVN B at that time that she could not find Resident #1. She said staff started searching for him. An interview on 03/22/23 at 1:15 PM with LVN B revealed she was assigned to Resident #1 during the day and evening shift. She said she had checked his Wander guard and said it was in place before and after lunch (did not know exact times) on 03/18/23. She said the last time she saw the resident was after lunch. She said she identified he was missing when CNA A said he did not eat dinner (did not know exact time). LVN B said staff looked in all the rooms inside and outside the facility looking for the resident but could not find him. She said she notified the Weekend Supervisor. LVN B said Resident #1's roommate, unknown time, told him he was going to South Dallas to visit a friend. An interview on 03/19/23 at 1:45 PM with the Weekend Supervisor revealed on 03/18/23 she saw Resident #1 at around 10:00 AM and he was in his room. She said at lunch time (did not know exact time) she saw Resident #1 at the nurse's station. She said around 4:30-5:00 PM CNA A reported she went to pick up the residents tray and noticed the resident was gone. The Weekend Supervisor said staff started searching the facility for him. She said Resident #1 had a wander guard, and while searching his room, they found it in his drawer. She said when staff could not find him, they called the police. She said the resident did not have a history of removing his wander guard. She said someone might have let the resident out of the Hall 200 door when they were going out to smoke. She said smoking residents knew the code to enter and exit the facility to smoke. She said the smoking area was not fenced and anyone could walk around the building. She said he told his roommate and had told residents before he wanted to go to South Dallas. An interview on 03/20/23 at 11:25 AM, with the Administrator revealed she had video footage showing Resident #1 outside of the building on 03/18/23. The video did not have a time stamp. The video showed Resident #1 in the courtyard. She said she spoke to Resident #3 and said he let Resident #1 out even though Resident #2 said no one followed or opened the door for Resident #1. The camera footage showed Resident #3 was outside. She said she did not know how Resident #1 eloped. An interview on 03/20/23 at 11:35 AM, Resident #3 revealed he was awake, alert, and oriented x3. The resident said he did not let Resident #1 out of the door and did not know why facility staff said he did. An interview on 03/20/23 at 11:40 AM with the [NAME] reflected he said they did not prop the Hall 200 door open while painting. An interview on 03/22/23 at 10:00 AM, the Administrator and DON revealed Resident #1 was still in the hospital. They said the facility should not be held responsible for the actions of Resident #1 because even though he had a BIMs score of 9 and had moderately impaired cognition the resident made a plan and executed it when he removed his wander guard. Record review of the facility policy, Wanderer Management, Monitoring System, and Resident Elopement Protocol, dated 01/17/18, reflected: It is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible . This failure resulted in an identification of an (IJ) Immediate Jeopardy on 03/19/23 at 2:50 PM, the administrator was notified The IJ template was provided to the Administrator on 03/19/23 at 3:00 PM and a Plan of Removal (POR) was requested. The Plan of Removal reflected: Resident #1 admitted to the facility on [DATE]. When he admitted , he made verbal statements about wishing to maintain his homeless lifestyle and go back to South Dallas (where he was from). As a result, a wander guard bracelet was provided as a precautionary measure. He willingly and knowingly created a plan to exit the building on 03/18/23. He intentionally cut his wander guard bracelet off, hid it in a toilet paper roll and placed it in the drawer to prevent it from being found. He also verbalized to his roommate that he planned to visit a friend in Dallas. In addition, he took a jacket and a hat to prepare for the weather. Our investigation also revealed that Resident #3 inadvertently let Resident #1 out while he was re-entering the facility. We have all our doors secured. Residents at elopement risk have wander guard bracelets which alarm when an elopement is attempted. The bracelet is checked every shift by nurses for placement and function. The door functions are checked weekly by the Maintenance Director. The Interdisciplinary team discusses our at-risk residents weekly to identify any changes in behavior that may be indicators of added risk . The Plan of Removal was accepted on 3/21/23 at 1:53 PM. Monitoring of the plan of removal included: Observations and interviews were conducted on 03/21/23 starting at 2:10 PM and continued through 03/22/23 at 1:15 PM with 9 staff from various shifts regarding in-services which included elopement and monitoring of residents with a wander guard. The staff members were able to: identify the residents with a wander guard, their responsibility for their monitoring, and what to do if they did have a resident who eloped. Interviewed staff members and shifts were: ADON C - worked all shifts ADON D - worked all shifts LVN E - worked 6:00 AM to 2:00 PM LVN F - worked 6:00 AM to 2:00 PM CNA A - worked 2:00 PM to 10:00 PM LVN B - worked 2:00 PM to 10:00 PM LVN G - worked 6:00 AM to 2:00 PM and worked 2:00 PM to 10:00 PM CNA H - worked 6:00 AM to 2:00 PM and worked 2:00 PM to 10:00 PM CNA I - worked 6:00 AM to 2:00 PM and worked 2:00 PM to 10:00 PM. Smoking signage observed in the smoking area said to notify staff to access the smoking area and to not share security codes. Three residents with wander guards were observed wearing them. An interview on 03/22/23 at 12:40 PM with the DON revealed there were three residents who wore a wander guard, and they were assessed every shift to make sure they were wearing the wander guard. The door codes had been changed, and the facility doors were routinely checked to make sure the wander guard system was working. She said the facility systems in place to prevent elopement were the Wander guard system and the facility doors required a passcode to enter and exit. The DON said Resident #1 was not returning to the facility. An interview on 03/22/23 at 12:55 PM with the Administrator revealed three residents who wore a Wander guard. He said there were multiple assessments completed by the different departments. He said the nurses checked residents every shift to make sure they were wearing the Wander guard ankle bracelet. He said maintenance performed weekly checks on the doors and that all doors required a security code to enter and exit. He said that on-going monitoring would include interdisciplinary team meetings and weekend supervision. The administrator was informed the Immediate Jeopardy was removed on 03/22/23 at 1:30 PM. While the IJ was removed the facility remained out of compliance at a severity level of actual harm that was not Immediate Jeopardy and a scope of isolated, due to the facility still monitoring the effectiveness of their Plan of Removal.

Based on interviews and record reviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (Resident #1) of seven residents reviewed for elopement. The facility failed to provide adequate supervision to Resident #1 for over an hour and a half, last seen on 08/09/22 at (2:00 AM) and as a result, the resident eloped from the facility and was observed by Law Enforcement walking down the sidewalk of a busy four lane street, (.7 miles) away from the facility and was returned to the facility on [DATE] at 3:48 AM. It was determined a past non-compliance Immediate Jeopardy existed from 08/09/22 at 2:04 AM to 08/09/22 at 3:48 AM, because the facility staff were unaware Resident #1 had eloped from the facility. The Immediate Jeopardy was determined to have been removed on 08/16/22 due to the facility's implemented actions that corrected the non-compliance of re-educating staff about assessing and identifying wandering residents, elopement risks and alarm management and educating residents about the door access code and not letting other residents outside prior to the beginning of the HHSC investigation on 08/23/22. The Staff and residents confirmed they were adequately trained about the prevention of elopements. This failure could place residents at risk for accidents, falls and serious injury resulting in a decreased psycho-social well-being, physical decline or death. Findings included: Review of Resident #1's undated Face Sheet revealed an [AGE] year-old male who admitted [DATE] with diagnoses Dementia, [CONDITION(S)], Anxiety, Depression, Alzheimer's, Hypertension, Acute [CONDITION(S)] and Urinary Incontinence. Review of Resident #1's Quarterly MDS assessment dated [DATE] revealed Resident #1's BIMS score was 6 (Severely Impaired), and the resident had no wandering behavior, independent with locomotion off unit, with setup only, not steady, but able to stabilize without staff assistance with balance during transitions and use of a wheelchair. Review of Resident #1's Quarterly MDS assessment dated [DATE] revealed, BIMS score of 6 (severely impairment), and the resident wandered between 1 to 3 times a day, supervision with locomotion off unit, one person assists and not steady, but able to stabilize with staff assistance for balance during transitions and walked with the use of a walker. Review of Resident #1's Care Plan dated 04/20/22 revealed, I have been evaluated as a high wandering risk related to decreased safety awareness, wanting to go home and exit seeking Resident trying to leave facility, redirected, [family member] notified .Interventions: Wandering alert bracelet to be checked by nurse for placement and function, if bracelet removed please replace or place on increase monitoring of my whereabouts .Wandering device placed on my left ankle to alert staff of me approaching an exit door. Review of Resident #1's Care Plan dated 02/02/22 revealed, ADL self-care performance, Impaired Cognitive function related to Alzheimer's, Falls, Depression, Bladder incontinence and etc. Review of Resident #1's Baseline Care Plan dated 01/14/22 revealed, .B. Functional abilities and Goals - mobility: No setup, or physical help from staff for bed mobility, transfers, walk in room, walk in corridor, locomotion and used a wheelchair, alert and cognitively intact, history of falls .Resident #1 ambulates ad lib, makes needs known, meds taken whole, feed self, wound care to blister, assist prn . Review of Resident #1's Physician Order Recap Report dated from 12/28/21 to 08/31/22 revealed the following orders: -12/28/21 [MEDICATION(S)] (for depression) 30 MG, -04/25/22 [MEDICATION(S)] Patch (for Dementia) and -04/25/22 0.5 MG [MEDICATION(S)] (for Anxiety), -05/02/22 Wander bracelet r/t wandering exit seeking behaviors, nurse to check placement and function q shift including skin check under bracelet, -07/12/22 [MEDICATION(S)] (Anxiety) 0.5 MG, -08/08/22 [MEDICATION(S)] (for [CONDITION(S)] with [CONDITION(S)]) 125 MG, -08/10/22 wander bracelet, and -08/10/22 [MEDICATION(S)] (for [CONDITION(S)] . severe psychotic) 2.5 MG, -[MEDICATION(S)] (Urinary Incontinence) Tablet 5 MG . Review on Resident #1's Wander Guard Collection Assessments scores indicated the following: Wander Data Total Score: 0-6 = Low, 7-11 = moderate, 12 and above = High -12/28/21 score was a 1 (low risk), -01/14/22 score was 12 (High risk), -02/06/22 score was 24 (high risk), -04/22/22 score was 5 (low risk), -05/06/22 score was 6 (low risk), and -08/09/22 score was 21 (high risk). Review of the facility's Camera footage titled Video 1, revealed Resident #1 on 08/09/22 at 2:04 AM walked with a red rolling walker, wearing grey sweatpants, red/black plaid long sleeve shirt, black hat and house shoes was seen leaving the south end of the facility where the gazebo was located. Review of the facility's Camera footage titled Video 2 revealed on 08/09/22 at 3:48 AM, a LE SUV arrived at the front entrance of the facility and two staff members and Resident #1's Family Member was standing outside the facility's front door. Review of the Facility's Provider Investigative Report dated 08/09/22 revealed on 08/09/22 Resident #1 left the facility at 2:05 AM and was found by LE and returned at 3:48 AM by LE, a head-to-toe assessment was completed, the resident had no injuries, notifications to Resident #1's Doctor, Family member and Ombudsman was done. And Resident #1 was assessed by his psychiatrist and received counseling. Resident #1 was given food/water, showered, put on 1:1 monitoring until Resident #1 was transferred to a secured unit on 08/11/22. The Facility conducted several Staff and Resident interviews and discovered Resident #2 opened the exit door for Resident #1 to elope. The Wander guard system and security locks on the doors were checked and working properly. Life satisfaction rounds and interviews with the residents and education with staff about the wander guard system, wander risks, alarm system and elopement were conducted, and staff statements were collected. Findings: confirmed. Review of Resident #1's Nurse Progress Note dated 08/09/22 at 4:23 AM written by the DON revealed, Resident was brought back to the facility by LE at around 3:45 AM .Resident #1 returned to the facility with no distress noted. Upon arrival into the facility resident was immediately assessed and placed on 1:1 monitoring, and room change completed immediately to room 301. Head to toe assessment completed no apparent injuries noted at this time. No break or abrasions noted. No indication of complaints of pain at this time . Review of Resident #1's Nurse Progress Note dated 02/06/22 at 8:12 PM, written by LVN G revealed, This nurse was told by aide that the resident went outside by the laundry room towards the trash cans. The aide redirected resident to his room. Resident #1 was asked where he was going and the resident responded Just to hang out with the people, its nice out . Interview on 08/25/22 at 5:38 PM, CNA I stated one day 02/06/22 he saw Resident #1 going towards the gazebo with the other residents, and CNA I stated he redirected Resident #1 back inside the facility then took him to the LVN G to report what happened. CNA I stated he had not ever seen Resident #1 touching the doors to open them or triggering the alarm system. Review of Resident #1's Former Social Worker Progress dated 04/20/22 at 2:31 PM written by SW H revealed, SW followed up with RP about residents' behavior, resident was trying to leave the facility, resident was redirected, RP said he would follow-up with resident, due to being something normal for him and said he will stop by before going to work to visit. Review of Resident #1's Nurse Progress Note dated 05/02/22 at 12:50 PM written by LVN D revealed, NP aware of resident increased agitation and wanting to go home . Review of Resident #1's Nurse Progress Note date 05/02/22 at 2:47 PM written by LVN D revealed, RP notified of wander guard gave permission for wander guard to be placed on the resident, wander guard placed on resident's right ankle. Review of the Resident #1's Progress Notes dated 07/08/22 written by the Psychiatrist revealed, Interval History: PT is guarded this morning and appears confused stating I don't live here PT believes he is going home and is irritable .Staff reports patient is trying to go home at times .recommend an increase in PT's antidepressant and to start a prn [MEDICATION(S)] for anxious episodes .continue to monitor mood, behaviors and potential side effects of medications . Review of Resident #1's Nurse Progress Note dated 08/05/22 at 6:00 AM written by LVN D revealed, Resident sitting in the hallway having delusional episodes stated I have to leave my niece is in the hospital, resident agitated but directable .will notify psychologist . Review of Resident #1's Nurse Progress Note dated at 08/09/22 at 9:23 AM written by LVN K revealed, Resident continues to be on one-to one supervision at his time due to wandering. Resident doesn't attempt to seek exit doors and monitored closely without any problems. Review of Resident #1's Progress Note dated 08/10/22 written by the Psychiatrist revealed, Staff requests for evaluation and medication review. Staff reports Patient eloped yesterday morning and returned safely with LE .Pt states I was going home because I got $30,000 in my bank account .Pt believes his house is down the road .A/O x 1 .Diagnoses [CONDITION(S)], Dementia, Generalized Anxiety Disorder .Recommend a Dementia unit. Review of Resident #1's Monitoring tool dated from 08/09/22 at 3:30 AM to 08/11/22 at 2:00 PM revealed Resident #1 documented his activities and signatures of staff doing the monitoring. Review of Resident #1's Nurse Progress Note dated 08/11/22 at 11:56 AM written by SW J revealed, Resident has been accepted for transfer to Another Nursing home facility's Secured Unit and will be picked up from the facility today at 3:00 PM . Interview on 08/23/22 at 10:46 AM, Resident #2 stated he had not ever seen residents wander out of this facility but one early morning about two weeks ago around 2:30 AM or so, Resident #1 was walking down the hall with a walker to the 200 hall doors and Resident #2 said he opened the door for Resident #1 to walk out of the facility. Resident #2 said he thought Resident #1 was a visitor and did not know he was a resident then the Admin spoke to him about not ever using the access code # to let anyone out of the facility again and report to staff if he saw a resident leaving the facility. Interview on 08/24/22 at 3:27 PM, Resident #3 stated he had seen Resident #2 let Resident #1 out of the door who walked with a red rollator, the door alarm sounded off, but there were no staff around, Resident #1 was gone for about an hour and was not injured, Resident #3 stated telling someone Resident #1 went out the door but could not remember who. Resident #3 stated the Admin told him to never let other residents out and report to staff immediately, if he saw a resident wandering out. Interview on 08/23/22 at 3:01 PM, CNA A said she worked 08/09/22 when Resident #1 eloped and saw Resident #1 and Resident #5 sitting in the hallway, then CNA A said she put Resident #5 to bed then Resident #1 went to his room, then saw Resident #1 at 1:00 AM in his room as she was taking another resident to their room, then close to 2:00 AM she saw Resident #1 at the nurses' station when she started her 2:00 AM rounds. CNA A stated they were unaware Resident #1 had left the facility until LE brought Resident #1 back to the facility. CNA A stated Resident #1 said he had been walking on a venture. Interview on 08/23/22 at 4:30 PM, CNA B stated on 08/09/22 at 12:00 AM, was when she last saw Resident #1 in the hallway talking to other residents. Interview on 08/25/22 at 2:01 PM, LVN C stated on 08/09/22, before Resident #1 eloped, Resident #2 was up and sitting in the hallway and usually up at night like resident #1. LVN C stated measures the facility had in place to prevent Resident #1 from eloping, were for staff to communicate via the nursing report and verbally to the oncoming nurse, about any changes in Resident #1's behavior, and placement and functioning of his wander guard that was checked every shift and redirected Resident #1 when needed. LVN C stated some nights Resident #1 slept and other nights it was not out of the norm if Resident #1 was up late night and listening to music. Interview on 08/24/22 at 1:49 PM, LVN F said he worked the night Resident #1 eloped and the wander guard system and exit door system was intact, but it was reported later that Resident #2 let Resident #1 out of the facility, and there was no problem with Resident #1's wander bracelet not working properly. LVN F said Resident #1 was not exit seeking prior to leaving the facility and when he eloped on 08/09/22 there was two nurses, and five aides working and there were no alarms going off to alert them about Resident #1 leaving the facility. LVN F stated he last saw Resident #1 at 1:30 AM, at the nurse's station, Resident #1 was walking down the hall, he was his usual self and there were no signs he was going to leave and did not see any residents letting him outside of the facility. LVN F stated he did not know Resident #1 had left the facility until LE returned Resident #1 to the facility. The resident was assessed with no injuries and placed on 1:1 monitoring until transferred to secured unit facility. LVN F stated having an elopement training earlier this year and after Resident #1 eloped. Interview on 08/23/22 at 4:44 PM, LVN C stated about three weeks ago she worked that night as Resident #1's nurse, she stated Resident #1 was his usual self that day. She stated the resident went to the TV area, nurses' station, then back to his room. LVN C stated the last time she saw him on 08/09/22 around 2:00 AM, she stated she knew it was around this time because Resident #1 came up to the nurses' station and asked, Have they found the lost girl LVN C said she redirected Resident #1 back to his room and told Resident #1 they would look for the lost girl tomorrow morning. LVN C said he was sitting at his bedside and thought he was settled in room, so she went to check on another resident and started the resident's 2:00 AM medications. LVN C stated she did not know Resident #1 was out of the facility until around 3:45 AM when LE brought him back saying Resident #1 was found walking down the street. Resident #1 was assessed, the Doctor, the Admin, the DON and [family member] was notified and Resident #1 was moved to another room then to a secured unit Nursing Facility. LVN C stated she had never seen Resident #2 let residents out of the facility and after Resident #1 eloped, she was Inservice trained on preventing resident elopements. Interview on 08/24/22 at 10:41 AM, CNA E stated she worked the 200 hall the night Resident #1 eloped and the last time she saw Resident #1 was at 2:00 AM by the nurses' station, he was talking to the nurses and did not see Resident #1 exiting the facility and had not seen residents letting another resident out of the facility. CNA E stated next time she saw him was after 3:00 AM when LE brought Resident #1 back to the facility. The last Elopement Inservice training was a few days ago and told if a resident wandered, she needed to redirect the resident and immediately report it to the nurse and closely monitor the resident and if the resident continued to show wandering behaviors to do 1:1 monitoring. Interview on 08/25/22 at 5:45 PM, Resident #4 stated she was up the morning of 08/09/22 and saw Resident #1 walking by the 200 hall doors. She stated Resident #1 followed Resident #2 then Resident #2 pressed the door code to let Resident #1 out of the door, then she told a staff member about it but Resident #1 was back at facility. Interview on 08/24/22 at 12:46 PM, LVN D stated when she arrived at this facility on 08/09/22 at 5:45 AM, Resident #1 had just returned and there were no issues with the wander guard alarm or door security alarms sounding off or malfunctioning, there were no issues with not having enough staff the night Resident #1 eloped. LVN D stated all staff were responsible for monitoring wandering residents with the nurse being primarily responsible. Interview on 08/24/22 9:50 AM, LVN D stated she was given a report from LVN C about Resident #1 leaving the building, the resident was assessed, the Doctor notified, the resident was moved to Room 301 and placed on 1:1 then he went to another facility. Resident #1 was A/O x1 and ambulated with minimum assistance with a walker and Resident #2 was A/O x3, able to get around without assist and said she had not ever seen Resident #2 letting the residents out of the facility. Interview on 08/23/22 at 10:00 AM, the Admin stated the facility had no secured unit but had a wander guard system and security lock and alarm system on all the exit doors, which required a code # to enter and exit the facility and stated they did not currently have any residents who wandered or wore wander guard bracelets. Interview on 08/24/22 11:23 AM, the Maintenance Director stated not having any issues with residents eloping the facility, until Resident #1 did on 08/09/22 and said he checked the exit door locks and alarms without any error codes, he checked the alarm systems weekly, and the exit doors checked daily. He stated there were no malfunctions with the wander guard system and security door alarms prior to 08/09/22 or after. He said there were no issues with Resident #1's wander guard bracelet and after Resident #1 eloped, he checked every single door and wander guard system and there were no issues with any of them. He stated Resident #1 started getting 1:1 monitoring after eloping and transferred to a secured unit facility, because they have no secured unit. He stated they have had elopement trainings with the staff upon hire, annually, and they do drills when an incident occurred. He stated the wander guard system was serviced quarterly, and if staff was to have a problem with exit doors and wander guard, they were to notify him, the admin, and the DON. He stated the facility was locked at all times and to get in or out required an access code # which was changed monthly. Interview on 08/23/22 at 2:16 PM, the DON stated a 4-digit code was needed to get out of the facility and based on their investigation Resident #1 walked out of the side door where the vending machines were located with the assistance of Resident #2 pressing the 4-digit code to unlock the door. None of the staff said the alarms had gone off, he was not an exit seeker but had a wander guard on because he wandered the halls but never left the facility. The DON stated after Resident #1 eloped on 08/09/22 they did a full head to toe assessment of Resident #1 with no treatment needed or injuries, replaced the wander guard bracelet, provided a snack and drink, moved the resident to room 301 (because the 200-hall had two exit doors and 300 hall only had one exit door), initiated 1:1 monitoring, and transferred Resident #1 to a secured facility. The DON stated they spoke to Resident #1's family member and RP agreed with moving Resident #1. The DON said there were no issues with the wander guard system not working properly and the admin educated Resident #2 and felt Resident #2's actions were not intentional but was out of courtesy, but they told him not to ever let any residents out again. Resident #1 was out of the facility for 1 hour and 32 minutes. The DON stated all nurses checked Resident #1 every shift changes to make sure the resident's wander guard remained active with the use of device checker. When asked how often staff should monitor resident who are wander risks the DON stated it was based on each residence circumstances. Interview on 08/23/22 at 2:52 PM, the Admin stated Resident #1 liked sitting with his walker at his room door, was very sociable, talked to the other residents, he had a wander guard bracelet on at all times, with no issues with the wander guard bracelet or system not working. She stated after LE brought Resident #1 back to the facility, LVN C called to inform of Resident #1's elopement, LVN C did Resident #1's head to toe assessment which revealed no injuries, maintenance checked the wander guard/system checks, she(Admin) and the DON did head counts of all residents, spoke to Resident #1's Responsible party and the Doctor. The Admin stated Resident #1's needs were met, and he was comfortable and not delusional or distressed, but had some confusion saying, He needed to help a lost Spanish girl. The Admin stated Resident #1 received 1:1 monitoring, had a wander guard in place, and had no other elopement history. She stated the Maintenance Director had no issue with door alarms and no staff said the alarm had sounded that morning. The Admin stated it was found out Resident #2 said he let Resident #1 out. The Admin stated she spoke to Resident #2 about overall safety and to not open the door for residents and that all residents do not have the same cognition levels, Resident #2 was A/O x 3 and understood and agreed. The Admin stated Resident #1 transferred to a secured unit facility and since Resident #1 eloped, they have had Quality Assurance meetings with Corporate and employee trainings in-services on elopements. The Admin stated after they investigated and confirmed their findings Resident #1 had eloped due to Resident #2 letting Resident #1 out of the building and the fact that staff had last seen Resident #1 around 2:00 AM and there being no reports of Resident #1 exit seeking. She did not see the facility staff at fault for Resident #1's elopement. The Admin stated the nurses checked the resident wander bracelets each shift, and department heads check the bracelets periodically and maintenance director checked the wander guard system weekly, and the staff knew to report any faulty bracelets to the Maintenance Director. Interview on 08/24/22 at 5:18 PM, the DON stated the reason Resident #1 had a wander guard on was because when he was readmitted on [DATE] to the facility he was walking everywhere inside of the facility, not exiting facility, and, he would say he wanted to go home and as a preventative measure, a wander guard was put on him because Resident #1 was unfamiliar with the facility. The DON stated a resident at risk for wandering was monitored daily by the nurses and CNAs at all times and every two hours and was primarily the responsibility of nurses to monitor the residents. The DON stated if a resident was exit seeking, they should be checked every 30-minutes and for an actual elopement 1:1 monitoring was needed. Interview on 08/25/22 at 8:46 AM, the DON stated Resident #1 discharged to a sister facility on 01/03/22 due to having an infection and upon re-admitting to this facility 01/14/22, Resident #1 was re-assessed for a wander guard based on information by Resident #1's RP at the care plan meeting and with Resident #1 being new to the facility, the precautionary measures were to get Resident #1 a wander guard. The DON stated Resident #1 wandered once to the laundry room on 02/06/22 but CNA I was sitting outside with other residents and saw Resident #1 and brought the resident back inside the facility. She stated on 04/20/22, the DON said she received clarification from SW J that Resident #1 did not try to physically leave the facility but was verbally making the statement to leave. Interview on 08/25/22 at 11:27 AM, the Admin stated Resident #1 statements to leave the facility were isolated, there were no reports of the resident actually going to the door and pushing it, Resident #1 only made statements to leave, going to work. The admin stated on 02/06/22 staff saw Resident #1 outside by the laundry room and a CNA redirected resident back into the facility and reported it to the nurse, a wander guard assessment was done, and care plan updated for staff to continue monitoring and reporting to nurse. She stated they have no cameras inside the facility or pointing towards the door. The Admin said during interviewing the residents, Resident #2 admitted to letting Resident #1 out and stated Resident #2's cognition was really good. The Admin stated she explained to Resident #2 not to do that again because all residents were different and cannot go outside without staff or RP. The Admin stated Resident #1 and Resident #2 were known to sit in the hallway and talk to one another and added her expectations was for all disciplines to ensure they were on the same page with communicating, providing services, activities, family notifications and involvement. The Admin stated Resident #1 eloped 08/09/22 wearing grey sweatpants, red/black plaid shirt with a rolling walker and Resident #1's Psychiatrist assessed the resident on 08/09/22 and a referral to a secured unit was made and on 08/11/22 Resident #1 was transferred to a secured unit facility. Interview on 08/25/22 at 5:32 PM, LVN G stated Resident #1 was new to the facility and on 02/06/22 Resident #1 wandered outside to the laundry area and CNA I brought Resident #1 to her and Resident #1 said, All these other nice men out getting some air and stated she assessed him and he was A/Ox4 and wanted to go outside get some fresh air, he wanted to hang out with the other male residents, LVN G said she assessed Resident #1 cognitively and physically, and determine Resident #1 had no motive to leave he wanted to socialize. She stated she did a wander guard assessment and notified her supervisors. LVN G stated that was a onetime thing he was found by staff and if a resident was actively wandering, they would put them on 1:1 monitoring, but Resident #1 was not actively wandering and was monitored every two hours. Interview on 08/25/22 at 2:58 PM, the Maintenance Director stated all of the facility doors were locked at all times, a code system with the grab bar and 15 second alarm will sound off, then once it stops sounding will open, the front entrance door was the only door with the wander guard detection system and all other doors did not. Resident #1's wander guard bracelet would not have caused the 200-hall side door alarm to sound off when he went out that day because it did not have a wander guard sensor, but if Resident #1 had pressed the door to open it, the alarm would have gone off to alert the staff. But in this case, Resident #2 pressed the access door code to let Resident #2 out and the reason why the door alarm did not go off and said they will be getting a wander guard sensor for the 200-hall door within the next month and was not sure why it was ordered. Interview on 08/25/22 at 3:45 PM, the DON stated they do wander guard assessments on all residents on admission and if the resident's wander assessment was high, they would contact the Doctor and if the Doctor deemed the resident needed secured unit would transfer them out. For all residents they were checked every two hours and for wanderers every two hours and when needed, if a CNA and other staff saw a resident trying to elope, they would redirect the resident and report it to the charge nurse, then the charge nurse would call the doctor, family on what to do next. The DON stated the facility had 11 residents with the door access code who has been assessed and educated about not to letting any residents out or allowing residents to follow them out of the facility. Interview on 08/25/22 at 4:15 PM, the Admin stated they have a centralized admissions team and since Resident #1 eloped on 08/09/22 they look more carefully at residents with wandering tendencies and were currently not accepting any residents with a wandering behavior. The Admin stated having a collaborative effort with their admissions process and with corporate office and now asked more questions, such as: if the resident had a history of wandering, were they coming from a secured unit facility, received 1:1, sitter service currently, review the resident's notes to see if the resident has any wandering history. She stated the facility admission team had an interdisciplinary approach with corporate, dept heads, family, and physician. She stated if a resident was not a wander risk upon admission and later had wandering tendencies, they would first exhaust all alternatives such as: counseling, psychiatric consults and medication review. She stated if the interventions were not effective, they would follow policy with increased monitoring until the resident was transferred to a secured unit facility. The Admin stated they assessed all the resident's safety and cognition and spoke to the family members and residents about not letting residents out, or letting them follow them out, and to make sure the doors were completely closed before walking away. The DON stated the 200-hall door had a security lock and alarm system and the facility was currently pending to get second form of security, a wander guard sensor for the 200-hall door. Interview on 08/25/22 at 5:12 PM, the Admin stated she educated Residents #2 and #3 on 08/09/22 and the other nine residents on 08/16/22 about not the letting other residents out of the facility. Review of the Provider Investigation Report dated 08/09/22 revealed Resident #1 was found by LE (Law Enforcement) on 08/09/22 and returned to the facility at 3:48 AM, Review of the LE Call Summary dated 08/09/22 at 6:22 AM revealed, On 8/9/2022 at 3:30AM, Resident #1 was found by LE at 1102 South [NAME] Hill Road, Duncanville, Texas struggling getting up onto a curb with his walker. Resident #1 was wearing house slippers, a jacket and long pants; the temperature at the time was 95 degrees Fahrenheit, Resident #1 was sweating, and he had a slight odor .Resident #1 mentioned trying to get to a military base . Review of https://www.mapquest.com/directions reflected the location LE found Resident#1 was .7 miles from the nursing facility, near US Highway 67. Observations from 08/23/22 at 8:50 AM to 08/25/22 at 5:45 PM did not reveal any residents exit seeking, wandering or being let outside by other residents and there were no issues with how the exit doors worked and signs were posted at the exit doors not to let the residents out of the facility. Observations on 08/25/22 from 3:09 PM - 3:20 PM, an inspection of the facility's exit doors with the Maintenance Director present revealed, all exit doors were checked and locked correctly and the door alarms worked loudly once the doors were pushed. There were no error codes at any of the wall panels at each door and the main panel display located directly across from the nurse's station did not have any error codes. Observation on 08/25/22 at 8:55 AM, Revealed the street facing this facility was a busy 4-lane Street. Review of the facility's Inservice trainings from 08/09/22 to 08/16/22 revealed trainings on wander risk assessments, Wander Risk and Elopement Protocol: what is elopement, identifying a wander risk resident, looking at the red wander binder for residents to monitor, steps to prevent elopements and if a resident eloped. Elopement Drill and information about the electronic monitoring system to ensure the doors worked properly and securely and the staff were provided the door access code. And the TELS Maintenance forms did not reveal any problems with the exit door mechanisms prior to 08/09/22 and after. And review of Resident #1's MAR revealed his wander guard checks had been done including on 08/09/22. Review of the Facility's Provider Investigative Report dated 08/09/22 revealed, the Admin educated Residents #2 and #3 on 08/09/22 about not letting the other residents out of the facility and not sharing the facility's door access code with anyone. Review of the Facility's Census Sheet dated 08/23/22 revealed, checkmarks of the ni [TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 (Resident #1) of 4 residents reviewed for quality of care. The facility failed to ensure Resident #1's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 06/20/22, Resident #1 admitted to the ICU after he was noted with a change in condition. The resident admitted with a blood glucose greater than 1200 milligrams per deciliter and was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . It was determined a past non-compliance Immediate Jeopardy existed from 06/04/22 to 06/20/22. The Immediate Jeopardy was determined to have been removed on 06/20/21 due to the facility's implemented actions that corrected the non-compliance prior to the beginning of the investigation on 06/24/22. These failures placed residents at risk of not receiving medications and care to address their medical conditions, which could cause exacerbations and manifest into other health complications resulting in serious injury, harm and/or death. Findings included: Review of Resident #1's undated electronic Admission Record revealed the resident was a [AGE] year-old male admitted to the facility on [DATE]. Physician's undated electronic order summary reflected diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's admission MDS assessment dated [DATE] reflected the resident required total physical assistance of two or more persons for bed mobility and hygiene and extensive assistance of two or more persons for dressing. The resident's BIMS score was 8 indicating moderately impaired cognition. The MDS assessment further reflected the resident received nutrition via a gastric feeding tube (feeding tube placed through the abdominal wall and into the stomach) and active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's comprehensive care plan dated 06/20/22 revealed the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included administering medications according to physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident#1's progress notes documented by the DON dated 06/20/22 reflected the resident was not responding at normal baseline. A telemedicine visit was performed, and the assessment reflected rapid respirations of 38 per minute with 12 seconds of apnea (temporary cessation of breathing). Orders were received to transfer the resident to the hospital for further evaluation. There was no documented evidence in the clinical records of Resident #1's medications were verified by the physician or NP on admission. Review of MARs and Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no orders for blood glucose monitoring and no evidence Resident #1's blood glucose was monitored in the facility. Review of Resident #1's hospital records (admitted [DATE]) prior to admission to the facility, revealed there were no discharge orders or instructions in the records provided to the facility from the transferring hospital. The records contained a recap of the resident stay in the hospital including five-day medication administration records dated 05/27/22 through 05/31/22. The medication administration records reflected the resident was receiving 20 units of [MEDICATION(S)] insulin two times a day and Regular insulin as needed according to a sliding scale (varied doses of insulin based on blood glucose level). The hospital records reflected the resident's blood glucose was routinely being monitored. Interview on 06/24/21 at 2:00 p.m. the DON stated prior to Resident #1's admission on 06/04/22 there had been no procedures in place to review and/or check to ensure orders were verified with the physician, transcrived and/or reconciled accurately. Interview with the Corporate Nurse and Administrator on 06/24/22 at 3:33 p.m. revealed no discharge orders were received from the hospital when Resident #1 admitted to the facility on [DATE]. They stated the admitting nurse (LVN A) used the hospital records that listed medications the resident had been receiving in the hospital and transcribed some but not all of the medications the resident was receiving onto the facility's medication administration records. They stated LVN A told them she became distracted and did not transcribe all of the medications from the hospital records. They further stated they had not been able to fully interview LVN A and had been attempting to reach the nurse without success. Interview with Resident #1's family D on 06/24/22 at 4:45 p.m. revealed they were present in the facility on 06/20/22 and noted the resident was not responding as usual. Facility nursing staff were notified and asked the family if the resident was a diabetic. After a telemedicine assessment the resident was transferred to the hospital. The family stated they were not sure if Resident #1 had been receiving Insulin in the facility but had been receiving Insulin prior to admitting to the facility. Observation of Resident #1 in the hospital on 06/27/22 at 10:15 a.m. revealed he was awake in bed. He was utilizing an external urinary catheter and a gastric feeding tube was in place. Attempts to interview the resident were unsuccessful. He stated he could not recall if he received insulin in the facility. The resident's family E was present at the bedside and stated the resident had been receiving Insulin for a long time and they had observed the resident self-administer insulin injections prior to admission to the facility. The hospital RN stated Resident #1 was receiving [CONDITION(S)] and was somewhat confused and forgetful. The RN further stated the resident was stable and blood glucose levels were currently within normal limits. Review of a hospital records dated 06/20/22 reflected Resident #1's chief complaints were [CONDITION(S)] (high blood glucose) and altered mental status (a disruption in how your brain works that causes a change in behavior). Past medical history included diabetes mellitus. The records reflected on arrival to the ER the resident was not speaking in clear words and was moaning and groaning in response to questions. The resident was treated with an IV antibiotic, IV fluids, IV Insulin drip and Insulin via slow IV push. The records reflected the resident was admitted to the ICU and his blood glucose was greater than 1200 milligrams per deciliter. Hospital lab reports dated 06/20/22 reflected Resident #1's blood glucose was 1,224 milligrams per deciliter (normal range (70-110). Resident #1 transferred to an intermediate care floor on 06/25/22. Interview with the DON on 06/27/22 at 12:09 p.m. revealed on 06/20/22 Resident #1's family D voiced concerns to the charge nurse LVN C, that the resident was not looking or responding as usual. The assigned charge nurse had been busy assisting another resident and she (the DON) assisted with Resident #1's assessment and telemedicine visit. She stated the resident was experiencing respiratory distress with rapid respirations and 12 seconds of apnea. The primary physician was notified, orders were received to transfer the resident to the hospital and 911 was summoned. The DON stated the medications transcribed by LVN A on Resident #1's admission (06/04/22) were from a physician's progress note listed in the clinical records sent from the hospital. She stated she did not know if LVN A verified the resident's admission medications with the physician. The DON stated the admitting nurse was responsible for verifying admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON further stated if the nurse had continued to have problems or issues with obtaining orders, she (the DON) should have been notified. Additionally, the DON stated she did not know if LVN A had contacted the facility's physician to verify Resident #1's admission medications. The DON stated if nursing staff did not verify admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated the medication list provided in the hospital records could have been used if the medications had been verified by the physician. Attempts to interview LVN C on 06/27/22 at 2:00 p.m. and 4:00 p.m. were unsuccessful as the voicemail box was full. Interview on 06/27/22 at 1:30 p.m. revealed Physician B was Resident #1's primary care physician at the facility. Physician B stated she nor her NP were notified of Resident #1's arrival to the facility on [DATE] or verified the resident's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated her expectations were that facility nursing staff would notify her or the NP for a review of the new admits history, medications, vitals, and skin assessment. Interview with LVN A via phone on 06/27/22 at 5:33 p.m. revealed she was the admitting nurse for Resident #1 on 06/04/22. She stated she did not receive report or discharge orders from the transferring hospital and when she attempted to contact someone at the hospital about the missing orders, she was unable to reach anyone. LVN A stated she only received medical records from the hospital and transcribed medications from a list of medications the resident received in the hospital. She initially stated she did not recall notifying the physician or NP then stated she did recall notifying the NP of Resident #1's arrival to the facility but she was not sure if she verified the medications or discussed the lack of admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . According to www.cdc.gov/diabetes viewed on 02/28/22, The patient with HHNC has severe [CONDITION(S)] and shows signs/symptoms of hypovolemia (decreased volume of circulating blood in the body) and severe dehydration. Central nervous system deficits may occur to include hallucinations, [CONDITION(S)] (loss of ability to understand or express speech), and focal or grand mal seizures. Coma may ensue. According to www.diabeteseducator.org viewed on 02/28/22, HHNC is a deadly and avoidable complication that is due to not having enough insulin for the present condition, is diagnosed when blood glucose is over 600 mg/dl (milligrams/deciliter) and usually takes days rather than hours to occur. Review of the facility's policy/procedure (P/P), revised July 2019, and titled Reconciliation of Medications on Admission reflected in part: The purpose of the procedure was to ensure medication safety by accurately accounting for the resident's medications, routes and dosages upon admission or readmission to the facility. Preparation included gathering information needed to reconcile the medication list to include the discharge summary from the referring facility and finding a quiet place that is free from distractions. Medication reconciliation is the process of comparing pre-discharge medications to post-discharge medication by creating an accurate list of both prescription and over the counter medications. Medication reconciliation reduces medication errors and enhances resident safety by ensuring that the medication the resident needs and has been taking continue to be administered without interruption. Medication reconciliation helps to ensure that medications, routes, and dosages have been accurately communicated to the Attending Physician and care team. If a discrepancy or conflict in medications, dose, route, or frequency is noted determine the most appropriate action to resolve the discrepancy including, contacting the nurse or physician from the referring facility, contacting admitting and/or the primary physician of the receiving facility. Review of the facility's P/P, revised10/01/19, titled Prescriber Medication Orders reflected in part: C. Written Transfer Orders, (sent with a resident by a hospital or other health care facility) a. Implement a transfer order without further validation if it is signed and dated by the resident's current attending physician, unless unclear or incomplete or the date signed is different from the date of admission. b. If the order is unsigned or signed by another prescriber or the date is other than the date of admission, the receiving nurse verifies the order with the current attending physician before medications are administered. The nurse documents verification on the admission order record by entering the time, date, and signature. Review education material, training records, and audits related to the reconciliation of medications on admission, transcribing medications from admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review, of the following reflected the facility was in compliance on 06/24/22. The facility implemented the following interventions: Immediately on 06/20/22 the Administrator suspended LVN A. Immediately on 06/20/22 the Corporate Nurse in-serviced the DON, ADON, LVN Treatment Nurse and MDS nurses on the policy for reconciliation of medications on admission to include transcribing medications from admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] Immediately on 06/20/22 the DON, ADON and Corporate Nurse audited resident orders on new admits/readmits for past 90 days to ensure all admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Immediately on 06/20/22 DON, ADON and Corporate Nurses audited all residents with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . DON and Nursing Administration in-serviced nurses on the policy for reconciliation of medication on admission to include transcribing medications from admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] Agency/CMA/Nurses to receive education from nursing administration prior to start of his/her next shift. Effective 06/20/22 and ongoing the above training material will be incorporated into the new hire orientation. On 06/20/22 in order to monitor current residents for potential risk the DON and Corporate Nurse initiated a daily review audit for compliance on admission/readmissions and will continue for 30 days. DON compliance will be monitored weekly for compliance for 90 days by Corporate Nurse. 06/21/22 Full Pharmacy audit conducted. Focus on Diabetes and resident (sic) on insulin, as well as full house medication audit. QA will monitor quarterly for up to a year for compliance, the facility QA committee will meet weekly for 8 weeks for compliance of action plan.

Based on interview, observation and record review, the facility failed to ensure pain management was provided to a resident who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the resident's goals and preferences for 1 of 5 resident reviewed for pain management. (Resident #33) The facility failed to ensure the prescription was completed timely to avoid a lapse in pain medication for Resident #33. The facility failed to ensure Resident #33's pain medication was available when he needed it. The facility did not assess Resident #33 for pain on 12/17/21 while his medication was not available. This facility failure could place residents on pain management at risk for unnecessary pain, discomfort and decreased quality of life. Findings included: Record review of Resident #33's face sheet dated 12/17/21 revealed Resident # 33 was a [AGE] year-old male admitted to the facility originally on 03/04/21 and was readmitted to the facility on [DATE]. The resident diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission records revealed Resident #33 admitted to the facility on [DATE] at 1:45 pm . Review of the Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] #3 ever 4 hours for pain. Review of Resident #33's base line care plan dated 12/17/21 revealed the facility would monitor the resident for pain. Review of Resident #33's MDS dated [DATE] revealed he had a BIMS of 13, which indicated he was cognitively intact. Review of the MAR for Resident #33 dated 12/17/21 revealed regularly scheduled [MEDICATION(S)]-acetaminophen10-325mg every 6 hours had not been giving to Resident #33 since admitting to the facility on [DATE]. Resident #33 was prescribed Tylenol with [MEDICATION(S)] #3 ever 4 hours for pain. He had not been provided the medication since admitted on [DATE]. An interview with Resident #33 on 12/17/21 at 11:05 am revealed he was admitted to the facility on [DATE]. He stated he had not received any of his scheduled medications since arriving at the facility. He admitted to the facility the afternoon on 12/16/21. He stated the nurse informed him; his medications were not at the facility. He stated he really needed his pain medications. He stated his pain level was 9/10. He had spoken with Med aide B regarding his meds and she stated the medications had not arrived at the facility. An interview with RN A on 12/17/21 at 11:12am she informed the resident on 12/16/21 after he admitted to the facility his medications had not arrived, there had been issue with pharmacy providing the medications to the facility. There were no medications to give to Resident #33 she stated. An interview with Med aide B on 12/17/21 at 11:37 am revealed Resident #33 had requested to have his medications. Resident informed her; he wanted his medications including his pain medications. She informed Resident #33 his medications were no one her cart. She told the resident his medications had not arrived at the facility. She informed RN A Resident #33 medication had not arrived at the facility. Review of Resident#33's pain assessment completed by LVN C dated 12/16/21 revealed the resident did not have a pain regimen. He did not require pain medications. The assessment reflected the resident was not in any pain. An interview with LVN C on 12/17/21 at 2:22pm revealed Resident #33 was admitted to the facility on [DATE]. She stated when the resident arrived at the facility, it was during the time of shift change (2pm) at the facility. She stated the resident did not come to the facility with medications, and the resident medication had not arrived on 12/16/21.The resident admitted from an assisted living facility. The resident informed her he was prescribed pain medications. She completed the pain assessment inaccurately. She stated the resident was provided a Tylenol 500 mg and [MEDICATION(S)] 5mg on 12/16/21. She stated the resident's other medication was not provided to the resident on 12/16/21. She did not document the medications given to the resident on 12/16/21 on his Medication Administration record. She did not document the medications given because it was a lot going on at the facility she stated. Observation and interview on 12/17/21 at 2:04 pm revealed Resident#33 medications arrived at the facility. RN A stated the medications for Resident #33 had arrived at the facility. Observation were completed and revealed all Resident #33's medication had arrived at the facility. An interview with the DON on 12/17/21 at 2:37 pm revealed she was not aware Resident #33 had not received his pain medications while at the facility. She stated the nurses should have informed her if the resident medications had not arrived at the facility. She would have expected the nurse to get a stat order for the resident medication and or check the facility medication kit. An interview with the Medical Director on 12/20/21 at 12:39 pm revealed he was not aware Resident #33 had not received his scheduled medication in over 24 hours. He stated he expected the facility to have contacted Resident #33 physician and got a stat order for Resident #33 medications. Review of the facility's Controlled Substance Medication orders policy dated 01/20 revealed Each controlled substance medication order is documented in the resident's medical record with the date, time and signature of the person receiving the prescription. An emergency order is placed with the provider pharmacy and the medication is scheduled to be given as received. Review of the Pain Management Program Policy revised on 08/20 revealed The facility will assess each individual for pain upon admission to the facility. The facility identify the characteristics of pain, such as location, intensity, frequency, pattern and severity.

Based on observation, interview, and record review, the facility failed to ensure adequate supervision was provided to prevent accidents for one (Resident #1) of three residents reviewed elopement. The facility failed to develop and implement effective methods of supervision to prevent Resident #1 who had a history of [REDACTED]. The facility was unaware the resident was missing until notified by the resident's family member that the resident was found at nearby store parking lot by law enforcement. An Immediate Jeopardy was identified on [DATE]. While the IJ was removed on 11/25/19 the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with a potential for more than minimal harm. This failure placed residents at risk of life-threatening accidents and injury, physical harm, or emotional distress. Findings included: Record review of Resident #1's face sheet revealed he was a [AGE] year-old male admitted on [DATE] with a discharge date [DATE]. [DIAGNOSES REDACTED]. Review of Resident #1's discharge MDS assessment dated [DATE] revealed Resident #1's was severely cognitively impaired, displayed wandering behaviors, required a wheelchair device, and was not stable without one-person staff assistance. Review of Resident #1's admission MDS assessment dated [DATE] revealed Resident #1's was discharged from the facility to another nursing home. Record review of Resident #1's care plan initiated on 10/12/19 and revised with intervention/tasks and behaviors on 11/21/19 reflected the resident had a been evaluated as a wandering risk. He was able to walk short distances but required minimal assistance for long distances due to unstable gait; the resident also used wheelchair. Care plan interventions included: Check my location frequently, wandering alert bracelet to be checked by nurses for placement and function, and observe for signs of agitation, pacing, repetitive verbalizations of wanting to leave/go home, restlessness, and report behaviors to nurses for further interventions. (Resident #1 discharged from the facility on 11/14/19, before the revisions.) Review of Resident #1's wandering risk evaluation dated 10/09/19 reflected the resident was categorized as a 'Low Risk for Wandering, with a score of zero. There were no areas checked on the evaluation, blank. Record review of Resident #1's nurses notes on 10/11/19 revealed Resident #1 was continuously going to exit doors attempting to exit. A wander-guard was placed on his lower right extremity for safety. Record review of Resident #1's nurses notes dated 10/28/19 revealed Resident #1 went outside of the facility. Staff noted him along the road and brought him back inside the facility. The wander-guard was noted in place. Review of Resident #1's wandering risk evaluation dated 10/28/19 reflected Resident #1 was categorized as a 'High Risk for Wandering, with a score of 12. Record review of Resident #1's nurses notes dated 11/05/19 at 6:40AM revealed resident kept seeking exit stating he must go to work. He was redirected several times by staff. Review of Resident #1's wandering risk evaluation dated 11/05/19 was categorized as a 'High Risk for Wandering, with a score of 11. The evaluation was triggered by Elopement on 11/05/19. Review of the facility's Provider Investigation Report dated 11/05/19 and signed by the Assistant Administrator reflected Resident #1's family made an allegation of Missing Resident/Individual on 11/05/19 at 7:59PM. The location of the incident was off property. A head to toe assessment was conducted of Resident #1, with no injuries noted. The wander guard was checked, was in place and working properly. The resident was picked up by the local Police Department and returned to the facility and placed on 1:1 (one on one) supervision. Observation on 11/21/19 at 8:30 AM revealed the mileage from the nursing home to the nearby clothing store was 1.1 miles. The clothing store is located at a major highway intersection that has a speed limit of 70 miles per hour (http://gis-txdot.opendata.arcgis.com/datasets/txdot-speed-limits?geometry=-96.905%2C32.656%2C-96.[AGE]4%2C32.663). The actual weather temperature on 11/05/19 was 67 degrees per https://www.accuweather.com/en/us/dallas/ /november-weather/ 4. Record review of the October 2019- November 2019 MAR indicated [REDACTED]. (Resident #1 eloped on 11/05/19) In an interview on [DATE] at 4:44 PM with LVN E, revealed Resident #1 wandered out of the facility's front door on 10/28/19. She stated when he wandered on 10/28/19 the alarm went off and she came to the desk to press the code. She told an aide to assist her and they went outside to the sidewalk area of the facility. She stated she had to run to get Resident #1 to bring him back inside. She notified the ADON, the 300-hall nurse, and the Administrator. The wander guard was on and working then. She stated she was not sure if an in-service was completed that day or the next day, but one was completed. She stated on 11/05/19 all four nurses on shift gathered to assist her with her resident who was having a [MEDICAL CONDITION]. LVN E believed during that time Resident #1 eloped. She stated the Assistant Administrator was asking if anyone had seen the resident because the family called the facility and said, the resident was not in the facility. LVN E stated the alarm did not go off because there was a maintenance issue. She stated maintenance was called right away to fix the wander guard system. She stated maintenance should have a maintenance log that was dated and time stamped with the maintenance visit that night. She stated she had not noticed the alarms malfunctioning any other time. All the doors were secured with key pads and if someone tried to push the door open the alarm will sound. She stated there was a white display pad on the wall and it will tell them which direction the zone alarm was sounding on. She stated on 11/05/19, the day Resident #1 eloped, the alarm did not go off. Once the resident returned, they had one-on-one supervision/monitoring. In an interview on [DATE] at 4:07 PM with Med Aide A she stated she had been a Medication Aide for about two months at the facility. She said she was working the night Resident #1 wandered off (11/05/19). She stated she did not know who he was because he was on 300 hall and she worked on a different hall. She stated after the resident was located, they placed him on one-on-one precautions, so she sat with him a few times. She did not recall any alarms going off the night of the incident, 11/05/19, or any other details. She stated when she sat with the resident he was not agitated; he slept and went to the restroom. She stated they had other residents who wore wander guards and she had heard the alarms before as they were a distinctive sound. In an interview on [DATE] at 4:24 PM with Medication Aide B, she stated she was working when Resident #1 left the building on 11/05/19. She stated around 2:00 PM she was doing rounds and she saw him in bed. After dinner she saw him leave the dining room heading to his room. When she passed medications in evening, a bit past 6:00 PM, she did not see Resident #1 in his room, so she continued passing meds. She stated the facility always told them to be mindful of him because he was constantly going to the exit door. She stated she did not hear an alarm go off that night, but in the past, she has had heard the front door go off because he had an ankle monitor (wander guard). She stated the exit doors had a code and there were no doors he could go out of without the code. She stated she had never seen anyone without a code using the door; everyone must utilize the code to get in and out. She stated she had been working at the facility for 2 years. She stated an in-service was conducted afterwards to monitor for elopement. She stated when the resident returned to the facility, on 11/05/19, she checked his blood pressure and gave him his medication and food. They conducted one-on-one monitoring with him until he discharged , from the facility on 11/14/19. She stated she documented that she provided one-on-one with him and handed the documentation to the nurse. In an interview on [DATE] at 4:36 PM with LVN D she stated she was working on 11/05/19, the night Resident #1 eloped. She recalled she last saw the resident around 4:00 PM. She stated there was an issue on 100 hall that required all four of the nurse's attention around 5-6 PM. She stated they were able to determine he was not in the facility when the family called to notify the facility. She was unaware Resident #1 was missing prior to the family calling. When the resident came back to the facility he was placed on one-on-one monitoring until he transferred from the facility on 11/14/19. She stated she was unsure how he left the faciity on [DATE] but he had to get out through the front door. He always wanted to leave, and they had to redirect him. She said it was required if staff saw residents were going to attempt to exit, they were to redirect them to their room or the dining room. The nurses monitored the wander guard system on the residents and she stated the night Resident #1 returned to the facility his wander guard system was working properly. In an interview on [DATE] at 4:30 PM with CNA C she stated she was working the night Resident #1 left, 11/05/19, but she did not see him leaving the building. She stated she heard the nurses and Social Worker saying that he had exited the building. She stated he had a tendency to go to the exit door. When she saw him she redirected Resident #1. She stated the resident was not one of the residents who could go to the store, so he should not be unsupervised outside. She stated she heard the alarms go off all the time but was not sure if his went off. She stated HR walked around providing an in-service, regarding elopement on 11/05/19. All exits in the building had key pads and they have a list of residents with wander guards at the nurses' station. If those residents got a few feet from door the alarm would loudly sound. She stated that alarm was for any of the exit doors. If visitors did not know the door code the alarm would also sound. She stated she worked on the 200 hall and he resided on the 300 hall. She stated she had no idea how Resident #1 got out of the building. She stated the door alarm could be heard when providing care, but if staff were providing care they could not leave a resident. She said if she was not giving care she would go check on the door if she heard the alarm. In an interview on [DATE] at 11:05 AM with CNA F she stated on 11/05/19 she was working on 100 hall, when Resident #1 got out of the facility. She did not remember the time, but said it was close to night time. She stated the alarm went off at some point that night but did not provide further details. She stated she was not at the facility when the resident returned. She said she left the facility at 10:00 PM that night. She stated when the alarm went off it meant a resident was missing and someone would make an intercom announcement. She stated the alarms and the intercom announcement could be heard in resident rooms. She said when that happens, staff are to look in the rooms and restrooms immediately for the missing resident. She stated there was always an alarm or announcement and staff were to check every time. In an interview on [DATE] at 1:07 PM with the Administrator in Training (AIT) she stated at around 5:45 PM, on 11/05/19, she and the Assistant Administrator's heard the alarm going off, so they both checked to see who was setting the alarm off. She stated they saw Resident #1 near the couch area, which was located on the left of the front door. She stated he was not facing the door and he was not exit seeking, he was trying to sit on the couch in the front lobby area. The AIT stated the Assistant Administrator redirected him to the TV room. She went to nurse's station to help the nurse turn off the alarm. The AIT stated she then went to 400 hall to notify Resident #1's nurse that the resident set the alarm off. She stated she could not account for how long he was in the TV room or when he moved. The last thing she remembered was when they redirected him at 5:45 PM because of the alarm. She stated she got off work around 7:00 PM but was not sure of the actual time. She said if an alarm went off, protocol was to check to see which door was triggered and make sure the wanderer did not go outside and to redirect back into the facility if they did. They were to make sure the residents were safe, then turn off alarms. The AIT stated staff conduct observations of the resident and if residents were wanders or were at risk nurses conducted assessments and during the morning meetings wander risks/ assessments were discussed. She stated the residents identified as at risk for wandering risk had a wrist band or ankle wander guard. In an interview on [DATE] at 10:45 AM with the Assistant Administrator she stated she was also the Social Worker. She stated she was at the facility on 11/05/19 with the AIT when the alarm sounded at 5:45PM due to Resident #1 being near the front door. She stated she and the AIT redirected Resident #1 away from the front door. She stated her office was less than 10 feet from the door. She escorted the resident to the TV area then went to her office and closed her door. She stated she did not hear the alarm go off/sound after that. She stated at 7:59 PM she was conducting rounds and a nurse advised her Resident #1's family member was on the phone. That was when she found out that the resident was at the local police department. She stated she called the police non-emergency line, but they did not know what she was referring to, so she called behavioral health hospital in an attempt see if the resident was dropped off but he was not at either location. She stated at that point the Van Driver came back to the facility and they drove the van to the police station. The resident was sitting in the lobby. She stated the resident was calm and in no distress. She spoke with the officer who only provided her with minimal details. She stated the resident was at a store down the street and someone reported he was wandering in the parking lot attempting to go home. The resident remembered his previous home address, so the police sent an officer to that address. The resident's prior roommate called the resident's family member who then called the facility to notify them the resident was missing. When arriving back to the facility, she stated the wander guard alarm sounded as he walked in, which meant his wander guard was working. She provided him with a snack and stayed with him. She stated Nurse A did an audit check on his device and it was working. The physician was notified by Nurse A before the resident came back to the facility. She notified the family, DON, and the roommate. The Assisted Administrator stated she did not know the resident was missing until she had the conversation with his family member. She stated the nurse had already notified the staff and they had started to look for him inside the facility even though the call from his family member stated he was at the police department. In an interview on [DATE] at 12:51 PM with the Assistant Administrator she stated she redirected the resident on 11/05/19 when the door alarm went off because he was not exit seeking. She stated she walked him to the big chair in the TV area. She stated the AIT just walked to the nursing station. She stated she did not notify anyone the alarm went off because there were several nurses at the desk. She stated she sat with him for about 5 minutes to make sure his mind was not on exiting. She stated protocol was to go to the door, remove any residents away from the door; or if a resident was not seen at the door, check outside. She stated staff should also check the alarm pad for the zone to see where the alarm was sounding. Staff must physically walk over to the area and put in the code to disarm the alarm. She stated if there were any concerns staff should talk to the nurses or the DON. The charge nurse was typically at the desk and notified. She stated there were at least 8-10 people that were at the nurses' station that night but she did not remember who, specifically. She said typically if an alarm was heard sounding off people could be seen going to the front to check. She stated she could hear the alarm from the front door going off from the resident rooms. She said if staff were in the rooms and the alarm went off, they should still check if they were available. She said they may not be physically looking at the zone, but staff could be seen peeking out of rooms, checking doors. She stated she had never made an intercom announcement and was unaware at what point that would be done. She stated every time she had heard an alarm it had always been handled immediately and the intercom was not needed. She stated staff knew through education about elopement procedure and there was a wander book at the nurses' station. When residents were initially admitted an assessment was completed to identify if there is an elopement risk. In morning meetings if there are concerns or if there is an increase with exit seeking behavior, they would put interventions (wander guard, add to wander book, etc.) in place. She stated the resident's names, room numbers, and pictures were in the wander book to make staff aware. In an interview on 11/21/19 at 5:04 PM with the Maintenance Director revealed he did come to the facility the night the resident eloped on 11/05/19. The wander guard system was working properly. He stated he checked every window, doors, and wander guards weekly. He stated he did not have a specific day of the week to conduct the weekly checks, but just made sure he completed the checks during the week. He stated he did not have problems with the system malfunctioning in a couple of years. He stated he did not know how Resident #1 got out the building while wearing a wander guard. Review of the facility's policy Wandering, Management, Monitoring System, and Resident Elopement revised 01/17/18 stated all residents are afforded adequate supervision to provide the safest environment possible. An Immediate Jeopardy was identified on [DATE]. The Administrator signed the IJ Template form on [DATE] at 3:23PM and the Plan of Removal was requested at this time. While the IJ was removed on 11/25/19 the facility remained out of compliance at scope of isolated and severity of no actual harm with potential for more than minimal harm. The Plan of Removal was accepted on 11/23/19 and reflected the following: On [DATE] to 11/23/19 the Administrator and the DON reminded the staff immediately that the policy is out at the nurse's station in a red binder which is the elopement risk. Each staff member was questioned and had to write out and speak verbally the policy and procedures of elopement which include: Identification & Prevention of elopement, interventions and documentation, at risk for elopement; monitoring, interdisciplinary interventions, door alarm sounds, procedure for missing residents/elopement, when resident is found, and post elopement. Each role was discussed in a scenario of an active elopement occurrence. Disclaimer: abuse coordinator can redefine roles at any time to ensure efficiency. On [DATE] to 11/23/19 the Administrator trained department managers on the roles of the nursing department and non- nursing departments when a resident is exit seeking and when a resident elopes, the protocol for resetting the door alarms and our elopement policy. Trained department managers will be responsible for training all staff on the roles of the nursing department and non-nursing departments when a resident is exit seeking and when a resident elopes, the protocol for resetting the alarms and our elopement policy. Non-nursing and nursing were trained on all roles. Non-nursing staff was retrained on 11/23/19 and nursing were retrained on redirection. Nursing roles - When a resident is exit seeking: Upon becoming aware of a resident with exit seeking behavior, the nurse will perform an assessment and identify the need for further interventions, including placement on 1:1. Notify Administrator/Don/physician and family. Non-nursing roles - When a resident is exit seeking If a resident who is exit seeking, redirect them by walking with the resident to the nurse nearby or accompany the resident until a nurse can come to you to assist. Nursing role - When a resident is noted to be missing The charge nurse who is assigned to the resident will implement a search and involve all staff who are present. Charge nurse will contact the local police department to report the missing resident. Charge nurse will notify the Administrator/designee immediately. Perform a complete search of the interior of the building. This should include every room, including bathrooms, breakrooms, storage rooms, closets, etc. Initiate an external search outside of the building, including the facility grounds and community, on foot and by vehicle. Interview staff to determine who may have seen the resident last and try to determine when they nay have been seen last, including what they were wearing, etc. Notify the resident's family and physician. Call area hospitals, bus stations, train stations, grocery stores, liquor stores, etc. Notify state agency per state law. Notify other nearby nursing homes. Non-nursing role - When a resident is noted to be missing Report resident missing to the charge nurse if they are the one who discover resident to be gone. Assist with search and follow direction of charge nurse. If an alarm sounds and needs to be reset, the charge nurse will be responsible for setting the alarm. In-service and training will be conducted and graded by the Administrator and the DON. All persons, the Administrator trained department managers that include: medical records, treatment nurse, Assistant Administrator, DON, ADON, ADON B and Corporate Clinical Specialist will train staff starting [DATE] and completed by 11/23/19 on the roles of the nursing department and non-nursing departments when a resident is exit seeking and when a resident elopes, the protocol for resetting the door alarms and our elopement policy. Trained department manager will be responsible for training all staff on the roles of the nursing department and non-nursing departments when a resident is exit seeking and when a resident elopes, the protocol for resetting the alarms and our elopement policy. Non-nursing and nursing were trained on all roles. Non-nursing staff was retained on 11/23/19 and nursing was trained on redirection. Each staff member must receive 100%. Employees who are on vacation, medical leave, and PRN staff will receive the in-service and training prior to being able to work. The Administrator/designee will compile a list of employees and track who has received the training. NO employee will be allowed to return to work without the training and HR/designee will be responsible to train upon returning to work Monitoring of the facility's Plan of Removal reflected the following: Interviews conducted on 11/23/19 through 11/25//19 with the following staff from multiple shifts: CNAs: C, F, G, H, I ,J, R,S,V,Z, QQ, Rr, SS, TT, VV, XX, YY; Med Aides: A, B, M, and T; LVNs: D, E, K, O, Q, CC, WW, and AAA. RNs: P, and AA, Dietary Aides W, X, GG, HH, II, JJ, KK, MM, ZZ; Housekeeping Staff: DD, EE, FF, and UU revealed they had been in-serviced on all elements of the plan of removal. All interviewed staff verbalized understanding regarding identifying residents who were exhibiting exit seeking behaviors, the elopement process for nursing and non-nursing staff, and resetting the alarm. In an interview on 11/24/19 at 1:07 PM with the DON we now have elopement quizzes for all staff. She stated education, observation of interactions with residents, oral testing, and continuing in-services were ways to be ensure staff were aware if a resident was exit seeking. The wander guard system, in-servicing, incident and accident system, and the communication system were in place to notify her and the Administrator of anything happened. She stated the wander guard system was a signal device in place for high risk residents that would trigger an alarm when they got within a certain number of feet from an exit door; and the incident-accident system was utilized if anything unusual happened from the resident's normal day, staff would fill out a form. She stated it was a form of communication for staff and another communication system was their 24-hour report system located at the desk. She stated she thought the IJ was the result of a system failure and breakdown in communication. She stated the first incident on 10/28/19, there should have been more preventions put into place. She stated the staff who were on leave would also need to be in-serviced on elopement and the wander guard system prior to returning to work. She stated they would continue to monitor their staff until they have a strong grip on the system and it would still be ongoing. The DON, ADON, Admin, HR, Dept heads would monitor it. In an interview on 1/24/19 at 1:07 PM with the Administrator she stated she honestly did not know how Resident #1 eloped because she did not know the specifics and it was so inconclusive to how he got out. She stated she was not sure if he was mistaken for family and not a resident or what. She stated they have added in-services, questionnaire pretest to test staff knowledge, and posttest to conduct open ended questions to make sure all staff understand and are on the same page regarding elopement and the wander guard system. She stated the managers will monitor their staff to see how they respond to things. She had been here on every shift to make sure they were following the system. While the IJ was removed on 11/25/19 the facility remained out of compliance at scope of isolated and severity of no actual harm with potential for more than minimal harm.

Based on observation, interview and record review, it was determined the facility failed to ensure that seven (DON, ADON A, ADON B, LVN G, LVN H, LVN I and LVN S) of sixteen nurses observed either provided services or arranged for services that met professional standards of quality. 1. The Director of Nurses (DON): a. Failed to ensure Resident #3 remained with his head elevated two to four huors after discontinuing an enteral feeding. Resident #3 was lowered to a flat position two minutes after the enteral feeding was stopped. b. Failed to instruct CNA C to continue to cleanse Resident # until the resident was completely free of feces on her skin and to perform hand hygiene between glove changes. c. Failed to asses Resident #7, a known insulin-dependent diabetic, when it was reported she could not be aroused during a noon meal. DON did not take Resident #7's blood sugar or vital signs at this time. 2. ADON B failed to provide appropriate pressure ulcer care and treatment for [REDACTED]. a. Did not set-up a clean field for wound care supplies; b. Did not perform hand hygiene between glove changes; c. Did smear feces over and into an open pressure sore wound bed during incontinent care; and d. Did not ensure interventions were ordered timely to prevent worsening of pressure sores and promote the healing of pressure sores. 3. LVN S failed to check placement prior to re-connecting and starting the infusion of Resident #3's enteral feedings. 4. ADON A failed to intervene when two nurse aides lowered Resident #1 to a flat position three times in a 30 minute time span while the enteral tube feeding continued to run. 5. LVN G and LVN H both failed to assess that the necessary emergency equipment was present and functioning in Resident #1's room to provide care in an emergency for his [MEDICAL CONDITION]. LVN G further failed to ensure the humidification system for Resident #1 set up properly to provide the necessary humidification for Resident #1. 6. LVN I failed to follow Resident #1's physician orders [REDACTED]. LVN I failed to assess and ensure the humidification system for Resident #1 was set up properly to provide the necessary humidification for Resident #1. LVN I also failed to check proper placement for Resident #1. Prior to administering medications LVN I did not check residuals for Resident #1. An Immediate Jeopardy (IJ) was identified on 10/27/14. While the IJ was removed on 11/02/14 the facility remained out of compliance at a severity level of "potential for than minimal 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. These failures placed Residents #1 and #3 at risk of aspiration, aspiration pneumonia and/or death. These failures could affect the additional 14 residents with [DEVICE]s by placing them at risk for aspiration, aspiration pneumonia, vomiting and a decreased quality of life. These failures placed Resident #1 and one additional resident, who had a trach, at risk of not receiving timely emergency care and services with resulting serious harm or death. These failures furthermore placed Resident #3 as well as all 87 residents at risk of not receiving appropriate care and services for prevention of pressure ulcers and promote healing of existing pressure ulcers. Findings included: I. Professional Standard The Texas Board of Nursing Rules and Regulations Relating to Nurse Education, Licensure and Practice published in August 2013 reflected, "?217.11. Standards of Nursing Practice. The Texas Board of Nursing is responsible for regulating the practice of nursing within the State of Texas for Vocational Nurses, Registered Nurses... (1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall... (C) Know the rationale for and the effects of medications and treatments and shall correctly administer the same...(G) Obtain instruction and supervision as necessary when implementing nursing procedures or practices; (H) Make a reasonable effort to obtain orientation/training for competency when encountering new equipment and technology or unfamiliar care situations... (M)Institute appropriate nursing interventions that might be required to stabilize a client ' s condition and/or prevent complications; (N) Clarify any order or treatment regimen that the nurse has reason to believe is inaccurate, non-efficacious or contraindicated by consulting with the appropriate licensed practitioner and notifying the ordering practitioner when the nurse makes the decision not to administer the medication or treatment...(S) Make assignments to others that take into consideration client safety and that are commensurate with the educational preparation, experience, knowledge, and physical and emotional ability of the person to whom the assignments are made; (T) Accept only those nursing assignments that take into consideration client safety and that are commensurate with the nurse's educational preparation, experience, knowledge, and physical and emotional ability; (U) Supervise nursing care provided by others for whom the nurse is professionally responsible...." II Failure to Residents #1 and #3 received appropriate Gastrostomy Treatment and Services Resident #1's face sheet, 09/29/14, reflected he admitted to the facility on [DATE] and his current age was 30. Resident #1 ' s MDS assessment, dated 8/27/14, reflected he had a [DEVICE] ([DEVICE]) and [MEDICAL CONDITION]. His [DIAGNOSES REDACTED]. It further notes he required total assistance of staff for care. Resident #1's care plans, dated 08/18/14, provided no evidence of a plan of care to address his enteral tube feedings or his risk for aspiration. Resident #1's physician's orders [REDACTED]. Observation on 10/27/14 at 4:52 p.m. of Resident #1 was in bed with his enteral feeding infusing at 65 ml/ar. CNA U lowered the head of Resident #1 ' s bed to a flat position while the formula continued to infuse. At this time, ADON A was in Resident #1's room at the resident ' s bedside and did not direct CNA U not to lay Resident #1 in a flat position. Resident #1 had the head of his bed raised and lowered to a flat position two additional times while being weighed at 5:20 p.m. by CNA V and again at 5:30 p.m. by CNA V when he was lowered back into the bed from the Hoyer scale. During the observation on 10/27/14, CNA U and CNA V each said they were not aware of the facility's policy regarding tube feeding and positioning. The interviews were conducted at 5:01 PM and 5:02 PM, respectively. On 10/27/14 approximately at 5:32 PM, ADON A stated she did not notice the head of the bed was lowered at that time. She stated the feeding should have been stopped and not allowed to continue to run at that time. Review of Perry & Potter Clinical Nursing Skills & Techniques 7th edition, 2010, Chapter 31 Enteral Nutrition & Care, revealed [MEDICAL CONDITION] aspiration is a common complication related to tube feedings and standard nursing practice is keeping the head of bed elevation greater than 30 degrees is a simple method to keep the risk of aspiration to a minimum. Review of the facility face sheet dated 09/29/14 revealed Resident #3 was a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses, which included Altered Mental Status, General Muscle Weakness, Dysphagia, Paralysis Agitans, [MEDICAL CONDITION] Reflux, Wheelchair Dependence, Lack of Coordination and Senile Dementia. Resident #3's care plan with problem onset date of 02/22/13 and last updated on 09/05/14 for risk of altered nutritional status secondary to Dementia, last updated on 09/05/14, reflected to continue the plan for 90 days, with approaches, which included: "Serve diet as ordered...Allow ample time to ingest meal...Determine food preference...offer resident's food preferences and avoid dislikes...offer between-meal supplement...Offer bedtime snack...Reg CC/RCS Diet (Regular Controlled Carbohydrates/Reduced Concentrated Sweets)." An updated care plan, which addressed the changes for Resident #3 to a NPO status with [DEVICE] and tube feedings, was not located. No care plan was located to update approaches regarding specific positioning requirements and gastronomy care approaches. Resident #3's Resident Summary, dated 09/27/14, completed upon readmission, reflected she exhibited an altered level of consciousness, was non-verbal, lacked awareness of her own needs, had a Stage II pressure ulcer, was incontinent of bowel and bladder, required total staff care for hygiene and grooming and received feedings via a [DEVICE]. Her hearing was impaired and she could not communicate her needs. Resident #3 required the assistance of two staff for transfers and positioning while in bed. Resident #3's MDS assessment, dated 10/04/14, reflected additional [DIAGNOSES REDACTED]. and Gastronomy Status. She had exhibited no speech and was rarely/never understood or was able to understand others, her vision was highly impaired, exhibited short and long-term memory problems, was severely impaired for daily decision making, was incontinent of bowel and bladder and required the extensive assistance of one person for bed mobility eating, toilet use and personal hygiene and required extensive assistance of two persons for transfers (including to or from bed, chair, wheelchair, etc.). Resident #3 weighed 150 pounds, had not had any weight loss or gain in the last 6 months, had a feeding tube, received 51% or more of her total calories through the tube feeding and had an average fluid intake by tube feeding of 501cc or more daily. Resident #3's November 2014 consolidated physician's orders [REDACTED]. ? NPO - [DEVICE] original order date was 09/27/14; ? Tube Feeding: via pump: Glucerna 1.2 cal @ 45cc/hr via pump - increase by 10 ml/hr Q 8 hrs until a goal of 75 ml/hr (original order date was 09/29/14); ? Flush tube with 200 cc water Q shift (original order date was 09/29/14); ? Flush tube with 30 cc water before and after medications (original order date was 09/29/14); ? Elevate HOB 30-45 degrees (original order date was 10/30/14); ? Check stomach contents for residual & return contents to stomach. If more than 100 cc noted, hold feeding and immediately notify MD. Document amount of residual (original order date was 10/30/14); ? Check tube for proper placement by auscultation prior to instilling medications, formula & water. (Initialing indicates that tube has been checked & placement if correct) (original order date was 10/30/14); ? Tube Feeding: via pump: Glucerna 1.2 cal @ 75cc/hr via pump - down time: 9am, Up time: 1pm with a notation to hold (original order date was 09/29/14); Observation of Resident #3 on 10/28/14 at 9:47 a.m. revealed she was lying in bed, with the HOB elevated. Her enteral formula (tube feedings) was not infusing, but the bottle of formula was still present. The bottle was labeled Glucerna 1.2, 1000cc total volume. Hand-written notations indicated the bottle was hung (started) on 10/28/14 at 12:30 a.m. to infuse at 75cc/hr. The bottle had 460 cc remaining, which indicated 540 cc had infused since starting the bottle. Resident #3 should have received 637cc in the time between 12:30 a.m. and 9:00 a.m., when the formula was disconnected. Interview with LVN D at that time confirmed she had disconnected the feeding at 9:00 a.m. Observation on 10/28/14 at 9:47 a.m. also revealed neither Resident #3 nor her roommate, Resident #5, both having [DEVICE]s and receiving enteral feedings via the [DEVICE], had a suction machine and/or suction set-up at bedside in case of an emergency. Observation on 10/30/14 at 1:07 p.m. revealed LVN D was preparing Resident #3's enteral formula for infusion. She stopped and requested CNA C transfer Resident #3 from her wheelchair to her bed. At 1:20 p.m., LVN D proceeded to check the placement of the [DEVICE], connect the feeding tubing and start infusion of enteral formula at 75 cc/hr. At 1:40 p.m., CNA C requested LVN D turn off and disconnect Resident #3's enteral feeding, so incontinent care could be completed. LVN D and the DON disconnected and flushed the [DEVICE] at 1:48 p.m. At 1:50 p.m. the DON lowered Resident #3's head of the bed, to a flat lying position, so incontinent care could proceed. On 10/30/14 at 2:53 p.m., observation of LVN S revealed she came to Resident #3's room to re-connect the enteral formula. LVN S applied gloves without performing any hand hygiene. She turned the pump on and placed the ear tips of her stethoscope in her ears. She placed the bell of the stethoscope on Resident #3's stomach and listened around the gastronomy insertion site. She lifted the [DEVICE] up and then proceeded to connect the enteral formula tubing to the [DEVICE] and started the pump to begin the enteral feeding infusion. LVN S did not check the placement of the [DEVICE] by auscultation of an air bolus (injection of a small amount of air through the tube and into the gut which produces an audible "whoosing" sound) or by aspiration of gastric contents to check for residual enteral formula, before starting the infusion of enteral formula for Resident #3. During an interview, at the end of day on 11/02/14 at 5:30 p.m., the Corporate RN P and Senior VP of Operations Q, after learning of the performance problems observed during gastronomy care, including checking placement and lowering of the HOB without waiting the specified hour after turning off enteral feedings prior to lowering the HOB, stated staff would be re-in-serviced, including the DON. An in-service training action plan dated 11/02/14 and received by the survey team on 11/03/14 from Corporate RN R, (for concerns from end of day interview on 11/02/14) indicated competencies and in-service training for gastronomy care and services, including placement checks, was to be initiated on 11/02/14 and continued until all staff trainings were completed. Interview with the Resident #1's physician, who was also the Medical Director, on 10/28/14 at 1:30 p.m., revealed he was not aware of the observation on 10/27/14 involving the lowering of Resident #1's bed while his enteral tube feeding was running. III. Failure to Provide Resident #1 Appropriate [MEDICAL CONDITION] Care and Services According to Review of Perry & Potter Clinical Nursing Skills & Techniques 7th edition, 2010, Chapter 25 Airway Management, Caring for a resident with [MEDICAL CONDITION] several high risk potentials of emergency situations including [MEDICAL CONDITION] accidently removed during positioning and other activities of daily, as well as developing hypoxemia (oxygen levels dropping) when being suctioned, which can lead to cardiac [MEDICAL CONDITION] and [MEDICAL CONDITION] as well as a mucous plug becoming dislodge and occluding [MEDICAL CONDITION] failure to humidify a resident with [MEDICAL CONDITION] cause secretions to thicken and cause a mucous plug. The necessary bedside equipment to handle these emergencies includes, an extra emergency trach, ambu bag, oxygen, suction catheters, working suction machine, canister and tubing as well as saline bullets for the removal of a mucous plug, peroxide and sterile tray or [MEDICAL CONDITION] kit to remove a mucous plug, oximeter and stethoscope. Resident #1's physician's orders [REDACTED]. Further review of Resident #1's October 2014 physician's orders [REDACTED]. [MEDICAL CONDITION] daily and PRN as follows: "...1. [MEDICAL CONDITION] change inner cannula " (#____DIC). " 2. Clean around Stoma area using normal saline and a q-tip, pat dry with 4x4. 3. Remove [MEDICAL CONDITION] and assess skin for redness/breakdown. 4. [MEDICAL CONDITION] and secure...." Resident #1's physician's orders [REDACTED]. Resident #1's MDS assessment, dated 08/27/14, reflected he was admitted from an acute care hospital, he was absent of speech, and his cognitive skills were severely impaired. Resident #1 was totally dependent on staff for bed mobility, transfers, dressing, personal hygiene, and his range of motion was impaired for both upper and lower extremities. Resident #1 was non ambulatory. He was incontinent of bowel and had an indwelling catheter. Record review of Resident #1's care plans revealed a care plan dated 8/18/14 for code status that noted Resident #1 is full code and that staff are to monitor for a decrease in change of condition and report to M.D. Record review of Resident #1's care plans revealed a care plan, dated 8/18/14, for [MEDICAL CONDITION] with the following directions. --Problem: Resident has a [MEDICAL CONDITION] and is at risk for increased secretions/congestion and infections. --Goal: Secretions/congestion will be relieved within five minutes of suctioning and no occurrence of infection will occur in 90 days. --Approach: 1. Monitor for need of suctioning of increased secretions/congestion-assess for relief 2. Provide O2,[MEDICAL CONDITION], and tubing change per order. 3. Give medications per order-monitor labs/x-rays-report " abn.s " to M.D. 4. Provide for support to prevent anxiety if shortness of breath occurs. 5. Monitor for signs and symptoms of infection and report to M.D.\6. Encourage socialization and activity attendance. Observation on 10/27/14 at 11:06 a.m. revealed Resident #1 had a #6 trach, an audibly weak, congested cough, [MEDICAL CONDITION] was around his neck, but was not positioned over [MEDICAL CONDITION] had slid down to the left side of the resident's neck. Further observation revealed there was not an emergency [MEDICAL CONDITION], suction catheters, sterile gloves or saline bullet flushes at the bedside. The water trap bag for the humidification system was laying in the floor and 2/3 full, the aerosol tubing was full of saline and the regulator valve for the amount of humidification was leaking saline out of it and dripping onto the floor and had approximately 50-100 cc of saline in it, the suction canister was clean without any signs of secretions in it and the tubing connected to it was coiled and wrapped inside a disposable glove on the night stand between the humidification compressor and the suction machine. Interview on 10/27/14 at 11:06 a.m. with LVN G revealed he was scheduled and assigned to Hall 100 the hall where Resident #1 resided. LVN G stated Resident #1 was currently being treated for [REDACTED]. LVN G stated the facility's policy for emergency equipment requirements for a resident with a trach, was for a [MEDICAL CONDITION] ambu bag to be available. At that time, LVN G was unable to locate an [MEDICAL CONDITION] Resident #1's room and stated he would get them. Observation of Resident #1 on 10/27/14 at 4:08 p.m. (five hours later), revealed no [MEDICAL CONDITION] equipment and supplies had been placed in the Resident #1 ' s room. Interview on 10/27/14 at 4:39 p.m. with LVN H, revealed he was scheduled and assigned to Hall 100. LVN H stated his daily routine was to come in and take a verbal report while walking the hall he was assigned to, with the nurse he was relieving. He stated he performed an assessment on all of his assigned residents within one hour of reporting to work to include emergency equipment checks specific to resident needs. During a subsequent interview with LVN H on 10/27/14 at 7:18 p.m., he stated he did not know what emergency equipment was required to be at bedside for a resident with a [MEDICAL CONDITION]. LVN H stated that if a resident decannulated ([MEDICAL CONDITION] out of the resident) unintentionally, he would run down to the supply room and get a replacement [MEDICAL CONDITION] and that every nurse had a key to the supply room on their facility key ring. Interview on 10/27/14 at 5:15 p.m. with ADON A revealed there was supposed to be an [MEDICAL CONDITION] an ambu bag at the bedside for a resident with a [MEDICAL CONDITION]. She stated she did not know why there was not and [MEDICAL CONDITION] Resident #1's room. At that time, ADON A was unable to locate an [MEDICAL CONDITION] suction catheters in Resident #1's room. ADON A directed LVN H to go to the supply room and "get me some proper suction tubing and [MEDICAL CONDITION] supplies." ADON A further told LVN H that when he was done to come see her because she had several in-services she needed him to complete. Further observation at this time (10/27/14 at 5:15 p.m.) revealed an oxygen cylinder in Resident #1's room with the level indicator on empty. ADON A revealed that in an emergency they would use the oxygen on the crash cart. Observation on 10/27/14 at approximately 6:00 p.m. of Resident #1's room revealed a # 6 [MEDICAL CONDITION] taped to the wall above the left side of the bed. 2-trach clean and care kits which have peroxide and brushes to remove a mucous plug, 2-suction catheter kits also to help remove secretions or a mucous plug and each type was stacked side by side on the bedside table, a full bottle of oxygen. IV. An IJ was identified on 10/27/14. On 10/27/14 at 8:30 PM, the Administrator and DON were notified of the IJ and a Plan of Removal was requested at that time. Interview with the Resident #1's physician, who was also the Medical Director, on 10/28/14 at 1:30 p.m., revealed he was notified on 10/27/14 of the IJ, but was not given specifics, only that it was in relation to quality of care. V. Plan of Removal The facility's Plan of Removal, dated 10/27/14, reflected, "...Immediately, on October 27 2014, in-service for nursing staff was initiated and conducted by (DON), (ADON B) Nursing staff and certified nursing assistants were in-serviced on the following: proper bed positioning for residents during and following tube feedings; to include if a CNA needs to adjust the bed for the resident who is receiving tube feeding that they need to alert an licensed nurse immediately; and the head of the bed must remain 30-45 degrees during tube feeding and for at least 1 hour after. On October 28, 2014 (ADON A) was in-serviced by (DON) on proper bed positioning for residents who receive tube feedings to include if a CNA needs to adjust the bed for the resident who is receiving tube feeding they need to alert an licensed nurse immediately; and the head of the bed must remain 30-45 degrees during tube feeding and for at least 1 hour after. In-service for nursing staff was reinitiated by (Corporate RN P) Regional Clinical Specialist on 10/31/14. Nursing staff and certified nursing assistants were in-serviced on the following: proper bed positioning for residents during and following tube feedings; to include if a CNA needs to adjust the bed for the resident who is receiving tube feeding that they need to alert an licensed nurse immediately; and the head of the bed must remain 30-45 degrees during tube feeding and for at least 1 hour after discontinuation of tube feeding. On October 31, 2014 (ADON A) was re-in-serviced by (Corporate RN P) on proper bed positioning for residents who receive tube feedings to include if a CNA needs to adjust the bed for the resident who is receiving tube feeding they need to alert an licensed nurse immediately; and the head of the bed must remain 30-45 degrees during tube feeding and for at least 1 hour after discontinuation of tube feeding. (DON) and (ADON B) in-serviced nursing staff for positioning of a resident while receiving feeding via [DEVICE] initiated on 10/27/14. The nursing staff verified understanding. The schedule includes to in-service 6-2 shift and 2-10 on 10/28/14 conducted by (DON). 10-6 shift will be in-serviced prior to their shift on 10/28/14 by (ADON B). In-services are set to be held October 29, 2014 at 10:00am and 3:00pm and will be conducted by (DON). (Corporate RN P) and (ADON T from another facility) re-in-serviced nursing staff for positioning of a resident while receiving feeding via [DEVICE] on 10/31/14 after discontinuation of tube feeding...(DON) and/or (ADON B) will monitor positioning of bed of residents receiving tube feedings daily beginning October 27, 2014 for 30 days on all residents via log...There are currently 15 residents who are receiving tube feedings that reside in the facility...Comprehensive rounds were initiated on 10/27/14 and completed on 10/28/14 by (DON) on residents with [DEVICE]s to ensure that the heads of the beds are/were elevated to 30-45 degrees and physician orders [REDACTED]. During these rounds 15 residents were reviewed and noted to not be receiving feeding/formula while laying flat in the bed. Comprehensive rounds were reinitiated on 10/31/14 by (Corporate RN P) on residents with [DEVICE]s to ensure that the heads of the beds are/were elevated to 30-45 degrees and physician orders [REDACTED]. Rounds will be completed by 10/31/14...." Interview on 11/01/14 at 1:35PM LVN D verbalized understanding regarding the positioning of residents with [DEVICE]s and enteral feedings [MEDICAL CONDITION] equipment. She was also able to inform/show the surveyor where extra emergency equipment was stored. Interview on 11/02/14 at 2:30 PM LVN L, at 3:00 PM LVN M, at 3:27 PM LVN O, at 4:27 PM LVN X and verbalized understanding regarding the positioning of residents with [DEVICE]s and enteral feedings [MEDICAL CONDITION] equipment. They were also able to inform/show the surveyor where extra emergency equipment was stored. Interview on 11/03/14 at 2:15 PM LVN I verbalized understanding regarding positioning of residents with [DEVICE]s and enteral feedings [MEDICAL CONDITION] equipment. She was also able to inform/show the surveyor where extra emergency equipment was stored. Interview on 11/01/14 at 2:09 PM CNA Y, at 2:L 18 PM CNA AA, at 2:25 PM CNA BB, at 2:29 PM CNA CC verbalized understanding regarding the positioning of residents with [DEVICE]s and enteral feedings. VII. Facility Census The facility's Form CM'S-672, Resident Census and Conditions of Residents, dated 10/27/14 and signed by the facility DON, reflected 12 residents received tube feedings The facility provided a list on 10/28/14, which reflected 15 residents as having [DEVICE]s and receiving tube feedings.

Based on observation, interview and record review, it was determined the facility failed to ensure residents received proper treatment and care for tracheostomies for one (Resident #1) of two residents with [MEDICAL CONDITION]. While scheduled for and providing care for Resident #1, two separate nurses (LVN G and LVN H) failed to ensure required emergency equipment including a replacement [MEDICAL CONDITION] and suction catheters were present at Resident #1's bedside. An Immediate Jeopardy (IJ) was identified on 10/27/14. While the IJ was removed on 11/02/14, the facility remained out of compliance at a severity level of "potential for more than minimal 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. These failures have the potential to affect two of two residents (Resident #1 and Resident #2) in the event of an emergency with the [MEDICAL CONDITION] occurred. Findings included: According to Review of Perry & Potter Clinical Nursing Skills & Techniques 7th edition, 2010, Chapter 25 Airway Management, Caring for a resident with [MEDICAL CONDITION] several high risk potentials of emergency situations including [MEDICAL CONDITION] accidently removed during positioning and other activities of daily, as well as developing hypoxemia (oxygen levels dropping) when being suctioned, which can lead to cardiac [MEDICAL CONDITION] and [MEDICAL CONDITION] as well as a mucous plug becoming dislodge and occluding [MEDICAL CONDITION] failure to humidify a resident with [MEDICAL CONDITION] cause secretions to thicken and cause a mucous plug. The necessary bedside equipment to handle these emergencies includes, an extra emergency trach, ambu bag, oxygen, suction catheters, working suction machine, canister and tubing as well as saline bullets for the removal of a mucous plug, peroxide and sterile tray or [MEDICAL CONDITION] kit to remove a mucous plug, oximeter and stethoscope. 1. Resident #1's physician's orders [REDACTED]. Further review of Resident #1's October 2014 physician's orders [REDACTED]. [MEDICAL CONDITION] daily and PRN as follows: "...1. [MEDICAL CONDITION] change inner cannula " (#____DIC). " 2. Clean around Stoma area using normal saline and a q-tip, pat dry with 4x4. 3. Remove [MEDICAL CONDITION] and assess skin for redness/breakdown. 4. [MEDICAL CONDITION] and secure...." Resident #1's physician's orders [REDACTED]. Resident #1's MDS assessment, dated 08/27/14, reflected he was admitted from an acute care hospital, he was absent of speech, and his cognitive skills were severely impaired. Resident #1 was totally dependent on staff for bed mobility, transfers, dressing, personal hygiene, and his range of motion was impaired for both upper and lower extremities. Resident #1 was non ambulatory. He was incontinent of bowel and had an indwelling catheter. Record review of Resident #1 ' s care plans revealed a care plan dated 8/18/14 for code status that noted Resident #1 is full code and that staff are to monitor for a decrease in change of condition and report to M.D. Record review of Resident #1 ' s care plans revealed a care plan, dated 8/18/14, for [MEDICAL CONDITION] with the following directions. --Problem: Resident has a [MEDICAL CONDITION] and is at risk for increased secretions/congestion and infections. --Goal: Secretions/congestion will be relieved within five minutes of suctioning and no occurrence of infection will occur in 90 days. --Approach: 1. Monitor for need of suctioning of increased secretions/congestion-assess for relief 2. Provide O2,[MEDICAL CONDITION], and tubing change per order. 3. Give medications per order-monitor labs/x-rays-report " abn.s " to M.D. 4. Provide for support to prevent anxiety if shortness of breath occurs. 5. Monitor for signs and symptoms of infection and report to M.D.\6. Encourage socialization and activity attendance. Observation on 10/27/14 at 11:06 a.m. revealed Resident #1 had a #6 trach, an audibly weak, congested cough, [MEDICAL CONDITION] was around his neck, but was not positioned over [MEDICAL CONDITION] had slid down to the left side of the resident's neck. Further observation revealed there was not an emergency [MEDICAL CONDITION], suction catheters, sterile gloves or saline bullet flushes at the bedside. The water trap bag for the humidification system was laying in the floor and 2/3 full, the aerosol tubing was full of saline and the regulator valve for the amount of humidification was leaking saline out of it and dripping onto the floor and had approximately 50-100 cc of saline in it, the suction canister was clean without any signs of secretions in it and the tubing connected to it was coiled and wrapped inside a disposable glove on the night stand between the humidification compressor and the suction machine. Interview on 10/27/14 at 11:06 a.m. with LVN G revealed he was scheduled and assigned to Hall 100 the hall where Resident #1 resided. LVN G stated Resident #1 was currently being treated for [REDACTED]. LVN G stated the facility's policy for emergency equipment requirements for a resident with a trach, was for a [MEDICAL CONDITION] ambu bag to be available. At that time, LVN G was unable to locate an [MEDICAL CONDITION] Resident #1 ' s room and stated he would get them. Observation of Resident #1 on 10/27/14 at 4:08 p.m. (five hours later), revealed no [MEDICAL CONDITION] equipment and supplies had been placed in the Resident #1 ' s room. Interview on 10/27/14 at 4:39 p.m. with LVN H, revealed he was scheduled and assigned to Hall 100. LVN H stated his daily routine was to come in and take a verbal report while walking the hall he was assigned to, with the nurse he was relieving. He stated he performed an assessment on all of his assigned residents within one hour of reporting to work to include emergency equipment checks specific to resident needs. During a subsequent interview with LVN H on 10/27/14 at 7:18 p.m., he stated he did not know what emergency equipment was required to be at bedside for a resident with a [MEDICAL CONDITION]. LVN H stated that if a resident decannulated ([MEDICAL CONDITION] out of the resident) unintentionally, he would run down to the supply room and get a replacement [MEDICAL CONDITION] and that every nurse had a key to the supply room on their facility key ring. Interview on 10/27/14 at 5:15 p.m. with ADON A revealed there was supposed to be an [MEDICAL CONDITION] an ambu bag at the bedside for a resident with a [MEDICAL CONDITION]. She stated she did not know why there was not and [MEDICAL CONDITION] Resident #1's room. At that time, ADON A was unable to locate an [MEDICAL CONDITION] suction catheters in Resident #1's room. ADON A directed LVN H to go to the supply room and "get me some proper suction tubing and [MEDICAL CONDITION] supplies." ADON A further told LVN H that when he was done to come see her because she had several in-services she needed him to complete. Further observation at this time (10/27/14 at 5:15 p.m.) revealed an oxygen cylinder in Resident #1's room with the level indicator on empty. ADON A revealed that in an emergency they would use the oxygen on the crash cart. Observation on 10/27/14 at approximately 6:00 p.m. of Resident #1's room revealed a # 6 [MEDICAL CONDITION] taped to the wall above the left side of the bed. 2-trach clean and care kits which have peroxide and brushes to remove a mucous plug, 2-suction catheter kits also to help remove secretions or a mucous plug and each type was stacked side by side on the bedside table, a full bottle of oxygen. On 10/27/14 an IJ was identified. On 10/27/14 at 8:30 p.m., the Administrator, DON, and Corporate RN R were notified of the IJ and a Plan of Removal was requested. The facility's Plan of Removal, dated 10/27/14 reflected, "...Immediately, on October 27 2014, in service for nursing staff was initiated and conducted by (DON), (ADON B). Nursing staff was in-serviced on availability of back up [MEDICAL CONDITION] equipment at bedside to include: a replacement [MEDICAL CONDITION], a suction machine, supply of suction catheters, exam and sterile gloves, ambu bag and flush solution. Nursing staff was also in-serviced that the [MEDICAL CONDITION] box at beside is used for emergencies only, and if routine equipment is needed the nursing staff need to obtain from Supply Room...in-servicing was initiated on October 28, 2014 to include ambu bag as necessary [MEDICAL CONDITION] equipment at bedside. In-service training will be completed by 10/29/14... (DON) and (ADON B) tested for competency of all nurses and certified nursing by utilizing: [MEDICAL CONDITION] Care Competency, Suctioning the Lower Airway Competency was initiated 10/28/14. The nursing staff verified competency by using these check lists and tools. The schedule includes to in-service 6-2 shift and 2-10 on 10/28/14 conducted by (DON). 10-6 shift will be in-serviced prior to their shift on 10/28/14 by (ADON B). In-services are set to be held October 29, 2014 at 10:00am and 3:00pm and will be conducted by (DON)...Charge nurses on all three shifts will monitor to ensure emergency equipment replacement [MEDICAL CONDITION] at bedside daily. Charge nurse will document on the MAR indicated [REDACTED]. Charge nurses who use emergency equipment will be responsible to replace it by the end of their shift. (DON) and/or (ADON B), (ADON A) will monitor MARs daily using Daily Nursing Management Tool beginning October 28, 2014. Daily Nursing Management Tool will be turned in daily to (DON) to monitor...Comprehensive rounds were initiated on 10/27/14 and completed on 10/28/14 on all residents who have [MEDICAL CONDITION] (DON) These rounds ensured that both residents with tracheostomies had emergency equipment at bedside. The emergency equipment included back-up trach, ambu bag, gloves, suction machine [MEDICAL CONDITION]. Both residents with tracheostomies were stable...." Initial observation on 10/28/14 at 8:28 a.m. of Resident #1's room revealed emergency equipment and supplies were available in Resident #1 ' s room appropriate to resolve an emergent situation. In order to observe the nurses for the assessment and the proper use of the necessary emergency equipment in an emergency such as a mucous plug or [MEDICAL CONDITION] out, there were numerous daily request from LVN I, Resident # ' 1 primary care nurse Monday through Friday 6:00 a.m. to 2:00 p.m. to [MEDICAL CONDITION] which included suctioning and or to hold for the next day. With each request it was always stated that it had been completed. Daily observations from 10-28-14 through 11/02/14 revealed emergency equipment was in the room however, the supplies and equipment to provide care and subsequent actual checks of the emergency equipment and functionality revealed suction equipment, catheter kits, suction canister clean and dry and suction canister and the tubing connected to it was always in the same location and position and did not appear to have been used or that [MEDICAL CONDITION] care had been completed. Further observations revealed that routine equipment was not running at the most optimal level to prevent emergencies. The facility's amended Plan of Removal, accepted on 10/31/14, reflected, "Amendment on 10/31/14 (DON) will be in-serviced by (Corporate RN P). The in-service will include: availability of back up [MEDICAL CONDITION] equipment at bedside to include: a replacement [MEDICAL CONDITION], a suction machine, supply of suction catheters, exam and sterile gloves, ambu bag and flush solution. The in-service also included the [MEDICAL CONDITION] box at beside is used for emergencies only, and if routine equipment is needed the nursing staff need to obtain from Supply Room...In-service for nursing staff was reinitiated by (Corporate RN P) Regional Clinical Specialist on 10/31/14. Nursing staff was in-serviced on availability of back up [MEDICAL CONDITION] equipment at bedside to include: a replacement [MEDICAL CONDITION], a suction machine, supply of suction catheters, exam and sterile gloves, ambu bag and flush solution. Nursing staff was also in-serviced that the [MEDICAL CONDITION] box at beside is used for emergencies only, and if routine equipment is needed the nursing staff need to obtain from Supply Room. The in-service also included how to identify the size of [MEDICAL CONDITION] well as the appropriate supplies specific to the resident and where to obtain those supplies. Nurses were also in-serviced on verifying MD order. A clarification order was obtained on October 31, 2014 to include the [MEDICAL CONDITION] for the current residents with tracheostomies...Any competencies that were done by (DON) will be reinitiated by (Corporate RN P) and (ADON T from another facility) on 10/31/14 and will be completed by 10/31/14...(Corporate RN P) will be responsible for maintaining the list of employees who have not been trained. (Corporate RN P) and (ADON T from another facility) will complete the training by 10/31/14. The nursing staff who cannot attend a scheduled in-service will receive training by (Corporate RN P) or (ADON T from another facility) prior to shift...(Corporate RN P) will monitor compliance of the Daily Nursing Management Tool starting 10/31/14 daily for 30 days and then weekly for 3 months...(Corporate RN P) and (ADON T from another facility) will initiate comprehensive rounds on all residents who have [MEDICAL CONDITION] 10/31/14 and then weekly thereafter...(Corporate RN P) will monitor compliance with the Daily Nursing Management Tool starting 10/31/14 daily for 30 days and then weekly for 3 months...." Interview on 11/01/14 at 1:35PM with LVN D revealed the nurse verbalized understanding regarding the positioning of residents with [DEVICE]s and enteral feedings [MEDICAL CONDITION] equipment. She was also able to inform/show where extra emergency equipment was stored. Observations and interview on 11/02/14 at between 2:30 p.m. and 3:27 p.m. with LVN L, M, O and at 4:27 p.m. for LVN X, revealed they were able to verbalize the correct equipment, demonstrate proper use of the equipment and locate the replacement emergency equipment in the supply room. Interview on 11/03/14 at 2:15 p.m. with LVN I revealed the nurse was able to verbalize understanding regarding positioning of residents with [DEVICE]s and enteral feedings [MEDICAL CONDITION] equipment. She was also able to inform/show the surveyor where extra emergency equipment was stored. The IJ was removed on 11/02/14 and the Administrator, D.O.N, Senior Vice President of Operations Q, Corporate RN R, and Corporate RN P were notified the IJ was removed. While the IJ was removed, the facility remained out of compliance at a severity level of "potential for more than minimal 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 facility's Form CMS 802, Roster/Sample Matrix, dated 11/27/14, reflected a census of 87. Interview with the DON revealed two residents with tracheostomies.

Based on observation, interview and record review, it was determined the facility failed to ensure two (Residents #1 and #3) of 15 residents with [DEVICE]s received the appropriate treatment and services to prevent aspiration, aspiration pneumonia, dehydration, vomiting, a decreased quality of life and/or possible death. Resident #1 ' s enteral feeding (tube feeding) was infusing when CNAs U and V laid the resident flat in bed three times during a 30 minutes period of time. ADON A was present and failed to intervene to prevent this from happening. Resident #3's enteral feeding was turned off by DON and LVN D. DON lowered Resident #3's head of the bed so she was in a flat-lying position. LVN S re-connected Resident #3's enteral feeding without first checking tube placement. An Immediate Jeopardy (IJ) was identified on 10/27/14. While the IJ was removed on 11/02/14 the facility remained out of compliance at a severity level of "potential for than minimal 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. These failures placed Residents #1 and #3 at risk of aspiration, aspiration pneumonia and/or death. These failures could affect the additional 14 residents with [DEVICE]s by placing them at risk for aspiration, aspiration pneumonia, vomiting and a decreased quality of life. Findings included: Resident #1's face sheet, 09/29/14, reflected he admitted to the facility on [DATE] and his current age was 30. Resident #1 ' s MDS assessment, dated 8/27/14, reflected he had a [DEVICE] ([DEVICE]) and [MEDICAL CONDITION]. His [DIAGNOSES REDACTED]. It further notes he required total assistance of staff for care. Resident #1's care plans, dated 08/18/14, provided no evidence evidence of a plan of care to address his enteral tube feedings or his risk for aspiration. Resident #1's physician's orders [REDACTED]. Observation on 10/27/14 at 4:52 p.m. of Resident #1 was in bed with his enteral feeding infusing at 65 ml/ar. CNA U lowered the head of Resident #1 ' s bed to a flat position while the formula continued to infuse. At this time, ADON A was in Resident #1's room at the resident ' s bedside and did not direct CNA U not to lay Resident #1 in a flat position. Resident #1 had the head of his bed raised and lowered to a flat position two additional times while being weighed at 5:20 p.m. by CNA V and again at 5:30 p.m. by CNA V when he was lowered back into the bed from the Hoyer scale. During the observation on 10/27/14, CNA U and CNA V each said they were not aware of the facility's policy regarding tube feeding and positioning. The interviews were conducted at 5:01 PM and 5:02 PM, respectively. On 10/27/14 approximately at 5:32 PM, ADON A stated she did not notice the head of the bed was lowered at that time. She stated the feeding should have been stopped and not allowed to continue to run at that time. Review of Perry & Potter Clinical Nursing Skills & Techniques 7th edition, 2010, Chapter 31 Enteral Nutrition & Care, revealed [MEDICAL CONDITION] aspiration is a common complication related to tube feedings and standard nursing practice is keeping the head of bed elevation greater than 30 degrees is a simple method to keep the risk of aspiration to a minimum. Review of the facility face sheet dated 09/29/14 revealed Resident #3 was a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses, which included Altered Mental Status, General Muscle Weakness, Dysphagia, Paralysis Agitans, [MEDICAL CONDITION] Reflux, Wheelchair Dependence, Lack of Coordination and Senile Dementia. Resident #3's care plan with problem onset date of 02/22/13 and last updated on 09/05/14 for risk of altered nutritional status secondary to Dementia, last updated on 09/05/14, reflected to continue the plan for 90 days, with approaches, which included: "Serve diet as ordered...Allow ample time to ingest meal...Determine food preference...offer resident's food preferences and avoid dislikes...offer between-meal supplement...Offer bedtime snack...Reg CC/RCS Diet (Regular Controlled Carbohydrates/Reduced Concentrated Sweets)." An updated care plan, which addressed the changes for Resident #3 to a NPO status with [DEVICE] and tube feedings, was not located. No care plan was located to update approaches regarding specific positioning requirements and gastronomy care approaches. Resident #3's Resident Summary, dated 09/27/14, completed upon readmission, reflected she exhibited an altered level of consciousness, was non-verbal, lacked awareness of her own needs, had a Stage II pressure ulcer, was incontinent of bowel and bladder, required total staff care for hygiene and grooming and received feedings via a [DEVICE]. Her hearing was impaired and she could not communicate her needs. Resident #3 required the assistance of two staff for transfers and positioning while in bed. Resident #3's MDS assessment, dated 10/04/14, reflected additional [DIAGNOSES REDACTED]. and Gastronomy Status. She had exhibited no speech and was rarely/never understood or was able to understand others, her vision was highly impaired, exhibited short and long-term memory problems, was severely impaired for daily decision making, was incontinent of bowel and bladder and required the extensive assistance of one person for bed mobility eating, toilet use and personal hygiene and required extensive assistance of two persons for transfers (including to or from bed, chair, wheelchair, etc.). Resident #3 weighed 150 pounds, had not had any weight loss or gain in the last 6 months, had a feeding tube, received 51% or more of her total calories through the tube feeding and had an average fluid intake by tube feeding of 501cc or more daily. Resident #3's November 2014 consolidated physician's orders [REDACTED]. ? NPO - [DEVICE] original order date was 09/27/14; ? Tube Feeding: via pump: Glucerna 1.2 cal @ 45cc/hr via pump - increase by 10 ml/hr Q 8 hrs until a goal of 75 ml/hr (original order date was 09/29/14); ? Flush tube with 200 cc water Q shift (original order date was 09/29/14); ? Flush tube with 30 cc water before and after medications (original order date was 09/29/14); ? Elevate HOB 30-45 degrees (original order date was 10/30/14); ? Check stomach contents for residual & return contents to stomach. If more than 100 cc noted, hold feeding and immediately notify MD. Document amount of residual (original order date was 10/30/14); ? Check tube for proper placement by auscultation prior to instilling medications, formula & water. (Initialing indicates that tube has been checked & placement if correct) (original order date was 10/30/14); ? Tube Feeding: via pump: Glucerna 1.2 cal @ 75cc/hr via pump - down time: 9am, Up time: 1pm with a notation to hold (original order date was 09/29/14); Observation of Resident #3 on 10/28/14 at 9:47 a.m. revealed she was lying in bed, with the HOB elevated. Her enteral formula (tube feedings) was not infusing, but the bottle of formula was still present. The bottle was labeled Glucerna 1.2, 1000cc total volume. Hand-written notations indicated the bottle was hung (started) on 10/28/14 at 12:30 a.m. to infuse at 75cc/hr. The bottle had 460 cc remaining, which indicated 540 cc had infused since starting the bottle. Resident #3 should have received 637cc in the time between 12:30 a.m. and 9:00 a.m., when the formula was disconnected. Interview with LVN D at that time confirmed she had disconnected the feeding at 9:00 a.m. Observation on 10/28/14 at 9:47 a.m. also revealed neither Resident #3 nor her roommate, Resident #5, both having [DEVICE]s and receiving enteral feedings via the [DEVICE], had a suction machine and/or suction set-up at bedside in case of an emergency. Observation on 10/30/14 at 1:07 p.m. revealed LVN D was preparing Resident #3's enteral formula for infusion. She stopped and requested CNA C transfer Resident #3 from her wheelchair to her bed. At 1:20 p.m., LVN D proceeded to check the placement of the [DEVICE], connect the feeding tubing and start infusion of enteral formula at 75 cc/hr. At 1:40 p.m., CNA C requested LVN D turn off and disconnect Resident #3's enteral feeding, so incontinent care could be completed. LVN D and the DON disconnected and flushed the [DEVICE] at 1:48 p.m. At 1:50 p.m. the DON lowered Resident #3's head of the bed, to a flat lying position, so incontinent care could proceed. On 10/30/14 at 2:53 p.m., observation of LVN S revealed she came to Resident #3's room to re-connect the enteral formula. LVN S applied gloves without performing any hand hygiene. She turned the pump on and placed the ear tips of her stethoscope in her ears. She placed the bell of the stethoscope on Resident #3's stomach and listened around the gastronomy insertion site. She lifted the [DEVICE] up and then proceeded to connect the enteral formula tubing to the [DEVICE] and started the pump to begin the enteral feeding infusion. LVN S did not check the placement of the [DEVICE] by auscultation of an air bolus (injection of a small amount of air through the tube and into the gut which produces an audible "whoosing" sound) or by aspiration of gastric contents to check for residual enteral formula, before starting the infusion of enteral formula for Resident #3. During an interview, at the end of day on 11/02/14 at 5:30 p.m., the Corporate RN P and Senior VP of Operations Q, after learning of the performance problems observed during gastronomy care, including checking placement and lowering of the HOB without waiting the specified hour after turning off enteral feedings prior to lowering the HOB, stated staff would be re-in-serviced, including the DON. An in-service training action plan dated 11/02/14 and received by the survey team on 11/03/14 from Corporate RN R, (for concerns from end of day interview on 11/02/14) indicated competencies and in-service training for gastronomy care and services, including placement checks, was to be initiated on 11/02/14 and continued until all staff trainings were completed. An IJ was identified on 10/27/14. On 10/27/14 at 8:30 PM, the Administrator and DON were notified of the IJ and a Plan of Removal was requested at that time. Interview with the Resident #1 ' s physician, who was also the Medical Director, on 10/28/14 at 1:30 p.m., revealed he was notified on 10/27/14 of the IJ, but was not given specifics, only that it was in relation to quality of care. He was not aware of the observation on 10/27/14 involving the lowering of Resident #1's bed while his enteral tube feeding was running. The facility's Plan of Removal, dated 10/27/14, reflected, "...Immediately, on October 27 2014, in-service for nursing staff was initiated and conducted by (DON), (ADON B) Nursing staff and certified nursing assistants were in-serviced on the following: proper bed positioning for residents during and following tube feedings; to include if a CNA needs to adjust the bed for the resident who is receiving tube feeding that they need to alert an licensed nurse immediately; and the head of the bed must remain 30-45 degrees during tube feeding and for at least 1 hour after. On October 28, 2014 (ADON A) was in-serviced by (DON) on proper bed positioning for residents who receive tube feedings to include if a CNA needs to adjust the bed for the resident who is receiving tube feeding they need to alert an licensed nurse immediately; and the head of the bed must remain 30-45 degrees during tube feeding and for at least 1 hour after. In-service for nursing staff was reinitiated by (Corporate RN P) Regional Clinical Specialist on 10/31/14. Nursing staff and certified nursing assistants were in-serviced on the following: proper bed positioning for residents during and following tube feedings; to include if a CNA needs to adjust the bed for the resident who is receiving tube feeding that they need to alert an licensed nurse immediately; and the head of the bed must remain 30-45 degrees during tube feeding and for at least 1 hour after discontinuation of tube feeding. On October 31, 2014 (ADON A) was re-in-serviced by (Corporate RN P) on proper bed positioning for residents who receive tube feedings to include if a CNA needs to adjust the bed for the resident who is receiving tube feeding they need to alert an licensed nurse immediately; and the head of the bed must remain 30-45 degrees during tube feeding and for at least 1 hour after discontinuation of tube feeding. (DON) and (ADON B) in-serviced nursing staff for positioning of a resident while receiving feeding via [DEVICE] initiated on 10/27/14. The nursing staff verified understanding. The schedule includes to in-service 6-2 shift and 2-10 on 10/28/14 conducted by (DON). 10-6 shift will be in-serviced prior to their shift on 10/28/14 by (ADON B). In-services are set to be held October 29, 2014 at 10:00am and 3:00pm and will be conducted by (DON). (Corporate RN P) and (ADON T from another facility) re-in-serviced nursing staff for positioning of a resident while receiving feeding via [DEVICE] on 10/31/14 after discontinuation of tube feeding...(DON) and/or (ADON B) will monitor positioning of bed of residents receiving tube feedings daily beginning October 27, 2014 for 30 days on all residents via log...There are currently 15 residents who are receiving tube feedings that reside in the facility...Comprehensive rounds were initiated on 10/27/14 and completed on 10/28/14 by (DON) on residents with [DEVICE]s to ensure that the heads of the beds are/were elevated to 30-45 degrees and physician orders [REDACTED]. During these rounds 15 residents were reviewed and noted to not be receiving feeding/formula while laying flat in the bed. Comprehensive rounds were reinitiated on 10/31/14 by (Corporate RN P) on residents with [DEVICE]s to ensure that the heads of the beds are/were elevated to 30-45 degrees and physician orders [REDACTED]. Rounds will be completed by 10/31/14...." Interview on 11/01/14 at 1:35PM LVN D verbalized understanding regarding the positioning of residents with [DEVICE]s and enteral feedings [MEDICAL CONDITION] equipment. She was also able to inform/show the surveyor where extra emergency equipment was stored. Interview on 11/02/14 at 2:30 PM LVN L, at 3:00 PM LVN M, at 3:27 PM LVN O, at 4:27 PM LVN X and verbalized understanding regarding the positioning of residents with [DEVICE]s and enteral feedings [MEDICAL CONDITION] equipment. They were also able to inform/show the surveyor where extra emergency equipment was stored. Interview on 11/03/14 at 2:15 PM LVN I verbalized understanding regarding positioning of residents with [DEVICE]s and enteral feedings [MEDICAL CONDITION] equipment. She was also able to inform/show the surveyor where extra emergency equipment was stored. Interview on 11/01/14 at 2:09 PM CNA Y, at 2:L 18 PM CNA AA, at 2:25 PM CNA BB, at 2:29 PM CNA CC verbalized understanding regarding the positioning of residents with [DEVICE]s and enteral feedings. The facility's Form CM'S-672, Resident Census and Conditions of Residents, dated 10/27/14 and signed by the facility DON, reflected 12 residents received tube feedings. The facility provided a list on 10/28/14, which reflected 15 residents as having [DEVICE]s and receiving tube feedings.

Based on interview and record review, it was determined the facility failed to consult with the resident's physician and notify the family when there was a significant change in the resident's physical condition from [DATE] to [DATE] for one (Resident #1) of eight residents reviewed for change in condition, who was not eating, not getting out of bed, running fevers, had diarrhea, was lethargic, had an altered mental status and ended up with pustules. Facility failures included: The physician/PA was not notified of the resident's fever on [DATE]. No attempt was made to notify the physician and/or PA until [DATE], and the message left was to please call the facility. There was nothing in the text regarding Resident #1's change of condition or current status. The physician/PA was not informed of Resident #1's actual temperature of 103.6 degrees F. The physician/PA were not informed of the resident's diarrhea. The physician/PA were not fully informed of the resident's status from [DATE] through [DATE]. These failures resulted in Resident #1's physician/PA not being able to make a fully informed decision in regard to the care the resident required. The resident was not sent to the hospital until [DATE], which occurred due to the development of the resident's pustules, not due to his fevers. At the hospital, Resident #1 was diagnosed with [REDACTED]. The resident went into [MEDICAL CONDITION] with CPR required, and he was put on a ventilator. On [DATE] at 4:45 PM, an Immediate Jeopardy (IJ) was identified in the areas of Resident Behavior/Facility Practice, Resident Rights, Professional Standards, Quality of Care and Administration. While the IJ was lowered on [DATE] at 1:55 PM, 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 still implementing the Plan of Removal. These failures could affect the seventy-five residents receiving services from the facility by placing them at risk for not receiving the care and services they needed to maintain their well-being, comfort and free of infection to ensure they live the life they desired. Findings included: 1) The Face Sheet dated [DATE] reflected Resident #1, a [AGE] year-old male, was admitted from an area hospital on [DATE] with [DIAGNOSES REDACTED]. Resident #1's Patient Transfer Form dated [DATE] reflected he had a history of [REDACTED]. The MDS assessment dated [DATE] reflected Resident #1 was able to make himself understood with clear intelligible words, and was able to clearly understand others; no behaviors were present and had no signs of altered mental status or [MEDICAL CONDITION]. The resident required extensive assistance from one person for physical assistance with bed mobility, transfers, locomotion on and off the unit, dressing, toileting, personal hygiene and bathing. The MDS assessment reflected Resident #1 had an active [DIAGNOSES REDACTED]. 2) Review of the Skilled Daily Nurses Note for Resident #1 revealed the following: On [DATE]: At 9:00 AM - Resident #1 had an elevated body temperature of 102.2 degrees F. LVN A (Licensed Vocational Nurse), administered two tablets of Tylenol 500 mg as a fever reducer. At 1:00 PM Resident #1's vital signs were checked. The notes reflected he had an elevated temperature, and his blood pressure ,[DATE] was low. The notes reflected LVN A applied cold compresses to Resident #1's body. He was administered two tablets of Tylenol as a fever reducer. Resident #1's [DATE] MAR from [DATE] through [DATE] reflected the resident's normal blood pressures included: systolic blood pressures of ,[DATE] and diastolic blood pressures of ,[DATE]. On [DATE]: At 3:00 AM, Resident #1 continued to have an elevated body temperature. (The specific temperature was not documented.) He was administered two tablets of Tylenol 500 mg as a fever reducer "per protocol." Review of Physician B's entire standing orders dated effective [DATE] revealed there were no standing orders for a resident with an elevated temperature. At 4:00 AM, the resident's temperature was checked again and it was 99.0 degrees Fahrenheit (F). At 10:00 AM, the notes reflected Resident #1's body temperature was 102.2 degrees F. "Two pain pills were administered, rechecked by 11:00 AM temp down to 98.0 degrees F." Resident #1's blood pressure had dropped to ,[DATE] with an electronic cuff, and was retaken with a manual cuff with a result of ,[DATE]. At 3:00 PM, Resident #1's temperature was 103.6 degrees F and the resident "looked confused." The notes reflected the physician was called four times and the Physician's Assistant (PA) was called three times with no response until the PA returned the call to the facility at 6:30 PM and ordered a UA (urinalysis), CBC (complete blood count) Culture and sensitivity. The PA further ordered if the resident's temperature did not go down, to either order a chest x-ray or send the resident to the ER. There was no further documentation about the resident's status until [DATE] at 1:30 AM. An interview was conducted on [DATE] at 1:10 PM with LVN A in regard to Resident #1. LVN A stated she was the weekend nurse for Saturday ([DATE]) and Sunday ([DATE]). She said when she came in on [DATE], Resident #1 was running a high fever of 102 degrees F and she administered Tylenol. She stated she checked on the resident (after one or two hours), took his clothes off and cooled him with wet towels on his forehead and body. LVN A said when she checked his temperature again; it had gone down to 99 degrees F. LVN A stated Resident #1's temperature would go down, but after one to two hours, "It would come right back up." She stated she called Physician B and PA F, and left a message for each of them to call the facility. LVN A said she then sent a text message to PA F and asked him to call the facility. LVN A stated when she came in Sunday morning ([DATE]), the night nurse told her Resident #1's fever was high. LVN A stated she sent a second text to PA F and asked him to call facility. She stated she called the physician and left a voice mail, but she did not leave specific information about Resident #1 in the text for PA F because of HIPAA (confidentiality of information). Continuing with the same interview on [DATE] at 1:10 PM, LVN A stated although Resident #1's Skilled Daily Nurses Note reflected PA F called her on [DATE] at 6:30 PM, the LVN said she did not actually receive a return call from PA F until 9:00 PM on [DATE]. LVN A said she told PA F the resident was confused. LVN A stated she asked PA F if she should send Resident #1 to the hospital. She said PA F instructed her to wait for the test results to come back. LVN A added she received a text from Physician B telling her to send the resident to the hospital after she had gone off shift and left the faciity on [DATE]. LVN A told the surveyor she did not ever call the facility and/or inform facility staff of the physician's orders [REDACTED]. Review of Resident #1's [DATE] MAR for both routine and PRN medications with LVN A revealed the Tylenol was not documented as administered. When questioned about it during the same interview, LVN A stated questioningly, "I didn't write it down?" Review of all of Resident #1's Physician's Telephone Orders revealed the orders given by the PA for the chest x-ray, CBC and UA with Culture and Sensitivity were never written. On [DATE]: At 1:30 AM, the Skilled Daily Nurses Note reflected a new order was received for labs and a chest x-ray. However, they were "Not able to obtained (sic) urine on this shift." Review of Resident #1's entire clinical record revealed no documentation either Physician B or PA F were notified of the results of the chest x-ray or the CBC or that staff were unable to obtain a urine specimen. At 10:00 AM, the notes reflected Resident #1 was in bed and had diarrhea with [MEDICATION NAME] (anti-diarrheal) was given. At 3:38 PM - "...call to the room by CNA, R/T (related to) the resident seemed weak, upon my assessment vs (vital signs) are ,[DATE] (blood pressure) 96.8 (temperature) 90 (pulse) SATS (Oxygen saturation) 98%, Resident just had an episode of diarrhea. ...resident seem (sic) very lethargic he hasn't eaten all day. DON stated that we shouldn't send resident to [MEDICAL TREATMENT], until call was made to Dr (Physician B), awaiting call back for any new orders...." This entry was signed by ADON N. At 4:30 PM - "...Charge nurse made aware of all things going on and is expecting a call back from Dr. (named Physician B)." This entry was signed by ADON N. At 8:30 PM - "...Orders Rec'd (received) and noted from Dr. (Physician B). [MEDICAL TREATMENT] was made aware that resident was not going to be sent to HD ([MEDICAL TREATMENT]) and why - agreed with that...." Review of the telephone order dated [DATE] at 11:45 PM from Physician B revealed orders to: "1. Hold B/P (blood pressure) meds ([MEDICAL CONDITION]) 2. Collect stools X 3 for [MEDICAL CONDITION] ([MEDICAL CONDITION] - bacterial infection) 3. Call [MEDICAL TREATMENT]/not going today...." Documentation reflected this order was received by LVN C. On [DATE] at 9:30 AM, Resident #1's Skilled Daily Nurses Note reflected "Resident lying in bed at shift change. Lethargic, diaphretic (sic) (sweating profusely). VS (blood pressure) ,[DATE], (temperature) 100.5 AX (axillary), pulse 96 FSBS (finger stick blood sugar) 101. Upon uncovering resident - noted to have a pustual (sic) rash over trunk of body and going down thighs. Call to Dr. (Physician B) and requested order to send to ____ hospital...." Review of Resident #1's entire clinical record revealed there was no documentation the resident's family had ever been notified of the resident's change of condition or hospitalization . 2) Review of the facility's 24 Hour Report/Change of Condition Report revealed the following: On [DATE], Resident #1 stayed in bed during the day and evening shifts. On [DATE], he was "O.K." and stayed in bed on the day shift except when he went to [MEDICAL TREATMENT]. On [DATE], the resident had an increased temperature, but the actual temperature was not specified. On [DATE], Tylenol was given for an elevated temperature, the temperature came down to 98 degrees F, but Resident #1's temperature later increased again. "Doctor was called." The PA called back on the evening shift and gave orders for UA, Culture and Sensitivity and CBC. On [DATE], the only remark on the day shift for Resident #1 was diarrhea. On the evening shift, Resident #1's blood pressure was low (no specifics) and the resident was very weak. On the night shift, the report reflected the resident's lab was drawn (from the orders received on [DATE]). On [DATE], Resident #1 was sent to the hospital and the physician was informed of the resident's rash, temperature and lethargy. 3) Review of Resident #1's Diet Sheet for [DATE] revealed documentation, which reflected the resident's eating patterns had changed. Resident #1 usually ate 78 - 100% of his meals and rarely 50%. On [DATE], Resident #1 ate 50% of his breakfast (normal was 80 - 100%) and nothing was marked for his supper. On [DATE], the resident did not eat any lunch or supper. On [DATE] and [DATE], the Diet Sheet reflected Resident #1 did not eat anything. 4) Resident #1's medication form dated [DATE] reflected Tylenol was not administered for the resident's fever from [DATE] to [DATE]. Review of the [DATE] MAR indicated [REDACTED]. On [DATE] vital sign readings taken revealed the residents pulse was high with a reading of 121 beats per minute. Previous readings prior to that date reflected the resident's pulse readings were ranging between ,[DATE] beats per minute. 5) Review of the Patient Transfer Form dated [DATE] revealed the [DIAGNOSES REDACTED]. Documentation on the transfer form revealed Residents #1's symptoms first started "with n/v (nausea and vomiting), diarrhea. > (greater than) ,[DATE] days - Now still has low grade (temperature) but > 99.9. Now 100.5 AX (axillary), B/P (blood pressure) has been low, unable to dialyse on [DATE]. Has a pustule rash over trunk of body and upper thighs, not noted [DATE]. There this AM. Also lethargic." The transfer form reflected the nurse spoke with Resident #1's primary care provider, who wanted him sent to hospital with a medical history of [REDACTED]. Although the Patient Transfer Form record reflected Resident #1 had nausea and vomiting, review of the resident's entire clinical record revealed no documentation of those symptoms. Review of Resident #1's hospital's History and Physical (H&P) dated [DATE] revealed the resident's reason for being admitted was due to "Fever and Altered Mental Status." The H&P reflected Resident #1 was transferred from the nursing home with a fever over the last ,[DATE] days. "Apparently the patient was increasingly confused and also having fever, so the patient was sent to the hospital for consult [MEDICAL CONDITION]. The patient was admitted on the floor and eventually his blood pressure dropped and also developed altered mental status with hypoxemia (low oxygen levels), so patient was transferred to the ICU (Intensive Care Unit) and intubated (tube inserted into his trachea to facilitate breathing). The patient is on vent support with a temperature of 101 degrees F." Review of the physician's assessment of Resident #1 revealed he was having coarse breath sounds in both lungs and had discoloration of both legs. The physician's "Assessment and Plan" reflected Resident #1 had "Acute [MEDICAL CONDITION], most likely secondary [MEDICAL CONDITION] with pneumonia." The second entry in the plan revealed Resident #1 had "[MEDICAL CONDITION]." Review of Resident #1's hospital Microbiology Reports revealed the following: The report for the culture of blood collected on [DATE] reflected growth [MEDICAL CONDITIONS]. The report for the culture of sputum collected on [DATE] reflected growth [MEDICAL CONDITION]. The report for the culture of his urine collected on [DATE] reflected growth of Proteus mirabillis. The report for the culture of Resident #1's Perma Cath Tip ([MEDICAL TREATMENT] catheter site) collected on [DATE] reflected probable Staphylococcus aureus. Resident #1's Nurses Narrative from the hospital dated [DATE] reflected the resident stopped breathing at 5:20 AM and a code was called with ACLS (Advanced Cardiac Life Support) protocol followed. Resident #1 was intubated and placed on mechanical ventilation. Resident #1's hospital Progress Notes dated [DATE] reflected the resident went into Acute [MEDICAL CONDITION] and received CPR (Cardiopulmonary Resuscitation). 6) A) On [DATE] at 11:30 AM, PA F was interviewed. The surveyor asked if he had received a call from the facility on [DATE] in regard to Resident #1's high fever and lethargy. PA F stated he spoke to LVN A later on [DATE] about Resident #1 and ordered lab work for the resident to make sure there was no infection. The PA stated the nurses were supposed to do a STAT (immediately) order on the lab work, so he could solve the problem. (The Physician's Telephone Orders dated [DATE] did not reflect any STAT orders.) PA F stated he never got a call about Resident #1's lab work results so he would know how to treat the resident. He stated, "They could call or text. I have told them that and I would get back to them as soon as I could." PA F said he was told by the nurse Resident #1's fever was over 100 degrees F and would come down with Tylenol. "So, I did a stat order for UA (Urine Analysis), CBC (Complete Blood Count) and a chest x-ray. If he was that ill with fever and was lethargic, I would have sent him out without question." PA F stated that the nurse did not tell him anything other than the resident's temperature was over 100 degrees F. PA F stated the staff never told him how high the temperature was or the resident had an altered mental state. PA F stated there was no reason for the staff not to leave him a message or a text to let him know how ill Resident #1 was at the time of the call. B) On [DATE] at 11:55 AM, the DON was interviewed regarding the health status of Resident #1. The DON stated she was aware the resident was running a temperature. She stated she went in to see the resident on [DATE] and he spoke to her, and his appetite was not that great. The DON said his temperature was up all day. The DON stated the nurses did not call her about the resident. "They were doing their own thing." The DON stated the Tylenol was working. She said on Wednesday ([DATE]) the resident developed pustules on his body. The DON stated she called the doctor and told him what was going on, and they decided to send him out to the hospital. She stated the resident was not under any stress when he left the facility. The DON stated there were Standing Orders for residents who run fevers, and were lethargic, and the nurses usually call her when there was a problem (but they did not on this occasion). The DON stated she did not see him until Sunday [DATE]. She added he was scheduled to go out for [MEDICAL TREATMENT] on Monday [DATE] but he was still ill so she called Physician B and documented it in the Skilled Daily Nurses on [DATE]. The DON stated she had read the Nurses Notes over and over and that she thought they (nurses) did what they were supposed to do. We have standing orders from the physicians. Review of Physician B's entire standing orders dated effective [DATE] revealed there were no standing orders for a resident with an elevated temperature. Review of Resident #1's Consolidated Physician order [REDACTED]. Additional review revealed Resident #1 was not on a routine antipyretic (fever reducing medication such as Tylenol). C) RA (Restorative Aide) E was interviewed on [DATE] at 11:10 AM in regard to Resident #1. RA E stated he provided care for Resident #1 all the time. RA E said this past Sunday on [DATE] he and CNA L were talking about how ill Resident #1 had been. RA E stated CNA L had told him (RA E) he (CNA L) was concerned about Resident #1 because the resident was running a fever and was not himself. RA E stated, "He looked ill." RA E stated Resident #1's illness "started back on Friday ([DATE]). He was ill that day. He was sent out to [MEDICAL TREATMENT]." RA E added, "He (Resident #1) was so weak that he couldn't sit up straight in his chair. The resident was sweaty and clammy that day. Can't believe they sent him out to [MEDICAL TREATMENT]." RA E said he went to the Charge Nurse at the time to tell her about Resident #1's condition. RA E stated, "I will go to the DON or talk to the nurse if there is a concern (with a resident)." RA E stated, "Both (charge) nurses (LVN A and LVN C) ...knew how ill he was and should not have sent him out (to [MEDICAL TREATMENT])." D) CNA L was interviewed on [DATE] at 12:15 PM regarding the health status of Resident #1. CNA L stated he returned to work on Sunday ([DATE]) and observed the Charge Nurse, LVN A, take Resident #1's temperature. CNA L stated the resident was unresponsive and he reported that information to ADON N on [DATE]. He stated he asked ADON N to come look at the resident. CNA L stated ADON N took Resident #1's blood pressure with a digital cuff and it was ,[DATE]. (Record review revealed this B/P was not documented.) CNA L stated he observed the resident as he laid there all day, and the next morning, [DATE], before they sent him out. CNA L stated when he tried to get the resident up out of bed, Resident #1 was hollering. CNA L stated the resident always liked his coffee, but starting last Thursday ([DATE]), he stopped asking for coffee. CNA L stated his biggest concerns were why would the staff wait so long to send him out to the hospital; and why they attempted to send him to [MEDICAL TREATMENT] on Monday ([DATE]). He also stated that the facility staff neglected Resident #1, and they should be caring for the residents by order of importance of resident's needs. The surveyor asked CNA L if he informed the Abuse Coordinator of his concerns and he stated "No," because he was afraid he would be fired. E) LVN D was interviewed on [DATE] at 10:40 AM in regard to Resident #1. LVN D verified she worked weekdays on the day shift and was a Charge Nurse. LVN D stated Resident #1 was a diabetic and did not like to get up. On Monday ([DATE]) he had some diarrhea. She stated the CNAs reported Resident #1 was having diarrhea on [DATE]. LVN D added Resident #1 did not have any fever on the 10:00 PM - 6:00 AM shift. LVN D stated Resident #1 went to the hospital the next day ([DATE]) because of his rash. LVN D said the hospital called the facility on [DATE] requesting next of kin information for Resident #1, because they were trying to locate the family. LVN D said the hospital staff told her Resident #1 came to the hospital in respiratory distress and he was now on a ventilator. LVN D stated she had been licensed as an LVN since [DATE] (three months), and she was still learning about [MEDICAL TREATMENT] residents. Review of the Skilled Daily Nurses Note dated [DATE] at 10:00 AM and signed by LVN D revealed "Resident lying in bed. [MEDICATION NAME] given. Resident has Dirrhea (sic) No temp this am. No bleeding or s/s (signs/symptoms) of infection at shunt site. Call light within reach - will cont. to monitor." F) On [DATE] at 12:49 PM, MA H was interviewed. She stated she noticed Resident #1 had a fever and low blood pressure on [DATE]. MA H stated she reported Resident #1's vital signs to LVN C, the Charge Nurse. MA H stated, "All they did was give him Tylenol." MA H stated she "knew the resident's temperatures had been over 104.4 degrees F." She stated, "He was really hot and sweaty. They did not even send him to [MEDICAL TREATMENT]." She stated, "He usually talked to me, he had not been eating, and he was shaking." MA H stated if she saw a problem like that, she would document her observations on the flow sheet and would then circle it for the nurse to see. M A H stated she was worried about Resident #1. Review of Resident #1's clinical record revealed no documentation the aide reported her concerns to her LVN C. G) Interview on [DATE] at 11:40 AM with CNA J revealed she went to both of the Charge Nurses, LVN C and LVN D, about Resident #1's condition, and told them he was sleeping a lot, not eating, was confused, was not alert and oriented, and had food all over him, all down the front of him. CNA J stated when she normally provided care to Resident#1, he would visit with her and he always spoke English to her; however, on that day he was not speaking English. She stated, "He knows I do not speak ____ (another language)" and it was not normal behavior for him. CNA J stated "he just kept getting worse." H) MA K was interviewed on [DATE] at 9:50 AM in regard to Resident #1's health status. MA K stated she took all the residents' temperatures and vital signs and documented them on notebook paper and handed it to the charge nurse, who put the information in the chart. MA K stated when Resident #1 was eating; he loved coffee and did not like to be bothered. She said on [DATE] he showed signs of confusion, he had an empty cup in his hand and he thought there was coffee in the cup. MA K stated she talked to the nurse about Resident #1's confusion. I) An interview was conducted on [DATE] at 10:05 AM with LVN C in regard to Resident #1. LVN C stated she was a PRN nurse and had not been familiar with Resident #1's normal behavior. She stated she took care of him the day before he was sent out ([DATE]). She stated she observed him lying in bed, never saw him up or with his eyes open. LVN C stated she thought he was non-verbal. "I would not have known that was not normal behavior for him." LVN C stated direct care staff came to her with concerns Resident #1 was not like himself. She stated she went to assess him, but did not have a baseline to go by for her evaluation of the resident. LVN C stated she expressed her concerns to ADON N and ADON N told her she (ADON N) was taking care of it and to go back to her Hall. Review of Resident #1's Skilled Daily Nurses Note dated [DATE] revealed LVN C recorded one set of vital signs for Resident #1 on [DATE] (T-96.8, P-90, R- 20 and B/P-,[DATE]) and a note orders were received from Physician B. J) An interview was conducted on [DATE] at 10:30 AM with ADON N in regard to Resident #1. ADON N stated on Monday ([DATE]), the facility van driver and CNA G called her about Resident #1's health status prior to putting him on the van to [MEDICAL TREATMENT]. At that time, ADON N said CNA G told her he thought Resident #1 did not feel good and had not eaten. ADON N stated she went to assess the resident on [DATE] at 3:38 PM prior to sending him to [MEDICAL TREATMENT]. ADON N stated when she called Resident #1 by his name he could barely raise his head. ADON N stated, "He wasn't himself." ADON N stated she called Physician B. Resident #1's Skilled Daily Nurses Note revealed ADON N documented a call to Physician B on [DATE] after 3:38 PM. During the same interview, ADON N stated the call went to voice mail. ADON N stated she sent a text to Physician B with Resident #1's vital signs, which were B/P ,[DATE], T- 96.8. P-90, and Oxygen Saturation 98%. ADON N said she called PA F and left a message for PA F to return the call. ADON N said the DON told her Resident #1 could not go to [MEDICAL TREATMENT]. ADON N stated she advised the Administrator on [DATE] of the situation with Resident #1 and informed her she could not get hold of Physician B. ADON N stated Physician B did not text back until 5:30 PM or 6:00 PM. Observation of ADON N's telephone revealed a text message was sent at 3:36 PM on [DATE]. The message reflected Resident #1 was weak and his stools smelled like[DIAGNOSES REDACTED]icile (an infection). However, no other symptoms were added to the text message regarding his blood pressure and temperature. At that time, ADON N stated the return text from Physician B told her to hold Resident #1's blood pressure medications (due to his low blood pressure of ,[DATE]) and to call the Nephrologist. Review of Resident #1's entire clinical record revealed no documentation ADON N or any nurse called the Nephrologist. The Skilled Daily Nurses Note dated [DATE] reflected LVN C notified the [MEDICAL TREATMENT] center Resident #1 would not be there that day ([DATE]). During the same interview, ADON N stated she then turned over Resident #1's care back to LVN C, the charge nurse. ADON N stated if she had been working the floor (as the charge nurse), "I would have called the DON and Corporate Nurse. The DON can send him out (to the hospital)." Resident #1's clinical record had no documentation ADON N instructed LVN C to notify the DON and Corporate Nurse and or what to do if Physician B did not return the call. K) An interview was conducted on [DATE] at 5:20 PM with the DON in regard to Resident #1's fevers, which had ranged from 102.7 to 104.4 degrees F over a four-day period. The DON was asked at what point she would expect her nursing staff to send the resident to the hospital with fevers that high. The DON stated, "That is a good question, but we were in communication with the doctor all along." L) An interview was conducted on [DATE] at 9:20 AM with Physician B, who was one of the facility's Medical Directors. Physician B stated if a resident had temperatures over 102 degrees F, an altered state of mind, and was short of breath or lethargic, then the resident should be sent to the hospital. Physician B was asked if he was specifically informed by facility staff on [DATE] about Resident #1's high fever, lethargy, and dropping blood pressure. Physician B stated he did not know his patient was that bad. Physician B stated if he had received a call from the facility on the fifteenth, they (facility staff) did not leave a message for him. He stated he had a call from the DON sometime after [DATE], regarding her inability to reach Resident #1's family and she informed him at that time Resident #1 did not go to [MEDICAL TREATMENT] on [DATE]. Physician B stated Resident #1 not going to [MEDICAL TREATMENT] was not good for the resident, because he had the potential for fluid overload due to his kidney failure and a history [MEDICAL CONDITION]. Physician B stated the last time he saw Resident #1 was on [DATE]. The physician stated if the resident's temperature was 103 degrees F, he should have been sent out to the hospital, especially since he was a [MEDICAL TREATMENT] patient. Physician B added fevers like that were not that simple, "The body is telling us something." Physician B stated there "...has to be some education with the nurses. As for the severity of a fever of 103 degrees, there is urgency with that kind of fever." Physician B repeated, "There needs to be more nursing education. Have to do some more education to nurses not to mess around with a fever of 103 degrees." M) On [DATE] at approximately 4:00 PM, the facility's other Medical Director, Physician M, was interviewed in regard to Resident #1. He stated he reviewed Resident #1's change of condition, and the resident should have been sent to the hospital when his fever was over 103 degrees F, and he had an altered mental status. Physician M stated the failure of the nurses was a communication and education problem. 7) Review of the facility's current, undated "Policy on Significant Change and Physician Notification" revealed the following: "Significant change and physician notification Purpose To ensure that resident's family and/or legal representative and physician are notified of resident changes that fell under the following categories: ? An accident resulting in injury and that has the potential for needed physician intervention. ? A significant change in the resident's physical, mental or psychosocial status. (See below for examples) ? A need to significantly alter treatment. ? Transfer of the resident from the facility. PROCEDURE When any of the above situations exists, the licensed nurse will contact the resident's family and their physician. Calls will be made to the family until they are reached. A message may be left on an answering machine which does not give specifics but leaves a request for the facility to be called. The physician will be contacted immediately for any emergencies irregardless (sic) of the time of day. Non-emergency notifications maybe made the next morning if the situation occurs on the late evening or night shift. This applies to any day of the week including holidays. If the physician cannot\immediately be reached in any emergency, the medical director will be called. If that physician cannot be reached, the director of nursing or the charge nurse can make arrangements for transportation to the emergency department. In a non-emergency situation, the primary physician will be called unless he/she has left an alternate name to call. If after two attempts, there is no response to the calls, the medical director will be contacted. Each attempt will be charted as to time the call was made, who was spoken to, and what information was given to the physician. Charting will be done in the medical record. EXAMPLES OF SIGNIFICANT CHANGES A fall resulting in head trauma, excessive pain or possible fracture. . A 5% weight change in 30 days or 10% change in 6 months. Development of a pressure sore. Refusal or inability to consume food or fluids for more than 2 shifts. A sudden change in mental status including agitation, lethargy, sudden lack of responsiveness or manic behavior. Elevated temperatures Bleeding Chest pain Diarrhea Emesis Abrupt onset of [MEDICAL CONDITION] Medication Error [MEDICAL CONDITION] Abrupt onset of shortness of breath New skin rash Abnormal Lab results New wounds or bruises." 8) On [DATE] at 4:15 PM, the Administr

Based on observation, interview and record review, it was determined the facility failed to implement the facility's policies and procedures that prohibit mistreatment and neglect by failing to consult with the resident's physician when there was a significant change in the resident's physical condition from [DATE] to [DATE] for one (Resident #1) of eight residents reviewed for neglect, who was not eating, not getting out of bed, running fevers, had diarrhea, was lethargic and had an altered mental status. Facility failures included: The physician was not notified of the resident's fever on [DATE]. No attempt was made to notify the physician and/or PA until [DATE], and the message left was to please call the facility. There was nothing in the text regarding Resident #1's change of condition or current status. The PA was not informed of Resident #1's actual temperature of 103.6 degrees F. LVN A received an order from the physician to send Resident #1 to the hospital on [DATE] after she was off shift and had left the facility. LVN A did not ever inform anyone at the facility of the physician's orders [REDACTED]. The physician/PA were not informed of the resident's diarrhea. The physician and PA were not fully informed of the resident's status from [DATE] through [DATE]. The licensed nurses frequently documented Resident #1's temperature as elevated and blood pressures as low without including the specific results. These failures resulted in Resident #1's physician/PA not being able to make a fully informed decision in regard to the care the resident required. The resident was not sent to the hospital until [DATE], which occurred due to the development of the resident's pustules, not due to his fevers. At the hospital, Resident #1 was diagnosed with [REDACTED]. The resident went into [MEDICAL CONDITION] with CPR required, and he was put on a ventilator. On [DATE] at 4:45 PM, an Immediate Jeopardy (IJ) was identified in the areas of Resident Behavior/Facility Practice, Resident Rights, Professional Standards, Quality of Care and Administration. While the IJ lowered on [DATE] at 1:55 PM, 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 still implementing the Plan of Removal. These failures could affect the seventy-five residents receiving services from the facility by placing them at risk for not receiving the care and services they needed to maintain their well-being, comfort and free of infection to ensure they live the life they desired. Findings included: 1) The Face Sheet dated [DATE] reflected Resident #1, a [AGE] year-old male, was admitted from an area hospital on [DATE] with [DIAGNOSES REDACTED]. Resident #1's Patient Transfer Form dated [DATE] reflected he had a history of [REDACTED]. The MDS assessment dated [DATE] reflected Resident #1 was able to make himself understood with clear intelligible words, and was able to clearly understand others; no behaviors were present and had no signs of altered mental status or [MEDICAL CONDITION]. The resident required extensive assistance from one person for physical assistance with bed mobility, transfers, locomotion on and off the unit, dressing, toileting, personal hygiene and bathing. The MDS assessment reflected Resident #1 had an active [DIAGNOSES REDACTED]. 2) Review of the Skilled Daily Nurses Note for Resident #1 revealed the following: On [DATE]: At 9:00 AM - Resident #1 had an elevated body temperature of 102.2 degrees F. LVN A (Licensed Vocational Nurse), administered two tablets of Tylenol 500 mg as a fever reducer. At 1:00 PM Resident #1's vital signs were checked. The notes reflected he had an elevated temperature, and his blood pressure ,[DATE] was low. The notes reflected LVN A applied cold compresses to Resident #1's body. He was administered two tablets of Tylenol as a fever reducer. Resident #1's [DATE] MAR from [DATE] through [DATE] reflected the resident's normal blood pressures included: systolic blood pressures of ,[DATE] and diastolic blood pressures of ,[DATE]. On [DATE]: At 3:00 AM, Resident #1 continued to have an elevated body temperature. (The specific temperature was not documented.) He was administered two tablets of Tylenol 500 mg as a fever reducer "per protocol." Review of Physician B's entire standing orders dated effective [DATE] revealed there were no standing orders for a resident with an elevated temperature. At 4:00 AM, the resident's temperature was checked again and it was 99.0 degrees Fahrenheit (F). At 10:00 AM, the notes reflected Resident #1's body temperature was 102.2 degrees F. "Two pain pills were administered, rechecked by 11:00 AM temp down to 98.0 degrees F." Resident #1's blood pressure had dropped to ,[DATE] with an electronic cuff, and was retaken with a manual cuff with a result of ,[DATE]. At 3:00 PM, Resident #1's temperature was 103.6 degrees F and the resident "looked confused." The notes reflected the physician was called four times and the Physician's Assistant (PA) was called three times with no response until the PA returned the call to the facility at 6:30 PM and ordered a UA (urinalysis), CBC (complete blood count) Culture and sensitivity. The PA further ordered if the resident's temperature did not go down, to either order a chest x-ray or send the resident to the ER. There was no further documentation about the resident's status until [DATE] at 1:30 AM. An interview was conducted on [DATE] at 1:10 PM with LVN A in regard to Resident #1. LVN A stated she was the weekend nurse for Saturday ([DATE]) and Sunday ([DATE]). She said when she came in on [DATE], Resident #1 was running a high fever of 102 degrees F and she administered Tylenol. She stated she checked on the resident (after one or two hours), took his clothes off and cooled him with wet towels on his forehead and body. LVN A said when she checked his temperature again; it had gone down to 99 degrees F. LVN A stated Resident #1's temperature would go down, but after one to two hours, "It would come right back up." She stated she called Physician B and PA F, and left a message for each of them to call the facility. LVN A said she then sent a text message to PA F and asked him to call the facility. LVN A stated when she came in Sunday morning ([DATE]), the night nurse told her Resident #1's fever was high. LVN A stated she sent a second text to PA F and asked him to call facility. She stated she called the physician and left a voice mail, but she did not leave specific information about Resident #1 in the text for PA F because of HIPAA (confidentiality of information). Continuing with the same interview on [DATE] at 1:10 PM, LVN A stated although Resident #1's Skilled Daily Nurses Note reflected PA F called her on [DATE] at 6:30 PM, the LVN said she did not actually receive a return call from PA F until 9:00 PM on [DATE]. LVN A said she told PA F the resident was confused. LVN A stated she asked PA F if she should send Resident #1 to the hospital. She said PA F instructed her to wait for the test results to come back. LVN A added she received a text from Physician B telling her to send the resident to the hospital after she had gone off shift and left the faciity on [DATE]. LVN A told the surveyor she did not ever call the facility and/or inform facility staff of the physician's orders [REDACTED]. Review of Resident #1's [DATE] MAR for both routine and PRN medications with LVN A revealed the Tylenol was not documented as administered. When questioned about it during the same interview, LVN A stated questioningly, "I didn't write it down?" Review of all of Resident #1's Physician's Telephone Orders revealed the orders given by the PA for the chest x-ray, CBC and UA with Culture and Sensitivity were never written. On [DATE]: At 1:30 AM, the Skilled Daily Nurses Note reflected a new order was received for labs and a chest x-ray. However, they were "Not able to obtained (sic) urine on this shift." Review of Resident #1's entire clinical record revealed no documentation either Physician B or PA F were notified of the results of the chest x-ray or the CBC or that staff were unable to obtain a urine specimen. At 10:00 AM, the notes reflected Resident #1 was in bed and had diarrhea with [MEDICATION NAME] (anti-diarrheal) was given. At 3:38 PM - "...call to the room by CNA, R/T (related to) the resident seemed weak, upon my assessment vs (vital signs) are ,[DATE] (blood pressure) 96.8 (temperature) 90 (pulse) SATS (Oxygen saturation) 98%, Resident just had an episode of diarrhea. ...resident seem (sic) very lethargic he hasn't eaten all day. DON stated that we shouldn't send resident to [MEDICAL TREATMENT], until call was made to Dr (Physician B), awaiting call back for any new orders...." This entry was signed by ADON N. At 4:30 PM - "...Charge nurse made aware of all things going on and is expecting a call back from Dr. (named Physician B)." This entry was signed by ADON N. At 8:30 PM - "...Orders Rec'd (received) and noted from Dr. (Physician B). [MEDICAL TREATMENT] was made aware that resident was not going to be sent to HD ([MEDICAL TREATMENT]) and why - agreed with that...." Review of the telephone order dated [DATE] at 11:45 PM from Physician B revealed orders to: "1. Hold B/P (blood pressure) meds ([MEDICAL CONDITION]) 2. Collect stools X 3 for [MEDICAL CONDITION] ([MEDICAL CONDITION] - bacterial infection) 3. Call [MEDICAL TREATMENT]/not going today...." Documentation reflected this order was received by LVN C. On [DATE] at 9:30 AM, Resident #1's Skilled Daily Nurses Note reflected "Resident lying in bed at shift change. Lethargic, diaphretic (sic) (sweating profusely). VS (blood pressure) ,[DATE], (temperature) 100.5 AX (axillary), pulse 96 FSBS (finger stick blood sugar) 101. Upon uncovering resident - noted to have a pustual (sic) rash over trunk of body and going down thighs. Call to Dr. (Physician B) and requested order to send to ____ hospital...." Review of Resident #1's entire clinical record revealed there was no documentation the resident's family had ever been notified of the resident's change of condition or hospitalization . 2) Review of the facility's 24 Hour Report/Change of Condition Report revealed the following: On [DATE], Resident #1 stayed in bed during the day and evening shifts. On [DATE], he was "O.K." and stayed in bed on the day shift except when he went to [MEDICAL TREATMENT]. On [DATE], the resident had an increased temperature, but the actual temperature was not specified. On [DATE], Tylenol was given for an elevated temperature, the temperature came down to 98 degrees F, but Resident #1's temperature later increased again. "Doctor was called." The PA called back on the evening shift and gave orders for UA, Culture and Sensitivity and CBC. On [DATE], the only remark on the day shift for Resident #1 was diarrhea. On the evening shift, Resident #1's blood pressure was low (no specifics) and the resident was very weak. On the night shift, the report reflected the resident's lab was drawn (from the orders received on [DATE]). On [DATE], Resident #1 was sent to the hospital and the physician was informed of the resident's rash, temperature and lethargy. 3) Review of Resident #1's Diet Sheet for [DATE] revealed documentation, which reflected the resident's eating patterns had changed. Resident #1 usually ate 78 - 100% of his meals and rarely 50%. On [DATE], Resident #1 ate 50% of his breakfast (normal was 80 - 100%) and nothing was marked for his supper. On [DATE], the resident did not eat any lunch or supper. On [DATE] and [DATE], the Diet Sheet reflected Resident #1 did not eat anything. 4) Resident #1's medication form dated [DATE] reflected Tylenol was not administered for the resident's fever from [DATE] to [DATE]. Review of the [DATE] MAR indicated [REDACTED]. On [DATE] vital sign readings taken revealed the residents pulse was high with a reading of 121 beats per minute. Previous readings prior to that date reflected the resident's pulse readings were ranging between ,[DATE] beats per minute. 5) Review of the Patient Transfer Form dated [DATE] revealed the [DIAGNOSES REDACTED]. Documentation on the transfer form revealed Residents #1's symptoms first started "with n/v (nausea and vomiting), diarrhea. > (greater than) ,[DATE] days - Now still has low grade (temperature) but > 99.9. Now 100.5 AX (axillary), B/P (blood pressure) has been low, unable to dialyse on [DATE]. Has a pustule rash over trunk of body and upper thighs, not noted [DATE]. There this AM. Also lethargic." The transfer form reflected the nurse spoke with Resident #1's primary care provider, who wanted him sent to hospital with a medical history of [REDACTED]. Although the Patient Transfer Form record reflected Resident #1 had nausea and vomiting, review of the resident's entire clinical record revealed no documentation of those symptoms. Review of Resident #1's hospital's History and Physical (H&P) dated [DATE] revealed the resident's reason for being admitted was due to "Fever and Altered Mental Status." The H&P reflected Resident #1 was transferred from the nursing home with a fever over the last ,[DATE] days. "Apparently the patient was increasingly confused and also having fever, so the patient was sent to the hospital for consult [MEDICAL CONDITION]. The patient was admitted on the floor and eventually his blood pressure dropped and also developed altered mental status with hypoxemia (low oxygen levels), so patient was transferred to the ICU (Intensive Care Unit) and intubated (tube inserted into his trachea to facilitate breathing). The patient is on vent support with a temperature of 101 degrees F." Review of the physician's assessment of Resident #1 revealed he was having coarse breath sounds in both lungs and had discoloration of both legs. The physician's "Assessment and Plan" reflected Resident #1 had "Acute [MEDICAL CONDITION], most likely secondary [MEDICAL CONDITION] with pneumonia." The second entry in the plan revealed Resident #1 had "[MEDICAL CONDITION]." Review of Resident #1's hospital Microbiology Reports revealed the following: The report for the culture of blood collected on [DATE] reflected growth [MEDICAL CONDITIONS]. The report for the culture of sputum collected on [DATE] reflected growth [MEDICAL CONDITION]. The report for the culture of his urine collected on [DATE] reflected growth of Proteus mirabillis. The report for the culture of Resident #1's Perma Cath Tip ([MEDICAL TREATMENT] catheter site) collected on [DATE] reflected probable Staphylococcus aureus. Resident #1's Nurses Narrative from the hospital dated [DATE] reflected the resident stopped breathing at 5:20 AM and a code was called with ACLS (Advanced Cardiac Life Support) protocol followed. Resident #1 was intubated and placed on mechanical ventilation. Resident #1's hospital Progress Notes dated [DATE] reflected the resident went into Acute [MEDICAL CONDITION] and received CPR (Cardiopulmonary Resuscitation). 6) A) On [DATE] at 11:30 AM, PA F was interviewed. The surveyor asked if he had received a call from the facility on [DATE] in regard to Resident #1's high fever and lethargy. PA F stated he spoke to LVN A later on [DATE] about Resident #1 and ordered lab work for the resident to make sure there was no infection. The PA stated the nurses were supposed to do a STAT (immediately) order on the lab work, so he could solve the problem. (The Physician's Telephone Orders dated [DATE] did not reflect any STAT orders.) PA F stated he never got a call about Resident #1's lab work results so he would know how to treat the resident. He stated, "They could call or text. I have told them that and I would get back to them as soon as I could." PA F said he was told by the nurse Resident #1's fever was over 100 degrees F and would come down with Tylenol. "So, I did a stat order for UA (Urine Analysis), CBC (Complete Blood Count) and a chest x-ray. If he was that ill with fever and was lethargic, I would have sent him out without question." PA F stated that the nurse did not tell him anything other than the resident's temperature was over 100 degrees F. PA F stated the staff never told him how high the temperature was or the resident had an altered mental state. PA F stated there was no reason for the staff not to leave him a message or a text to let him know how ill Resident #1 was at the time of the call. B) On [DATE] at 11:55 AM, the DON was interviewed regarding the health status of Resident #1. The DON stated she was aware the resident was running a temperature. She stated she went in to see the resident on [DATE] and he spoke to her, and his appetite was not that great. The DON said his temperature was up all day. The DON stated the nurses did not call her about the resident. "They were doing their own thing." The DON stated the Tylenol was working. She said on Wednesday ([DATE]) the resident developed pustules on his body. The DON stated she called the doctor and told him what was going on, and they decided to send him out to the hospital. She stated the resident was not under any stress when he left the facility. The DON stated there were Standing Orders for residents who run fevers, and were lethargic, and the nurses usually call her when there was a problem (but they did not on this occasion). The DON stated she did not see him until Sunday [DATE]. She added he was scheduled to go out for [MEDICAL TREATMENT] on Monday [DATE] but he was still ill so she called Physician B and documented it in the Skilled Daily Nurses on [DATE]. The DON stated she had read the Nurses Notes over and over and that she thought they (nurses) did what they were supposed to do. We have standing orders from the physicians. Review of Physician B's entire standing orders dated effective [DATE] revealed there were no standing orders for a resident with an elevated temperature. Review of Resident #1's Consolidated Physician order [REDACTED]. Additional review revealed Resident #1 was not on a routine antipyretic (fever reducing medication such as Tylenol). C) RA (Restorative Aide) E was interviewed on [DATE] at 11:10 AM in regard to Resident #1. RA E stated he provided care for Resident #1 all the time. RA E said this past Sunday on [DATE] he and CNA L were talking about how ill Resident #1 had been. RA E stated CNA L had told him (RA E) he (CNA L) was concerned about Resident #1 because the resident was running a fever and was not himself. RA E stated, "He looked ill." RA E stated Resident #1's illness "started back on Friday ([DATE]). He was ill that day. He was sent out to [MEDICAL TREATMENT]." RA E added, "He (Resident #1) was so weak that he couldn't sit up straight in his chair. The resident was sweaty and clammy that day. Can't believe they sent him out to [MEDICAL TREATMENT]." RA E said he went to the Charge Nurse at the time to tell her about Resident #1's condition. RA E stated, "I will go to the DON or talk to the nurse if there is a concern (with a resident)." RA E stated, "Both (charge) nurses (LVN A and LVN C) ...knew how ill he was and should not have sent him out (to [MEDICAL TREATMENT])." D) CNA L was interviewed on [DATE] at 12:15 PM regarding the health status of Resident #1. CNA L stated he returned to work on Sunday ([DATE]) and observed the Charge Nurse, LVN A, take Resident #1's temperature. CNA L stated the resident was unresponsive and he reported that information to ADON N on [DATE]. He stated he asked ADON N to come look at the resident. CNA L stated ADON N took Resident #1's blood pressure with a digital cuff and it was ,[DATE]. (Record review revealed this B/P was not documented.) CNA L stated he observed the resident as he laid there all day, and the next morning, [DATE], before they sent him out. CNA L stated when he tried to get the resident up out of bed, Resident #1 was hollering. CNA L stated the resident always liked his coffee, but starting last Thursday ([DATE]), he stopped asking for coffee. CNA L stated his biggest concerns were why would the staff wait so long to send him out to the hospital; and why they attempted to send him to [MEDICAL TREATMENT] on Monday ([DATE]). He also stated that the facility staff neglected Resident #1, and they should be caring for the residents by order of importance of resident's needs. The surveyor asked CNA L if he informed the Abuse Coordinator of his concerns and he stated "No," because he was afraid he would be fired. E) LVN D was interviewed on [DATE] at 10:40 AM in regard to Resident #1. LVN D verified she worked weekdays on the day shift and was a Charge Nurse. LVN D stated Resident #1 was a diabetic and did not like to get up. On Monday ([DATE]) he had some diarrhea. She stated the CNAs reported Resident #1 was having diarrhea on [DATE]. LVN D added Resident #1 did not have any fever on the 10:00 PM - 6:00 AM shift. LVN D stated Resident #1 went to the hospital the next day ([DATE]) because of his rash. LVN D said the hospital called the facility on [DATE] requesting next of kin information for Resident #1, because they were trying to locate the family. LVN D said the hospital staff told her Resident #1 came to the hospital in respiratory distress and he was now on a ventilator. LVN D stated she had been licensed as an LVN since [DATE] (three months), and she was still learning about [MEDICAL TREATMENT] residents. Review of the Skilled Daily Nurses Note dated [DATE] at 10:00 AM and signed by LVN D revealed "Resident lying in bed. [MEDICATION NAME] given. Resident has Dirrhea (sic) No temp this am. No bleeding or s/s (signs/symptoms) of infection at shunt site. Call light within reach - will cont. to monitor." F) On [DATE] at 12:49 PM, MA H was interviewed. She stated she noticed Resident #1 had a fever and low blood pressure on [DATE]. MA H stated she reported Resident #1's vital signs to LVN C, the Charge Nurse. MA H stated, "All they did was give him Tylenol." MA H stated she "knew the resident's temperatures had been over 104.4 degrees F." She stated, "He was really hot and sweaty. They did not even send him to [MEDICAL TREATMENT]." She stated, "He usually talked to me, he had not been eating, and he was shaking." MA H stated if she saw a problem like that, she would document her observations on the flow sheet and would then circle it for the nurse to see. M A H stated she was worried about Resident #1. Review of Resident #1's clinical record revealed no documentation the aide reported her concerns to her LVN C. G) Interview on [DATE] at 11:40 AM with CNA J revealed she went to both of the Charge Nurses, LVN C and LVN D, about Resident #1's condition, and told them he was sleeping a lot, not eating, was confused, was not alert and oriented, and had food all over him, all down the front of him. CNA J stated when she normally provided care to Resident#1, he would visit with her and he always spoke English to her; however, on that day he was not speaking English. She stated, "He knows I do not speak ____ (another language)" and it was not normal behavior for him. CNA J stated "he just kept getting worse." H) MA K was interviewed on [DATE] at 9:50 AM in regard to Resident #1's health status. MA K stated she took all the residents' temperatures and vital signs and documented them on notebook paper and handed it to the charge nurse, who put the information in the chart. MA K stated when Resident #1 was eating; he loved coffee and did not like to be bothered. She said on [DATE] he showed signs of confusion, he had an empty cup in his hand and he thought there was coffee in the cup. MA K stated she talked to the nurse about Resident #1's confusion. I) An interview was conducted on [DATE] at 10:05 AM with LVN C in regard to Resident #1. LVN C stated she was a PRN nurse and had not been familiar with Resident #1's normal behavior. She stated she took care of him the day before he was sent out ([DATE]). She stated she observed him lying in bed, never saw him up or with his eyes open. LVN C stated she thought he was non-verbal. "I would not have known that was not normal behavior for him." LVN C stated direct care staff came to her with concerns Resident #1 was not like himself. She stated she went to assess him, but did not have a baseline to go by for her evaluation of the resident. LVN C stated she expressed her concerns to ADON N and ADON N told her she (ADON N) was taking care of it and to go back to her Hall. Review of Resident #1's Skilled Daily Nurses Note dated [DATE] revealed LVN C recorded one set of vital signs for Resident #1 on [DATE] (T-96.8, P-90, R- 20 and B/P-,[DATE]) and a note orders were received from Physician B. J) An interview was conducted on [DATE] at 10:30 AM with ADON N in regard to Resident #1. ADON N stated on Monday ([DATE]), the facility van driver and CNA G called her about Resident #1's health status prior to putting him on the van to [MEDICAL TREATMENT]. At that time, ADON N said CNA G told her he thought Resident #1 did not feel good and had not eaten. ADON N stated she went to assess the resident on [DATE] at 3:38 PM prior to sending him to [MEDICAL TREATMENT]. ADON N stated when she called Resident #1 by his name he could barely raise his head. ADON N stated, "He wasn't himself." ADON N stated she called Physician B. Resident #1's Skilled Daily Nurses Note revealed ADON N documented a call to Physician B on [DATE] after 3:38 PM. During the same interview, ADON N stated the call went to voice mail. ADON N stated she sent a text to Physician B with Resident #1's vital signs, which were B/P ,[DATE], T- 96.8. P-90, and Oxygen Saturation 98%. ADON N said she called PA F and left a message for PA F to return the call. ADON N said the DON told her Resident #1 could not go to [MEDICAL TREATMENT]. ADON N stated she advised the Administrator on [DATE] of the situation with Resident #1 and informed her she could not get hold of Physician B. ADON N stated Physician B did not text back until 5:30 PM or 6:00 PM. Observation of ADON N's telephone revealed a text message was sent at 3:36 PM on [DATE]. The message reflected Resident #1 was weak and his stools smelled like[DIAGNOSES REDACTED]icile (an infection). However, no other symptoms were added to the text message regarding his blood pressure and temperature. At that time, ADON N stated the return text from Physician B told her to hold Resident #1's blood pressure medications (due to his low blood pressure of ,[DATE]) and to call the Nephrologist. Review of Resident #1's entire clinical record revealed no documentation ADON N or any nurse called the Nephrologist. The Skilled Daily Nurses Note dated [DATE] reflected LVN C notified the [MEDICAL TREATMENT] center Resident #1 would not be there that day ([DATE]). During the same interview, ADON N stated she then turned over Resident #1's care back to LVN C, the charge nurse. ADON N stated if she had been working the floor (as the charge nurse), "I would have called the DON and Corporate Nurse. The DON can send him out (to the hospital)." Resident #1's clinical record had no documentation ADON N instructed LVN C to notify the DON and Corporate Nurse and or what to do if Physician B did not return the call. K) An interview was conducted on [DATE] at 5:20 PM with the DON in regard to Resident #1's fevers, which had ranged from 102.7 to 104.4 degrees F over a four-day period. The DON was asked at what point she would expect her nursing staff to send the resident to the hospital with fevers that high. The DON stated, "That is a good question, but we were in communication with the doctor all along." L) An interview was conducted on [DATE] at 9:20 AM with Physician B, who was one of the facility's Medical Directors. Physician B stated if a resident had temperatures over 102 degrees F, an altered state of mind, and was short of breath or lethargic, then the resident should be sent to the hospital. Physician B was asked if he was specifically informed by facility staff on [DATE] about Resident #1's high fever, lethargy, and dropping blood pressure. Physician B stated he did not know his patient was that bad. Physician B stated if he had received a call from the facility on the fifteenth, they (facility staff) did not leave a message for him. He stated he had a call from the DON sometime after [DATE], regarding her inability to reach Resident #1's family and she informed him at that time Resident #1 did not go to [MEDICAL TREATMENT] on [DATE]. Physician B stated Resident #1 not going to [MEDICAL TREATMENT] was not good for the resident, because he had the potential for fluid overload due to his kidney failure and a history [MEDICAL CONDITION]. Physician B stated the last time he saw Resident #1 was on [DATE]. The physician stated if the resident's temperature was 103 degrees F, he should have been sent out to the hospital, especially since he was a [MEDICAL TREATMENT] patient. Physician B added fevers like that were not that simple, "The body is telling us something." Physician B stated there "...has to be some education with the nurses. As for the severity of a fever of 103 degrees, there is urgency with that kind of fever." Physician B repeated, "There needs to be more nursing education. Have to do some more education to nurses not to mess around with a fever of 103 degrees." M) On [DATE] at approximately 4:00 PM, the facility's other Medical Director, Physician M, was interviewed in regard to Resident #1. He stated he reviewed Resident #1's change of condition, and the resident should have been sent to the hospital when his fever was over 103 degrees F, and he had an altered mental status. Physician M stated the failure of the nurses was a communication and education problem. 7) Record review of the facility's current policy and procedures entitled Abuse Policy with a revised date of [DATE] provided by the Administrator reflected the following: INTENT: This protocol was intended to assist in the prevention of abuse, neglect and misappropriation of property. Each resident has the right to be free from abuse, mistreatment, neglect, corporal punishment, involuntary seclusion and financial abuse. POLICY: 1. The facility will prohibit neglect, mental or physical abuse, including involuntary seclusion and the misappropriation of property or finances of residents. 2. The facility will conduct an investigation of alleged or suspected abuse, neglect, or misappropriation of property, and will provide notification of information to the proper authorities according to state and federal regulations. 3. The facility will designate a qualified staff member to oversee the abuse prohibition program... DEFINITIONS: ... Neglect is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness...." Review of the facility's current, undated "Policy on Significant Change and Physician Notification" revealed the following: "Significant change and physician notification Purpose To ensure that resident's family and/or legal representative and physician are notified of resident changes that fell under the following categories: ? An accident resulting in injury and that has the potential for needed physician intervention. ? A significant change in the resident's physical, mental or psychosocial status. (See below for examples) ? A need to significantly alter treatment. ? Transfer of the resident from the facility. PROCEDURE When any of the above situations exists, the licensed nurse will contact the resident's family and their physician. Calls will be made to the family until they are reached. A message may be left on an answering machine which does not give specifics but leaves a request for the facility to be called. The physician will be contacted immediately for any emerge

Based on observation, interview and record review, it was determined the facility failed to implement the facility's written policies and procedures that prohibit mistreatment and neglect by failing to consult with the resident's physician when there was a significant change in the resident's physical condition from [DATE] to [DATE] for one (Resident #1) of eight residents reviewed for neglect, who was not eating, not getting out of bed, running fevers, had diarrhea, was lethargic, had an altered mental status and ended up with pustules. Facility failures included: The physician was not notified of the resident's fever on [DATE]. No attempt was made to notify the physician and/or PA until [DATE], and the message left was to please call the facility. There was nothing in the text regarding Resident #1's change of condition or current status. The PA was not informed of Resident #1's actual temperature of 103.6 degrees F. LVN A received an order from the physician to send Resident #1 to the hospital on [DATE] after she was off shift and had left the facility. LVN A did not ever inform anyone at the facility of the physician's orders [REDACTED]. The physician/PA were not informed of the resident's diarrhea. The physician and PA were not fully informed of the resident's status from [DATE] through [DATE]. The licensed nurses frequently documented Resident #1's temperature as elevated and blood pressures as low without including the specific results. These failures resulted in Resident #1's physician/PA not being able to make a fully informed decision in regard to the care the resident required. The resident was not sent to the hospital until [DATE], which occurred due to the development of the resident's pustules, not due to his fevers. At the hospital, Resident #1 was diagnosed with [REDACTED]. The resident went into [MEDICAL CONDITION] with CPR required, and he was put on a ventilator. On [DATE] at 4:45 PM, an Immediate Jeopardy (IJ) was identified in the areas of Resident Behavior/Facility Practice, Resident Rights, Professional Standards, Quality of Care and Administration. While the IJ was lowered on [DATE] at 1:55 PM, 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 still implementing the Plan of Removal. These failures could affect the seventy-five residents receiving services from the facility by placing them at risk for not receiving the care and services they needed to maintain their well-being, comfort and free of infection to ensure they live the life they desired. Findings included: Record review of the facility's current policy and procedures entitled Abuse Policy with a revised date of [DATE] provided by the Administrator reflected the following: INTENT: This protocol was intended to assist in the prevention of abuse, neglect and misappropriation of property. Each resident has the right to be free from abuse, mistreatment, neglect, corporal punishment, involuntary seclusion and financial abuse. POLICY: 1. The facility will prohibit neglect, mental or physical abuse, including involuntary seclusion and the misappropriation of property or finances of residents. 2. The facility will conduct an investigation of alleged or suspected abuse, neglect, or misappropriation of property, and will provide notification of information to the proper authorities according to state and federal regulations. 3. The facility will designate a qualified staff member to oversee the abuse prohibition program... DEFINITIONS: ... Neglect is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness...." 1) The Face Sheet dated [DATE] reflected Resident #1, a [AGE] year-old male, was admitted from an area hospital on [DATE] with [DIAGNOSES REDACTED]. Resident #1's Patient Transfer Form dated [DATE] reflected he had a history of [REDACTED]. The MDS assessment dated [DATE] reflected Resident #1 was able to make himself understood with clear intelligible words, and was able to clearly understand others; no behaviors were present and had no signs of altered mental status or [MEDICAL CONDITION]. The resident required extensive assistance from one person for physical assistance with bed mobility, transfers, locomotion on and off the unit, dressing, toileting, personal hygiene and bathing. The MDS assessment reflected Resident #1 had an active [DIAGNOSES REDACTED]. 2) Review of the Skilled Daily Nurses Note for Resident #1 revealed the following: On [DATE]: At 9:00 AM - Resident #1 had an elevated body temperature of 102.2 degrees F. LVN A (Licensed Vocational Nurse), administered two tablets of Tylenol 500 mg as a fever reducer. At 1:00 PM Resident #1's vital signs were checked. The notes reflected he had an elevated temperature, and his blood pressure ,[DATE] was low. The notes reflected LVN A applied cold compresses to Resident #1's body. He was administered two tablets of Tylenol as a fever reducer. Resident #1's [DATE] MAR from [DATE] through [DATE] reflected the resident's normal blood pressures included: systolic blood pressures of ,[DATE] and diastolic blood pressures of ,[DATE]. On [DATE]: At 3:00 AM, Resident #1 continued to have an elevated body temperature. (The specific temperature was not documented.) He was administered two tablets of Tylenol 500 mg as a fever reducer "per protocol." Review of Physician B's entire standing orders dated effective [DATE] revealed there were no standing orders for a resident with an elevated temperature. At 4:00 AM, the resident's temperature was checked again and it was 99.0 degrees Fahrenheit (F). At 10:00 AM, the notes reflected Resident #1's body temperature was 102.2 degrees F. "Two pain pills were administered, rechecked by 11:00 AM temp down to 98.0 degrees F." Resident #1's blood pressure had dropped to ,[DATE] with an electronic cuff, and was retaken with a manual cuff with a result of ,[DATE]. At 3:00 PM, Resident #1's temperature was 103.6 degrees F and the resident "looked confused." The notes reflected the physician was called four times and the Physician's Assistant (PA) was called three times with no response until the PA returned the call to the facility at 6:30 PM and ordered a UA (urinalysis), CBC (complete blood count) Culture and sensitivity. The PA further ordered if the resident's temperature did not go down, to either order a chest x-ray or send the resident to the ER. There was no further documentation about the resident's status until [DATE] at 1:30 AM. An interview was conducted on [DATE] at 1:10 PM with LVN A in regard to Resident #1. LVN A stated she was the weekend nurse for Saturday ([DATE]) and Sunday ([DATE]). She said when she came in on [DATE], Resident #1 was running a high fever of 102 degrees F and she administered Tylenol. She stated she checked on the resident (after one or two hours), took his clothes off and cooled him with wet towels on his forehead and body. LVN A said when she checked his temperature again; it had gone down to 99 degrees F. LVN A stated Resident #1's temperature would go down, but after one to two hours, "It would come right back up." She stated she called Physician B and PA F, and left a message for each of them to call the facility. LVN A said she then sent a text message to PA F and asked him to call the facility. LVN A stated when she came in Sunday morning ([DATE]), the night nurse told her Resident #1's fever was high. LVN A stated she sent a second text to PA F and asked him to call facility. She stated she called the physician and left a voice mail, but she did not leave specific information about Resident #1 in the text for PA F because of HIPAA (confidentiality of information). Continuing with the same interview on [DATE] at 1:10 PM, LVN A stated although Resident #1's Skilled Daily Nurses Note reflected PA F called her on [DATE] at 6:30 PM, the LVN said she did not actually receive a return call from PA F until 9:00 PM on [DATE]. LVN A said she told PA F the resident was confused. LVN A stated she asked PA F if she should send Resident #1 to the hospital. She said PA F instructed her to wait for the test results to come back. LVN A added she received a text from Physician B telling her to send the resident to the hospital after she had gone off shift and left the faciity on [DATE]. LVN A told the surveyor she did not ever call the facility and/or inform facility staff of the physician's orders [REDACTED]. Review of Resident #1's [DATE] MAR for both routine and PRN medications with LVN A revealed the Tylenol was not documented as administered. When questioned about it during the same interview, LVN A stated questioningly, "I didn't write it down?" Review of all of Resident #1's Physician's Telephone Orders revealed the orders given by the PA for the chest x-ray, CBC and UA with Culture and Sensitivity were never written. On [DATE]: At 1:30 AM, the Skilled Daily Nurses Note reflected a new order was received for labs and a chest x-ray. However, they were "Not able to obtained (sic) urine on this shift." Review of Resident #1's entire clinical record revealed no documentation either Physician B or PA F were notified of the results of the chest x-ray or the CBC or that staff were unable to obtain a urine specimen. At 10:00 AM, the notes reflected Resident #1 was in bed and had diarrhea with [MEDICATION NAME] (anti-diarrheal) was given. At 3:38 PM - "...call to the room by CNA, R/T (related to) the resident seemed weak, upon my assessment vs (vital signs) are ,[DATE] (blood pressure) 96.8 (temperature) 90 (pulse) SATS (Oxygen saturation) 98%, Resident just had an episode of diarrhea. ...resident seem (sic) very lethargic he hasn't eaten all day. DON stated that we shouldn't send resident to [MEDICAL TREATMENT], until call was made to Dr (Physician B), awaiting call back for any new orders...." This entry was signed by ADON N. At 4:30 PM - "...Charge nurse made aware of all things going on and is expecting a call back from Dr. (named Physician B)." This entry was signed by ADON N. At 8:30 PM - "...Orders Rec'd (received) and noted from Dr. (Physician B). [MEDICAL TREATMENT] was made aware that resident was not going to be sent to HD ([MEDICAL TREATMENT]) and why - agreed with that...." Review of the telephone order dated [DATE] at 11:45 PM from Physician B revealed orders to: "1. Hold B/P (blood pressure) meds ([MEDICAL CONDITION]) 2. Collect stools X 3 for [MEDICAL CONDITION] ([MEDICAL CONDITION] - bacterial infection) 3. Call [MEDICAL TREATMENT]/not going today...." Documentation reflected this order was received by LVN C. On [DATE] at 9:30 AM, Resident #1's Skilled Daily Nurses Note reflected "Resident lying in bed at shift change. Lethargic, diaphretic (sic) (sweating profusely). VS (blood pressure) ,[DATE], (temperature) 100.5 AX (axillary), pulse 96 FSBS (finger stick blood sugar) 101. Upon uncovering resident - noted to have a pustual (sic) rash over trunk of body and going down thighs. Call to Dr. (Physician B) and requested order to send to ____ hospital...." Review of Resident #1's entire clinical record revealed there was no documentation the resident's family had ever been notified of the resident's change of condition or hospitalization . 2) Review of the facility's 24 Hour Report/Change of Condition Report revealed the following: On [DATE], Resident #1 stayed in bed during the day and evening shifts. On [DATE], he was "O.K." and stayed in bed on the day shift except when he went to [MEDICAL TREATMENT]. On [DATE], the resident had an increased temperature, but the actual temperature was not specified. On [DATE], Tylenol was given for an elevated temperature, the temperature came down to 98 degrees F, but Resident #1's temperature later increased again. "Doctor was called." The PA called back on the evening shift and gave orders for UA, Culture and Sensitivity and CBC. On [DATE], the only remark on the day shift for Resident #1 was diarrhea. On the evening shift, Resident #1's blood pressure was low (no specifics) and the resident was very weak. On the night shift, the report reflected the resident's lab was drawn (from the orders received on [DATE]). On [DATE], Resident #1 was sent to the hospital and the physician was informed of the resident's rash, temperature and lethargy. 3) Review of Resident #1's Diet Sheet for [DATE] revealed documentation, which reflected the resident's eating patterns had changed. Resident #1 usually ate 78 - 100% of his meals and rarely 50%. On [DATE], Resident #1 ate 50% of his breakfast (normal was 80 - 100%) and nothing was marked for his supper. On [DATE], the resident did not eat any lunch or supper. On [DATE] and [DATE], the Diet Sheet reflected Resident #1 did not eat anything. 4) Resident #1's medication form dated [DATE] reflected Tylenol was not administered for the resident's fever from [DATE] to [DATE]. Review of the [DATE] MAR indicated [REDACTED]. On [DATE] vital sign readings taken revealed the residents pulse was high with a reading of 121 beats per minute. Previous readings prior to that date reflected the resident's pulse readings were ranging between ,[DATE] beats per minute. 5) Review of the Patient Transfer Form dated [DATE] revealed the [DIAGNOSES REDACTED]. Documentation on the transfer form revealed Residents #1's symptoms first started "with n/v (nausea and vomiting), diarrhea. > (greater than) ,[DATE] days - Now still has low grade (temperature) but > 99.9. Now 100.5 AX (axillary), B/P (blood pressure) has been low, unable to dialyse on [DATE]. Has a pustule rash over trunk of body and upper thighs, not noted [DATE]. There this AM. Also lethargic." The transfer form reflected the nurse spoke with Resident #1's primary care provider, who wanted him sent to hospital with a medical history of [REDACTED]. Although the Patient Transfer Form record reflected Resident #1 had nausea and vomiting, review of the resident's entire clinical record revealed no documentation of those symptoms. Review of Resident #1's hospital's History and Physical (H&P) dated [DATE] revealed the resident's reason for being admitted was due to "Fever and Altered Mental Status." The H&P reflected Resident #1 was transferred from the nursing home with a fever over the last ,[DATE] days. "Apparently the patient was increasingly confused and also having fever, so the patient was sent to the hospital for consult [MEDICAL CONDITION]. The patient was admitted on the floor and eventually his blood pressure dropped and also developed altered mental status with hypoxemia (low oxygen levels), so patient was transferred to the ICU (Intensive Care Unit) and intubated (tube inserted into his trachea to facilitate breathing). The patient is on vent support with a temperature of 101 degrees F." Review of the physician's assessment of Resident #1 revealed he was having coarse breath sounds in both lungs and had discoloration of both legs. The physician's "Assessment and Plan" reflected Resident #1 had "Acute [MEDICAL CONDITION], most likely secondary [MEDICAL CONDITION] with pneumonia." The second entry in the plan revealed Resident #1 had "[MEDICAL CONDITION]." Review of Resident #1's hospital Microbiology Reports revealed the following: The report for the culture of blood collected on [DATE] reflected growth [MEDICAL CONDITIONS]. The report for the culture of sputum collected on [DATE] reflected growth [MEDICAL CONDITION]. The report for the culture of his urine collected on [DATE] reflected growth of Proteus mirabillis. The report for the culture of Resident #1's Perma Cath Tip ([MEDICAL TREATMENT] catheter site) collected on [DATE] reflected probable Staphylococcus aureus. Resident #1's Nurses Narrative from the hospital dated [DATE] reflected the resident stopped breathing at 5:20 AM and a code was called with ACLS (Advanced Cardiac Life Support) protocol followed. Resident #1 was intubated and placed on mechanical ventilation. Resident #1's hospital Progress Notes dated [DATE] reflected the resident went into Acute [MEDICAL CONDITION] and received CPR (Cardiopulmonary Resuscitation). 6) A) On [DATE] at 11:30 AM, PA F was interviewed. The surveyor asked if he had received a call from the facility on [DATE] in regard to Resident #1's high fever and lethargy. PA F stated he spoke to LVN A later on [DATE] about Resident #1 and ordered lab work for the resident to make sure there was no infection. The PA stated the nurses were supposed to do a STAT (immediately) order on the lab work, so he could solve the problem. (The Physician's Telephone Orders dated [DATE] did not reflect any STAT orders.) PA F stated he never got a call about Resident #1's lab work results so he would know how to treat the resident. He stated, "They could call or text. I have told them that and I would get back to them as soon as I could." PA F said he was told by the nurse Resident #1's fever was over 100 degrees F and would come down with Tylenol. "So, I did a stat order for UA (Urine Analysis), CBC (Complete Blood Count) and a chest x-ray. If he was that ill with fever and was lethargic, I would have sent him out without question." PA F stated that the nurse did not tell him anything other than the resident's temperature was over 100 degrees F. PA F stated the staff never told him how high the temperature was or the resident had an altered mental state. PA F stated there was no reason for the staff not to leave him a message or a text to let him know how ill Resident #1 was at the time of the call. B) On [DATE] at 11:55 AM, the DON was interviewed regarding the health status of Resident #1. The DON stated she was aware the resident was running a temperature. She stated she went in to see the resident on [DATE] and he spoke to her, and his appetite was not that great. The DON said his temperature was up all day. The DON stated the nurses did not call her about the resident. "They were doing their own thing." The DON stated the Tylenol was working. She said on Wednesday ([DATE]) the resident developed pustules on his body. The DON stated she called the doctor and told him what was going on, and they decided to send him out to the hospital. She stated the resident was not under any stress when he left the facility. The DON stated there were Standing Orders for residents who run fevers, and were lethargic, and the nurses usually call her when there was a problem (but they did not on this occasion). The DON stated she did not see him until Sunday [DATE]. She added he was scheduled to go out for [MEDICAL TREATMENT] on Monday [DATE] but he was still ill so she called Physician B and documented it in the Skilled Daily Nurses on [DATE]. The DON stated she had read the Nurses Notes over and over and that she thought they (nurses) did what they were supposed to do. We have standing orders from the physicians. Review of Physician B's entire standing orders dated effective [DATE] revealed there were no standing orders for a resident with an elevated temperature. Review of Resident #1's Consolidated Physician order [REDACTED]. Additional review revealed Resident #1 was not on a routine antipyretic (fever reducing medication such as Tylenol). C) RA (Restorative Aide) E was interviewed on [DATE] at 11:10 AM in regard to Resident #1. RA E stated he provided care for Resident #1 all the time. RA E said this past Sunday on [DATE] he and CNA L were talking about how ill Resident #1 had been. RA E stated CNA L had told him (RA E) he (CNA L) was concerned about Resident #1 because the resident was running a fever and was not himself. RA E stated, "He looked ill." RA E stated Resident #1's illness "started back on Friday ([DATE]). He was ill that day. He was sent out to [MEDICAL TREATMENT]." RA E added, "He (Resident #1) was so weak that he couldn't sit up straight in his chair. The resident was sweaty and clammy that day. Can't believe they sent him out to [MEDICAL TREATMENT]." RA E said he went to the Charge Nurse at the time to tell her about Resident #1's condition. RA E stated, "I will go to the DON or talk to the nurse if there is a concern (with a resident)." RA E stated, "Both (charge) nurses (LVN A and LVN C) ...knew how ill he was and should not have sent him out (to [MEDICAL TREATMENT])." D) CNA L was interviewed on [DATE] at 12:15 PM regarding the health status of Resident #1. CNA L stated he returned to work on Sunday ([DATE]) and observed the Charge Nurse, LVN A, take Resident #1's temperature. CNA L stated the resident was unresponsive and he reported that information to ADON N on [DATE]. He stated he asked ADON N to come look at the resident. CNA L stated ADON N took Resident #1's blood pressure with a digital cuff and it was ,[DATE]. (Record review revealed this B/P was not documented.) CNA L stated he observed the resident as he laid there all day, and the next morning, [DATE], before they sent him out. CNA L stated when he tried to get the resident up out of bed, Resident #1 was hollering. CNA L stated the resident always liked his coffee, but starting last Thursday ([DATE]), he stopped asking for coffee. CNA L stated his biggest concerns were why would the staff wait so long to send him out to the hospital; and why they attempted to send him to [MEDICAL TREATMENT] on Monday ([DATE]). He also stated that the facility staff neglected Resident #1, and they should be caring for the residents by order of importance of resident's needs. The surveyor asked CNA L if he informed the Abuse Coordinator of his concerns and he stated "No," because he was afraid he would be fired. E) LVN D was interviewed on [DATE] at 10:40 AM in regard to Resident #1. LVN D verified she worked weekdays on the day shift and was a Charge Nurse. LVN D stated Resident #1 was a diabetic and did not like to get up. On Monday ([DATE]) he had some diarrhea. She stated the CNAs reported Resident #1 was having diarrhea on [DATE]. LVN D added Resident #1 did not have any fever on the 10:00 PM - 6:00 AM shift. LVN D stated Resident #1 went to the hospital the next day ([DATE]) because of his rash. LVN D said the hospital called the facility on [DATE] requesting next of kin information for Resident #1, because they were trying to locate the family. LVN D said the hospital staff told her Resident #1 came to the hospital in respiratory distress and he was now on a ventilator. LVN D stated she had been licensed as an LVN since [DATE] (three months), and she was still learning about [MEDICAL TREATMENT] residents. Review of the Skilled Daily Nurses Note dated [DATE] at 10:00 AM and signed by LVN D revealed "Resident lying in bed. [MEDICATION NAME] given. Resident has Dirrhea (sic) No temp this am. No bleeding or s/s (signs/symptoms) of infection at shunt site. Call light within reach - will cont. to monitor." F) On [DATE] at 12:49 PM, MA H was interviewed. She stated she noticed Resident #1 had a fever and low blood pressure on [DATE]. MA H stated she reported Resident #1's vital signs to LVN C, the Charge Nurse. MA H stated, "All they did was give him Tylenol." MA H stated she "knew the resident's temperatures had been over 104.4 degrees F." She stated, "He was really hot and sweaty. They did not even send him to [MEDICAL TREATMENT]." She stated, "He usually talked to me, he had not been eating, and he was shaking." MA H stated if she saw a problem like that, she would document her observations on the flow sheet and would then circle it for the nurse to see. M A H stated she was worried about Resident #1. Review of Resident #1's clinical record revealed no documentation the aide reported her concerns to her LVN C. G) Interview on [DATE] at 11:40 AM with CNA J revealed she went to both of the Charge Nurses, LVN C and LVN D, about Resident #1's condition, and told them he was sleeping a lot, not eating, was confused, was not alert and oriented, and had food all over him, all down the front of him. CNA J stated when she normally provided care to Resident#1, he would visit with her and he always spoke English to her; however, on that day he was not speaking English. She stated, "He knows I do not speak ____ (another language)" and it was not normal behavior for him. CNA J stated "he just kept getting worse." H) MA K was interviewed on [DATE] at 9:50 AM in regard to Resident #1's health status. MA K stated she took all the residents' temperatures and vital signs and documented them on notebook paper and handed it to the charge nurse, who put the information in the chart. MA K stated when Resident #1 was eating; he loved coffee and did not like to be bothered. She said on [DATE] he showed signs of confusion, he had an empty cup in his hand and he thought there was coffee in the cup. MA K stated she talked to the nurse about Resident #1's confusion. I) An interview was conducted on [DATE] at 10:05 AM with LVN C in regard to Resident #1. LVN C stated she was a PRN nurse and had not been familiar with Resident #1's normal behavior. She stated she took care of him the day before he was sent out ([DATE]). She stated she observed him lying in bed, never saw him up or with his eyes open. LVN C stated she thought he was non-verbal. "I would not have known that was not normal behavior for him." LVN C stated direct care staff came to her with concerns Resident #1 was not like himself. She stated she went to assess him, but did not have a baseline to go by for her evaluation of the resident. LVN C stated she expressed her concerns to ADON N and ADON N told her she (ADON N) was taking care of it and to go back to her Hall. Review of Resident #1's Skilled Daily Nurses Note dated [DATE] revealed LVN C recorded one set of vital signs for Resident #1 on [DATE] (T-96.8, P-90, R- 20 and B/P-,[DATE]) and a note orders were received from Physician B. J) An interview was conducted on [DATE] at 10:30 AM with ADON N in regard to Resident #1. ADON N stated on Monday ([DATE]), the facility van driver and CNA G called her about Resident #1's health status prior to putting him on the van to [MEDICAL TREATMENT]. At that time, ADON N said CNA G told her he thought Resident #1 did not feel good and had not eaten. ADON N stated she went to assess the resident on [DATE] at 3:38 PM prior to sending him to [MEDICAL TREATMENT]. ADON N stated when she called Resident #1 by his name he could barely raise his head. ADON N stated, "He wasn't himself." ADON N stated she called Physician B. Resident #1's Skilled Daily Nurses Note revealed ADON N documented a call to Physician B on [DATE] after 3:38 PM. During the same interview, ADON N stated the call went to voice mail. ADON N stated she sent a text to Physician B with Resident #1's vital signs, which were B/P ,[DATE], T- 96.8. P-90, and Oxygen Saturation 98%. ADON N said she called PA F and left a message for PA F to return the call. ADON N said the DON told her Resident #1 could not go to [MEDICAL TREATMENT]. ADON N stated she advised the Administrator on [DATE] of the situation with Resident #1 and informed her she could not get hold of Physician B. ADON N stated Physician B did not text back until 5:30 PM or 6:00 PM. Observation of ADON N's telephone revealed a text message was sent at 3:36 PM on [DATE]. The message reflected Resident #1 was weak and his stools smelled like[DIAGNOSES REDACTED]icile (an infection). However, no other symptoms were added to the text message regarding his blood pressure and temperature. At that time, ADON N stated the return text from Physician B told her to hold Resident #1's blood pressure medications (due to his low blood pressure of ,[DATE]) and to call the Nephrologist. Review of Resident #1's entire clinical record revealed no documentation ADON N or any nurse called the Nephrologist. The Skilled Daily Nurses Note dated [DATE] reflected LVN C notified the [MEDICAL TREATMENT] center Resident #1 would not be there that day ([DATE]). During the same interview, ADON N stated she then turned over Resident #1's care back to LVN C, the charge nurse. ADON N stated if she had been working the floor (as the charge nurse), "I would have called the DON and Corporate Nurse. The DON can send him out (to the hospital)." Resident #1's clinical record had no documentation ADON N instructed LVN C to notify the DON and Corporate Nurse and or what to do if Physician B did not return the call. K) An interview was conducted on [DATE] at 5:20 PM with the DON in regard to Resident #1's fevers, which had ranged from 102.7 to 104.4 degrees F over a four-day period. The DON was asked at what point she would expect her nursing staff to send the resident to the hospital with fevers that high. The DON stated, "That is a good question, but we were in communication with the doctor all along." L) An interview was conducted on [DATE] at 9:20 AM with Physician B, who was one of the facility's Medical Directors. Physician B stated if a resident had temperatures over 102 degrees F, an altered state of mind, and was short of breath or lethargic, then the resident should be sent to the hospital. Physician B was asked if he was specifically informed by facility staff on [DATE] about Resident #1's high fever, lethargy, and dropping blood pressure. Physician B stated he did not know his patient was that bad. Physician B stated if he had received a call from the facility on the fifteenth, they (facility staff) did not leave a message for him. He stated he had a call from the DON sometime after [DATE], regarding her inability to reach Resident #1's family and she informed him at that time Resident #1 did not go to [MEDICAL TREATMENT] on [DATE]. Physician B stated Resident #1 not going to [MEDICAL TREATMENT] was not good for the resident, because he had the potential for fluid overload due to his kidney failure and a history [MEDICAL CONDITION]. Physician B stated the last time he saw Resident #1 was on [DATE]. The physician stated if the resident's temperature was 103 degrees F, he should have been sent out to the hospital, especially since he was a [MEDICAL TREATMENT] patient. Physician B added fevers like that were not that simple, "The body is telling us something." Physician B stated there "...has to be some education with the nurses. As for the severity of a fever of 103 degrees, there is urgency with that kind of fever." Physician B repeated, "There needs to be more nursing education. Have to do some more education to nurses not to mess around with a fever of 103 degrees." M) On [DATE] at approximately 4:00 PM, the facility's other Medical Director, Physician M, was interviewed in regard to Resident #1. He stated he reviewed Resident #1's change of condition, and the resident should have been sent to the hospital when his fever was over 103 degrees F, and he had an altered mental status. Physician M stated the failure of the nurses was a communication and education problem. 7) Review of the facility's current, undated "Policy on Significant Change and Physician Notification" revealed the following: "Significant change and physician notification Purpose To ensure that resident's family and/or legal representative and physician are notified of resident changes that fell under the following categories: ? An accident resulting in injury and that has the potential for needed physician intervention. ? A significant change in the resident's physical, mental or psychosocial status. (See below for examples) ? A need to significantly alter treatment. ? Transfer of the resident from the facility. PROCEDURE When any of the above situations exists, the licensed nurse will contact the resident's family and their physician. Calls will be made to the family until they are reached. A message may be left on an answering machine which does not give specifics but leaves a request for the facility to be called. The physician will

Based on observation, interview and record review, it was determined the facility failed to ensure the services provided and/or arranged by the facility meet professional standards of quality to ensure from [DATE] to [DATE] for one (Resident #1) of eight residents reviewed for being provided medical care that meets professional standards, who was not eating, not getting out of bed, running fevers, had diarrhea, was lethargic, had an altered mental status and ended up with pustules. LVN A failed to notify the physician of the resident's fever on [DATE]. The LVN made to notify the physician and/or PA until [DATE], and the message left was to please call the facility. There was nothing in the text regarding Resident #1's change of condition or current status. The LVN did not inform the physician/PA of Resident #1's actual temperature of 103.6 degrees F. LVN A received an order from the physician to send Resident #1 to the hospital on [DATE] after she was off shift and had left the facility. LVN A did not ever inform anyone at the facility of the physician's orders [REDACTED]. The physician/PA were not informed of the resident's diarrhea by the LVN. The physician and PA were not fully informed by the LVN of the resident's status from [DATE] through [DATE]. LVN A frequently documented Resident #1's temperature as elevated and blood pressures as low without including the specific results. These failures resulted in Resident #1's physician/PA not being able to make a fully informed decision in regard to the care the resident required. The resident was not sent to the hospital until [DATE], which occurred due to the development of the resident's pustules, not due to his fevers. At the hospital, Resident #1 was diagnosed with [REDACTED]. The resident went into [MEDICAL CONDITION] with CPR required, and he was put on a ventilator. On [DATE] at 4:45 PM, an Immediate Jeopardy (IJ) was identified in the areas of Resident Behavior/Facility Practice, Resident Rights, Professional Standards, Quality of Care and Administration. While the IJ was lowered on [DATE] at 1:55 PM, 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 still implementing the Plan of Removal. These failures could affect the seventy-five residents receiving services from the facility by placing them at risk for not receiving the care and services they needed to maintain their well-being, comfort and free of infection to ensure they live the life they desired. Findings included: The Texas Administrative Code, Title 22, Examining Boards, Part 11, Texas Board of Nursing, Chapter 217, Licensure, Peer Assistance and Practice, Rule ? 217.11 Standards of Nursing Practice reflected: 1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: (A) Know and conform to the Texas Nursing Practice Act and the board's rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse's current area of nursing practice; (B) Implement measures to promote a safe environment for clients and others; (C) Know the rationale for and the effects of medications and treatments and shall correctly administer the same; (D) Accurately and completely report and document: (i) the client's status including signs and symptoms; (ii) nursing care rendered; (iii) physician, dentist or podiatrist orders; (iv) administration of medications and treatments; (v) client response(s); and (vi) contacts with other health care team members concerning significant events regarding client's status.... 1) The Face Sheet dated [DATE] reflected Resident #1, a [AGE] year-old male, was admitted from an area hospital on [DATE] with [DIAGNOSES REDACTED]. Resident #1's Patient Transfer Form dated [DATE] reflected he had a history of [REDACTED]. The MDS assessment dated [DATE] reflected Resident #1 was able to make himself understood with clear intelligible words, and was able to clearly understand others; no behaviors were present and had no signs of altered mental status or [MEDICAL CONDITION]. The resident required extensive assistance from one person for physical assistance with bed mobility, transfers, locomotion on and off the unit, dressing, toileting, personal hygiene and bathing. The MDS assessment reflected Resident #1 had an active [DIAGNOSES REDACTED]. 2) Review of the Skilled Daily Nurses Note for Resident #1 revealed the following: On [DATE]: At 9:00 AM - Resident #1 had an elevated body temperature of 102.2 degrees F. LVN A (Licensed Vocational Nurse), administered two tablets of Tylenol 500 mg as a fever reducer. At 1:00 PM Resident #1's vital signs were checked. The notes reflected he had an elevated temperature, and his blood pressure ,[DATE] was low. The notes reflected LVN A applied cold compresses to Resident #1's body. He was administered two tablets of Tylenol as a fever reducer. Resident #1's [DATE] MAR from [DATE] through [DATE] reflected the resident's normal blood pressures included: systolic blood pressures of ,[DATE] and diastolic blood pressures of ,[DATE]. On [DATE]: At 3:00 AM, Resident #1 continued to have an elevated body temperature. (The specific temperature was not documented.) He was administered two tablets of Tylenol 500 mg as a fever reducer "per protocol." Review of Physician B's entire standing orders dated effective [DATE] revealed there were no standing orders for a resident with an elevated temperature. At 4:00 AM, the resident's temperature was checked again and it was 99.0 degrees Fahrenheit (F). At 10:00 AM, the notes reflected Resident #1's body temperature was 102.2 degrees F. "Two pain pills were administered, rechecked by 11:00 AM temp down to 98.0 degrees F." Resident #1's blood pressure had dropped to ,[DATE] with an electronic cuff, and was retaken with a manual cuff with a result of ,[DATE]. At 3:00 PM, Resident #1's temperature was 103.6 degrees F and the resident "looked confused." The notes reflected the physician was called four times and the Physician's Assistant (PA) was called three times with no response until the PA returned the call to the facility at 6:30 PM and ordered a UA (urinalysis), CBC (complete blood count) Culture and sensitivity. The PA further ordered if the resident's temperature did not go down, to either order a chest x-ray or send the resident to the ER. There was no further documentation about the resident's status until [DATE] at 1:30 AM. An interview was conducted on [DATE] at 1:10 PM with LVN A in regard to Resident #1. LVN A stated she was the weekend nurse for Saturday ([DATE]) and Sunday ([DATE]). She said when she came in on [DATE], Resident #1 was running a high fever of 102 degrees F and she administered Tylenol. She stated she checked on the resident (after one or two hours), took his clothes off and cooled him with wet towels on his forehead and body. LVN A said when she checked his temperature again; it had gone down to 99 degrees F. LVN A stated Resident #1's temperature would go down, but after one to two hours, "It would come right back up." She stated she called Physician B and PA F, and left a message for each of them to call the facility. LVN A said she then sent a text message to PA F and asked him to call the facility. LVN A stated when she came in Sunday morning ([DATE]), the night nurse told her Resident #1's fever was high. LVN A stated she sent a second text to PA F and asked him to call facility. She stated she called the physician and left a voice mail, but she did not leave specific information about Resident #1 in the text for PA F because of HIPAA (confidentiality of information). Continuing with the same interview on [DATE] at 1:10 PM, LVN A stated although Resident #1's Skilled Daily Nurses Note reflected PA F called her on [DATE] at 6:30 PM, the LVN said she did not actually receive a return call from PA F until 9:00 PM on [DATE]. LVN A said she told PA F the resident was confused. LVN A stated she asked PA F if she should send Resident #1 to the hospital. She said PA F instructed her to wait for the test results to come back. LVN A added she received a text from Physician B telling her to send the resident to the hospital after she had gone off shift and left the faciity on [DATE]. LVN A told the surveyor she did not ever call the facility and/or inform facility staff of the physician's orders [REDACTED]. Review of Resident #1's [DATE] MAR for both routine and PRN medications with LVN A revealed the Tylenol was not documented as administered. When questioned about it during the same interview, LVN A stated questioningly, "I didn't write it down?" Review of all of Resident #1's Physician's Telephone Orders revealed the orders given by the PA for the chest x-ray, CBC and UA with Culture and Sensitivity were never written. On [DATE]: At 1:30 AM, the Skilled Daily Nurses Note reflected a new order was received for labs and a chest x-ray. However, they were "Not able to obtained (sic) urine on this shift." Review of Resident #1's entire clinical record revealed no documentation either Physician B or PA F were notified of the results of the chest x-ray or the CBC or that staff were unable to obtain a urine specimen. At 10:00 AM, the notes reflected Resident #1 was in bed and had diarrhea with [MEDICATION NAME] (anti-diarrheal) was given. At 3:38 PM - "...call to the room by CNA, R/T (related to) the resident seemed weak, upon my assessment vs (vital signs) are ,[DATE] (blood pressure) 96.8 (temperature) 90 (pulse) SATS (Oxygen saturation) 98%, Resident just had an episode of diarrhea. ...resident seem (sic) very lethargic he hasn't eaten all day. DON stated that we shouldn't send resident to [MEDICAL TREATMENT], until call was made to Dr (Physician B), awaiting call back for any new orders...." This entry was signed by ADON N. At 4:30 PM - "...Charge nurse made aware of all things going on and is expecting a call back from Dr. (named Physician B)." This entry was signed by ADON N. At 8:30 PM - "...Orders Rec'd (received) and noted from Dr. (Physician B). [MEDICAL TREATMENT] was made aware that resident was not going to be sent to HD ([MEDICAL TREATMENT]) and why - agreed with that...." Review of the telephone order dated [DATE] at 11:45 PM from Physician B revealed orders to: "1. Hold B/P (blood pressure) meds ([MEDICAL CONDITION]) 2. Collect stools X 3 for [MEDICAL CONDITION] ([MEDICAL CONDITION] - bacterial infection) 3. Call [MEDICAL TREATMENT]/not going today...." Documentation reflected this order was received by LVN C. On [DATE] at 9:30 AM, Resident #1's Skilled Daily Nurses Note reflected "Resident lying in bed at shift change. Lethargic, diaphretic (sic) (sweating profusely). VS (blood pressure) ,[DATE], (temperature) 100.5 AX (axillary), pulse 96 FSBS (finger stick blood sugar) 101. Upon uncovering resident - noted to have a pustual (sic) rash over trunk of body and going down thighs. Call to Dr. (Physician B) and requested order to send to ____ hospital...." Review of Resident #1's entire clinical record revealed there was no documentation the resident's family had ever been notified of the resident's change of condition or hospitalization . 2) Review of the facility's 24 Hour Report/Change of Condition Report revealed the following: On [DATE], Resident #1 stayed in bed during the day and evening shifts. On [DATE], he was "O.K." and stayed in bed on the day shift except when he went to [MEDICAL TREATMENT]. On [DATE], the resident had an increased temperature, but the actual temperature was not specified. On [DATE], Tylenol was given for an elevated temperature, the temperature came down to 98 degrees F, but Resident #1's temperature later increased again. "Doctor was called." The PA called back on the evening shift and gave orders for UA, Culture and Sensitivity and CBC. On [DATE], the only remark on the day shift for Resident #1 was diarrhea. On the evening shift, Resident #1's blood pressure was low (no specifics) and the resident was very weak. On the night shift, the report reflected the resident's lab was drawn (from the orders received on [DATE]). On [DATE], Resident #1 was sent to the hospital and the physician was informed of the resident's rash, temperature and lethargy. 3) Review of Resident #1's Diet Sheet for [DATE] revealed documentation, which reflected the resident's eating patterns had changed. Resident #1 usually ate 78 - 100% of his meals and rarely 50%. On [DATE], Resident #1 ate 50% of his breakfast (normal was 80 - 100%) and nothing was marked for his supper. On [DATE], the resident did not eat any lunch or supper. On [DATE] and [DATE], the Diet Sheet reflected Resident #1 did not eat anything. 4) Resident #1's medication form dated [DATE] reflected Tylenol was not administered for the resident's fever from [DATE] to [DATE]. Review of the [DATE] MAR indicated [REDACTED]. On [DATE] vital sign readings taken revealed the residents pulse was high with a reading of 121 beats per minute. Previous readings prior to that date reflected the resident's pulse readings were ranging between ,[DATE] beats per minute. 5) Review of the Patient Transfer Form dated [DATE] revealed the [DIAGNOSES REDACTED]. Documentation on the transfer form revealed Residents #1's symptoms first started "with n/v (nausea and vomiting), diarrhea. > (greater than) ,[DATE] days - Now still has low grade (temperature) but > 99.9. Now 100.5 AX (axillary), B/P (blood pressure) has been low, unable to dialyse on [DATE]. Has a pustule rash over trunk of body and upper thighs, not noted [DATE]. There this AM. Also lethargic." The transfer form reflected the nurse spoke with Resident #1's primary care provider, who wanted him sent to hospital with a medical history of [REDACTED]. Although the Patient Transfer Form record reflected Resident #1 had nausea and vomiting, review of the resident's entire clinical record revealed no documentation of those symptoms. Review of Resident #1's hospital's History and Physical (H&P) dated [DATE] revealed the resident's reason for being admitted was due to "Fever and Altered Mental Status." The H&P reflected Resident #1 was transferred from the nursing home with a fever over the last ,[DATE] days. "Apparently the patient was increasingly confused and also having fever, so the patient was sent to the hospital for consult [MEDICAL CONDITION]. The patient was admitted on the floor and eventually his blood pressure dropped and also developed altered mental status with hypoxemia (low oxygen levels), so patient was transferred to the ICU (Intensive Care Unit) and intubated (tube inserted into his trachea to facilitate breathing). The patient is on vent support with a temperature of 101 degrees F." Review of the physician's assessment of Resident #1 revealed he was having coarse breath sounds in both lungs and had discoloration of both legs. The physician's "Assessment and Plan" reflected Resident #1 had "Acute [MEDICAL CONDITION], most likely secondary [MEDICAL CONDITION] with pneumonia." The second entry in the plan revealed Resident #1 had "[MEDICAL CONDITION]." Review of Resident #1's hospital Microbiology Reports revealed the following: The report for the culture of blood collected on [DATE] reflected growth [MEDICAL CONDITIONS]. The report for the culture of sputum collected on [DATE] reflected growth [MEDICAL CONDITION]. The report for the culture of his urine collected on [DATE] reflected growth of Proteus mirabillis. The report for the culture of Resident #1's Perma Cath Tip ([MEDICAL TREATMENT] catheter site) collected on [DATE] reflected probable Staphylococcus aureus. Resident #1's Nurses Narrative from the hospital dated [DATE] reflected the resident stopped breathing at 5:20 AM and a code was called with ACLS (Advanced Cardiac Life Support) protocol followed. Resident #1 was intubated and placed on mechanical ventilation. Resident #1's hospital Progress Notes dated [DATE] reflected the resident went into Acute [MEDICAL CONDITION] and received CPR (Cardiopulmonary Resuscitation). 6) A) On [DATE] at 11:30 AM, PA F was interviewed. The surveyor asked if he had received a call from the facility on [DATE] in regard to Resident #1's high fever and lethargy. PA F stated he spoke to LVN A later on [DATE] about Resident #1 and ordered lab work for the resident to make sure there was no infection. The PA stated the nurses were supposed to do a STAT (immediately) order on the lab work, so he could solve the problem. (The Physician's Telephone Orders dated [DATE] did not reflect any STAT orders.) PA F stated he never got a call about Resident #1's lab work results so he would know how to treat the resident. He stated, "They could call or text. I have told them that and I would get back to them as soon as I could." PA F said he was told by the nurse Resident #1's fever was over 100 degrees F and would come down with Tylenol. "So, I did a stat order for UA (Urine Analysis), CBC (Complete Blood Count) and a chest x-ray. If he was that ill with fever and was lethargic, I would have sent him out without question." PA F stated that the nurse did not tell him anything other than the resident's temperature was over 100 degrees F. PA F stated the staff never told him how high the temperature was or the resident had an altered mental state. PA F stated there was no reason for the staff not to leave him a message or a text to let him know how ill Resident #1 was at the time of the call. B) On [DATE] at 11:55 AM, the DON was interviewed regarding the health status of Resident #1. The DON stated she was aware the resident was running a temperature. She stated she went in to see the resident on [DATE] and he spoke to her, and his appetite was not that great. The DON said his temperature was up all day. The DON stated the nurses did not call her about the resident. "They were doing their own thing." The DON stated the Tylenol was working. She said on Wednesday ([DATE]) the resident developed pustules on his body. The DON stated she called the doctor and told him what was going on, and they decided to send him out to the hospital. She stated the resident was not under any stress when he left the facility. The DON stated there were Standing Orders for residents who run fevers, and were lethargic, and the nurses usually call her when there was a problem (but they did not on this occasion). The DON stated she did not see him until Sunday [DATE]. She added he was scheduled to go out for [MEDICAL TREATMENT] on Monday [DATE] but he was still ill so she called Physician B and documented it in the Skilled Daily Nurses on [DATE]. The DON stated she had read the Nurses Notes over and over and that she thought they (nurses) did what they were supposed to do. We have standing orders from the physicians. Review of Physician B's entire standing orders dated effective [DATE] revealed there were no standing orders for a resident with an elevated temperature. Review of Resident #1's Consolidated Physician order [REDACTED]. Additional review revealed Resident #1 was not on a routine antipyretic (fever reducing medication such as Tylenol). C) RA (Restorative Aide) E was interviewed on [DATE] at 11:10 AM in regard to Resident #1. RA E stated he provided care for Resident #1 all the time. RA E said this past Sunday on [DATE] he and CNA L were talking about how ill Resident #1 had been. RA E stated CNA L had told him (RA E) he (CNA L) was concerned about Resident #1 because the resident was running a fever and was not himself. RA E stated, "He looked ill." RA E stated Resident #1's illness "started back on Friday ([DATE]). He was ill that day. He was sent out to [MEDICAL TREATMENT]." RA E added, "He (Resident #1) was so weak that he couldn't sit up straight in his chair. The resident was sweaty and clammy that day. Can't believe they sent him out to [MEDICAL TREATMENT]." RA E said he went to the Charge Nurse at the time to tell her about Resident #1's condition. RA E stated, "I will go to the DON or talk to the nurse if there is a concern (with a resident)." RA E stated, "Both (charge) nurses (LVN A and LVN C) ...knew how ill he was and should not have sent him out (to [MEDICAL TREATMENT])." D) CNA L was interviewed on [DATE] at 12:15 PM regarding the health status of Resident #1. CNA L stated he returned to work on Sunday ([DATE]) and observed the Charge Nurse, LVN A, take Resident #1's temperature. CNA L stated the resident was unresponsive and he reported that information to ADON N on [DATE]. He stated he asked ADON N to come look at the resident. CNA L stated ADON N took Resident #1's blood pressure with a digital cuff and it was ,[DATE]. (Record review revealed this B/P was not documented.) CNA L stated he observed the resident as he laid there all day, and the next morning, [DATE], before they sent him out. CNA L stated when he tried to get the resident up out of bed, Resident #1 was hollering. CNA L stated the resident always liked his coffee, but starting last Thursday ([DATE]), he stopped asking for coffee. CNA L stated his biggest concerns were why would the staff wait so long to send him out to the hospital; and why they attempted to send him to [MEDICAL TREATMENT] on Monday ([DATE]). He also stated that the facility staff neglected Resident #1, and they should be caring for the residents by order of importance of resident's needs. The surveyor asked CNA L if he informed the Abuse Coordinator of his concerns and he stated "No," because he was afraid he would be fired. E) LVN D was interviewed on [DATE] at 10:40 AM in regard to Resident #1. LVN D verified she worked weekdays on the day shift and was a Charge Nurse. LVN D stated Resident #1 was a diabetic and did not like to get up. On Monday ([DATE]) he had some diarrhea. She stated the CNAs reported Resident #1 was having diarrhea on [DATE]. LVN D added Resident #1 did not have any fever on the 10:00 PM - 6:00 AM shift. LVN D stated Resident #1 went to the hospital the next day ([DATE]) because of his rash. LVN D said the hospital called the facility on [DATE] requesting next of kin information for Resident #1, because they were trying to locate the family. LVN D said the hospital staff told her Resident #1 came to the hospital in respiratory distress and he was now on a ventilator. LVN D stated she had been licensed as an LVN since [DATE] (three months), and she was still learning about [MEDICAL TREATMENT] residents. Review of the Skilled Daily Nurses Note dated [DATE] at 10:00 AM and signed by LVN D revealed "Resident lying in bed. [MEDICATION NAME] given. Resident has Dirrhea (sic) No temp this am. No bleeding or s/s (signs/symptoms) of infection at shunt site. Call light within reach - will cont. to monitor." F) On [DATE] at 12:49 PM, MA H was interviewed. She stated she noticed Resident #1 had a fever and low blood pressure on [DATE]. MA H stated she reported Resident #1's vital signs to LVN C, the Charge Nurse. MA H stated, "All they did was give him Tylenol." MA H stated she "knew the resident's temperatures had been over 104.4 degrees F." She stated, "He was really hot and sweaty. They did not even send him to [MEDICAL TREATMENT]." She stated, "He usually talked to me, he had not been eating, and he was shaking." MA H stated if she saw a problem like that, she would document her observations on the flow sheet and would then circle it for the nurse to see. M A H stated she was worried about Resident #1. Review of Resident #1's clinical record revealed no documentation the aide reported her concerns to her LVN C. G) Interview on [DATE] at 11:40 AM with CNA J revealed she went to both of the Charge Nurses, LVN C and LVN D, about Resident #1's condition, and told them he was sleeping a lot, not eating, was confused, was not alert and oriented, and had food all over him, all down the front of him. CNA J stated when she normally provided care to Resident#1, he would visit with her and he always spoke English to her; however, on that day he was not speaking English. She stated, "He knows I do not speak ____ (another language)" and it was not normal behavior for him. CNA J stated "he just kept getting worse." H) MA K was interviewed on [DATE] at 9:50 AM in regard to Resident #1's health status. MA K stated she took all the residents' temperatures and vital signs and documented them on notebook paper and handed it to the charge nurse, who put the information in the chart. MA K stated when Resident #1 was eating; he loved coffee and did not like to be bothered. She said on [DATE] he showed signs of confusion, he had an empty cup in his hand and he thought there was coffee in the cup. MA K stated she talked to the nurse about Resident #1's confusion. I) An interview was conducted on [DATE] at 10:05 AM with LVN C in regard to Resident #1. LVN C stated she was a PRN nurse and had not been familiar with Resident #1's normal behavior. She stated she took care of him the day before he was sent out ([DATE]). She stated she observed him lying in bed, never saw him up or with his eyes open. LVN C stated she thought he was non-verbal. "I would not have known that was not normal behavior for him." LVN C stated direct care staff came to her with concerns Resident #1 was not like himself. She stated she went to assess him, but did not have a baseline to go by for her evaluation of the resident. LVN C stated she expressed her concerns to ADON N and ADON N told her she (ADON N) was taking care of it and to go back to her Hall. Review of Resident #1's Skilled Daily Nurses Note dated [DATE] revealed LVN C recorded one set of vital signs for Resident #1 on [DATE] (T-96.8, P-90, R- 20 and B/P-,[DATE]) and a note orders were received from Physician B. J) An interview was conducted on [DATE] at 10:30 AM with ADON N in regard to Resident #1. ADON N stated on Monday ([DATE]), the facility van driver and CNA G called her about Resident #1's health status prior to putting him on the van to [MEDICAL TREATMENT]. At that time, ADON N said CNA G told her he thought Resident #1 did not feel good and had not eaten. ADON N stated she went to assess the resident on [DATE] at 3:38 PM prior to sending him to [MEDICAL TREATMENT]. ADON N stated when she called Resident #1 by his name he could barely raise his head. ADON N stated, "He wasn't himself." ADON N stated she called Physician B. Resident #1's Skilled Daily Nurses Note revealed ADON N documented a call to Physician B on [DATE] after 3:38 PM. During the same interview, ADON N stated the call went to voice mail. ADON N stated she sent a text to Physician B with Resident #1's vital signs, which were B/P ,[DATE], T- 96.8. P-90, and Oxygen Saturation 98%. ADON N said she called PA F and left a message for PA F to return the call. ADON N said the DON told her Resident #1 could not go to [MEDICAL TREATMENT]. ADON N stated she advised the Administrator on [DATE] of the situation with Resident #1 and informed her she could not get hold of Physician B. ADON N stated Physician B did not text back until 5:30 PM or 6:00 PM. Observation of ADON N's telephone revealed a text message was sent at 3:36 PM on [DATE]. The message reflected Resident #1 was weak and his stools smelled like[DIAGNOSES REDACTED]icile (an infection). However, no other symptoms were added to the text message regarding his blood pressure and temperature. At that time, ADON N stated the return text from Physician B told her to hold Resident #1's blood pressure medications (due to his low blood pressure of ,[DATE]) and to call the Nephrologist. Review of Resident #1's entire clinical record revealed no documentation ADON N or any nurse called the Nephrologist. The Skilled Daily Nurses Note dated [DATE] reflected LVN C notified the [MEDICAL TREATMENT] center Resident #1 would not be there that day ([DATE]). During the same interview, ADON N stated she then turned over Resident #1's care back to LVN C, the charge nurse. ADON N stated if she had been working the floor (as the charge nurse), "I would have called the DON and Corporate Nurse. The DON can send him out (to the hospital)." Resident #1's clinical record had no documentation ADON N instructed LVN C to notify the DON and Corporate Nurse and or what to do if Physician B did not return the call. K) An interview was conducted on [DATE] at 5:20 PM with the DON in regard to Resident #1's fevers, which had ranged from 102.7 to 104.4 degrees F over a four-day period. The DON was asked at what point she would expect her nursing staff to send the resident to the hospital with fevers that high. The DON stated, "That is a good question, but we were in communication with the doctor all along." L) An interview was conducted on [DATE] at 9:20 AM with Physician B, who was one of the facility's Medical Directors. Physician B stated if a resident had temperatures over 102 degrees F, an altered state of mind, and was short of breath or lethargic, then the resident should be sent to the hospital. Physician B was asked if he was specifically informed by facility staff on [DATE] about Resident #1's high fever, lethargy, and dropping blood pressure. Physician B stated he did not know his patient was that bad. Physician B stated if he had received a call from the facility on the fifteenth, they (facility staff) did not leave a message for him. He stated he had a call from the DON sometime after [DATE], regarding her inability to reach Resident #1's family and she informed him at that time Resident #1 did not go to [MEDICAL TREATMENT] on [DATE]. Physician B stated Resident #1 not going to [MEDICAL TREATMENT] was not good for the resident, because he had the potential for fluid overload due to his kidney failure and a history [MEDICAL CONDITION]. Physician B stated the last time he saw Resident #1 was on [DATE]. The physician stated if the resident's temperature was 103 degrees F, he should have been sent out to the hospital, especially since he was a [MEDICAL TREATMENT] patient. Physician B added fevers like that were not that simple, "The body is telling us something." Physician B stated there "...has to be some education with the nurses. As for the severity of a fever of 103 degrees, there is urgency with that kind of fever." Physician B repeated, "There needs to be more nursing education. Have to do some more education to nurses not to mess around with a fever of 103 degrees." M) On [DATE] at approximately 4:00 PM, the facility's other Medical Director, Physician M, was interviewed in regard to Resident #1. He stated he reviewed Resident #1's change of condition, and the resident should have been sent to the hospital when his fever was over 103 degrees F, and he had an altered mental status. Physician M stated the failure of the nurses was a communication and education problem. 7) Record review of the facility's current policy and procedures entitled Abuse Policy with a revised date of [DATE] provided by the Administrator reflected the following: INTENT: This protocol was intended to assist in the prevention of abuse, neglect and misappropriation of property. Each resident has the right to be free from abuse, mistreatment, neglect, corporal punishment, involuntary seclusion and financial abuse. POLICY: 1. The facility will prohibit neglect, mental or physical abuse, including involuntary seclusion and the misappropriation of property or finances of residents. 2. The facility will conduct an investigation of alleged or suspected abuse, neglect, or misappropriation of property, and will provide notification of information to the proper authorities according to state and federal regulations. 3. The facility will designate a qualified staff member to oversee the abuse prohibition program... DEFI

Based on observation, interview and record review, it was determined 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 from [DATE] to [DATE] for one (Resident #1) of eight residents reviewed for quality of care, who was not eating, not getting out of bed, running fevers, had diarrhea, was lethargic, had an altered mental status and ended up with pustules. Facility failures included: The physician was not notified of the resident's fever on [DATE]. No attempt was made to notify the physician and/or PA until [DATE], and the message left was to please call the facility. There was nothing in the text regarding Resident #1's change of condition or current status. The PA was not informed of Resident #1's actual temperature of 103.6 degrees F. LVN A received an order from the physician to send Resident #1 to the hospital on [DATE] after she was off shift and had left the facility. LVN A did not ever inform anyone at the facility of the physician's orders [REDACTED]. The physician/PA were not informed of the resident's diarrhea. The physician and PA were not fully informed of the resident's status from [DATE] through [DATE]. The licensed nurses frequently documented Resident #1's temperature as elevated and blood pressures as low without including the specific results. These failures resulted in Resident #1's physician/PA not being able to make a fully informed decision in regard to the care the resident required. The resident was not sent to the hospital until [DATE], which occurred due to the development of the resident's pustules, not due to his fevers. At the hospital, Resident #1 was diagnosed with [REDACTED]. The resident went into [MEDICAL CONDITION] with CPR required, and he was put on a ventilator. On [DATE] at 4:45 PM, an Immediate Jeopardy (IJ) was identified in the areas of Resident Behavior/Facility Practice, Resident Rights, Professional Standards, Quality of Care and Administration. While the IJ was lowered on [DATE] at 1:55 PM, 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 still implementing the Plan of Removal. These failures could affect the seventy-five residents receiving services from the facility by placing them at risk for not receiving the care and services they needed to maintain their well-being, comfort and free of infection to ensure they live the life they desired. Findings included: 1) The Face Sheet dated [DATE] reflected Resident #1, a [AGE] year-old male, was admitted from an area hospital on [DATE] with [DIAGNOSES REDACTED]. Resident #1's Patient Transfer Form dated [DATE] reflected he had a history of [REDACTED]. The MDS assessment dated [DATE] reflected Resident #1 was able to make himself understood with clear intelligible words, and was able to clearly understand others; no behaviors were present and had no signs of altered mental status or [MEDICAL CONDITION]. The resident required extensive assistance from one person for physical assistance with bed mobility, transfers, locomotion on and off the unit, dressing, toileting, personal hygiene and bathing. The MDS assessment reflected Resident #1 had an active [DIAGNOSES REDACTED]. 2) Review of the Skilled Daily Nurses Note for Resident #1 revealed the following: On [DATE]: At 9:00 AM - Resident #1 had an elevated body temperature of 102.2 degrees F. LVN A (Licensed Vocational Nurse), administered two tablets of Tylenol 500 mg as a fever reducer. At 1:00 PM Resident #1's vital signs were checked. The notes reflected he had an elevated temperature, and his blood pressure ,[DATE] was low. The notes reflected LVN A applied cold compresses to Resident #1's body. He was administered two tablets of Tylenol as a fever reducer. Resident #1's [DATE] MAR from [DATE] through [DATE] reflected the resident's normal blood pressures included: systolic blood pressures of ,[DATE] and diastolic blood pressures of ,[DATE]. On [DATE]: At 3:00 AM, Resident #1 continued to have an elevated body temperature. (The specific temperature was not documented.) He was administered two tablets of Tylenol 500 mg as a fever reducer "per protocol." Review of Physician B's entire standing orders dated effective [DATE] revealed there were no standing orders for a resident with an elevated temperature. At 4:00 AM, the resident's temperature was checked again and it was 99.0 degrees Fahrenheit (F). At 10:00 AM, the notes reflected Resident #1's body temperature was 102.2 degrees F. "Two pain pills were administered, rechecked by 11:00 AM temp down to 98.0 degrees F." Resident #1's blood pressure had dropped to ,[DATE] with an electronic cuff, and was retaken with a manual cuff with a result of ,[DATE]. At 3:00 PM, Resident #1's temperature was 103.6 degrees F and the resident "looked confused." The notes reflected the physician was called four times and the Physician's Assistant (PA) was called three times with no response until the PA returned the call to the facility at 6:30 PM and ordered a UA (urinalysis), CBC (complete blood count) Culture and sensitivity. The PA further ordered if the resident's temperature did not go down, to either order a chest x-ray or send the resident to the ER. There was no further documentation about the resident's status until [DATE] at 1:30 AM. An interview was conducted on [DATE] at 1:10 PM with LVN A in regard to Resident #1. LVN A stated she was the weekend nurse for Saturday ([DATE]) and Sunday ([DATE]). She said when she came in on [DATE], Resident #1 was running a high fever of 102 degrees F and she administered Tylenol. She stated she checked on the resident (after one or two hours), took his clothes off and cooled him with wet towels on his forehead and body. LVN A said when she checked his temperature again; it had gone down to 99 degrees F. LVN A stated Resident #1's temperature would go down, but after one to two hours, "It would come right back up." She stated she called Physician B and PA F, and left a message for each of them to call the facility. LVN A said she then sent a text message to PA F and asked him to call the facility. LVN A stated when she came in Sunday morning ([DATE]), the night nurse told her Resident #1's fever was high. LVN A stated she sent a second text to PA F and asked him to call facility. She stated she called the physician and left a voice mail, but she did not leave specific information about Resident #1 in the text for PA F because of HIPAA (confidentiality of information). Continuing with the same interview on [DATE] at 1:10 PM, LVN A stated although Resident #1's Skilled Daily Nurses Note reflected PA F called her on [DATE] at 6:30 PM, the LVN said she did not actually receive a return call from PA F until 9:00 PM on [DATE]. LVN A said she told PA F the resident was confused. LVN A stated she asked PA F if she should send Resident #1 to the hospital. She said PA F instructed her to wait for the test results to come back. LVN A added she received a text from Physician B telling her to send the resident to the hospital after she had gone off shift and left the faciity on [DATE]. LVN A told the surveyor she did not ever call the facility and/or inform facility staff of the physician's orders [REDACTED]. Review of Resident #1's [DATE] MAR for both routine and PRN medications with LVN A revealed the Tylenol was not documented as administered. When questioned about it during the same interview, LVN A stated questioningly, "I didn't write it down?" Review of all of Resident #1's Physician's Telephone Orders revealed the orders given by the PA for the chest x-ray, CBC and UA with Culture and Sensitivity were never written. On [DATE]: At 1:30 AM, the Skilled Daily Nurses Note reflected a new order was received for labs and a chest x-ray. However, they were "Not able to obtained (sic) urine on this shift." Review of Resident #1's entire clinical record revealed no documentation either Physician B or PA F were notified of the results of the chest x-ray or the CBC or that staff were unable to obtain a urine specimen. At 10:00 AM, the notes reflected Resident #1 was in bed and had diarrhea with [MEDICATION NAME] (anti-diarrheal) was given. At 3:38 PM - "...call to the room by CNA, R/T (related to) the resident seemed weak, upon my assessment vs (vital signs) are ,[DATE] (blood pressure) 96.8 (temperature) 90 (pulse) SATS (Oxygen saturation) 98%, Resident just had an episode of diarrhea. ...resident seem (sic) very lethargic he hasn't eaten all day. DON stated that we shouldn't send resident to [MEDICAL TREATMENT], until call was made to Dr (Physician B), awaiting call back for any new orders...." This entry was signed by ADON N. At 4:30 PM - "...Charge nurse made aware of all things going on and is expecting a call back from Dr. (named Physician B)." This entry was signed by ADON N. At 8:30 PM - "...Orders Rec'd (received) and noted from Dr. (Physician B). [MEDICAL TREATMENT] was made aware that resident was not going to be sent to HD ([MEDICAL TREATMENT]) and why - agreed with that...." Review of the telephone order dated [DATE] at 11:45 PM from Physician B revealed orders to: "1. Hold B/P (blood pressure) meds ([MEDICAL CONDITION]) 2. Collect stools X 3 for [MEDICAL CONDITION] ([MEDICAL CONDITION] - bacterial infection) 3. Call [MEDICAL TREATMENT]/not going today...." Documentation reflected this order was received by LVN C. On [DATE] at 9:30 AM, Resident #1's Skilled Daily Nurses Note reflected "Resident lying in bed at shift change. Lethargic, diaphretic (sic) (sweating profusely). VS (blood pressure) ,[DATE], (temperature) 100.5 AX (axillary), pulse 96 FSBS (finger stick blood sugar) 101. Upon uncovering resident - noted to have a pustual (sic) rash over trunk of body and going down thighs. Call to Dr. (Physician B) and requested order to send to ____ hospital...." Review of Resident #1's entire clinical record revealed there was no documentation the resident's family had ever been notified of the resident's change of condition or hospitalization . 2) Review of the facility's 24 Hour Report/Change of Condition Report revealed the following: On [DATE], Resident #1 stayed in bed during the day and evening shifts. On [DATE], he was "O.K." and stayed in bed on the day shift except when he went to [MEDICAL TREATMENT]. On [DATE], the resident had an increased temperature, but the actual temperature was not specified. On [DATE], Tylenol was given for an elevated temperature, the temperature came down to 98 degrees F, but Resident #1's temperature later increased again. "Doctor was called." The PA called back on the evening shift and gave orders for UA, Culture and Sensitivity and CBC. On [DATE], the only remark on the day shift for Resident #1 was diarrhea. On the evening shift, Resident #1's blood pressure was low (no specifics) and the resident was very weak. On the night shift, the report reflected the resident's lab was drawn (from the orders received on [DATE]). On [DATE], Resident #1 was sent to the hospital and the physician was informed of the resident's rash, temperature and lethargy. 3) Review of Resident #1's Diet Sheet for [DATE] revealed documentation, which reflected the resident's eating patterns had changed. Resident #1 usually ate 78 - 100% of his meals and rarely 50%. On [DATE], Resident #1 ate 50% of his breakfast (normal was 80 - 100%) and nothing was marked for his supper. On [DATE], the resident did not eat any lunch or supper. On [DATE] and [DATE], the Diet Sheet reflected Resident #1 did not eat anything. 4) Resident #1's medication form dated [DATE] reflected Tylenol was not administered for the resident's fever from [DATE] to [DATE]. Review of the [DATE] MAR indicated [REDACTED]. On [DATE] vital sign readings taken revealed the residents pulse was high with a reading of 121 beats per minute. Previous readings prior to that date reflected the resident's pulse readings were ranging between ,[DATE] beats per minute. 5) Review of the Patient Transfer Form dated [DATE] revealed the [DIAGNOSES REDACTED]. Documentation on the transfer form revealed Residents #1's symptoms first started "with n/v (nausea and vomiting), diarrhea. > (greater than) ,[DATE] days - Now still has low grade (temperature) but > 99.9. Now 100.5 AX (axillary), B/P (blood pressure) has been low, unable to dialyse on [DATE]. Has a pustule rash over trunk of body and upper thighs, not noted [DATE]. There this AM. Also lethargic." The transfer form reflected the nurse spoke with Resident #1's primary care provider, who wanted him sent to hospital with a medical history of [REDACTED]. Although the Patient Transfer Form record reflected Resident #1 had nausea and vomiting, review of the resident's entire clinical record revealed no documentation of those symptoms. Review of Resident #1's hospital's History and Physical (H&P) dated [DATE] revealed the resident's reason for being admitted was due to "Fever and Altered Mental Status." The H&P reflected Resident #1 was transferred from the nursing home with a fever over the last ,[DATE] days. "Apparently the patient was increasingly confused and also having fever, so the patient was sent to the hospital for consult [MEDICAL CONDITION]. The patient was admitted on the floor and eventually his blood pressure dropped and also developed altered mental status with hypoxemia (low oxygen levels), so patient was transferred to the ICU (Intensive Care Unit) and intubated (tube inserted into his trachea to facilitate breathing). The patient is on vent support with a temperature of 101 degrees F." Review of the physician's assessment of Resident #1 revealed he was having coarse breath sounds in both lungs and had discoloration of both legs. The physician's "Assessment and Plan" reflected Resident #1 had "Acute [MEDICAL CONDITION], most likely secondary [MEDICAL CONDITION] with pneumonia." The second entry in the plan revealed Resident #1 had "[MEDICAL CONDITION]." Review of Resident #1's hospital Microbiology Reports revealed the following: The report for the culture of blood collected on [DATE] reflected growth [MEDICAL CONDITIONS]. The report for the culture of sputum collected on [DATE] reflected growth [MEDICAL CONDITION]. The report for the culture of his urine collected on [DATE] reflected growth of Proteus mirabillis. The report for the culture of Resident #1's Perma Cath Tip ([MEDICAL TREATMENT] catheter site) collected on [DATE] reflected probable Staphylococcus aureus. Resident #1's Nurses Narrative from the hospital dated [DATE] reflected the resident stopped breathing at 5:20 AM and a code was called with ACLS (Advanced Cardiac Life Support) protocol followed. Resident #1 was intubated and placed on mechanical ventilation. Resident #1's hospital Progress Notes dated [DATE] reflected the resident went into Acute [MEDICAL CONDITION] and received CPR (Cardiopulmonary Resuscitation). 6) A) On [DATE] at 11:30 AM, PA F was interviewed. The surveyor asked if he had received a call from the facility on [DATE] in regard to Resident #1's high fever and lethargy. PA F stated he spoke to LVN A later on [DATE] about Resident #1 and ordered lab work for the resident to make sure there was no infection. The PA stated the nurses were supposed to do a STAT (immediately) order on the lab work, so he could solve the problem. (The Physician's Telephone Orders dated [DATE] did not reflect any STAT orders.) PA F stated he never got a call about Resident #1's lab work results so he would know how to treat the resident. He stated, "They could call or text. I have told them that and I would get back to them as soon as I could." PA F said he was told by the nurse Resident #1's fever was over 100 degrees F and would come down with Tylenol. "So, I did a stat order for UA (Urine Analysis), CBC (Complete Blood Count) and a chest x-ray. If he was that ill with fever and was lethargic, I would have sent him out without question." PA F stated that the nurse did not tell him anything other than the resident's temperature was over 100 degrees F. PA F stated the staff never told him how high the temperature was or the resident had an altered mental state. PA F stated there was no reason for the staff not to leave him a message or a text to let him know how ill Resident #1 was at the time of the call. B) On [DATE] at 11:55 AM, the DON was interviewed regarding the health status of Resident #1. The DON stated she was aware the resident was running a temperature. She stated she went in to see the resident on [DATE] and he spoke to her, and his appetite was not that great. The DON said his temperature was up all day. The DON stated the nurses did not call her about the resident. "They were doing their own thing." The DON stated the Tylenol was working. She said on Wednesday ([DATE]) the resident developed pustules on his body. The DON stated she called the doctor and told him what was going on, and they decided to send him out to the hospital. She stated the resident was not under any stress when he left the facility. The DON stated there were Standing Orders for residents who run fevers, and were lethargic, and the nurses usually call her when there was a problem (but they did not on this occasion). The DON stated she did not see him until Sunday [DATE]. She added he was scheduled to go out for [MEDICAL TREATMENT] on Monday [DATE] but he was still ill so she called Physician B and documented it in the Skilled Daily Nurses on [DATE]. The DON stated she had read the Nurses Notes over and over and that she thought they (nurses) did what they were supposed to do. We have standing orders from the physicians. Review of Physician B's entire standing orders dated effective [DATE] revealed there were no standing orders for a resident with an elevated temperature. Review of Resident #1's Consolidated Physician order [REDACTED]. Additional review revealed Resident #1 was not on a routine antipyretic (fever reducing medication such as Tylenol). C) RA (Restorative Aide) E was interviewed on [DATE] at 11:10 AM in regard to Resident #1. RA E stated he provided care for Resident #1 all the time. RA E said this past Sunday on [DATE] he and CNA L were talking about how ill Resident #1 had been. RA E stated CNA L had told him (RA E) he (CNA L) was concerned about Resident #1 because the resident was running a fever and was not himself. RA E stated, "He looked ill." RA E stated Resident #1's illness "started back on Friday ([DATE]). He was ill that day. He was sent out to [MEDICAL TREATMENT]." RA E added, "He (Resident #1) was so weak that he couldn't sit up straight in his chair. The resident was sweaty and clammy that day. Can't believe they sent him out to [MEDICAL TREATMENT]." RA E said he went to the Charge Nurse at the time to tell her about Resident #1's condition. RA E stated, "I will go to the DON or talk to the nurse if there is a concern (with a resident)." RA E stated, "Both (charge) nurses (LVN A and LVN C) ...knew how ill he was and should not have sent him out (to [MEDICAL TREATMENT])." D) CNA L was interviewed on [DATE] at 12:15 PM regarding the health status of Resident #1. CNA L stated he returned to work on Sunday ([DATE]) and observed the Charge Nurse, LVN A, take Resident #1's temperature. CNA L stated the resident was unresponsive and he reported that information to ADON N on [DATE]. He stated he asked ADON N to come look at the resident. CNA L stated ADON N took Resident #1's blood pressure with a digital cuff and it was ,[DATE]. (Record review revealed this B/P was not documented.) CNA L stated he observed the resident as he laid there all day, and the next morning, [DATE], before they sent him out. CNA L stated when he tried to get the resident up out of bed, Resident #1 was hollering. CNA L stated the resident always liked his coffee, but starting last Thursday ([DATE]), he stopped asking for coffee. CNA L stated his biggest concerns were why would the staff wait so long to send him out to the hospital; and why they attempted to send him to [MEDICAL TREATMENT] on Monday ([DATE]). He also stated that the facility staff neglected Resident #1, and they should be caring for the residents by order of importance of resident's needs. The surveyor asked CNA L if he informed the Abuse Coordinator of his concerns and he stated "No," because he was afraid he would be fired. E) LVN D was interviewed on [DATE] at 10:40 AM in regard to Resident #1. LVN D verified she worked weekdays on the day shift and was a Charge Nurse. LVN D stated Resident #1 was a diabetic and did not like to get up. On Monday ([DATE]) he had some diarrhea. She stated the CNAs reported Resident #1 was having diarrhea on [DATE]. LVN D added Resident #1 did not have any fever on the 10:00 PM - 6:00 AM shift. LVN D stated Resident #1 went to the hospital the next day ([DATE]) because of his rash. LVN D said the hospital called the facility on [DATE] requesting next of kin information for Resident #1, because they were trying to locate the family. LVN D said the hospital staff told her Resident #1 came to the hospital in respiratory distress and he was now on a ventilator. LVN D stated she had been licensed as an LVN since [DATE] (three months), and she was still learning about [MEDICAL TREATMENT] residents. Review of the Skilled Daily Nurses Note dated [DATE] at 10:00 AM and signed by LVN D revealed "Resident lying in bed. [MEDICATION NAME] given. Resident has Dirrhea (sic) No temp this am. No bleeding or s/s (signs/symptoms) of infection at shunt site. Call light within reach - will cont. to monitor." F) On [DATE] at 12:49 PM, MA H was interviewed. She stated she noticed Resident #1 had a fever and low blood pressure on [DATE]. MA H stated she reported Resident #1's vital signs to LVN C, the Charge Nurse. MA H stated, "All they did was give him Tylenol." MA H stated she "knew the resident's temperatures had been over 104.4 degrees F." She stated, "He was really hot and sweaty. They did not even send him to [MEDICAL TREATMENT]." She stated, "He usually talked to me, he had not been eating, and he was shaking." MA H stated if she saw a problem like that, she would document her observations on the flow sheet and would then circle it for the nurse to see. M A H stated she was worried about Resident #1. Review of Resident #1's clinical record revealed no documentation the aide reported her concerns to her LVN C. G) Interview on [DATE] at 11:40 AM with CNA J revealed she went to both of the Charge Nurses, LVN C and LVN D, about Resident #1's condition, and told them he was sleeping a lot, not eating, was confused, was not alert and oriented, and had food all over him, all down the front of him. CNA J stated when she normally provided care to Resident#1, he would visit with her and he always spoke English to her; however, on that day he was not speaking English. She stated, "He knows I do not speak ____ (another language)" and it was not normal behavior for him. CNA J stated "he just kept getting worse." H) MA K was interviewed on [DATE] at 9:50 AM in regard to Resident #1's health status. MA K stated she took all the residents' temperatures and vital signs and documented them on notebook paper and handed it to the charge nurse, who put the information in the chart. MA K stated when Resident #1 was eating; he loved coffee and did not like to be bothered. She said on [DATE] he showed signs of confusion, he had an empty cup in his hand and he thought there was coffee in the cup. MA K stated she talked to the nurse about Resident #1's confusion. I) An interview was conducted on [DATE] at 10:05 AM with LVN C in regard to Resident #1. LVN C stated she was a PRN nurse and had not been familiar with Resident #1's normal behavior. She stated she took care of him the day before he was sent out ([DATE]). She stated she observed him lying in bed, never saw him up or with his eyes open. LVN C stated she thought he was non-verbal. "I would not have known that was not normal behavior for him." LVN C stated direct care staff came to her with concerns Resident #1 was not like himself. She stated she went to assess him, but did not have a baseline to go by for her evaluation of the resident. LVN C stated she expressed her concerns to ADON N and ADON N told her she (ADON N) was taking care of it and to go back to her Hall. Review of Resident #1's Skilled Daily Nurses Note dated [DATE] revealed LVN C recorded one set of vital signs for Resident #1 on [DATE] (T-96.8, P-90, R- 20 and B/P-,[DATE]) and a note orders were received from Physician B. J) An interview was conducted on [DATE] at 10:30 AM with ADON N in regard to Resident #1. ADON N stated on Monday ([DATE]), the facility van driver and CNA G called her about Resident #1's health status prior to putting him on the van to [MEDICAL TREATMENT]. At that time, ADON N said CNA G told her he thought Resident #1 did not feel good and had not eaten. ADON N stated she went to assess the resident on [DATE] at 3:38 PM prior to sending him to [MEDICAL TREATMENT]. ADON N stated when she called Resident #1 by his name he could barely raise his head. ADON N stated, "He wasn't himself." ADON N stated she called Physician B. Resident #1's Skilled Daily Nurses Note revealed ADON N documented a call to Physician B on [DATE] after 3:38 PM. During the same interview, ADON N stated the call went to voice mail. ADON N stated she sent a text to Physician B with Resident #1's vital signs, which were B/P ,[DATE], T- 96.8. P-90, and Oxygen Saturation 98%. ADON N said she called PA F and left a message for PA F to return the call. ADON N said the DON told her Resident #1 could not go to [MEDICAL TREATMENT]. ADON N stated she advised the Administrator on [DATE] of the situation with Resident #1 and informed her she could not get hold of Physician B. ADON N stated Physician B did not text back until 5:30 PM or 6:00 PM. Observation of ADON N's telephone revealed a text message was sent at 3:36 PM on [DATE]. The message reflected Resident #1 was weak and his stools smelled like[DIAGNOSES REDACTED]icile (an infection). However, no other symptoms were added to the text message regarding his blood pressure and temperature. At that time, ADON N stated the return text from Physician B told her to hold Resident #1's blood pressure medications (due to his low blood pressure of ,[DATE]) and to call the Nephrologist. Review of Resident #1's entire clinical record revealed no documentation ADON N or any nurse called the Nephrologist. The Skilled Daily Nurses Note dated [DATE] reflected LVN C notified the [MEDICAL TREATMENT] center Resident #1 would not be there that day ([DATE]). During the same interview, ADON N stated she then turned over Resident #1's care back to LVN C, the charge nurse. ADON N stated if she had been working the floor (as the charge nurse), "I would have called the DON and Corporate Nurse. The DON can send him out (to the hospital)." Resident #1's clinical record had no documentation ADON N instructed LVN C to notify the DON and Corporate Nurse and or what to do if Physician B did not return the call. K) An interview was conducted on [DATE] at 5:20 PM with the DON in regard to Resident #1's fevers, which had ranged from 102.7 to 104.4 degrees F over a four-day period. The DON was asked at what point she would expect her nursing staff to send the resident to the hospital with fevers that high. The DON stated, "That is a good question, but we were in communication with the doctor all along." L) An interview was conducted on [DATE] at 9:20 AM with Physician B, who was one of the facility's Medical Directors. Physician B stated if a resident had temperatures over 102 degrees F, an altered state of mind, and was short of breath or lethargic, then the resident should be sent to the hospital. Physician B was asked if he was specifically informed by facility staff on [DATE] about Resident #1's high fever, lethargy, and dropping blood pressure. Physician B stated he did not know his patient was that bad. Physician B stated if he had received a call from the facility on the fifteenth, they (facility staff) did not leave a message for him. He stated he had a call from the DON sometime after [DATE], regarding her inability to reach Resident #1's family and she informed him at that time Resident #1 did not go to [MEDICAL TREATMENT] on [DATE]. Physician B stated Resident #1 not going to [MEDICAL TREATMENT] was not good for the resident, because he had the potential for fluid overload due to his kidney failure and a history [MEDICAL CONDITION]. Physician B stated the last time he saw Resident #1 was on [DATE]. The physician stated if the resident's temperature was 103 degrees F, he should have been sent out to the hospital, especially since he was a [MEDICAL TREATMENT] patient. Physician B added fevers like that were not that simple, "The body is telling us something." Physician B stated there "...has to be some education with the nurses. As for the severity of a fever of 103 degrees, there is urgency with that kind of fever." Physician B repeated, "There needs to be more nursing education. Have to do some more education to nurses not to mess around with a fever of 103 degrees." M) On [DATE] at approximately 4:00 PM, the facility's other Medical Director, Physician M, was interviewed in regard to Resident #1. He stated he reviewed Resident #1's change of condition, and the resident should have been sent to the hospital when his fever was over 103 degrees F, and he had an altered mental status. Physician M stated the failure of the nurses was a communication and education problem. 7) Record review of the facility's current policy and procedures entitled Abuse Policy with a revised date of [DATE] provided by the Administrator reflected the following: INTENT: This protocol was intended to assist in the prevention of abuse, neglect and misappropriation of property. Each resident has the right to be free from abuse, mistreatment, neglect, corporal punishment, involuntary seclusion and financial abuse. POLICY: 1. The facility will prohibit neglect, mental or physical abuse, including involuntary seclusion and the misappropriation of property or finances of residents. 2. The facility will conduct an investigation of alleged or suspected abuse, neglect, or misappropriation of property, and will provide notification of information to the proper authorities according to state and federal regulations. 3. The facility will designate a qualified staff member to oversee the abuse prohibition program... DEFINITIONS: ... Neglect is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness...." Review of the facility's current, undated "Policy on Significant Change and Physician Notification" revealed the following: "Significant change and physician notification Purpose To ensure that resident's family and/or legal representative and physician are notified of resident changes that fell under the following categories: ? An accident resulting in injury and that has the potential for needed physician intervention. ? A significant change in the resident's physical, mental or psychosocial status. (See below for examples) ? A need to significantly alter treatment. ? Transfer of the resident from the facility. PROCEDURE When any of the above situations exists, the licensed nurse will contact the resident's family and their physician. Calls will be made to the family until they are reached. A message may be left on an answering machine which does not give specifics but leaves a request for the facility to be called. The physician will be contacted immediately for any e

Based on observation, interview and record review, it was determined the Administrator, the DON, and ADON N failed to ensure the facility used its resources effectively and efficiently to attain or maintain the highest practicable physical well-being from [DATE] to [DATE] for one (Resident #1) of eight residents reviewed for quality of care, professional standards, neglect, and change of condition, who was not eating, not getting out of bed, running fevers, had diarrhea, was lethargic, had an altered mental status and ended up with pustules. 1) The Administrator failed to ensure the facility's written policies and procedures to prevent neglect were implemented when Resident #1 did not receive the care and services he needed and the policy/procedure for a resident's change of condition was implemented. 2) The DON failed to supervise and monitor ADON N to ensure Resident #1's physician and/or PA were fully informed about the resident's status to ensure informed medical decisions could be made, which fully encompassed the resident's change in condition. 3) ADON N failed to supervise and monitor the charge nurses to ensure: A) Licensed nurses consulted and fully informed Resident #1's physician/PA of the resident's deteriorating status. B) Licensed nurses responded appropriately to the reports from the CNAs as early as [DATE] when Resident #1 stayed in bed and did not eat supper and through [DATE]. C) Licensed nurses' documentation included specific vital signs, especially with abnormal readings and did not only use symbols, which indicated increased/elevated and/or decreased/lower to indicate a change of condition. D) LVN A notified the facility when she received a physician's orders [REDACTED]. The physician/PA was not notified of the resident's fever on [DATE]. No attempt was made to notify the physician and/or PA until [DATE], and the message left was to please call the facility. There was nothing in the text regarding Resident #1's change of condition or current status. The physician/PA was not informed of Resident #1's actual temperature of 103.6 degrees F. LVN A received an order from the physician to send Resident #1 to the hospital on [DATE] after she was off shift and had left the facility. LVN A did not ever inform anyone at the facility of the physician's orders [REDACTED]. The physician/PA were not informed of the resident's diarrhea. The physician/PA were not fully informed of the resident's status from [DATE] through [DATE]. The licensed nurses frequently documented Resident #1's temperature as elevated and blood pressures as low without including the specific results. These failures resulted in Resident #1's physician/PA not being able to make a fully informed decision in regard to the care the resident required. The resident was not sent to the hospital until [DATE], which occurred due to the development of the resident's pustules, not due to his fevers. At the hospital, Resident #1 was diagnosed with [REDACTED]. The resident went into [MEDICAL CONDITION] with CPR required, and he was put on a ventilator. On [DATE] at 4:45 PM, an Immediate Jeopardy (IJ) was identified in the areas of Resident Behavior/Facility Practice, Resident Rights, Professional Standards, Quality of Care and Administration. While the IJ was lowered on [DATE] at 1:55 PM, 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 still implementing the Plan of Removal. These failures could affect the seventy-five residents receiving services from the facility by placing them at risk for not receiving the care and services they needed to maintain their well-being, comfort and free of infection to ensure they live the life they desired. Findings included: 1) The Face Sheet dated [DATE] reflected Resident #1, a [AGE] year-old male, was admitted from an area hospital on [DATE] with [DIAGNOSES REDACTED]. Resident #1's Patient Transfer Form dated [DATE] reflected he had a history of [REDACTED]. The MDS assessment dated [DATE] reflected Resident #1 was able to make himself understood with clear intelligible words, and was able to clearly understand others; no behaviors were present and had no signs of altered mental status or [MEDICAL CONDITION]. The resident required extensive assistance from one person for physical assistance with bed mobility, transfers, locomotion on and off the unit, dressing, toileting, personal hygiene and bathing. The MDS assessment reflected Resident #1 had an active [DIAGNOSES REDACTED]. 2) Review of the Skilled Daily Nurses Note for Resident #1 revealed the following: On [DATE]: At 9:00 AM - Resident #1 had an elevated body temperature of 102.2 degrees F. LVN A (Licensed Vocational Nurse), administered two tablets of Tylenol 500 mg as a fever reducer. At 1:00 PM Resident #1's vital signs were checked. The notes reflected he had an elevated temperature, and his blood pressure ,[DATE] was low. The notes reflected LVN A applied cold compresses to Resident #1's body. He was administered two tablets of Tylenol as a fever reducer. Resident #1's [DATE] MAR from [DATE] through [DATE] reflected the resident's normal blood pressures included: systolic blood pressures of ,[DATE] and diastolic blood pressures of ,[DATE]. On [DATE]: At 3:00 AM, Resident #1 continued to have an elevated body temperature. (The specific temperature was not documented.) He was administered two tablets of Tylenol 500 mg as a fever reducer "per protocol." Review of Physician B's entire standing orders dated effective [DATE] revealed there were no standing orders for a resident with an elevated temperature. At 4:00 AM, the resident's temperature was checked again and it was 99.0 degrees Fahrenheit (F). At 10:00 AM, the notes reflected Resident #1's body temperature was 102.2 degrees F. "Two pain pills were administered, rechecked by 11:00 AM temp down to 98.0 degrees F." Resident #1's blood pressure had dropped to ,[DATE] with an electronic cuff, and was retaken with a manual cuff with a result of ,[DATE]. At 3:00 PM, Resident #1's temperature was 103.6 degrees F and the resident "looked confused." The notes reflected the physician was called four times and the Physician's Assistant (PA) was called three times with no response until the PA returned the call to the facility at 6:30 PM and ordered a UA (urinalysis), CBC (complete blood count) Culture and sensitivity. The PA further ordered if the resident's temperature did not go down, to either order a chest x-ray or send the resident to the ER. There was no further documentation about the resident's status until [DATE] at 1:30 AM. An interview was conducted on [DATE] at 1:10 PM with LVN A in regard to Resident #1. LVN A stated she was the weekend nurse for Saturday ([DATE]) and Sunday ([DATE]). She said when she came in on [DATE], Resident #1 was running a high fever of 102 degrees F and she administered Tylenol. She stated she checked on the resident (after one or two hours), took his clothes off and cooled him with wet towels on his forehead and body. LVN A said when she checked his temperature again; it had gone down to 99 degrees F. LVN A stated Resident #1's temperature would go down, but after one to two hours, "It would come right back up." She stated she called Physician B and PA F, and left a message for each of them to call the facility. LVN A said she then sent a text message to PA F and asked him to call the facility. LVN A stated when she came in Sunday morning ([DATE]), the night nurse told her Resident #1's fever was high. LVN A stated she sent a second text to PA F and asked him to call facility. She stated she called the physician and left a voice mail, but she did not leave specific information about Resident #1 in the text for PA F because of HIPAA (confidentiality of information). Continuing with the same interview on [DATE] at 1:10 PM, LVN A stated although Resident #1's Skilled Daily Nurses Note reflected PA F called her on [DATE] at 6:30 PM, the LVN said she did not actually receive a return call from PA F until 9:00 PM on [DATE]. LVN A said she told PA F the resident was confused. LVN A stated she asked PA F if she should send Resident #1 to the hospital. She said PA F instructed her to wait for the test results to come back. LVN A added she received a text from Physician B telling her to send the resident to the hospital after she had gone off shift and left the faciity on [DATE]. LVN A told the surveyor she did not ever call the facility and/or inform facility staff of the physician's orders [REDACTED]. Review of Resident #1's [DATE] MAR for both routine and PRN medications with LVN A revealed the Tylenol was not documented as administered. When questioned about it during the same interview, LVN A stated questioningly, "I didn't write it down?" Review of all of Resident #1's Physician's Telephone Orders revealed the orders given by the PA for the chest x-ray, CBC and UA with Culture and Sensitivity were never written. On [DATE]: At 1:30 AM, the Skilled Daily Nurses Note reflected a new order was received for labs and a chest x-ray. However, they were "Not able to obtained (sic) urine on this shift." Review of Resident #1's entire clinical record revealed no documentation either Physician B or PA F were notified of the results of the chest x-ray or the CBC or that staff were unable to obtain a urine specimen. At 10:00 AM, the notes reflected Resident #1 was in bed and had diarrhea with [MEDICATION NAME] (anti-diarrheal) was given. At 3:38 PM - "...call to the room by CNA, R/T (related to) the resident seemed weak, upon my assessment vs (vital signs) are ,[DATE] (blood pressure) 96.8 (temperature) 90 (pulse) SATS (Oxygen saturation) 98%, Resident just had an episode of diarrhea. ...resident seem (sic) very lethargic he hasn't eaten all day. DON stated that we shouldn't send resident to [MEDICAL TREATMENT], until call was made to Dr (Physician B), awaiting call back for any new orders...." This entry was signed by ADON N. At 4:30 PM - "...Charge nurse made aware of all things going on and is expecting a call back from Dr. (named Physician B)." This entry was signed by ADON N. At 8:30 PM - "...Orders Rec'd (received) and noted from Dr. (Physician B). [MEDICAL TREATMENT] was made aware that resident was not going to be sent to HD ([MEDICAL TREATMENT]) and why - agreed with that...." Review of the telephone order dated [DATE] at 11:45 PM from Physician B revealed orders to: "1. Hold B/P (blood pressure) meds ([MEDICAL CONDITION]) 2. Collect stools X 3 for [MEDICAL CONDITION] ([MEDICAL CONDITION] - bacterial infection) 3. Call [MEDICAL TREATMENT]/not going today...." Documentation reflected this order was received by LVN C. On [DATE] at 9:30 AM, Resident #1's Skilled Daily Nurses Note reflected "Resident lying in bed at shift change. Lethargic, diaphretic (sic) (sweating profusely). VS (blood pressure) ,[DATE], (temperature) 100.5 AX (axillary), pulse 96 FSBS (finger stick blood sugar) 101. Upon uncovering resident - noted to have a pustual (sic) rash over trunk of body and going down thighs. Call to Dr. (Physician B) and requested order to send to ____ hospital...." Review of Resident #1's entire clinical record revealed there was no documentation the resident's family had ever been notified of the resident's change of condition or hospitalization . 2) Review of the facility's 24 Hour Report/Change of Condition Report revealed the following: On [DATE], Resident #1 stayed in bed during the day and evening shifts. On [DATE], he was "O.K." and stayed in bed on the day shift except when he went to [MEDICAL TREATMENT]. On [DATE], the resident had an increased temperature, but the actual temperature was not specified. On [DATE], Tylenol was given for an elevated temperature, the temperature came down to 98 degrees F, but Resident #1's temperature later increased again. "Doctor was called." The PA called back on the evening shift and gave orders for UA, Culture and Sensitivity and CBC. On [DATE], the only remark on the day shift for Resident #1 was diarrhea. On the evening shift, Resident #1's blood pressure was low (no specifics) and the resident was very weak. On the night shift, the report reflected the resident's lab was drawn (from the orders received on [DATE]). On [DATE], Resident #1 was sent to the hospital and the physician was informed of the resident's rash, temperature and lethargy. 3) Review of Resident #1's Diet Sheet for [DATE] revealed documentation, which reflected the resident's eating patterns had changed. Resident #1 usually ate 78 - 100% of his meals and rarely 50%. On [DATE], Resident #1 ate 50% of his breakfast (normal was 80 - 100%) and nothing was marked for his supper. On [DATE], the resident did not eat any lunch or supper. On [DATE] and [DATE], the Diet Sheet reflected Resident #1 did not eat anything. 4) Resident #1's medication form dated [DATE] reflected Tylenol was not administered for the resident's fever from [DATE] to [DATE]. Review of the [DATE] MAR indicated [REDACTED]. On [DATE] vital sign readings taken revealed the residents pulse was high with a reading of 121 beats per minute. Previous readings prior to that date reflected the resident's pulse readings were ranging between ,[DATE] beats per minute. 5) Review of the Patient Transfer Form dated [DATE] revealed the [DIAGNOSES REDACTED]. Documentation on the transfer form revealed Residents #1's symptoms first started "with n/v (nausea and vomiting), diarrhea. > (greater than) ,[DATE] days - Now still has low grade (temperature) but > 99.9. Now 100.5 AX (axillary), B/P (blood pressure) has been low, unable to dialyse on [DATE]. Has a pustule rash over trunk of body and upper thighs, not noted [DATE]. There this AM. Also lethargic." The transfer form reflected the nurse spoke with Resident #1's primary care provider, who wanted him sent to hospital with a medical history of [REDACTED]. Although the Patient Transfer Form record reflected Resident #1 had nausea and vomiting, review of the resident's entire clinical record revealed no documentation of those symptoms. Review of Resident #1's hospital's History and Physical (H&P) dated [DATE] revealed the resident's reason for being admitted was due to "Fever and Altered Mental Status." The H&P reflected Resident #1 was transferred from the nursing home with a fever over the last ,[DATE] days. "Apparently the patient was increasingly confused and also having fever, so the patient was sent to the hospital for consult [MEDICAL CONDITION]. The patient was admitted on the floor and eventually his blood pressure dropped and also developed altered mental status with hypoxemia (low oxygen levels), so patient was transferred to the ICU (Intensive Care Unit) and intubated (tube inserted into his trachea to facilitate breathing). The patient is on vent support with a temperature of 101 degrees F." Review of the physician's assessment of Resident #1 revealed he was having coarse breath sounds in both lungs and had discoloration of both legs. The physician's "Assessment and Plan" reflected Resident #1 had "Acute [MEDICAL CONDITION], most likely secondary [MEDICAL CONDITION] with pneumonia." The second entry in the plan revealed Resident #1 had "[MEDICAL CONDITION]." Review of Resident #1's hospital Microbiology Reports revealed the following: The report for the culture of blood collected on [DATE] reflected growth [MEDICAL CONDITIONS]. The report for the culture of sputum collected on [DATE] reflected growth [MEDICAL CONDITION]. The report for the culture of his urine collected on [DATE] reflected growth of Proteus mirabillis. The report for the culture of Resident #1's Perma Cath Tip ([MEDICAL TREATMENT] catheter site) collected on [DATE] reflected probable Staphylococcus aureus. Resident #1's Nurses Narrative from the hospital dated [DATE] reflected the resident stopped breathing at 5:20 AM and a code was called with ACLS (Advanced Cardiac Life Support) protocol followed. Resident #1 was intubated and placed on mechanical ventilation. Resident #1's hospital Progress Notes dated [DATE] reflected the resident went into Acute [MEDICAL CONDITION] and received CPR (Cardiopulmonary Resuscitation). 6) A) On [DATE] at 11:30 AM, PA F was interviewed. The surveyor asked if he had received a call from the facility on [DATE] in regard to Resident #1's high fever and lethargy. PA F stated he spoke to LVN A later on [DATE] about Resident #1 and ordered lab work for the resident to make sure there was no infection. The PA stated the nurses were supposed to do a STAT (immediately) order on the lab work, so he could solve the problem. (The Physician's Telephone Orders dated [DATE] did not reflect any STAT orders.) PA F stated he never got a call about Resident #1's lab work results so he would know how to treat the resident. He stated, "They could call or text. I have told them that and I would get back to them as soon as I could." PA F said he was told by the nurse Resident #1's fever was over 100 degrees F and would come down with Tylenol. "So, I did a stat order for UA (Urine Analysis), CBC (Complete Blood Count) and a chest x-ray. If he was that ill with fever and was lethargic, I would have sent him out without question." PA F stated that the nurse did not tell him anything other than the resident's temperature was over 100 degrees F. PA F stated the staff never told him how high the temperature was or the resident had an altered mental state. PA F stated there was no reason for the staff not to leave him a message or a text to let him know how ill Resident #1 was at the time of the call. B) On [DATE] at 11:55 AM, the DON was interviewed regarding the health status of Resident #1. The DON stated she was aware the resident was running a temperature. She stated she went in to see the resident on [DATE] and he spoke to her, and his appetite was not that great. The DON said his temperature was up all day. The DON stated the nurses did not call her about the resident. "They were doing their own thing." The DON stated the Tylenol was working. She said on Wednesday ([DATE]) the resident developed pustules on his body. The DON stated she called the doctor and told him what was going on, and they decided to send him out to the hospital. She stated the resident was not under any stress when he left the facility. The DON stated there were Standing Orders for residents who run fevers, and were lethargic, and the nurses usually call her when there was a problem (but they did not on this occasion). The DON stated she did not see him until Sunday [DATE]. She added he was scheduled to go out for [MEDICAL TREATMENT] on Monday [DATE] but he was still ill so she called Physician B and documented it in the Skilled Daily Nurses on [DATE]. The DON stated she had read the Nurses Notes over and over and that she thought they (nurses) did what they were supposed to do. We have standing orders from the physicians. Review of Physician B's entire standing orders dated effective [DATE] revealed there were no standing orders for a resident with an elevated temperature. Review of Resident #1's Consolidated Physician order [REDACTED]. Additional review revealed Resident #1 was not on a routine antipyretic (fever reducing medication such as Tylenol). C) RA (Restorative Aide) E was interviewed on [DATE] at 11:10 AM in regard to Resident #1. RA E stated he provided care for Resident #1 all the time. RA E said this past Sunday on [DATE] he and CNA L were talking about how ill Resident #1 had been. RA E stated CNA L had told him (RA E) he (CNA L) was concerned about Resident #1 because the resident was running a fever and was not himself. RA E stated, "He looked ill." RA E stated Resident #1's illness "started back on Friday ([DATE]). He was ill that day. He was sent out to [MEDICAL TREATMENT]." RA E added, "He (Resident #1) was so weak that he couldn't sit up straight in his chair. The resident was sweaty and clammy that day. Can't believe they sent him out to [MEDICAL TREATMENT]." RA E said he went to the Charge Nurse at the time to tell her about Resident #1's condition. RA E stated, "I will go to the DON or talk to the nurse if there is a concern (with a resident)." RA E stated, "Both (charge) nurses (LVN A and LVN C) ...knew how ill he was and should not have sent him out (to [MEDICAL TREATMENT])." D) CNA L was interviewed on [DATE] at 12:15 PM regarding the health status of Resident #1. CNA L stated he returned to work on Sunday ([DATE]) and observed the Charge Nurse, LVN A, take Resident #1's temperature. CNA L stated the resident was unresponsive and he reported that information to ADON N on [DATE]. He stated he asked ADON N to come look at the resident. CNA L stated ADON N took Resident #1's blood pressure with a digital cuff and it was ,[DATE]. (Record review revealed this B/P was not documented.) CNA L stated he observed the resident as he laid there all day, and the next morning, [DATE], before they sent him out. CNA L stated when he tried to get the resident up out of bed, Resident #1 was hollering. CNA L stated the resident always liked his coffee, but starting last Thursday ([DATE]), he stopped asking for coffee. CNA L stated his biggest concerns were why would the staff wait so long to send him out to the hospital; and why they attempted to send him to [MEDICAL TREATMENT] on Monday ([DATE]). He also stated that the facility staff neglected Resident #1, and they should be caring for the residents by order of importance of resident's needs. The surveyor asked CNA L if he informed the Abuse Coordinator of his concerns and he stated "No," because he was afraid he would be fired. E) LVN D was interviewed on [DATE] at 10:40 AM in regard to Resident #1. LVN D verified she worked weekdays on the day shift and was a Charge Nurse. LVN D stated Resident #1 was a diabetic and did not like to get up. On Monday ([DATE]) he had some diarrhea. She stated the CNAs reported Resident #1 was having diarrhea on [DATE]. LVN D added Resident #1 did not have any fever on the 10:00 PM - 6:00 AM shift. LVN D stated Resident #1 went to the hospital the next day ([DATE]) because of his rash. LVN D said the hospital called the facility on [DATE] requesting next of kin information for Resident #1, because they were trying to locate the family. LVN D said the hospital staff told her Resident #1 came to the hospital in respiratory distress and he was now on a ventilator. LVN D stated she had been licensed as an LVN since [DATE] (three months), and she was still learning about [MEDICAL TREATMENT] residents. Review of the Skilled Daily Nurses Note dated [DATE] at 10:00 AM and signed by LVN D revealed "Resident lying in bed. [MEDICATION NAME] given. Resident has Dirrhea (sic) No temp this am. No bleeding or s/s (signs/symptoms) of infection at shunt site. Call light within reach - will cont. to monitor." F) On [DATE] at 12:49 PM, MA H was interviewed. She stated she noticed Resident #1 had a fever and low blood pressure on [DATE]. MA H stated she reported Resident #1's vital signs to LVN C, the Charge Nurse. MA H stated, "All they did was give him Tylenol." MA H stated she "knew the resident's temperatures had been over 104.4 degrees F." She stated, "He was really hot and sweaty. They did not even send him to [MEDICAL TREATMENT]." She stated, "He usually talked to me, he had not been eating, and he was shaking." MA H stated if she saw a problem like that, she would document her observations on the flow sheet and would then circle it for the nurse to see. M A H stated she was worried about Resident #1. Review of Resident #1's clinical record revealed no documentation the aide reported her concerns to her LVN C. G) Interview on [DATE] at 11:40 AM with CNA J revealed she went to both of the Charge Nurses, LVN C and LVN D, about Resident #1's condition, and told them he was sleeping a lot, not eating, was confused, was not alert and oriented, and had food all over him, all down the front of him. CNA J stated when she normally provided care to Resident#1, he would visit with her and he always spoke English to her; however, on that day he was not speaking English. She stated, "He knows I do not speak ____ (another language)" and it was not normal behavior for him. CNA J stated "he just kept getting worse." H) MA K was interviewed on [DATE] at 9:50 AM in regard to Resident #1's health status. MA K stated she took all the residents' temperatures and vital signs and documented them on notebook paper and handed it to the charge nurse, who put the information in the chart. MA K stated when Resident #1 was eating; he loved coffee and did not like to be bothered. She said on [DATE] he showed signs of confusion, he had an empty cup in his hand and he thought there was coffee in the cup. MA K stated she talked to the nurse about Resident #1's confusion. I) An interview was conducted on [DATE] at 10:05 AM with LVN C in regard to Resident #1. LVN C stated she was a PRN nurse and had not been familiar with Resident #1's normal behavior. She stated she took care of him the day before he was sent out ([DATE]). She stated she observed him lying in bed, never saw him up or with his eyes open. LVN C stated she thought he was non-verbal. "I would not have known that was not normal behavior for him." LVN C stated direct care staff came to her with concerns Resident #1 was not like himself. She stated she went to assess him, but did not have a baseline to go by for her evaluation of the resident. LVN C stated she expressed her concerns to ADON N and ADON N told her she (ADON N) was taking care of it and to go back to her Hall. Review of Resident #1's Skilled Daily Nurses Note dated [DATE] revealed LVN C recorded one set of vital signs for Resident #1 on [DATE] (T-96.8, P-90, R- 20 and B/P-,[DATE]) and a note orders were received from Physician B. J) An interview was conducted on [DATE] at 10:30 AM with ADON N in regard to Resident #1. ADON N stated on Monday ([DATE]), the facility van driver and CNA G called her about Resident #1's health status prior to putting him on the van to [MEDICAL TREATMENT]. At that time, ADON N said CNA G told her he thought Resident #1 did not feel good and had not eaten. ADON N stated she went to assess the resident on [DATE] at 3:38 PM prior to sending him to [MEDICAL TREATMENT]. ADON N stated when she called Resident #1 by his name he could barely raise his head. ADON N stated, "He wasn't himself." ADON N stated she called Physician B. Resident #1's Skilled Daily Nurses Note revealed ADON N documented a call to Physician B on [DATE] after 3:38 PM. During the same interview, ADON N stated the call went to voice mail. ADON N stated she sent a text to Physician B with Resident #1's vital signs, which were B/P ,[DATE], T- 96.8. P-90, and Oxygen Saturation 98%. ADON N said she called PA F and left a message for PA F to return the call. ADON N said the DON told her Resident #1 could not go to [MEDICAL TREATMENT]. ADON N stated she advised the Administrator on [DATE] of the situation with Resident #1 and informed her she could not get hold of Physician B. ADON N stated Physician B did not text back until 5:30 PM or 6:00 PM. Observation of ADON N's telephone revealed a text message was sent at 3:36 PM on [DATE]. The message reflected Resident #1 was weak and his stools smelled like[DIAGNOSES REDACTED]icile (an infection). However, no other symptoms were added to the text message regarding his blood pressure and temperature. At that time, ADON N stated the return text from Physician B told her to hold Resident #1's blood pressure medications (due to his low blood pressure of ,[DATE]) and to call the Nephrologist. Review of Resident #1's entire clinical record revealed no documentation ADON N or any nurse called the Nephrologist. The Skilled Daily Nurses Note dated [DATE] reflected LVN C notified the [MEDICAL TREATMENT] center Resident #1 would not be there that day ([DATE]). During the same interview, ADON N stated she then turned over Resident #1's care back to LVN C, the charge nurse. ADON N stated if she had been working the floor (as the charge nurse), "I would have called the DON and Corporate Nurse. The DON can send him out (to the hospital)." Resident #1's clinical record had no documentation ADON N instructed LVN C to notify the DON and Corporate Nurse and or what to do if Physician B did not return the call. K) An interview was conducted on [DATE] at 5:20 PM with the DON in regard to Resident #1's fevers, which had ranged from 102.7 to 104.4 degrees F over a four-day period. The DON was asked at what point she would expect her nursing staff to send the resident to the hospital with fevers that high. The DON stated, "That is a good question, but we were in communication with the doctor all along." L) An interview was conducted on [DATE] at 9:20 AM with Physician B, who was one of the facility's Medical Directors. Physician B stated if a resident had temperatures over 102 degrees F, an altered state of mind, and was short of breath or lethargic, then the resident should be sent to the hospital. Physician B was asked if he was specifically informed by facility staff on [DATE] about Resident #1's high fever, lethargy, and dropping blood pressure. Physician B stated he did not know his patient was that bad. Physician B stated if he had received a call from the facility on the fifteenth, they (facility staff) did not leave a message for him. He stated he had a call from the DON sometime after [DATE], regarding her inability to reach Resident #1's family and she informed him at that time Resident #1 did not go to [MEDICAL TREATMENT] on [DATE]. Physician B stated Resident #1 not going to [MEDICAL TREATMENT] was not good for the resident, because he had the potential for fluid overload due to his kidney failure and a history [MEDICAL CONDITION]. Physician B stated the last time he saw Resident #1 was on [DATE]. The physician stated if the resident's temperature was 103 degrees F, he should have been sent out to the hospital, especially since he was a [MEDICAL TREATMENT] patient. Physician B added fevers like that were not that simple, "The body is telling us something." Physician B stated there "...has to be some education with the nurses. As for the severity of a fever of 103 degrees, there is urgency with that kind of fever." Physician B repeated, "There needs to be more nursing education. Have to do some more education to nurses not to mess around with a fever of 103 degrees." M) On [DATE] at approximately 4:00 PM, the facility's other Medical Director, Physician M, was interviewed in regard to Resident #1. He stated he reviewed Resident #1's change of condition, and the resident should have been sent to the hospital when his fever was over 103 degrees F, and he had an altered mental status. Physician M stated the failure of the nurses was a communication and education problem. 7) Record review of the facility's current policy and procedures entitled Abuse Policy with a revised date of [DATE] provided by the Administrator reflected the following: INTENT: This protocol was intended to assist in the prevention of abuse, neglect and misappropriation of property. Each resident has the right to be free from abuse, mistreatment, neglect, corporal punishment, involuntary seclusion and financial abuse. POLICY: 1. The facility will prohibit neglect, mental or physical abuse, including involuntary seclusion and the misappropriation of property or finances of residents. 2. The facility will conduct an investigation of alleged or suspected abuse, neglect, or misappropriation of property, and will provide notification of information to the proper authorities according to state and federal regulations. 3. The facility will desig

Based on observation, interview and record review, it was determined the facility failed to provide the necessary care and services to ensure three (Residents #1, #2, and #5) of seven residents sampled for pain management were assessed for pain, had physician ordered medications for pain management and/or received appropriate pain control. 1) Resident #1 was admitted on [DATE] with pain rated as a nine on a scale of one to ten (9/10). The resident had a physician's orders [REDACTED]. The MAR was marked as PRN for the [MEDICATION NAME] and none had been given to the resident. 2) Resident #2 was admitted on [DATE] with a [DIAGNOSES REDACTED]. He experienced pain at a 9/10 and 10/10 and had difficulty sleeping due to the pain. The resident was assessed and medicated for pain as ordered twice during his three day stay, prior to surveyor inquiry. Pain assessments were not consistently performed and pain medication was not administered as ordered for this resident. 3) Resident #5 was admitted on [DATE] with [DIAGNOSES REDACTED]. Sixteen hours transpired between pain assessment for this resident on 12/08/10, 12/11/10 and 12/12/10. Pain assessments were not consistently performed for Resident #5. No pain medication was documented on his PAINAD (facility Pain Monitoring and Flowsheet). This failure could affect the facility's 56 residents, including residents (Residents #1, #2, and #5) who were on a pain management regimen, by placing them at risk for unrelieved pain leading to a decreased quality of life. The facility census was 80. Findings included: 1) Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #1's Admission Resident Summary, dated 12/15/10, reflected a [DIAGNOSES REDACTED]. She had severe pain in her left hip that was relieved by medication and massage with medicated cream. The resident was admitted to the facility to receive physical, occupational and speech therapies. A Wong-Baker pain chart was used to assess the resident's level of pain. Resident #1 rated her pain as 9/10 (10 = severe). The resident was admitted with an order from the hospital for [MEDICATION NAME] 5/500 mg on to two tablets every four hours prn. An admission Skilled Daily Nurses Note, dated 12/15/10, reflected an entry by the 2:00 p.m. to 10:00 p.m. shift nurse: Resident #1 was admitted with pain (9/10 severe) in the left hip. Resident #1 told the admitting nurse she also used a medicated cream on her hip and took pain medication at home. During observation rounds on 12/17/10 at 8:10 a.m. Resident #1 was identified by staff as alert and oriented to person, place and time. The resident was frowning and rubbing her hip as she lay in bed while being interviewed by the surveyor. An interview with Resident #1 on 12/17/10 at 8:10 a.m. revealed, "I have been here a few days, and I don't have any pain medication. They said they can't get the pain meds. I am in pain." The resident revealed her hip was hurting due to a damaged sciatic nerve, and she had been given a Tylenol earlier. The medication had not relieved nor dulled her pain. She had been taking [MEDICATION NAME] for pain at home. Following surveyor inquiry, the resident was administered Tylenol 325 mg, one tablet on 12/17/10 for pain rated at 8/10 using the Wong-Baker pain scale. When the resident rated her pain as 9/10, the physician-ordered [MEDICATION NAME] was not available. An interview with the ADM on 12/17/10 at 8:20 a.m. revealed, "__ (Resident #1) came in on the 15th at night, with a [MEDICAL CONDITION], Hypertension, [MEDICAL CONDITION] and Bilateral [MEDICAL CONDITION]. [MEDICATION NAME] prn was ordered for pain." An interview with the DON on 12/17/10 at 8:45 a.m. revealed, "____ (Resident #1) has a prn order for [MEDICATION NAME]. The MAR indicated no [MEDICATION NAME] was administered to the resident." At 9:20 a.m. on 12/17/10 the DON and LVN A were unable to locate any physician-ordered [MEDICATION NAME] medication for Resident #1 in medication storage or on the medication carts. LVN A stated, "We (staff) faxed the order to the pharmacy and are waiting on the doctor to send the order. I have been giving ___ (Resident #1) Tylenol." The DON stated, "I faxed the order when she was admitted on [DATE]. There is no excuse." The DON then said to LVN A to "get it out of the Emergency Box now." An interview with the DON at 10:00 a.m. on 12/17/10 revealed, "Pain meds (for Resident #1) will be here in an hour. Don't know if a pain assessment was done." Review of standing orders for all residents treated by Physicians B and C, including Resident #1, reflected Tylenol 325 mg tablet, 1 or 2 q 4 h prn for fever and/or pain. Resident #1's December 2010 PAINAD (pain assessment and treatment tool) reflected no pain medication was documented on the form. No pain assessment was documented by the 6:00 a.m. to 2:00 p.m. or 2:00 p.m. to 10:00 p.m. shifts on 12/17/10. The PAINAD reflected those pain assessments that were performed were rated as 0/10. The December 2010 MAR and Nurses Notes for Resident #1 reflected she was administered Tylenol 325 mg, one tablet on 12/17/10 for pain rated at 8/10 by LVN A on the 6:00 a.m. to 2:00 p.m. shift. This documentation confirmed Tylenol was administered on 12/17/10 at 7:00 a.m. Resident #1's MAR reflected she was administered [MEDICATION NAME] 5/500 mg by LVN A on 12/17/10 on the 6:00 a.m. to 2:00 p.m. shift . The number of tablets administered and pain severity were not documented. Review of Resident #1's Controlled Drug Record reflected a sheet showing 60 tablets of [MEDICATION NAME]-APAP, 5/500 mg tablets, which were ordered on [DATE]. LVN A's signature was lined out on the record with no date, dosage or other pertinent information documented. The count of 60 tablets was lined through and was currently 58 tablets. No supporting information was found for the change. An undated and unsigned Pain Evaluation form reflected Resident #1 reported sharp pain (8/10 severe) in her left buttock due to sciatic nerve damage and it was constant with or without activity. A pain medication prn list, generated and submitted by the DON on 12/17/10, reflected Resident #1's attending physician ordered [MEDICATION NAME] 5/500 mg tablet, 1-2 q 4 h prn for pain on 12/15/10. This information was confirmed on the December 2010 Nurses MAR. Review of Resident #1's monthly Pain Monitoring and Flow Sheet for December 2010 reflected pain monitoring was conducted on the following days and times: a) 12/15/10, 2:00 p.m. to 10:00 p.m., 10:00 p.m. to 6:00 a.m. b) 12/16/10, 2:00 p.m. to 10:00 p.m., 10:00 p.m. to 6:00 a.m. and c) 12/17/10, 6:00 a.m. to 2:00 p.m., 10:00 p.m. to 6:00 a.m. However, pain severity ratings were not reflected on all the checks. Review of Resident #1's monthly prn MAR dated December 2010 revealed [MEDICATION NAME] 5/500 mg was administered by LVN A on 12/17/10 during the 6:00 a.m. to 2:00 p.m. shift. No level of pain severity, effectiveness of the medication or number of tablets administered was documented. 2) Resident #2's face sheet dated 12/16/10 reflected the resident was admitted on [DATE] with a [DIAGNOSES REDACTED]. During observation rounds on 12/17/10 at 1:53 p.m., Resident #2 was alert and oriented. He stated he received pain medication when he requested it, but it usually took "a while. I had half of my colon removed and came here for rehab." He stated his pain medication from this morning "was starting to wear off." Review of Resident #2's December 2010 PAINAD revealed he had a physician's orders [REDACTED].o. q 4 h prn for pain (start date: 12/15/10). The resident rated his abdominal pain at 9/10 on 12/16/10 and 10/10 on 12/17/10. These assessments were documented by the 6:00 a.m. to 2:00 p.m. shift nurse. The PAINAD further reflected Resident #2 was administered the physician-ordered [MEDICATION NAME]: on 12/16/10 at 11:00 p.m. for pain (9/10) which was effective (4/10); on 12/17/10 at 7:00 a.m. for pain (10/10) which was effective (2/10); and 12/17/10 at 10:30 (no a.m. or p.m. on form) for pain (9/10) and there was no reassessment for effectiveness. Continued review of the PAINAD revealed no pain evaluations were performed by the 2:00 p.m. to 10:00 p.m. and 10:00 p.m. to 6:00 a.m. shift nurses on 12/16/10 or 12/17/10. Resident #2 reported difficulty sleeping at night due to pain. Review of Resident #2's notes on the December 2010 MAR revealed LVN A did not document which pain scale tool was used to assess the resident's pain. Physician-ordered [MEDICATION NAME] 7.5/325 mg, 2 tablets was administered on: 12/16/10 at 11:00 p.m. for pain 9/10; 12/17/10 at 7:00 a.m. for pain 10/10 and 12/17/10 at 10:30 p.m. for pain 9/10. The December 2010 Nurses MAR reflected Resident #2's pain was assessed at a 9/10 on 12/16/10 and at a 10/10 on 12/17/10. There were no other documented pain assessments prior to surveyor inquiry for December 2010. Resident #2's Physicians orders, dated 12/15/10, reflected [MEDICATION NAME] 7.5/325 mg tab, 2 q 4 h prn. 3) Resident #5's face sheet dated 12/08/10 reflected he was admitted on [DATE] with [DIAGNOSES REDACTED]. His December 2010 PAINAD reflected there was no pain assessment by the 10:00 p.m. to 6:00 a.m. shift nurse from 12/07/10 to 12/10/10 and on 12/15/10; no pain assessment by the 2:00 p.m. to 10:00 p.m. shift nurse on 12/08/10, 12/11/10, 12/12/10, 12/17/10 and by the 6:00 a.m. to 2:00 p.m. shift nurse on 12/11/10 and 12/12/10. Sixteen hours transpired between pain assessments on 12/08/10, 12/11/10 and 12/12/10. Review of Resident #5's December 2010 Physicians Orders reflected [MEDICATION NAME], 10/325 mg one tablet was ordered by mouth every four hours for pain as needed. The Controlled Drug Record and the December 2010 MAR reflected no [MEDICATION NAME] had been administered to Resident #5. An interview with Resident #5 on 12/17/10 at 12:30 p.m. revealed he had not received any pain medication for his leg. Resident #5 further stated facility staff had never asked him if he had pain. Resident #5 stated his leg pain was "tolerable if I stay still and don't try to do too much. I haven't been going to therapy." 4) An interview with ADM on 12/20/10 at 8:45 a.m. revealed facility staff reviewed all residents' clinical records for pain management this weekend and corrected any records that were incomplete. The facility Pain Monitoring and Flowsheet (PAINAD) was identified by the DON as the current pain assessment and treatment tool used by facility nursing staff. PAINAD reflected instruction to monitor pain level q shift and included signs and symptoms of pain. Each pain rating was entered in the appropriate daily slot. Pain medication orders with physician order [REDACTED]. Review of an undated facility Pain Management Program, submitted on 12/20/10 and identified by the ADM as current, reflected: "Definition...Pain is whatever the experiencing person says it, whenever the experiencing person say it does." (McCaffery & Beebe, 1989) ... Standard: 3. Qualified staff will utilize a Pain Assessment tool to evaluate patients/residents experiencing either acute or chronic pain and develop a plan of care customized to the needs of each individual ... 4. Qualified staff will recognize that pain is a co-existing condition with a number of diseases, e.g. a patient/resident [MEDICAL CONDITION] ... 5. Qualified staff will recognize that unrelieved pain has an enormous physiological and psychological effect on patients/residents, therefore, will effectively manage pain as an integral component of their care. A Physician order [REDACTED]. Each resident's name, medication order and date of the physician's orders [REDACTED]. The facility's CMS-672 dated 12/17/10 and signed by the DON reflected only eight residents were on a pain management program.