Every finding on record at Fair City Health and Rehab

Based on record review and interview, the facility's binding arbitration agreement failed to explicitly grant the resident or his/her representative the right to rescind the agreement within 30 calendar days of signing it for 3 of 3 (#9, #31, and #102) Residents sampled for signing the facility's binding arbitration on admission. This deficient practice had to the potential to affect the 98 residents residing in the facility. Review of Resident #9's admission records revealed she was admitted to the facility on [DATE] and included a signed binding arbitration agreement which revealed it did not explicitly grant the resident or his/her representative the right to rescind the agreement within 30 calendar days of signing it as required. Review of Resident #31's admission records revealed he was admitted to the facility on [DATE] and included a signed binding arbitration agreement which revealed it did not explicitly grant the resident or his/her representative the right to rescind the agreement within 30 calendar days of signing it as required. Review of Resident #102's admission records revealed she was admitted to the facility on [DATE] and included a signed binding arbitration agreement which revealed it did not explicitly grant the resident or his/her representative the right to rescind the agreement within 30 calendar days of signing it as required. On 03/18/2026 at 7:50 a.m., an interview was conducted with S6AD. She stated she was responsible for the facility's admissions. She stated the facility had a binding arbitration agreement contained in its admissions documents. She reviewed Resident's #9, #31, and #102 admission documents and confirmed the binding arbitration agreements did not explicitly grant the resident or his/her representative the right to rescind the agreement within 30 calendar days of signing it as required.

Based on record review and interviews, on readmission, the facility failed to accurately document a cardiopulmonary resuscitation code status in the resident's clinical record for 1 (#9) out of 3 residents reviewed for readmission clinical records.Review of Resident #9's clinical record revealed she was originally admitted on [DATE] and then readmitted to the facility on [DATE]. Review of Resident #9's admission MDS with the ARD of [DATE] revealed she had a BIMs score of 14, which indicated she was cognitively intact. Review of Resident #9's physical hard chart revealed a document titled Resident/Family Consent for Cardiopulmonary Resuscitation signed and dated [DATE] by Resident #9's representative, S6AD, and physician. Further review revealed Resident #9's representative initials next to the following statement:I understand that CPR constitutes an extraordinary measure and should not be done on this resident. However I wish that other interventions be performed unless specifically noted in advance directives this not be done. Review of Resident #9's local rehabilitation hospital Discharge Instructions revealed she was discharged on [DATE] with a physician order for a full code status.Review of Resident #9's current Physician Orders on [DATE] revealed she was readmitted with an order for a full code status. An interview was conducted on [DATE] at 2:29 p.m. with S12LPN. S12LPN reviewed Resident #9's physical hard chart and confirmed the aforementioned Resident/Family Consent for Cardiopulmonary Resuscitation dated [DATE] indicated Resident #9 was a DNR. S12LPN further reviewed Resident #9's current physician orders and confirmed an order for full code. S12LPN confirmed the physician order did not accurately reflect Resident #9's DNR consent and should have. An interview was conducted on [DATE] at 2:32 p.m. with S5QA. S5QA reviewed Resident #9's physical hard chart and confirmed the aforementioned Resident/Family Consent for Cardiopulmonary Resuscitation dated [DATE] indicated Resident #9 was a DNR. S5QA further reviewed Resident #9's current physician orders and confirmed an order for full code. S5QA confirmed the physician order did not accurately reflect Resident #9's DNR consent and should have. An interview was conducted on [DATE] at 2:40 p.m. with Resident #9. She stated she had not wanted to change her code status from a DNR to full code after returning from rehab. She stated her wishes are currently to be a DNR. An interview was conducted on [DATE] at 3:00 p.m. with S2DON. S2DON reviewed Resident #9's physical hard chart and confirmed the aforementioned Resident/Family Consent for Cardiopulmonary Resuscitation dated [DATE] indicated Resident #9 was a DNR. S2DON further reviewed Resident #9's current physician orders and confirmed an order for full code. S2DON confirmed the physician order did not accurately reflect Resident #9's DNR consent and should have. S2DON confirmed on readmission, the nurse was expected to identify the code status discrepancy and immediately clarify and document Resident #9's accurate code status and did not.

Based on interviews and record review, the facility failed to ensure staff accurately implemented the comprehensive care plan requiring a 2-person total body mechanical lift transfer for 1 (#85) of 21 residents reviewed for care plans.Review of Resident #85's medical record revealed he was admitted to the facility on [DATE] with diagnoses which included Lack of Coordination, Dementia, Parkinsons, Repeated Falls, Transient Cerebral Ischemic Attack, Abnormalities of Gait and Mobility, Forms of Tremor, and Muscle Weakness. Review of Resident #85's MDS with an ARD of 12/22/2026 revealed a BIMS of 15, which indicated the resident was cognitively intact. Review of Resident #85's medical record revealed Transfer/Mobility Criteria assessment dated [DATE] revealed he was totally dependent on staff for activities of daily living support and the total mechanical lift with full body sling to be used. Review of Resident #85's current Plan of Care revealed he was at risk for falls with an ADL intervention that included total body mechanical lift with 2 staff members for transfers. An interview was conducted on 03/16/2026 at 11:20 a.m. with Resident #85. He stated S8CNA worked the night shift last night and transferred him from the wheelchair to the bed with the mechanical lift. He stated during the transfer when he was in the mechanical lift, he began to have jerking movements and felt like he was going to fall. He stated during the entire transfer, S8CNA was the only staff in the room. An interview was conducted on 03/18/2026 at 2:11 p.m. with S8CNA. S8CNA stated she worked on 03/15/2026 during the night shift. She stated on 03/15/2026 at 6:30 p.m., Resident #85 requested to be transferred from the wheelchair to the bed, and she requested assistance from another CNA. She stated while waiting for the CNA to assist with the transfer, Resident #85 started showing signs of anxiousness and began to rock back and forth and tried to sling or slide himself out of the wheelchair. She stated Resident #85 was at risk for falling on the floor, so she transferred him with the total body mechanical lift without a second staff person. S8CNA confirmed when the total body mechanical lift was used to transfer Resident #85, she should have had another staff present to assist with the transfer. An interview was conducted on 03/18/2026 at 3:20 p.m. with S2DON. S2DON was made aware of the above mentioned circumstance with Resident #85. She stated a total body mechanical lift transfer with 1 staff member was not safe for Resident #85. S2DON confirmed for all residents, the total body mechanical lift transfers should always be completed with 2 staff members for any circumstance.

Based on observations, interviews, and record review the facility failed to store and prepare food in accordance with professional standards for food service safety. The facility failed to ensure: 1. Food was properly labeled in the refrigerators of the facility's kitchen; 2. Food products had not exceeded their expiration date; 3. Safe practices for thawing pork chops; and 4. Liquid pasteurized egg were maintained at a holding temperature of 41 degrees F or below. This deficient practice had the potential to affect 87 residents who were served food and beverages from the kitchen. Findings: Review of the facility's policy last revised [DATE] and titled, Food Receiving and Storage revealed the following, in part: Policy Statement: Foods shall be stored in a manner that complies with safe and handling practices. Refrigerated/Frozen Storage 1. All foods stored in the refrigerator . are . labeled and dated. 2. Potentially Hazard Food and Time/Temperature Control for Safety foods are stored at or below 41degrees Fahrenheit. On [DATE] at 8:45 a.m., an initial tour was made of the kitchen with S5CK. The observations were made of the following items: Refrigerator A: 4 red juices in 8oz plastic cups covered with no label or date. Refrigerator B: 6 sandwiches wrapped in clear wrapping with no label or date; and 7 salads in covered plastic bowls with no label or date. Dry Storage: 1 large can of pumpkin with a use by date of [DATE]. 1 large can of black beans with a use by date of [DATE]. 4 large cans of corned beef hash with a use by date of [DATE]. Kitchen: 1 pack of 15 pork chops sitting in water in the sink with no running water. 6 32 ounce cartons of pasteurized liquid egg sitting on the counter. On [DATE] at 8:55 a.m., an interview was conducted with S5CK. She confirmed the above refrigerated items were not labeled or dated and should have been. She confirmed the above canned items were expired and should have been discarded. S5CK confirmed there was no running cold water on the pork chops. She confirmed the cartons of liquids eggs were on the counter. On [DATE] at 10:28 a.m., an interview and tour of the kitchen was conducted with S4DM. S4DM observed and confirmed the above food items in Refrigerator A and Refrigerator B were not labeled or dated and should have been. S4DM observed and confirmed the above named canned goods were expired and should have been discarded. S4DM observed 15 thawed pork chops in the kitchen sink sitting in water. S4DM confirmed the pork chops should have cold running water over them and they should have been discarded. S4DM further observed 6 32 ounce cartons of pasteurized eggs sitting out at room temperature on the counter. The temperature was taken of the liquid eggs and registered at 62.5 degrees Fahrenheit. S4DM confirmed eggs should be stored to keep a temperature of 41degrees or lower. On [DATE] at 2:20 p.m. an interview was conducted with S1ADM. He was made aware of the above findings in the kitchen. He confirmed these findings were unacceptable and staff should have used safe food handling practices.

Based on record reviews and interviews, the facility failed to ensure residents' Medication Administration Records (MAR) were accurately documented for 2 (#63 and #66) of 37 ( #2, #4, #7, #10, #11, #13, #18, #19, #20, #22, #25, #27, #29, #37, #38, #44, #46, #48, #49, #58, #61, #63, #66, #71, #73, #76, #83, #85, #88, #91, #92, #93, #244, #245, #344, #345 and #346) residents reviewed for pharmaceutical services. This deficient practice had the potential to affect any of the 89 residents residing in the facility. Findings: Review of the facility's policy Documentation of Medication Administration, with a revision date of November 2022 revealed in part: Policy Statement: A medication administration record is used to document all medications administered. Policy Interpretation and Implementation: 2. Administration of medication is documented immediately after it is given. 3. Documentation of medication administration includes, as a minimum: f. reason(s) why a medication was withheld, not administered, or refused (as applicable); g. initials, signature, and title of the person administering the medication; Resident #63 Review of Resident #63's Clinical Record revealed an admitted [DATE], with diagnoses which included End Stage Renal Disease, Schizoaffective Disorder, Bipolar Type, Hypertension, Diabetes Mellitus-Type 2, Major Depressive Disorder, Heart Failure, Lack of Coordination, History of Falling, Repeated Falls, Unspecified Mood (affective) Disorder, and Dysphagia. Review of Resident #63's January 2025-March 2025 Physician Orders revealed in part, the following: Procardia XL oral tablet extended release 24 hour 30mg, give one tablet by mouth in the morning for Hypertension check Blood pressure prior. Start date 12/22/2024 at 6:00 a.m. [NAME]-Vite oral tablet give tablet by mouth one time a day for mild malnutrition, weight loss related to weakness for appetite. Start date 02/02/2025 discontinue date 03/24/2025. Sevelamer HCL oral tablet 800mg, give one tablet by mouth three times a day related to end stage renal disease. Start date 03/03/2025 at 2:00 p.m. 1 liter fluid restriction 240ml with each meal, 140ml with am and pm med-pass every shift. Start date 03/11/2025 at 7:00 p.m. Assess resident for pain every shift: Non-pharmacological interventions. Start Date 01/06/2023 at 7:00 p.m. Check AV shunt each shift assess for bruit and thrill every shift for monitoring. Start date 02/06/2025 at 7:00 p.m. Review of Resident #63's January 2025-March 2025 MAR revealed in part, the following: Monitor for behaviors twice daily. No documentation noted on 03/20/2025 at 7:00 a.m. Monitoring Anticoagulants-check for bleeding and bruising every shift. No documentation of monitoring noted on 03/20/2025 a.m. shift. Hourly checks related to fall prevention every hour. No documentation of hourly checks noted on 03/20/2025 at 9:00 a.m., 10:00 a.m., 11:00 a.m., 12:00 p.m., 1:00 p.m., 2:00 p.m., 3:00 p.m., 4:00 p.m., 5:00 p.m., and 6:00 p.m. Monitoring side effects: 1) Tardive dyskinesia, 2) Hypotension, 3) Sedation/drowsiness, 4) increased fall/dizziness 5) Appetite changes/weight change, 6) Headache, 7) Insomnia, 8) Weakness, 9) Visual Disturbances, 10) Gastrointestinal disturbances, 11) Other: see progress notes every shift for monitoring put in corresponding code, Start Date 01/06/2023. No documentation on 03/20/2025 a.m. shift. Type of intervention attempted every shift put in corresponding code from above, Start Date 01/06/2023. No documentation of administration on 03/20/2025 at 7:00 a.m. shift. Procardia XL oral tablet extended release 24 hour 30mg, give one tablet by mouth in the morning for Hypertension check Blood pressure prior-Start date 12/22/2024 at 6:00 a.m. No documentation of administration noted on 02/20/2025 and 03/20/2025. [NAME]-Vite oral tablet give tablet by mouth one time a day for mild malnutrition, weight loss related to weakness for appetite. Start date 02/02/2025 D/C date 03/24/2025. No documentation of administration noted on 02/20/2025. Sevelamer HCL oral tablet 800mg, give one tablet by mouth three times a day related to end stage renal disease-start date- 03/03/2025 at 2:00 p.m. No documentation of administration noted on 03/20/2025 at 2:00 p.m. 1 liter fluid restriction 240ml with each meal, 140ml with am and pm med-pass every shift-Start date-03/11/2025 at 7:00pm. No documentation of fluid restriction noted on 03/20/2025 at 7:00 a.m. Assess resident for pain every shift: Non-pharmacological interventions. No documentation of pain assessment noted on 03/20/2025 at 7:00 a.m. Check arteriovenous fistula shunt each shift assess for bruit and thrill every shift for monitoring. Start date 02/06/2025 at 7:00pm. No documentation of assessment noted on 03/20/2025 at 7:00 a.m. Daily weights every day shift related to End Stage Renal Disease-Start date-03/13/2025 at 7:00 a.m. No documentation of weight noted on 03/20/2025. Resident #66 Review of Resident #66's Clinical Record revealed an admitted [DATE], with diagnoses which included: unspecified Dementia, Psychotic Disturbance, Mood Disturbance, Anxiety, Bipolar Disorder, Mild and Major Depressive Disorder and unspecified Psychosis. Review of Resident #66's January 2025-March 2025 Physician Orders revealed in part, the following: Seroquel Oral Tablet (Quetiapine Fumarate), Give 75mg by mouth every night. Start date 07/11/2024 at 7:00 p.m. Review of Resident #66's January 2025-March 2025 MAR revealed in part, the following: On 02/24/2025 no documentation of the above medication being administered. On 04/02/2025 3:46 p.m., a telephone interview was conducted with S14LPN. S14LPN stated she worked on 02/18/2025 and was assigned to Resident # 63. S14LPN was notified per Resident #63's MAR, the scheduled 6 a.m. dose Procardia XL 30 MG and [NAME]-Vite tablet was blank. She could not recall why the medications were not documented. S14LPN stated Resident #63 frequently refuses his medications and treatments. S14LPN stated she should have documented medications and treatments as administered, or documented why they were not administered, and she did not. On 04/02/2025 at 3:48 p.m., an interview was conducted with S11LPN. S11LPN confirmed she worked on 02/24/2025. S11LPN confirmed medications should have been documented as administered on the MAR. S11LPN stated her review of Resident #63's (date) MAR revealed the scheduled 6 a.m. administration of Seroquel 75mg was blank. S11LPN stated she had given the medication, but forgot to enter as administered. On 04/02/2025 at 4:14 p.m., an interview was conducted with S13LPN. S13LPN stated LPNs are responsible for completing documentation on resident's MARs. S13LPN stated she worked on 02/20/2025 and 03/20/2025 and was assigned to Resident # 63. S13LPN reviewed Resident #63's MARs dated 02/01/2025 and 03/01/2025 and confirmed the following medication and treatment administrations were blank. S13LPN stated Resident # 63 received Procardia XL 30mg on 02/20/2025. S13LPN stated Resident #63 received Sevelamer HCL 800mg on 03/20/2025. S13LPN stated monitoring of behaviors, 1 liter fluid restrictions 240ml with each meal, 140 ml with morning med pass, assessments of resident for pain every shift, and AV shunt assessments each shift were completed. S13LPN confirmed the above dates on Resident #63's MAR were blank. S13LPN stated she should have documented medications and treatments immediately after administration, but did not. On 04/02/2025 at 11:00 a.m., an interview was conducted with S2DON. S2DON reviewed the above mentioned MARs and confirmed the missing documentation of medications and treatments on Resident #63 and Resident #66's MARs. S2DON stated if medications/treatments are missed, refused, or resident is out of the facility it should be documented on the resident's MAR. S2DON confirmed all medications and treatments should be documented on the resident's MAR immediately after being administered, and were not.

Based on observations, interviews, and record review, the facility failed to ensure meals were served at regular times comparable to normal times in the community or in accordance with residents preferences for 2 of 2 (Hall A and Hall B) halls observed for dining. Findings: Review of the facility's policy last revised July 2017 and titled, Frequency of Meals revealed the following, in part: Policy: Each resident shall receive at least three meals daily, at times comparable to typical mealtimes in the community, or in accordance with resident needs, preferences, requests . Policy interpretation and implementation: 3. A schedule of meal times and snacks shall be posted in resident area. Review of the facility's posted meal times revealed lunch should be served at 11:00 a.m. on resident hallways. On 04/01/2025 at 10:45 a.m., an interview was conducted with S6LPN. She stated she worked Hall B. She stated meals were consistently served late. She stated the residents complained and would start to look and ask for their food. On 04/01/2025 at 10:50 a.m., an interview was conducted with S8CNA. She stated she worked Hall B. She stated meals were consistently served late and residents complained. On 04/01/2025 at 10:59 a.m., an interview was conducted with S7LPN. She stated she worked Hall A. She stated meals were consistently served late and residents complained. She stated this had been an ongoing concern since she was hired a year ago. On 04/01/2025 at 12:16 p.m., an observation was made of a Resident #11 sitting in the activity room between Hall A and Hall B asking staff for his lunch tray. Staff responded to him stating, Lunch is late, they did not forget about you, they are coming. On 04/01/2025 at 12:20 p.m., an interview was conducted with Resident #11. He stated he resided on Hall B and meals were consistently served late. He stated he was hungry. On 04/01/2025 at 12:46 p.m., an observation was made of staff serving lunch trays on Hall A. On 04/01/2025 at 12:50 p.m., an observation was made of staff serving Resident #76's lunch tray on Hall A. On 04/01/2025 at 12:51 p.m., an interview was conducted with Resident #76. She stated meals were often served late and she would prefer meals be served more consistent according to the posted meal times. She stated she was often hungry by the time the meals were served. She stated staff were aware of this issue but it had not improved. On 04/01/2025 at 12:52 p.m., an observation was made of staff serving lunch trays on Hall B. On 04/01/2025 at 1:00 p.m., an observation was made of staff serving Resident #11's lunch tray. On 04/01/2025 at 1:10 p.m., an interview was conducted with S8CNA. She confirmed residents on Hall B were being passed their lunch tray and this was late. On 04/01/2025 at 2:00 p.m., an interview was conducted with S4DM. She was made aware of the posted meal stating lunch was to be served at 11:00 a.m. to hallways and 11:30 a.m. in the dining area. She stated lunch was never served to the hallways first at 11:00 a.m. She stated lunch was served to the dining hall first and her goal was to start at 12:00 p.m. She confirmed lunch was served first at 12:11 p.m. to the dining hall today, which was late according to the posted meal times. On 04/01/2025 at 2:05 p.m., an interview was conducted with S3DDM. She was made aware lunch was served first in the dining hall at 12:11 p.m., Hall A at 12:46 p.m. and then Hall B at 12:52 p.m. She stated meals should be served according to the posted meal times, and they were not. She confirmed lunch was served late. On 04/01/2025 at 2:20 p.m., an interview was conducted with S1ADM. He stated he was aware residents were unhappy with meals served late. He stated he has had many conversations with the contracted dietary staff about the matter with no resolution. He stated the scheduled lunch time was 11:30 a.m. and he expected meals to be served at scheduled times. He was made aware lunch was first served today in the dining area at 12:11 p.m., Hall A at 12:46 p.m. and Hall B at 12:52 p.m. He confirmed lunch was not served at the posted scheduled time and should have been. He stated this was unacceptable. 49343

Based on record reviews and interviews, the facility failed to ensure pain management was provided to residents who require such services, consistent with professional standards of practice and the comprehensive person-centered care plan for 1 (#2) out of 3 (#2, #25, and #88) residents reviewed for pressure ulcers. The facility failed to 1. Administer scheduled narcotics to Resident #2; and 2. Document narcotic administration for Resident #2. Findings: A review of the facility's policy titled Administering Pain Medication, with a revision date of October 2022, revealed the following, in part: Steps in the Procedure 6. Administer pain medications as ordered Documentation Document the following in the resident's medical record: 2. Medication Review of Resident #2's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included Pressure Ulcer of Left Buttock and Pressure Ulcer of Sacral Region. Review of Resident #2's current Care Plan revealed the following, in part: Focus: Resident is at risk for pain. Interventions: Administer medications as ordered. Review of Resident #2's current Physician Orders revealed the following, in part: Hydrocodone-Acetaminophen Oral Tablet 10-325mg: Give 10 mg via PEG-Tube every 6 hours with a start date 01/17/2025. 1. Review of Resident #2's Medication Administration Records (MAR), dated February 2025 and March 2025, revealed the following, in part: Hydrocodone-Acetaminophen Oral Tablet 10-325mg: Give 10 mg via PEG-Tube every 6 hours. Further review revealed the medication was not documented as administered on 02/11/2025 6:00 a.m., 02/15/2025 06:00 a.m., 03/01/2025 06:00 a.m., and 03/05/2025 6:00 p.m. Review of Resident #2's Narcotics Log, dated February 2025 and March 2025, revealed Hydrocodone-Acetaminophen 10-325mg was not signed out on 02/11/2025 6:00 a.m., 02/15/2025 6:00 a.m., 03/01/2025 6:00 a.m., and 03/05/2025 6:00 p.m. On 04/02/2025 at 3:52 p.m., an interview was conducted with S12LPN. She confirmed she worked on 02/11/2025 at 6:00 a.m. and 03/05/2025 at 6:00 p.m. She was notified Hydrocodone-Acetaminophen 10-325mg was not documented on the MAR as administered nor was it signed out on Resident #2's Narcotic Log on the above mentioned dates. She confirmed if a medication was not signed out on the Narcotic Log or documented as administered on the MAR then it was not given. She confirmed she did not administer Resident #2's Hydrocodone-Acetaminophen 10-325mg per the physician order and should have. 2. Review of Resident #2's Medication Administration Records, dated February 2025 and March 2025, revealed the following, in part: Hydrocodone-Acetaminophen Oral Tablet 10-325mg: Give 10 mg via PEG-Tube every 6 hours. Further review revealed the medication was not documented as administered on 02/04/2025 6:00 a.m., 02/08/2025 6:00 a.m., 02/16/2025 6:00 a.m., 02/21/2025 6:00 a.m., and 03/18/2025 6:00 a.m. Review of Resident #2's Narcotics Log for Hydrocodone-Acetaminophen 10-325mg, dated February 2025 and March 2025, revealed the medication was signed out on 02/04/2025 6:00 a.m., 02/08/2025 6:00 a.m., 02/16/2025 6:00 a.m., 02/21/2025 6:00 a.m., and 03/18/2025 6:00 a.m. On 04/02/2025 at 3:48 p.m., an interview was conducted with S11LPN. She confirmed she worked on 02/21/2025 at 06:00 a.m. and 03/18/2025 at 06:00 p.m. She was notified Hydrocodone-Acetaminophen 10-325mg was signed out on Resident #2's Narcotic Log but was not documented on the MAR as administered on the above mentioned dates. She confirmed if she signed a medication out on the Narcotic Log, then she administered it. She confirmed she should have documented Hydrocodone-Acetaminophen 10-325mg on the MAR when she administered it and did not. On 04/02/2025 at 9:20 a.m., an interview was conducted with S2DON. She reviewed Resident #2's MAR and Narcotic Log dated February 2025 and March 2025. She confirmed on 02/11/2025 at 6:00 a.m., 02/15/2025 at 6:00 a.m., 03/01/2025 at 6:00 a.m. and 03/05/2025 at 6:00 p.m. Resident #2's Hydrocodone-Acetaminophen 10-325 mg was not administered per the Physician order and should have been. S2DON also confirmed on 02/04/2025 at 6:00 a.m., 02/08/2025 at 6:00 a.m., 02/16/2025 at 6:00 a.m., 02/21/2025 at 6:00 a.m. and 03/18/2025 at 6:00 a.m., Hydrocodone-Acetaminophen 10-325 mg was not documented as administered on the MAR and should have been.

49343 Based on interviews and record review, the facility failed to ensure resident's MDS assessments accurately reflected the resident's status for 5 (#19, #27, #46, #73, and #91) out of 19 residents reviewed in the final sample. The facility failed to ensure: 1. Resident #19 was coded accurately for urinary tract infections within the last 30 days; 2. Resident #27 and Resident #46 were accurately coded for PASRR (Pre-admission Screening and Resident Review); 3. Resident #73 was coded accurately for use of Physical Restraints; and 4. Resident #91 was coded accurately for discharge. Findings: 1. Resident #19 Review of Resident #19's Clinical Record revealed she was admitted to the facility on [DATE], with diagnoses which included Urinary Tract Infections. Review of Resident #19's Annual MDS with an ARD of 02/06/2025 revealed she was coded as no for having a urinary tract infection (UTI) within the past 30 days. Review of the Infection Log dated January 2025 revealed Resident #19 was diagnosed with a UTI on 01/24/2025. On 04/02/2025 at 9:04 a.m., an interview was conducted with S9MDS. S9MDS stated she was responsible for completing Resident #19's MDS assessment. S9MDS reviewed the Annual MDS with an ARD of 02/06/2025 and the Infection Log dated January 2025. She verified resident #19 had a urinary tract infection on 01/24/2025. S9MDS confirmed resident #19 should have been coded for having a UTI within the last 30 days and was not. On 04/02/2025 at 09:09 a.m., an interview was conducted with S2DON. S2DON reviewed resident #19's Annual MDS with an ARD of 02/06/2025. She confirmed resident #19 was not coded accurately for urinary tract infections within the last 30 days. 2. Resident #27 Review of Resident #27's Clinical Record revealed he was admitted to the facility on [DATE], with diagnoses which included Major Depressive Disorder and Unspecified Psychosis not due to a substance or known physiological condition. Review of Resident #27's 142 Form titled Louisiana Department of Health and Hospitals Medicaid Program Notice of Medical Certification dated 05/06/2024, revealed an approval for admission by the State Level II Authority for a temporary period effective 05/06/2024 through 05/05/2025. Review of Resident #27's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/30/2024 revealed Section A1500: Resident evaluated by PASRR was coded 0. No. Further review revealed section A1510: Serious Mental Illness was blank. Resident #46 Review of Resident #46's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included Major Depressive Disorder, Schizoaffective Disorder, and Panic Disorder. Review of Resident #46's 142 Form titled Louisiana Department of Health and Hospitals Medicaid Program Notice of Medical Certification dated 10/04/2024, revealed an approval for admission by the State Level II Authority for a temporary period effective 10/04/2024 through 10/03/2025. Review of Resident #46's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/07/2025 revealed Section A1500: Resident evaluated by PASRR was coded 0. No. Further review revealed section A1510: Serious Mental Illness was blank. On 04/02/2025 at 9:00 a.m., an interview was conducted with S9MDS. She verified Resident #27 and Resident #46's Form 142 indicated approval for admission by the State Level II Authority for a temporary period. She reviewed Resident #27 and Resident #46's most recent Annual MDS assessments and confirmed Section A1500 should have been coded as 1-Yes, and was not. On 04/02/2025 at 9:10 a.m., an interview was conducted with S2DON. She reviewed the aforementioned findings for Resident's #27 and #46. She confirmed the resident's most recent Annual MDS assessments should have been coded correctly and were not. 3. Resident #73 Review of Resident #73's Clinical Record revealed he was admitted to the facility on [DATE]. Review of Resident #73's Quarterly MDS with an ARD of 03/11/2025 revealed Resident #73 was coded for use of Physical Restraints as followed: Section P- Restraints and Alarms- P0100- used in chair or out of bed- G. Chair prevent rising- 1.-used less than daily. Further review revealed Resident #73 had a BIMS score of 15 which indicated he was cognitively intact. On 04/01/2025 at 10:06 a.m., an interview was conducted with Resident #73. He confirmed he had never been physically restrained. On 04/01/2025 at 1:50 p.m., an interview was conducted with S9MDS. She reviewed Resident #73's Quarterly MDS dated [DATE]. She stated Section P- Restraints and Alarms-G-Chair prevents rising was inaccurately coded as 1. Used less than daily. She confirmed it should have been coded as 0.-Not Used. On 04/02/2025 at 9:10 a.m., an interview was conducted with S2DON. She confirmed Resident #73 had never required use of physical restraints. She reviewed Resident #73's Quarterly MDS dated [DATE]. She stated Section P- Restraints and Alarms-G-Chair prevents rising was inaccurately coded as 1.-Used less than daily. She confirmed it should have been coded as 0.-Not Used. 4. Resident #91 Review of Resident #91's Clinical Record revealed he was admitted to the facility on [DATE] and was discharged on [DATE]. Review of Resident #91's Discharge MDS with an ARD of 01/20/2025 revealed Section A2105 Discharge Status: Short Term General Hospital. Review of Resident #91's Progress Notes dated 01/20/2025 revealed Resident #91 was released to local law enforcement custody. On 04/02/2025 at 11:35 a.m., an interview was conducted with S10MDS. She confirmed Resident #91 was released into local law enforcement custody. She reviewed Resident #91's Discharge MDS and confirmed Section A2105 indicated the resident was discharged to Short Term General Hospital, and should have been coded for 99. Not Listed. On 04/02/2025 at 11:55 a.m., an interview was conducted with S2DON. She confirmed Resident #91 was released into local law enforcement custody. She reviewed Resident #91's Discharge MDS and confirmed Section A2105 indicated the resident was discharged to Short Term General Hospital, and should have been coded for 99. Not Listed. 52121

Based on observations and interview, the facility failed to: 1. Post the names, addresses, and telephone numbers of pertinent state agencies and advocacy groups, such as the State Survey Agency, the State licensure office, the protection and advocacy network, home and community based service programs, and the Medicaid Fraud Control Unit; and 2. Post a statement for how a resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulation for all required postings reviewed. Findings: On 04/01/2025 at 11:24 a.m., a tour of the facility was conducted. A list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency, the State licensure office, the protection and advocacy network, home and community based service programs, and the Medicaid Fraud Control Unit was not observed to be posted in the facility. Further observation revealed a statement for how a resident may file a complaint with the State Survey Agency concerning any suspected violation of a state or federal nursing facility regulation was not observed to be posted. On 04/01/2025 at 12:22 p.m., a tour of the facility was conducted with S1ADM. He confirmed a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency, the State licensure office, the protection and advocacy network, home and community based service programs, and the Medicaid Fraud Control Unit was not posted in the facility. He further confirmed a statement for how a resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulation was not posted.

Based on record reviews and interviews, the facility failed to ensure a resident's Care Plan was revised to reflect a change in code status from Full Code to Do Not Resuscitate (DNR) for 1 (#3) of 3 (#1, #2 and #3) sampled residents reviewed for care plans. This deficient practice had the potential to affect 84 Residents residing in the facility. Findings: Review of the facility's policy dated 03/2022, titled Care Plans, Comprehensive Person-Centered revealed, in part: 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 11. Assessments of residents are ongoing and care plans are revised as information about the residents' condition change. 12. The interdisciplinary team reviews and updates the care plan. Review of Resident #3's Clinical Record revealed an admitted [DATE]. Review of Resident # 3's most recent Care Plan revealed the following, in part: 08/07/23- Resident #3 wishes to be a Full Code. Review of Resident #3's current Physician's Orders revealed the following, in part: 08/01/2023-Full Code 10/02/2024- Do Not Resuscitate (DNR) On 12/12/2024 at 11:00 a.m., an interview was conducted with S4MDS. She stated she was responsible for updating resident's care plans. S4MDS reviewed and confirmed Resident #3 was care planned for a Full Code, dated 08/07/2023. On 12/12/2024 at 11:45 a.m., an interview was conducted with S2DON. S2DON reviewed and confirmed Resident #3's Physician's order for code status, dated 10/02/2024, was Do Not Resuscitate (DNR). S2DON confirmed Resident #3's Care Plan was dated 08/07/2023 and reflected a code status of Full Code. S2DON confirmed the current Care Plan should have been updated to reflect Resident #3's current code status of DNR and was not.

Based on record reviews and interviews, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the resident's status for 1 (#3) of 3 ( #1, #2, and #3) sampled residents. The facility failed to ensure Resident #3's status correctly reflected he had an Advanced Directive. Findings: Review of Resident #3's Clinical Record revealed he was admitted to the facility on [DATE]. Review of Resident #3's Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/27/2024 revealed no Advanced Directive was selected in Section S. Review of Resident #3's Care Plan dated 08/07/2023 revealed he had an Advanced Directive. On 12/12/2024 at 11:15 a.m., an interview was conducted with S3SSD. She stated she was responsible for completing Section S in the MDS. S3SSD reviewed the Electronic Health Record and verified Resident #3 had an Advanced Directive. She confirmed the Significant Change MDS had not indicated he had one. On 12/12/2024 at 11:45 a.m., an interview was conducted with S2DON. S2DON reviewed Resident #3's Advanced Directive dated 08/01/2023 and the Significant Change MDS with an ARD of 09/27/2024. S2DON confirmed the Significant Change MDS should have reflected Resident #3's Advanced Directive and did not.

Based on record review and interviews, the facility failed to ensure all medical records regarding the resident's code status consistently reflected the resident's wishes for 1 (#3) of 3( #1, #R1 and #R2) residents reviewed for advanced directives. Findings: Review of Resident #3's clinical record revealed he was admitted to the facility on [DATE]. Review of Resident #3's Physician Orders in the electronic health record (EHR) revealed: Date [DATE]- Full Code. Review of Resident #3' Physician Orders in the physical chart revealed: Date [DATE]- DNR. On [DATE] at 10:40 a.m., an interview was conducted with S10LPN. She stated in the event of an emergency she would refer to the physical chart to determine a resident's code status. On [DATE] at 10:50 a.m., an interview was conducted with S11LPN. She stated in the event of an emergency she would refer to the physical chart to determine a resident's code status. On [DATE] at 10:52 a.m., an interview was conducted with S12LPN. She stated in the event of an emergency she would refer to the physical chart to determine a resident's code status. On [DATE] at 11:10 a.m., an interview was conducted with S13LPN. She stated on [DATE], a CNA reported to her that Resident #3 looked pale. She stated she went and checked Resident #3 and found him with no pulse and no respirations. She stated she verified Resident #3's code status with the physical chart under the advanced directive tab. She stated Resident #3 was a DNR so she did not perform CPR. On [DATE] at 11:45 a.m., an interview was conducted with S2DON. S2DON stated it was the nurse's responsibility to enter a physician's order into the EHR upon receiving the verbal/written order. S2DON reviewed Resident #3's hand written physician's order dated [DATE], and confirmed the order was never placed into the EHR and should have been. She reviewed the EHR and confirmed the Physician's Order dated [DATE] was for a Full Code. She confirmed the EHR did not reflect the most recent physician's order dated [DATE], DNR and should have.

Based on record review and interviews, the facility failed to ensure services were provided to meet quality professional standards by failing to ensure physician's orders were accurately transcribed for 1 (#3) of 3 (#1, #2 and #3) residents reviewed for physician's orders. Findings: Review of Resident #3's Clinical Record revealed he was admitted to the facility on [DATE]. Review of Resident #3's Physician's Orders in the Electronic Health Record (EHR) revealed the following: 08/01/2023-Full Code Review of Resident #3's hand written Physician's Orders in the physical hard chart revealed the following: 10/02/2024- Do Not Resuscitate (DNR) On 12/12/2024 at 9:20 a.m., an interview was conducted with S5MR. S5MR confirmed when a nurse received a verbal or written physician's order, the nurse was responsible for the written/verbal order's entry into the EHR. S5MR confirmed it was her responsibility to upload written, paper orders into the EHR. S5MR confirmed she never received Resident #3's written DNR order dated 10/02/2024, and it was never uploaded into the EHR. On 12/12/2024 at 11:45 a.m., an interview was conducted with S2DON. S2DON stated it was the nurse's responsibility to enter a physician's order into the EHR upon receiving the verbal/written order. S2DON reviewed Resident #3's hand written physician's order dated 10/02/2024 and Resident #3's EHR. S2DON confirmed Resident #3's ordered DNR status had not been entered or uploaded in the EHR and should have been.

Based on observations, interviews, and record review, the facility failed to ensure menus were followed to meet the nutritional needs of residents by failing to ensure the correct portion sizes ordered were provided for 1(#2) of 2(#1 and #2) residents reviewed for dining. Findings: Review of Resident #2's current Care Plan revealed the following: 08/13/2024-I am at risk for malnutrition, dehydration and weight fluctuations due to dialysis. I have a regular diet with double protein portions on each meal. Review of Resident #2's Physician's Orders dated 12/09/2024 revealed the following: 08/13/2024- Regular diet, double protein with every meal. On 12/09/2024 at 12:25 p.m., an observation was made of Resident #2's meal tray. One sausage link, one bun, French fries, green bell peppers, onions and cake. On 12/09/2024 at 12:35 p.m., an interview was conducted with S8DC. She stated a meal slip was printed with the diet, including the portion size, for every resident. She stated today's lunch served was a sausage link, one bun, pepper, onions and French fries. She stated if a resident was ordered double protein they would have been served two sausage links. On 12/09/2024 at 12:39 p.m., an interview was conducted with S9ST. She confirmed Resident #2 was served one sausage link for lunch. On 12/10/2024 at 11:55 a.m., an observation was made of Resident #2's lunch tray served with 3 meatballs. An observation was made of Resident #2's meal ticket which read, double protein with all meals. Swedish meatballs- 6 each. On 12/10/2024 at 11:56 a.m., an interview conducted with S7CNA. She confirmed Resident #2 was served 3 Swedish meatballs and should have been served 6. On 12/10/2024 at 12:00 p.m., an interview was conducted with S2DON. She confirmed the meal ticket read double protein with all meals, Swedish Meatballs-6 each. She confirmed Resident #2 was served 3 meatballs and should have been served 6.

Based on interviews and record reviews, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 3 (#20, #21, and #90) of 21 sampled residents by failing to ensure: 1. Resident #20 was coded correctly for hospice services, 2. Resident #21 was coded correctly for diagnosis; and 3. Resident #90 was coded correctly for Right Arm Splint. Findings: 1. Resident #20 Review of Resident #20's Clinical Record revealed he was admitted to the facility on [DATE]. Review of Resident #20's Quarterly MDS with an ARD of 04/15/2024 revealed a BIMS of 99, which indicated he was unable to complete the BIMs interview. Further review revealed the following: Section O-Hospice: Blank Review of Resident #20's Hospice Admission Sheet revealed he was admitted to hospice on 02/15/2024. On 05/22/2024 at 9:55 a.m., an interview was conducted with S6LPN. She stated Resident #20 had been receiving hospice services for a few months. On 05/21/2024 at 1:25 p.m., an interview was conducted with S4MDS. She stated she was responsible for completing the resident's MDS assessments. She verified she was aware Resident #20 received hospice services. She reviewed Resident #20's Quarterly MDS assessment dated [DATE] and confirmed he was not coded for hospice and should have been. On 05/21/2024 at 2:52 p.m., an interview was conducted with S5DON. He verified Resident #20 received hospice services. He reviewed Resident #20's last Quarterly MDS assessment and confirmed he was not coded for hospice. 2. Resident #21 Review of Resident #21's Clinical Record revealed he was admitted to the facility on [DATE] with a diagnosis, which included Extended Spectrum Beta Lactamase ( ESBL)Resistance. Review of Resident #21's Quarterly MDS with an ARD of 05/09/2024 revealed the following: Section I- Active Diagnoses -Multi Drug Resistant Organism Review of Resident #21's Physician Orders revealed the following: 2/1/2024-2/12/2024- Contact Isolation precautions related to ESBL in urine On 05/22/2024 at 9:05 a.m., an interview was conducted with S8IP. She stated Resident #21 did not have a current MDRO infection nor did she have a colonization of a MDRO. On 05/22/2024 at 10:32 a.m. an interview was conducted with S4MDS. She confirmed Resident #21 did not have a current MDRO infection and the MDS should not reflect it. On 05/22/2024 at 4:05 p.m. an interview was conducted with S5DON. He stated he was responsible for updating the Enhanced Barrier Precautions list weekly and as needed. He stated Resident #21 recently had a urinary tract infection which had resolved. He confirmed she did not have a current MDRO infection and the MDS should not reflect this diagnosis as being active. 3. Resident #90 Review of Resident #90's Clinical Record revealed he was admitted to the facility on [DATE] with a diagnosis, which included Hemiplegia or Hemiparesis following Cerebral Infarction affecting Right Dominant Side. Review of Resident #90's Quarterly MDS with an ARD of 03/26/2024 revealed the following: Section O-Special Treatments, Procedures, and Programs -No splint or brace assistance Review of Resident #90's Physician Orders revealed the following: 01/20/2024 -Right resting hand splint to be worn during the day and off at night. Review of Resident #90's MAR revealed the following: 02/01/2024-03/31/2024- Right Resting Hand Splint worn daily On 05/22/2024 at 10:50 a.m., an interview was conducted with S8LPN. She stated Resident #90 wore his Right Hand Splint as ordered. She stated no one had ever reported Resident #90 refusing his splint. She stated if Resident #90 would refuse his splint it would reflect in the MAR. On 05/21/2024 at 1:40 p.m., an interview was conducted with S4MDS. She confirmed Resident #90 had an order for a Right Hand Splint and the MDS was not coded for one. On 05/22/2024 at 4:05 p.m., an interview was conducted with S5DON. He confirmed Resident #90 had an order for a Right Hand Splint. He stated the MDS should have been coded for a splint and was not. 47173

Based on interviews and record review, the facility failed to ensure PRN orders for psychotropic medications were limited to 14 days and indicated the duration for 3 (#30, #58, and #62) of 6 (#2, #8, #13, #30, #58, and #62) residents reviewed for unnecessary psychotropic medications. Findings: Resident #30 Review of Resident #30's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses which included Unspecified Psychosis. Review of Resident #30's May 2024 Physician's Orders revealed an order written on 03/07/2024 for Ativan 0.5 mg tablet, one tablet by mouth every 12 hours as needed (PRN) for anxiety. Further review revealed the PRN medication had no stop date. Review of Resident #30's May 2024 Medication Administration Record (MAR)revealed Ativan 0.5 mg tablet, one tablet by mouth every 12 hours as needed (PRN) for anxiety was started on 03/07/2024. Further review revealed the PRN medication had no stop date. Resident #58 Review of Resident #58's clinical record revealed the resident was admitted to the facility on [DATE] and admitted to a local hospice agency on 01/18/2024. Review of Resident #58's May 2024 Physician's Orders revealed an order written on 01/18/2024 for Ativan 0.5 mg tablet, one tablet by mouth every 4 hours as needed (PRN) for anxiety/terminal restlessness. Further review revealed the PRN medication had no stop date. Review of Resident #58's May 2024 Medication Administration Record (MAR) revealed Ativan 0.5 mg tablet by mouth every four hours as needed for anxiety/terminal restlessness was started on 01/18/2024. Further review revealed the PRN medication had no stop date. Resident #62 Review of Resident #62's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses which included Insomnia. Review of Resident #62's May 2024 Physician's Orders revealed an order written on 02/05/2024 for Belsomra 5mg tablet, one tablet by mouth every 24 hours as needed for sleep. Further review revealed the PRN medication had no stop date. Review of Resident #62's May 2024 MAR revealed Belsomra 5mg tablet, one tablet by mouth every 24 hours as needed for sleep was started on 02/05/2024. Further review revealed the PRN medication had no stop date. On 05/22/2024 at 9:00 a.m., an interview was conducted with S5DON. He reviewed the aforementioned findings and confirmed there was no duration or stop date documented for the resident's psychotropic PRN medications. 47191

Based on record review, observation, and interview the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles for 1 (Cart A ) of 2 (Cart A and Cart B) medication carts observed. The facility failed to ensure: 1. Insulin pens were labeled with the date opened; and 2. Insulin pens were discarded 28 days after the date opened. Findings: Review of the updated 02/2023 facility policy titled Medication Labeling and Storage on 05/20/2024, revealed, in part: Multidose vials that have been opened or accessed are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for open vial. An observation was made of Cart A on 05/20/2024 at 9:30 a.m. with S3LPN who confirmed the below observations: Resident # 7's Humalog insulin pen was open, in use, and not dated to indicate when the insulin pen was opened. Resident #47's Lantus insulin pen was open, in use, and not dated to indicate when the insulin pen was opened. Resident #58's Humalog insulin pen was open, in use, and not dated to indicate when the insulin pen was opened. An interview was conducted with S3LPN on 05/20/2024. S3LPN stated the above insulin pens should have been labeled with the open date to indicate when the pen was opened and discarded 28 days after opening and they were not. An interview was conducted with S2ADON on 05/20/2024 at 10:00 a.m. She confirmed the facility uses the above noted Medication Labeling and Storage Policy. She stated insulin pens should be labeled with the open date and discarded per this guideline, and were not.

Based on observations and interviews, the facility failed to ensure an infection prevention and control program was maintained by failing to ensure S9CNA appropriately discarded a soiled brief and wipes with visible feces. Findings: On 05/20/2024 at 8:35 a.m., an observation and interview was conducted with S9CNA. S9CNA was observed walking down the hallway with soiled gloves, holding an exposed soiled diaper and soiled wipes with visible feces. S9CNA stated she should not have walked down a hallway with soiled gloves, a soiled brief and soiled wipes with visible feces and did. On 05/22/2024 at 9:40 a.m., an interview was conducted with S8IP. She stated she would expect staff to bag soiled items in a resident's room, dispose of gloves and use hand hygiene prior to exiting a room. She confirmed S9CNA should not have walked down the hallway with soiled gloves, a soiled brief and soiled wipes with visible feces. On 05/22/2024 at 4:05 p.m., an interview was conducted with S1ADM and S5DON. They confirmed S9CNA should not have walked down the hallway with soiled gloves, soiled brief and soiled wipes with visible feces.

Based on observation, record review, and interviews, the facility failed to ensure services were provided to meet quality professional standards for 2 (#1, #R1) of 4 (#1, #2, #3, and #R1) residents reviewed with urinary catheters. The facility failed to ensure Resident #1 and Resident #R1 had a physician's order to maintain an indwelling urinary catheter. Findings: Resident #1 Review of the Clinical Record for Resident #1 revealed a facility admitted on 01/05/2024. Review of the Emergency Department Records for Resident #1 revealed, in part, Resident #1 had an emergency room visit on 02/20/2024 and was discharged from the emergency roiagnom on [DATE] with an indwelling urinary catheter in place. Review of the Physician Orders for Resident #1 dated February 2024 to March 2024 revealed the following, in part: 02/20/2024 Send to emergency room for treatment and evaluation . 03/06/2024 Remove Foley catheter . Further review revealed no physician's order for Resident #1's urinary catheter. Review of the Nurses Daily Skilled Notes for Resident #1 dated February 2024 to March 2024 revealed, in part, he returned to the facility from the emergency roiagnom on [DATE] with a urinary catheter. Review of the MAR/TAR for Resident #1 dated February 2024 to March 2024 revealed, in part, no documentation pertaining to his urinary catheter. An interview was conducted with S6LPN on 03/19/2024 at 11:10 a.m. She stated on 02/21/2024 Resident #1 returned from the hospital with a urinary catheter. She reviewed Resident #1's physician orders, and confirmed there were no orders entered for the urinary catheter and there should have been. An interview was conducted with S7LPN on 03/20/2024 at 10:30 a.m. She stated she was assigned to Resident #1 after he returned from the hospital on 02/21/2024 with a urinary catheter, and she entered Resident #1's physician orders. She stated she did not request urinary catheter orders from the hospital or Resident #1's physician and should have. An interview was conducted with S3ADON on 03/19/2024 at 12:50 p.m. She stated the nurses were responsible for entering physician orders for residents. She reviewed the clinical record for Resident #1, and confirmed when he returned from the hospital on 02/21/2024 with a urinary catheter there were no physician orders entered for the catheter and there should have been. An interview was conducted with S2DON on 03/19/2024 at 4:06 p.m. He stated the nurses were responsible for entering physician orders. He reviewed Resident #1's physician orders dated February 2024 to March 2024 and confirmed there were no orders for the urinary catheter. He stated the nurse who received Resident #1 from the hospital on 02/21/2024, should have realized he had a urinary catheter and no orders for it. He stated he would have expected the nurses to contact the provider and request urinary catheter orders. An interview was conducted with S1ADM on 03/20/2024 at 9:00 a.m. He verified Resident #1 had a urinary catheter placed in the emergency roiagnom on [DATE]. He stated Resident #1 was discharged to the facility with a urinary catheter and no orders were obtained and entered for the catheter and should have been. Resident #R1 Review of the Clinical Record for Resident #R1 revealed a facility admitted [DATE] with diagnoses which included, Neuromuscular Dysfunction of the Bladder and Other Retention of Urine. Review of the Hospital Discharge Records for Resident #R1 revealed, in part, Resident #R1 was discharged from the hospital on 03/15/2024 with an indwelling urinary catheter in place due to urinary retention. Review of the Physician Orders for Resident #R1 from 03/15/2024 to 03/18/2024 revealed no physician's order for Resident #R1's urinary catheter. Review of the Nurses Notes for Resident #R1 dated March 2024 revealed the following, in part: 03/15/2024 at 11:41 p.m. Resident arrived at 9:41 p.m. Resident #R1 noted with indwelling urinary catheter. An observation was made of Resident #R1 on 03/19/2024 at 10:30 a.m. He had a urinary catheter with a drainage bag on the right side of his wheelchair. An interview was conducted with S10LPN on 03/21/2024 at 12:32 p.m. She stated on 03/15/2024 she admitted Resident #R1 from the hospital, and he had a urinary catheter. She stated at that time she was unaware the nurses were responsible for entering resident's physician orders. She confirmed she did not contact Resident #R1's provider for urinary catheter orders on 03/15/2024 and should have. An interview was conducted with S6LPN on 03/21/2024 at 12:40 p.m. She verified she worked on 03/18/2024 and 03/19/2024 and was assigned to Resident #R1. She stated he had a urinary catheter. She stated on 03/19/2024, when she realized he did not have catheter orders she contacted the physician. She stated the admitting nurse should have contacted the physician and entered the urinary catheter orders in the computer. An interview was conducted with S7LPN on 03/21/2024 at 1:05 p.m. She stated the admitting nurse was responsible for entering resident's physician orders. She stated Resident #R1 was admitted to the facility on [DATE] at 9:50 p.m. with a urinary catheter. She stated she entered physician orders on 03/16/2024 at 7:43 a.m. for Resident #R1. She reviewed Resident #R1's physician orders and confirmed urinary catheter orders were not entered until 03/19/2024. She stated she did not notice Resident #R1 did not have orders for the urinary catheter when she worked on 03/16/2024. She stated she should have contacted the physician and entered urinary catheter orders for Resident #R1. An interview was conducted with S3ADON on 03/21/2024 at 1:14 p.m. She stated S6LPN notified S1ADM, S2DON and herself on 03/19/2024 that Resident #R1 did not have orders for the urinary catheter upon admit to the facility on [DATE]. She stated the admitting nurse should have contacted Resident #R1's physician for urinary catheter orders. An interview was conducted with S2DON on 03/21/2024 at 1:16 p.m. He stated S6LPN notified S1ADM, S3ADON and himself on 03/19/2024 that Resident #R1 did not have orders for the urinary catheter upon admit to the facility on [DATE]. He stated the admitting nurse should have contacted Resident #R1's physician for urinary catheter orders.

Based on record review and interviews, the facility failed to maintain accurate records in accordance with accepted professional standards and practices for 2 (#1, #R1) of 4 (#1, #2, #3, and #R1) residents reviewed with indwelling urinary catheters. The facility failed to ensure nursing staff documented catheter care and monitoring of adverse signs and symptoms every shift for Resident #1 and Resident #R1. Findings: Review of the facility's policy titled, Catheter Care, Urinary revealed the following, in part: Purpose: The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections. Documentation: The following information should be recorded in the resident's medical record: 1. The date and time the catheter care was given. 2. The name and title of the individual(s) giving the catheter care. 4. Character of urine such as color (straw-colored, dark, red), clarity (cloudy, solid particles, or blood), and odor. Resident #1 Review of the Clinical Record for Resident #1 revealed a facility admitted [DATE]. Review of the Emergency Department Records for Resident #1 revealed, in part, Resident #1 had an emergency room visit on 02/20/2024 and was discharged from the emergency roiagnom on [DATE] with an indwelling urinary catheter in place. Review of the Physician Orders for Resident #1 dated February 2024 to March 2024 revealed the following, in part: 02/20/2024 Send to emergency room for treatment and evaluation . 03/06/2024 Remove Foley catheter . Further review revealed no physician's order for Resident #1's urinary catheter. Review of the Nurses Daily Skilled Notes for Resident #1, dated February 2024 to March 2024 revealed, in part, he returned to the facility from the emergency roiagnom on [DATE] with a urinary catheter. Further review revealed no documentation of urinary catheter care or that the urinary catheter was monitored every shift for adverse signs and symptoms. Review of the MAR/TAR for Resident #1, dated February 2024 to March 2024 revealed, in part, no documentation pertaining to his urinary catheter. An interview was conducted with S6LPN on 03/19/2024 at 11:10 a.m. She stated on 02/21/2024 Resident #1 returned from the hospital with a urinary catheter. She stated catheter orders entered into the electronic record populated tasks for the nurses to monitor the catheter and provide care every shift. She stated the populated tasks and monitoring were to ensure catheter care was provided every shift by the nurse or CNAs, and the catheter was monitored for infection and blockages every shift. She stated these tasks and monitoring would be documented by the nurse on the MAR or TAR. She reviewed Resident #1's MAR and TAR and confirmed there was no documentation that catheter care and monitoring of the catheter had been provided every shift for Resident #1. An interview was conducted with S8CNA on 03/19/2024 at 3:53 p.m. She stated Resident #1 returned from the hospital on 02/21/2024 with a urinary catheter. She stated she provided catheter care for Resident #1 and the nurses documented the care provided. An interview was conducted with S7LPN on 03/20/2024 at 10:30 a.m. She stated when a resident had a urinary catheter the process was to enter a batch order in the computer that included tasks assigned to the nurses for catheter care and monitoring for signs and symptoms of infection and patency every shift. She stated the nurses or the CNAs provided catheter care and the nurses documented the catheter care on the MAR or the TAR. She reviewed Resident #1's MAR and TAR, and confirmed there was no documentation that catheter care and monitoring had been done every shift for Resident #1. An interview was conducted with S3ADON on 03/19/2024 at 12:50 p.m. She reviewed the clinical record for Resident #1, and confirmed when he returned from the hospital on 02/21/2024, with a urinary catheter, there were no orders entered for catheter care and monitoring of the catheter for infection and patency and there should have been. She stated the nurses were responsible for documenting care provided on the MAR or TAR. She confirmed from 02/21/2024 until the urinary catheter was removed on 03/06/2024 there was no documentation that catheter care and monitoring of the catheter was done every shift for Resident #1. An interview was conducted with S2DON on 03/19/2024 at 4:06 p.m. He stated urinary catheter care could be provided by the nurses or the CNAs and would be documented by the nurses on the MAR or TAR. He reviewed Resident #1's MAR and TAR dated February 2024 to March 2024 and confirmed there were no orders for the urinary catheter, catheter care and monitoring of the catheter. He confirmed from 02/21/2024 until the urinary catheter was removed on 03/06/2024 there was no documentation that catheter care and monitoring was provided every shift for Resident #1. An interview was conducted with S1ADM on 03/20/2024 at 9:00 a.m. He verified Resident #1 had a urinary catheter placed in the emergency roiagnom on [DATE]. He stated Resident #1 was discharged to the facility with a urinary catheter and no orders were entered for the catheter, catheter care and monitoring the catheter for infection. He confirmed the nursing staff had not entered urinary catheter orders to trigger staff to document catheter care for Resident #1. He confirmed the nursing staff had not documented catheter care and monitoring of the catheter every shift from 02/21/2024 until the urinary catheter was removed on 03/06/2024. He stated the facility had not followed their catheter care policy. Resident #R1 Review of the Clinical Record for Resident #R1 revealed a facility admitted [DATE] with diagnoses which included, Neuromuscular Dysfunction of the Bladder and Other Retention of Urine. Review of the Hospital Discharge Records for Resident #R1 revealed, in part, Resident #R1 was discharged from the hospital on 03/15/2024 with an indwelling urinary catheter in place due to urinary retention. Review of the Physician Orders for Resident #R1 from 03/15/2024 to 03/18/2024 revealed no physician's order for Resident #R1's urinary catheter. Review of the Nurses Notes for Resident #R1 for March 2024 revealed the following, in part: 03/15/2024 at 11:41 p.m., Resident arrived at 9:41 p.m. Resident #R1 noted with indwelling urinary catheter. An observation was made of Resident #R1 on 03/19/2024 at 10:30 a.m. He had a urinary catheter with a drainage bag on the right side of his wheelchair. An interview was conducted with S10LPN on 03/21/2024 at 12:32 p.m. She stated when urinary catheter orders were entered for a resident, tasks for catheter care and monitoring for infections and patency were assigned to and documented by the nurses on the TAR. She confirmed she did not contact Resident #R1's provider for urinary catheter orders on 03/15/2024. An interview was conducted with S6LPN on 03/21/2024 at 12:40 p.m. She verified she worked on 03/18/2024 and 03/19/2024 and was assigned to Resident #R1. She stated he had a urinary catheter. She stated there were no tasks to trigger the nurses to provide catheter care or monitoring for infections. She confirmed she had not documented catheter care and monitoring of the catheter every shift for Resident #R1 and should have. An interview was conducted with S7LPN on 03/21/2024 at 1:05 p.m. She stated Resident #R1 was admitted to the facility on [DATE] at 9:50 p.m. with a urinary catheter. She confirmed there was no documentation that catheter care and monitoring of the catheter had been provided every shift for Resident #R1. An interview was conducted with S3ADON on 03/21/2024 at 1:14 p.m. She confirmed there was no documentation that catheter care and monitoring of the catheter had been provided every shift for Resident #R1 from 03/15/2024 to 03/18/2024. An interview was conducted with S2DON on 03/21/2024 at 1:16 p.m. He confirmed there was no documentation that catheter care and monitoring of the catheter had been provided every shift for Resident #R1 from 03/15/2024 to 03/18/2024.

Based on observations, interviews, and record reviews, the facility failed to ensure residents were free from sexual abuse for 1 (Resident #5) of 6 (Residents #1, #2, #3, #4, #5, and #6) sampled residents reviewed for sexual abuse. The deficient practice resulted in an Immediate Jeopardy situation on 08/29/2023 when Resident #4, a moderately cognitively impaired resident, returned to the facility from a psychiatric hospital stay for sexually inappropriate behaviors. Upon Resident #4 returning to the facility on [DATE], he continued to exhibit sexually inappropriate behaviors with staff. On 09/13/2023 at 1:45 p.m., Resident #4 grabbed Resident #5's breast. After the incident, Resident #4 was placed on 1:1 supervision for 72 hours. After 72 hours, the 1:1 supervision was discontinued and no new interventions were implemented to ensure Resident #4 would not sexually abuse another resident. Staff interviews revealed Resident #4 continued to exhibit sexually inappropriate behaviors after the incident on 09/13/2023. Due to the lack of new interventions, there was a likelihood of Resident #4 sexually abusing other residents if not immediately corrected. S1ADM, S2DON, and S3CVP were notified of the Immediate Jeopardy on 10/04/2023 at 6:55 p.m. The Immediate Jeopardy was removed on 10/05/2023 at 2:50 p.m. when the facility submitted an acceptable Plan of Removal. Through observations, interviews and record reviews, the surveyors confirmed the following had been initiated and/or implemented prior to exit. The Immediate Jeopardy Plan of Removal included the following: -On 10/04/2023 Resident #4's care plan was updated to include intervention of one on one observation and inpatient behavioral services. -On 10/04/2023 at 7:30 p.m. Immediately Resident #4 was placed on one on one observation. -On 10/04/2023 physician was notified and orders noted to send Resident #4 to inpatient behavioral health services. Resident discharged from building at 10:00 p.m. on 10/04/2023 to behavioral inpatient. Resident is not to return to the facility. -On 10/04/2023 at 10:00 p.m. Resident #4 was transported to inpatient behavioral health services. -On 10/05/2023 76 interviews with Residents with BIMS (Brief Interview for Mental Status) of 9 or greater were interviewed by IDT Team to ensure that they had not been abused and had not witnessed any abuse or neglect of a fell ow resident as well as to inquire about their safety. Process initiated on 10/04/2023 8:00 p.m. Time of completion on assessments: 10/05/2023 8:30 a.m. -On 10/05/2023 26 Residents were assessed by licensed nurses conducting skin sweeps for suspicious injuries. Process initiated on 10/04/2023 8:00 p.m. Time of completion on assessments: 10/05/2023 8:30 a.m. -On 10/05/2023 Resident #5 to receive psychiatric consultation and ongoing weekly monitoring by psychiatric services and social worker. -Quality Assurance Performance Committee (QAPI) met on 10/04/2023 at 9:30 p.m. to review 09/13/2023 incident of Resident #4's inappropriate sexual behavior and determine a Root Cause. Meeting was led by Assistant Regional [NAME] President of Operations and Executive Director. Attendees were Executive Director (ED), Regional [NAME] President of Operations (RVPO), Social Services Director (SSD), Housekeeping Supervisor (HKS), Business Office Manager (BOM), and Director of Nursing (DON), Activities Director (AD, Therapy Manager (TM), Maintenance Supervisor (MS), Licensed Nurse (LPN) and Medical Records Clerk (MRC) and Director of Sales and Marketing (DSM). The Root Cause was determined to be that the facility failed to ensure resources were effectively and efficiently used to put interventions in place to prevent sexual abuse. -On 10/04/2023 at 8:00 p.m. education was conducted with the Executive Director (ED) and the Director of Nursing (DON) by the Regional [NAME] President of Operations (RVPO) on Abuse, Neglect, and Misappropriation and on ensuring resources are effectively and efficiently used to put interventions in place to prevent sexual abuse by Residents with inappropriate sexual behavior. -Quality Monitoring on effectiveness of education to be reviewed by Assistant Regional [NAME] President of Operations by weekly visitation with the Regional Director of Clinical Services, Director of Nursing, and Executive Director weekly for 4 weeks and monthly for 3 months following. Monitoring will be held weekly by Administrator, Director of Nursing, Business Development Director, Admissions Coordinator, and Social Services Director or comparable designee. Monitoring team will review confirmed admission packets for potential hyper-sexual behaviors or tendencies. Any adverse findings will be rectified through care planning and appropriate interventions. Team will review baseline care plans of recent admissions. A random sample of 10 residents shall be interviewed for psychosocial well-being and reviewed with corporate leadership. To begin on 10/06/2023 and complete on 02/06/2024. All findings of reviews will be reported monthly to IDT through the QAPI meeting. -On 10/05/2023 7:00 a.m. education was conducted on Abuse, Neglect, and Misappropriation with emphasis on sexual abuse and appropriate interventions for a Resident with sexually inappropriate behaviors to prevent sexual abuse. All present staff completed on 10/05/2023 at 10:00 a.m., including MDS staff. Expected completion time on Full-Time staff by 10/06/2023 6:00 p.m. PRN staff will be requiring education prior to working their next shift. No staff shall be allowed to work his or her assignment until training has been completed. -Employees will receive training upon hire and prior to accepting assignment. The deficient practice continued at a potential for more than minimal harm for the 97 residents currently residing in the facility. Findings: Review of the facility's policy titled, Employee Acknowledgment of Resident -Patient Rights revealed the following, in part: Policy: These Resident Rights ensure that each resident admitted : 7. Is free from sexual abuse. Review of the facility's policy titled, Abuse, Neglect, Exploitation and Misappropriation revealed the following, in part: Policy: It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse. Definitions: Sexual Abuse is non- consensual sexual contact of any type with a resident. Sexual abuse include but is not limited to: -Unwanted intimate touching of any kind especially of breast or perineal area -All types of sexual assault or battery, such as rape, sodomy and coerced nudity -Forced observation of masturbation and/or pornography Generally, sexual contact is non-consensual if the resident either: -Does not want the contact to occur. Resident #4 Review of Resident #4's Pre-facility admission Hospital Records dated 08/03/2023, revealed in part, the following: Resident #4 was admitted to the hospital on 06/15/2023 with hypersexual behaviors, verbally aggressive with staff, and masturbating in front of staff over the past few days. On 08/11/2023 Resident #4 was discharged and transferred to the nursing facility. Review of Resident #4's clinical records revealed he was admitted to the facility on [DATE] with diagnosis, which included: Alzheimer's disease, Unspecified Dementia, and Delirium Due to Known Physiological Condition. Review of the admission MDS with an ARD of 08/18/2023 revealed Resident #4 had a BIMS of 11, which indicated he was moderately cognitively impaired. Further review of Resident #4's functional status revealed he required setup help only during locomotion on unit per wheelchair. Review of Resident #4's Baseline Care Plan revealed, in part, the following: Date 08/11/2023 Resident Problem: Sexually inappropriate behaviors. Resident Goal: Will have fewer episodes of sexually inappropriate behaviors. Interventions: Monitor behaviors. Review of Resident #4's Nurse's Notes dated August 2023 revealed the following: 08/17/2023 at 9:27 a.m., Resident grabbed staff member's breast and back saying Don't you want to ****? Staff redirected resident to cross his hands over his chest while performing care. During care resident continues to ask staff Why won't you let me **** you? Reminded resident that his language and actions are inappropriate. RP and NP notified of the above. No new orders at this time, states to continue care. Plan of care ongoing. S5LPN. 08/17/2023 at 11:00 a.m., Conducted BIMS assessment with resident. BIMS score is 11. During assessment resident was very verbally and sexually inappropriate. S15SW. Review of the Facility's Transfer Log dated August 2023 revealed Resident #4 was transferred to a psychiatric hospital on 08/18/2023 for behaviors and returned to the facility on [DATE]. Review of the Hospital Records revealed Resident #4 was sent to a psychiatric hospital on 08/18/2023 for sexually inappropriate behaviors and discharged following treatment. Review of the Hospital Discharge documents dated 08/18/2023 revealed no changes to Resident #4's medications and no new orders. Review of Resident #4's most recent Physician Orders, dated August 2023 through October 2023, revealed in part, the following: Monitor for behaviors each shift, start date 08/29/2023. Further review revealed no Physician Orders changes related to Resident #4's sexually inappropriate behaviors. Review of Resident #4's Physician's Progress Notes dated August 2023 through October 2023 revealed the following: 08/30/2023 at 9:41 a.m., Resident was seen today after discharge from the psychiatric hospital. Admit due to hypersexual behaviors, including exposing himself and inappropriate comments and behaviors. Administer medications as prescribed. No new consults at this time. S13NP. 09/08/2023 at 11:16 a.m., Resident continues to have inappropriate behaviors including grabbing at staff and inappropriate comments. Neurologic: Grossly intact. Assessment: Hypersexual Behaviors. Plan: Monitor behaviors. S13NP. 09/21/2023 at 11:16 a.m., Resident continues to have occasional inappropriate behaviors including grabbing at staff and inappropriate comments. Neurologic: Grossly intact. Assessment: Hypersexual Behaviors. Plan: Monitor behaviors. S14MD. Review of Resident #4's Nurse's Notes dated August 2023 through October 2023 revealed the following: 09/13/2023 at 1:52 p.m., at approximately 1:45 p.m., it was reported that Resident #4 was rolling his wheelchair through the dayroom when he stopped by another resident grabbing Resident #5's whole breast and feeling on it. Resident #5 stated she was pushing his hand away and telling him don't touch me. The aide that was walking through the room got the resident away from victim and redirected to resident's room and reported it to the nurse. RP aware. S6LPN. 09/20/2023 at 10:41 a.m., Resident #4 presents with sexually inappropriate behavior during routine wound care treatment with CNA present. Resident grabbing at staff private parts and stating suck my d**k, suck it good, suck it all the way off. Resident redirected throughout treatment without success. MD and RP aware. S4WC. Resident #5 Review of the clinical record revealed Resident #5 was admitted to the facility on [DATE] with diagnosis, which included Hemiplegia, Major Depressive Disorder, Generalized Anxiety, and Lack of Coordination. Review of the quarterly MDS with an ARD of 07/27/2023 revealed Resident #5 had a BIMS of 14 which indicated she was cognitively intact. Review of Resident #5's Physician's Progress Notes dated August 2023 through October 2023 revealed no documentation of the incident with Resident #4. Further review revealed no documentation of changes in plan of care. Review of Resident #5's Nurse's Notes dated August 2023 through October 2023 revealed no documentation of the incident with Resident #4. Further review revealed no documentation of changes in plan of care. Review of Resident #5's most recent Care Plan revealed no documentation related to the incident with Resident #4 and no documentation of any changes to her plan of care related to sexual abuse. An interview was conducted on 10/04/2023 at 1:05 p.m. with Resident #5. She stated, about a month ago, she had an encounter with Resident #4 in the day room. She stated she was sitting in her wheelchair when Resident #4 approached her, grabbed her breast and did a milking motion on her breast. She told Resident #4 not to touch her and to get away from her. She stated the CNAs walked by and saw what was happening and separated him from her. She stated staff did not complete a physical assessment on her after he grabbed her breast and only asked if she was ok. She stated when Resident #4 grabbed her breast she felt degraded and violated. She stated now, when she sees Resident #4 coming in her direction, she turns to go the opposite way and purposely avoids him. An interview was conducted on 10/04/2023 at 1:07 p.m. with S5LPN. She stated Resident #4 began having sexually inappropriate behaviors about a week after he was admitted to the facility. She stated Resident #4 was aware of his actions. She stated on 08/17/2023 she was performing care on Resident #4 when he began asking her to have sexual relations with him, and grabbed at her private area and her breasts. S5LPN reported this behavior to the NP. S5LPN stated the NP visited the facility the same day and sent Resident #4 to the psychiatric facility on 08/17/2023 after the resident grabbed the NP's buttocks. She stated there were no changes to Resident #4's medications when he returned to the facility on [DATE]. She confirmed Resident #4 continued to exhibit the same sexual behaviors after he returned to the facility on [DATE]. She stated the NP and MD were notified of Resident #4's continued sexual behaviors. She stated on 09/13/2023, Resident #4 grabbed Resident #5's breast. She stated after the incident dated 09/13/2023, Resident #4 was placed on 1:1 supervision for 72 hours. She confirmed other than being placed on 72 hour 1:1 supervision, there were not any other changes in his plan of care. She stated Resident #4 continued to exhibit sexual behaviors after the 1:1 was discontinued. She stated Resident #4 was seen masturbating in the dayroom with multiple residents present after his incident with Resident #5. S5LPN confirmed there were no new interventions put into place once the 72 hour supervision ended to prevent Resident #4 from sexually abusing another resident. An interview was conducted on 10/04/2023 at 1:19 p.m. with S4WC. She stated Resident #4 began having sexually inappropriate behaviors about a week after he was admitted to the facility. She stated Resident #4 was aware of his actions. She stated Resident #4 would attempt to grab her daily and spoke vulgar to her. She stated staff attempted to get him to cross his arms during care to prevent him from sexually grabbing them, but this was often ineffective. She stated the NP sent Resident #4 to the psychiatric facility on 08/17/2023 after the resident grabbed the NP's buttocks. She stated after Resident #4 returned to the facility on [DATE], there were no changes to his medications. She stated the resident continued to exhibit the same sexual behaviors. She stated the NP and MD were notified of Resident #4's continued sexual behaviors. She stated on 09/13/2023 Resident #4 grabbed Resident #5's breast. She stated after the incident dated 09/13/2023, Resident #4 was placed on 1:1 supervision for 72 hours. She confirmed other than the resident being placed on 72 hour 1:1 supervision, there had not been any other changes to his plan of care. She stated Resident #4 continued to exhibit sexual behaviors after the 1:1 was discontinued. S4WC confirmed there were no new interventions put into place once the 72 hour supervision ended to prevent Resident #4 from sexually abusing another resident. An interview was conducted on 10/04/2023 at 2:10 p.m. with S2DON. He stated Resident #4 began having sexually inappropriate behaviors about a week after he was admitted to the facility. He stated Resident #4 was aware of his actions. He stated Resident #4 would inappropriately and sexually touch literally anyone. He stated the NP sent Resident #4 to the psychiatric facility on 08/17/2023 after the resident grabbed the NP's buttocks. He stated after Resident #4 returned to the facility on [DATE], there were no changes to his medications. He stated the resident continued to exhibit the same sexual behaviors. He stated the NP and MD were notified of Resident #4's continued sexual behaviors. He stated on 09/13/2023 Resident #4 grabbed Resident #5's breast. S2DON stated staff did not assess Resident #5 to see if she had been physically or mentally injured after Resident #4 grabbed her breast. He stated after the incident dated 09/13/2023, Resident #4 was placed on 1:1 supervision for 72 hours. He confirmed other than the resident being placed on 72 hour 1:1 supervision, there had not been any other changes to his plan of care. He stated Resident #4 continued to exhibit sexual behaviors after the 1:1 was discontinued. He stated the development of a plan to further protect residents from Resident #4 would depend on how many incidents occurred. S2DON confirmed there were no new interventions put into place once the 72 hour supervision ended to prevent Resident #4 from sexually abusing another resident. An interview was conducted on 10/04/2023 at 2:22 p.m. with S13NP. She stated Resident #4 began having sexually inappropriate behaviors about a week after he was admitted to the facility. She stated Resident #4 was aware of his actions. She stated on 08/17/2023 staff verbalized concern that Resident #4 might try to touch a resident inappropriately. She stated Resident #4 was sent to the psychiatric facility on 08/17/2023 after the resident grabbed her buttocks. She stated after Resident #4 returned to the facility on [DATE], there were no changes to his medications. She stated the resident continued to exhibit the same sexual behaviors. She stated on 09/13/2023 Resident #4 grabbed Resident #5's breast. She stated after the incident dated 09/13/2023, Resident #4 was placed on 1:1 supervision for 72 hours. She confirmed other than the resident being placed on 72 hour 1:1 supervision, there had not been any other changes to his plan of care. She stated Resident #4 continued to exhibit sexual behaviors after the 1:1 was discontinued. She stated she received multiple phone calls from staff about Resident #4's sexually inappropriate behaviors which included touching. She stated physicians did not like to send residents to psychiatric facilities often for behaviors because it could confuse the resident. She stated the physician did not change any medications or put Resident #4 on further 1:1 supervision from admission to now. S13NP confirmed there were no new interventions put into place once the 72 hour supervision ended to prevent Resident #4 from sexually abusing another resident. An interview was conducted on 10/04/2023 at 3:30 p.m. with S1ADM. He stated Resident #4 began having sexually inappropriate behaviors about a week after he was admitted to the facility. He stated Resident #4 was aware of his actions. He stated Resident #4 was sent to the psychiatric facility on 08/17/2023 after the resident grabbed the NP's buttocks. He stated after Resident #4 returned to the facility on [DATE] there were no changes to his medications. He stated the resident continued to exhibit the same sexual behaviors. He stated the NP and MD were notified of Resident #4's continued sexual behaviors. He stated on 09/13/2023 Resident #4 grabbed Resident #5's breast. He stated after the incident dated 09/13/2023, Resident #4 was placed on 1:1 supervision for 72 hours. He confirmed other than the resident being placed on 72 hour 1:1 supervision, there had not been any other changes to his plan of care. He stated Resident #4 continued to exhibit sexual behaviors after the 1:1 was discontinued. He stated Resident #4 should have been on 1:1 supervision following his return from the psychiatric facility on 08/29/2023. He stated if Resident #4 had been on 1:1 supervision, staff could have prevented Resident #5 from being touched inappropriately by Resident #4. He stated Resident #4 had only 1 incident of touching another resident inappropriately that they were aware of. He explained since it was only once, they did not initiate any further supervision. An observation was made on 10/04/2023 at 4:02 p.m. of Resident #4 in his room. A nurse entered the room with surveyors and observed Resident #4 was masturbating in front of male roommate, nurse, and surveyors. The nurse instructed Resident #4 to stop that. An interview was conducted on 10/04/2023 at 4:05 p.m. with Resident #4. He stated he loved to touch people and didn't see what the problem was. He stated he remembered when he grabbed Resident #5's breast in the dayroom. An interview was conducted on 10/04/2023 at 6:00 p.m. with S16MDS. She stated Resident #4's care plan was not completed. She confirmed Resident #4 had inappropriate sexual behaviors upon admission, and should have been care planned with appropriate interventions in place as well as after his incident with another resident on 09/13/2023. An interview was conducted on 10/04/2023 at 6:02 p.m. with S15SW. She stated Resident #4 began having sexually inappropriate behaviors about a week after he was admitted to the facility. She stated Resident #4 was aware of his actions. She stated on 08/17/2023 she was performing a BIMS assessment on Resident #4 when he began asking her to have sexual relations with him, and grabbed at her private area and her breasts. S15SW reported this behavior to the NP. S15SW stated the NP visited the facility the same day and sent Resident #4 to the psychiatric facility on 08/17/2023 after the resident grabbed the NP's buttocks. She stated there were no changes to Resident #4's medications when he returned to the facility on [DATE]. She confirmed Resident #4 continued to exhibit the same sexual behaviors after he returned to the facility on [DATE]. She stated on 09/13/2023, Resident #4 grabbed Resident #5's breast. She stated after the incident dated 09/13/2023, Resident #4 was placed on 1:1 supervision for 72 hours. She confirmed other than being placed on 72 hour 1:1 supervision, there were not any other changes in his plan of care. She stated Resident #4 continued to exhibit sexual behaviors after the 1:1 was discontinued. S5LPN confirmed there were no new interventions put into place once the 72 hour supervision ended to prevent Resident #4 from sexually abusing another resident. An interview was conducted on 10/05/2023 at 8:40 a.m. with S11CNA. She stated Resident #4 began having sexually inappropriate behaviors about a week after he was admitted to the facility. She stated Resident #4 was aware of his actions. She stated on 09/13/2023, she was in the nurse's station when she saw Resident #4 wheel his wheelchair up to Resident #5 in the day room and grabbed her breast. She stated she immediately separated the residents and reported the incident to S6LPN. She stated she regularly bathed Resident #4, and it was very difficult to bathe him or provide peri care due to his inappropriate sexual remarks and constantly touching her inappropriately. She stated his behaviors happened everyday. She stated she notified the nurse on most incidents. She stated she tried to redirect Resident #4, but it was ineffective. An interview was conducted on 10/05/2023 at 11:05 a.m. with S6LPN. She stated staff was aware of Resident #4 having a previous diagnosis of hypersexual behaviors from the facility he was at prior to coming to this facility. She stated the previous facility had reported to the nursing staff when he grabbed at them inappropriately, they would tell him to put his arms across his chest. She stated that would sometimes be effective but not long after, he needed further redirection. She stated she would frequently tell Resident #4 to keep his hands to himself. She stated Resident #4 was able to mobilize around the facility on his own in his wheelchair. She stated she was at the nurse's station on 09/13/2023 when Resident #4 wheeled his wheelchair to Resident #5, reached out, and grabbed her breast. She stated Resident #5 told Resident #4 to not touch her and get away from her. She stated staff separated the residents, and she notified the doctor. She stated there were no new orders given. She stated she did not complete a physical assessment on Resident #5 after the incident. She stated she did speak with Resident #5 and asked her if she was ok. She confirmed no physical assessment was performed on Resident #5 after Resident #4 grabbed her breast. S13NP confirmed there were no new interventions put into place once the 72 hour supervision ended to prevent Resident #4 from sexually abusing another resident. 47732 49343

Based on interviews and record review, the facility failed to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to ensure 1 (Resident #5) of 6 (#1, #2, #3, #4, #5, and #6) sampled residents reviewed for sexual abuse were free from sexual abuse by failing to: 1. Protect 1 (Resident #5) female resident from sexual abuse by Resident #4, a resident with known sexually inappropriate behaviors; and 2. Implement interventions to prevent further sexual abuse by Resident #4. The deficient practice resulted in an Immediate Jeopardy situation on 08/29/2023 when Resident #4, a moderately cognitively impaired resident, returned to the facility from a psychiatric hospital stay for sexually inappropriate behaviors. Upon Resident #4 returning to the facility on [DATE], he continued to exhibit sexually inappropriate behaviors with staff. On 09/13/2023 at 1:45 p.m., Resident #4 grabbed Resident #5's breast. After the incident, Resident #4 was placed on 1:1 supervision for 72 hours. After 72 hours, the 1:1 supervision was discontinued and no new interventions were implemented to ensure Resident #4 would not sexually abuse another resident. Staff interviews revealed Resident #4 continued to exhibit sexually inappropriate behaviors after the incident on 09/13/2023. Due to the lack of new interventions, there was a likelihood of Resident #4 sexually abusing other residents if not immediately corrected. S1ADM, S2DON, and S3CVP were notified of the Immediate Jeopardy on 10/04/2023 at 6:55 p.m. The Immediate Jeopardy was removed on 10/05/2023 at 2:50 p.m. when the facility submitted an acceptable Plan of Removal. Through observations, interviews and record reviews, the surveyors confirmed the following had been initiated and/or implemented prior to exit. The Immediate Jeopardy Plan of Removal included the following: -On 10/04/2023 Resident #4's care plan was updated to include intervention of one on one observation and inpatient behavioral services. -On 10/04/2023 at 7:30 p.m. Immediately Resident #4 was placed on one on one observation. -On 10/04/2023 physician was notified and orders noted to send Resident #4 to inpatient behavioral health services. Resident discharged from building at 10:00 p.m. on 10/04/2023 to behavioral inpatient. Resident is not to return to the facility. -On 10/04/2023 at 10:00 p.m. Resident #4 was transported to inpatient behavioral health services. -On 10/05/2023 76 Residents with BIMS (Brief Interview for Mental Status) of 9 or greater were interviewed by IDT Team to ensure that they had not been abused and had not witnessed any abuse or neglect of a fell ow resident as well as to inquire about their safety. Process initiated on 10/04/2023 8:00 p.m. Time of completion on assessments: 10/05/2023 8:30 a.m. -On 10/05/2023 26 Residents were assessed by licensed nurses conducting skin sweeps for suspicious injuries. Process initiated on 10/04/2023 8:00 p.m. Time of completion on assessments: 10/05/2023 8:30 a.m. -On 10/05/2023 Resident #5 to receive psychiatric consultation and ongoing weekly monitoring by psychiatric services and social worker. -Quality Assurance Performance Committee (QAPI) met on 10/04/2023 at 9:30 p.m. to review 09/13/2023 incident of Resident #4's inappropriate sexual behavior and determine a Root Cause. Meeting was led by Assistant Regional [NAME] President of Operations and Executive Director. Attendees were Executive Director (ED), Regional [NAME] President of Operations (RVPO), Social Services Director (SSD), Housekeeping Supervisor (HKS), Business Office Manager (BOM), and Director of Nursing (DON), Activities Director (AD, Therapy Manager (TM), Maintenance Supervisor (MS), Licensed Nurse (LPN) and Medical Records Clerk (MRC) and Director of Sales and Marketing (DSM). The Root Cause was determined to be that the facility failed to ensure resources were effectively and efficiently used to put interventions in place to prevent sexual abuse. -On 10/04/2023 at 8:00 p.m. education was conducted with the Executive Director (ED) and the Director of Nursing (DON) by the Regional [NAME] President of Operations (RVPO) on Abuse, Neglect, and Misappropriation and on ensuring resources are effectively and efficiently used to put interventions in place to prevent sexual abuse by Residents with inappropriate sexual behavior. -Quality Monitoring on effectiveness of education to be reviewed by Assistant Regional [NAME] President of Operations by weekly visitation with the Regional Director of Clinical Services, Director of Nursing, and Executive Director weekly for 4 weeks and monthly for 3 months following. Monitoring will be held weekly by Administrator, Director of Nursing, Business Development Director, Admissions Coordinator, and Social Services Director or comparable designee. Monitoring team will review confirmed admission packets for potential hyper-sexual behaviors or tendencies. Any adverse findings will be rectified through care planning and appropriate interventions. Team will review baseline care plans of recent admissions. A random sample of 10 residents shall be interviewed for psychosocial well-being and reviewed with corporate leadership. To begin on 10/06/2023 and complete on 02/06/2024. All findings of reviews will be reported monthly to IDT through the QAPI meeting. -On 10/05/2023 7:00 a.m. education was conducted on Abuse, Neglect, and Misappropriation with emphasis on sexual abuse and appropriate interventions for a Resident with sexually inappropriate behaviors to prevent sexual abuse. All present staff completed on 10/05/2023 at 10:00 a.m., including MDS staff. Expected completion time on Full-Time staff by 10/06/2023 6:00 p.m. PRN staff will be requiring education prior to working their next shift. No staff shall be allowed to work his or her assignment until training has been completed. -Employees will receive training upon hire and prior to accepting assignment. The deficient practice continued at a potential for more than minimal harm for the 97 residents currently residing in the facility. Findings: Cross Reference F600 Review of Resident #4's Pre-facility admission Hospital Records dated 08/03/2023, revealed in part, the following: Resident #4 was admitted to the hospital on 06/15/2023 with hypersexual behaviors, verbally aggressive with staff, and masturbating in front of staff over the past few days. On 08/11/2023 Resident #4 was discharged and transferred to the nursing facility. Review of Resident #4's Nurse's Notes 09/13/2023 at 1:52 p.m., at approximately 1:45 p.m., it was reported that Resident #4 was rolling his wheelchair through the dayroom when he stopped by another resident grabbing Resident #5's whole breast and feeling on it. Resident #5 stated she was pushing his hand away and telling him don't touch me. The aide that was walking through the room got the resident away from victim and redirected to resident's room and reported it to the nurse. RP aware. S6LPN. Review of the clinical record revealed Resident #5 was admitted to the facility on [DATE] with diagnosis, which included Hemiplegia, Major Depressive Disorder, Generalized Anxiety, and Lack of Coordination. Review of the quarterly MDS with an ARD of 07/27/2023 revealed Resident #5 had a BIMS of 14 which indicated she was cognitively intact. An interview was conducted on 10/04/2023 at 6:02 p.m. with S15SW. She stated Resident #4 began having sexually inappropriate behaviors about a week after he was admitted to the facility. She stated Resident #4 was aware of his actions. She stated on 08/17/2023 she was performing a BIMS assessment on Resident #4 when he began asking her to have sexual relations with him, and grabbed at her private area and her breasts. S15SW reported this behavior to the NP. S15SW stated the NP visited the facility the same day and sent Resident #4 to the psychiatric facility on 08/17/2023 after the resident grabbed the NP's buttocks. She stated there were no changes to Resident #4's medications when he returned to the facility on [DATE]. She confirmed Resident #4 continued to exhibit the same sexual behaviors after he returned to the facility on [DATE]. She stated on 09/13/2023, Resident #4 grabbed Resident #5's breast. She stated after the incident dated 09/13/2023, Resident #4 was placed on 1:1 supervision for 72 hours. She confirmed other than being placed on 72 hour 1:1 supervision, there were not any other changes in his plan of care. She stated Resident #4 continued to exhibit sexual behaviors after the 1:1 was discontinued. S5LPN confirmed there were no new interventions put into place once the 72 hour supervision ended to prevent Resident #4 from sexually abusing another resident. An interview was conducted on 10/04/2023 at 2:10 p.m. with S2DON. He stated Resident #4 began having sexually inappropriate behaviors about a week after he was admitted to the facility. He stated Resident #4 was aware of his actions. He stated Resident #4 would inappropriately and sexually touch literally anyone. He stated the NP sent Resident #4 to the psychiatric facility on 08/17/2023 after the resident grabbed the NP's buttocks. He stated after Resident #4 returned to the facility on [DATE], there were no changes to his medications. He stated the resident continued to exhibit the same sexual behaviors. He stated on 09/13/2023 Resident #4 grabbed Resident #5's breast. S2DON stated staff did not assess Resident #5 to see if she had been physically or mentally injured after Resident #4 grabbed her breast. He stated after the incident dated 09/13/2023, Resident #4 was placed on 1:1 supervision for 72 hours. He confirmed other than the resident being placed on 72 hour 1:1 supervision, there had not been any other changes to his plan of care. He stated Resident #4 continued to exhibit sexual behaviors after the 1:1 was discontinued. He stated the development of a plan to further protect residents from Resident #4 would depend on how many incidents occurred. S2DON confirmed there were no new interventions put into place once the 72 hour supervision ended to prevent Resident #4 from sexually abusing another resident. An interview was conducted on 10/04/2023 at 2:22 p.m. with S13NP. She stated Resident #4 began having sexually inappropriate behaviors about a week after he was admitted to the facility. She stated Resident #4 was aware of his actions. She stated on 08/17/2023 staff verbalized concern that Resident #4 might try to touch a resident inappropriately. She stated Resident #4 was sent to the psychiatric facility on 08/17/2023 after the resident grabbed her buttocks. She stated after Resident #4 returned to the facility on [DATE], there were no changes to his medications. She stated the resident continued to exhibit the same sexual behaviors. She stated on 09/13/2023 Resident #4 grabbed Resident #5's breast. She stated after the incident dated 09/13/2023, Resident #4 was placed on 1:1 supervision for 72 hours. She confirmed other than the resident being placed on 72 hour 1:1 supervision, there had not been any other changes to his plan of care. She stated Resident #4 continued to exhibit sexual behaviors after the 1:1 was discontinued. She stated she received multiple phone calls from staff about Resident #4's sexually inappropriate behaviors which included touching. She stated physicians did not like to send residents to psychiatric facilities often for behaviors because it could confuse the resident. She stated the physician did not change any medications or put Resident #4 on further 1:1 supervision from admission to now. S13NP confirmed there were no new interventions put into place once the 72 hour supervision ended to prevent Resident #4 from sexually abusing another resident. An interview was conducted on 10/04/2023 at 3:30 p.m. with S1ADM. He stated Resident #4 began having sexually inappropriate behaviors about a week after he was admitted to the facility. He stated Resident #4 was aware of his actions. He stated Resident #4 was sent to the psychiatric facility on 08/17/2023 after the resident grabbed the NP's buttocks. He stated after Resident #4 returned to the facility on [DATE] there were no changes to his medications. He stated the resident continued to exhibit the same sexual behaviors. He stated on 09/13/2023 Resident #4 grabbed Resident #5's breast. He stated after the incident dated 09/13/2023, Resident #4 was placed on 1:1 supervision for 72 hours. He confirmed other than the resident being placed on 72 hour 1:1 supervision, there had not been any other changes to his plan of care. He stated Resident #4 continued to exhibit sexual behaviors after the 1:1 was discontinued. He stated Resident #4 should have been on 1:1 supervision following his return from the psychiatric facility on 08/29/2023. He stated if Resident #4 had been on 1:1 supervision, staff could have prevented Resident #5 from being touched inappropriately by Resident #4. He stated Resident #4 had only 1 incident of touching another resident inappropriately that they were aware of. He explained since it was only once, they did not initiate any further supervision. 47732 49343

Based on observations, interviews and record review, the facility failed to protect the residents' right to be free from physical abuse by staff for 1 (#7) of 5 (#1, #2, #4, #6, and #7) sampled residents. This deficient practice resulted in an actual harm for Resident #7, who was dependent on staff for ADL care, on 03/21/2023 when S20CNA threw a bed remote at the resident's face resulting in a Non-displaced Nasal Bone Fracture. Resident #7 was sent to the emergency room with a laceration. The injury caused Resident #7 severe pain and required an irrigation and debridement of the nasal cavity and wound care. Findings: Review of facility's policy titled Abuse, Neglect, Exploitation and Misappropriation revealed, in part, the following: It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation and/or misappropriation of property. Physical abuse includes but is not limited to: Hitting with an object. Review of Resident #7's clinical record revealed he was admitted to the facility on [DATE] with diagnoses which included, Unspecified Sequelae of Cerebral Infarction, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Rhabdomyolysis, Other Lack of Coordination, and Muscle Weakness. Review of the MDS with an ARD of 01/03/2023, revealed the Resident #7 was assessed by the facility to have a BIMS of 12, which indicated he was moderately cognitively intact. Further review revealed the resident required 2 person assistance with transfers, dressing, toileting, bed mobility and sit to lying position changes. Resident #7 was unable to walk with or without assistance. Review of Resident #7's current Care Plan revealed the following, in part: Onset date: 01/03/2023 Problem: Resident had an ADL self-care performance deficit. Approaches: Resident required 2 person assistance with transfers. Resident required 2 person assistance with dressing. Resident required 2 person assistance with toileting. Resident required 2 person assistance with chair to bed transfer. Resident is dependent. Review of Resident #7's Progress Notes documented by Direct Care Staff on 03/21/2023, revealed, in part, the following: 8:01 a.m., Called to room by S16CNA. Resident states S20CNA hit him in the face with a bed remote. Upon assessing face of resident, small amount of swelling noted to left cheek area, no bruising nor discoloration noted. New order noted, CT of Maxillofacial related to pain/swelling. Signed by S8UM. Review of Physician's Orders dated from admission through 03/20/2023, revealed no active orders to treat pain. Review of the facility's Internal Investigation Report dated 03/21/2023, revealed, in part, the following: Detailed Description of Event/Allegation: Resident #7 alleges S20CNA threw a bed remote and hit him in the face. Resident named employee and stated it happened on night shift. Accused Allegations: Physical Abuse Allegation Findings: Substantiated Review of the local Emergency Department's discharge documentation dated 03/21/2023 at 11:32 a.m., revealed, in part, the following: Resident #7 was brought to the Emergency Department with a chief complaint of nasal drainage and nasal pain. Assessment of head: Left swelling, laceration, left lateral brow area with 0.5cm laceration without bleeding. Assessment of nose: Moderate tenderness, swelling, left side worse than right, serosanguinous drainage from bilateral nares, left greater than right. CT Maxillofacial Findings: There is nasal soft tissue swelling noted. There is a non-displaced nasal bones fracture identified. There is tortuosity of the nasal septum. Review of Resident #7's Facility Physician's Orders placed after ER visit on 03/21/2023, revealed, in part, the following: Referral to ENT. New appointment for ENT on 03/23/2023 related to non-displaced nasal bone fracture and soft tissue swelling and Tramadol HCL Oral Tablet. Give 1 tablet by mouth every 8 hours as needed for pain. Review of Resident #7's Progress Notes documented by Direct Care Staff, on 03/21/2023, revealed, in part, the following: 3:30 p.m., CT results received showing non-displaced nasal bone fracture and soft tissue swelling. New order noted referral to ENT. Signed by S8UM. Review of the facility's CNA schedule dated 03/20/2023 revealed S20CNA was assigned to care for Resident #7 from 6:00 p.m. on 03/20/2023 through 6:00 a.m. on 03/21/2023. On 03/22/2023 at 2:35 p.m., an observation was made of Resident #7. Resident #7 was observed on the EMS stretcher being transferred to the local Emergency Department for evaluation. Resident #7's nose was observed to be reddened and swollen. Resident #7's left cheek was swollen. On 03/22/2023 at 2:40 p.m., an interview was conducted with S3RDOCS. She stated Resident #7 was being transferred to the Emergency Department for a third time to be evaluated for nasal drainage after S20CNA allegedly threw a remote, hitting the resident in the face and breaking his nose. On 03/23/2023 at 8:40 a.m., an attempt was made to conduct a telephone interview with S20CNA. No answer or return call received. On 03/23/2023 at 11:15 a.m., an interview was conducted with S8UM. She confirmed caring for Resident #7 and described him as a reliable source that could verbally communicate his wants and needs. She stated due to weakness after having a stroke, Resident #7 would not be able to get himself off the floor and back into bed without staff assistance if he fell . She stated she was notified by S16CNA on 03/21/2023 at 8:50 a.m. that Resident #7 reported S20CNA hit him in the face with a bed remote during the night of 03/20/2023. She stated upon assessment of Resident #7, his nose and left cheek were swollen. She stated Resident #7 told her S20CNA came to assist him with incontinent care, and before leaving his room, S20CNA grabbed the bed remote and threw it at his face. She stated Resident #7 said S20CNA threw the remote at his face on purpose. She confirmed S20CNA provided care for Resident #7 on 03/20/2023 from 6:00 p.m. through 03/21/2023 at 6:00 a.m. She confirmed throwing an object and hitting a resident was physically abusive. She stated Resident #7 was sent to the Emergency Department on 03/21/2023 and then again twice on 03/22/2023 related to the nasal fracture. On 03/23/2023 at 11:23 a.m., an interview was conducted with S11LPN. She stated if Resident #7 fell , he would not be able to get himself back into bed without staff assistance due to weakness after having a stroke. She stated Resident #7 was a reliable source that could verbally communicate his wants and needs. She stated a staff member throwing an object and hitting a resident in the face was physically abusive. She stated Resident #7 returned from the Emergency Department on 03/21/2023 with a diagnosis of a nasal fracture and was then again sent to the Emergency Department twice on 03/22/2023 due to increased nasal drainage and an elevated temperature. On 03/23/2023 at 11:34 a.m., an interview was conducted with S21CNA. She confirmed caring for Resident #7 and described him as a reliable source that could verbally communicate his wants and needs. She stated due to weakness after having a stroke, Resident #7 would not be able to get himself off the floor and back into bed without staff assistance if he fell . She stated on 03/21/2023 at 8:50 a.m., Resident #7 told her and S16CNA that S20CNA threw the bed remote at him and it hit his face. She stated the resident's face was swollen and red on his left cheek. She stated Resident #7 told her it was painful. She stated she and S16CNA notified S8UM immediately. On 03/23/2023 at 12:05 p.m., an interview was conducted with S1ADM. He stated on 03/21/2023 at 08:50 a.m. he was notified Resident #7 alleged S20CNA threw a bed remote at his head and hit him in the face. He stated after investigation into the allegation of abuse, he determined physical abuse occurred after Resident #7's CT scan confirmed a nasal fracture. He described Resident #7 as a reliable source. He stated Resident #7 selected S20CNA in a photo lineup as the perpetrator of abuse during police investigation. He confirmed throwing an object and hitting a resident physical abuse. On 03/23/2023 at 12:27 p.m., an attempt was made to conduct a telephone interview with S20CNA. No answer or return call received. On 03/23/2023 at 1:30 p.m., an observation was made of Resident #7. Resident #7's nose was observed to be swollen and red. Resident #7's left cheek was observed to be swollen with a small laceration. On 03/23/2023 at 1:31 p.m., an interview was conducted with Resident #7. Resident #7 stated S20CNA threw the bed remote at him and it hit him in the face on the night of 03/21/2023. He stated he did not know why the CNA threw it at him. He stated S20CNA threw the remote at him on purpose. He stated S20CNA did not say anything when it happened, and she just left. He stated he told the morning CNAs, S16CNA and S21CNA, what happened when they came on shift. He stated his face and nose were extremely painful, and now he had an abscess in his nose that the ENT had to stick with a needle. He stated if he had fallen out of his bed, he would not be able to get back into bed without staff assistance. On 03/23/2023 at 1:55 p.m., an interview was conducted with S3RDOCS. She stated Resident #7 was able to voice his wants, needs, and was reliable in conversation. She stated she and S1ADM worked together to perform the investigation into Resident #7's allegation of physical abuse from S20CNA. She stated herself and S1ADM called S20CNA on 03/21/2023. S20CNA confirmed she provided care for Resident #7 on 03/20/2023 from 6:00 p.m. through 03/21/2023 at 6:00 a.m. She stated S20CNA would not confirm an incident happened with Resident #7 during her shift. On 03/23/2023 at 2:00 p.m., a telephone interview was conducted with S23LPN. She confirmed caring for Resident #7 and described him as a reliable source that could verbally communicate his wants and needs. She stated due to weakness after having a stroke, Resident #7 would not be able to get himself off the floor and back into bed without staff assistance if he fell . She stated she gave Resident #7 his 10:00 p.m. medications on 03/20/2023 in his room. She stated at that time, Resident #7 had no complaints of pain and had no marks or swelling to his face. She confirmed S20CNA provided care for Resident #7 on 03/20/2023 from 6:00 p.m. through 03/21/2023 at 6:00 a.m. On 03/23/2023 at 3:05 p.m., an interview was conducted with S16CNA. She confirmed caring for Resident #7 and described him as a reliable source that could verbally communicate his wants and needs. She stated due to weakness after having a stroke, Resident #7 would not be able to get himself off the floor and back into bed without staff assistance if he fell . She stated Resident #7 was resting in his bed when she entered his room on 03/21/2023 at 8:50 a.m. She stated she observed Resident #7's face to be swollen and red. She stated Resident #7 told her and S21CNA that S20CNA threw the bed remote and the remote hit him in the face. She stated Resident #7 stated his face was painful. She stated she and S21CNA then notified S8UM immediately. Based on interviews and record reviews, the facility failed to protect the resident's right to be free from neglect for 1 (#2) of 5 (#1, #2, #4, #6, #7) sampled residents when S15CNA and S24CNA neglected to transfer Resident #2 according to his care plan. This deficient practice resulted in an actual harm on the morning of 02/06/2023. Resident #2, a cognitively intact resident diagnosed with paraplegia, was transferred by S15CNA and S24CNA without the use of a mechanical lift. During the transfer, Resident #2 heard a pop in his right knee, and immediately reported this to S15CNA and S24CNA. Resident #2 developed severe pain and was later transferred to the emergency room and diagnosed with a Right Tibia Fracture. Findings: A review of the facility's policy and procedure titled: Abuse, Neglect, Exploitation, and Misappropriation revealed the following, in part: Policy: It is inherent that each resident be afforded the right to be free from neglect. Employees are charged with a continuing obligation to treat residents so they are free from neglect. No employee may at any time commit an act of neglect against any resident. Definitions: Neglect is the failure of the center, its employees or service providers to provide services to a resident that are necessary to avoid physical harm or pain. Examples include: 2. Failure to take precautionary measures to protect the health and safety of the resident. 3. Failure to provide services that result in harm to the resident. A review of the facility's policy and procedure titled: Transfer/Mobility Evaluation Low Lift revealed the following, in part: Policy: Center will evaluate the transfer and lifting needs of the resident to safely and comfortably transfer according to their individualized needs. Procedure: 4. Lift status will be indicated on the resident's care plan and Kardex. A review of the facility's policy and procedure titled: Lifting and Moving Residents revealed the following, in part: Use a mechanical lift to transfer a resident who cannot stand from the bed to the wheelchair. Review of the medical records for Resident #2 revealed he was admitted to the facility on [DATE] with diagnoses which included Paraplegia, End Stage Renal Disease (Hemodialysis Dependent), Peripheral Vascular Disease, and Type 2 Diabetes Mellitus. Further review revealed Resident #2 was later diagnosed with a Fracture of the Right Tibia on 02/06/2023. A review of the Significant Change MDS with an ARD of 02/13/2023 revealed Resident #2 had a BIMS of 15, which indicated he was cognitively intact. Further review revealed Resident #2 required two plus person physical assistance with mechanical lifts for transferring and was totally dependent upon staff for all mobility. Resident #2 had impairment to lower extremities on both side and was unable to stand, turn, or ambulate. A review of the current Care Plan revealed the following, in part: Onset: 06/17/2020 Resident #2 has an ADL self-care performance deficit related to paraplegia. Transfer: The resident needs full assistance with staff X 2 and mechanical lift for transfers. A review of the facility's incident report revealed 02/06/2023 S10LPN reported to S8UM: Resident #2 came to the nurses' station with complaints of right knee pain and unable to move his toes. He stated it happened while CNA's were transporting him from bed to chair this a.m. He heard a pop in his knee. S5MD was notified and instructed resident to go in to the ER when he returns from dialysis. A review of the facility's Incident Investigation revealed the following statements dated 02/06/2023: Resident #2 stated S15CNA and S24CNA came into my room to get me up. They told me they could not get the lift to work and they would have to stand and pivot me into my chair. After I stood up and went to pivot, my right foot stayed in place and didn't turn with my body. I heard a pop. S24CNA stated she assisted another CNA with getting Resident #2 up and into his chair. S24CNA stood on the left side and the other CNA was on the right of him. They slid him in his chair. Resident #2 did state that he felt his leg pop and complained of pain afterwards. We placed his legs on the leg rest. We left his room. We did not use a lift because the battery was dead and because Resident #2 stated that he had to be up at that time to eat breakfast before dialysis. S15CNA stated she had asked another CNA to help her get Resident #2 up for dialysis. We sat him up on the side of his bed. With the other CNA on one side and S15CNA on the other side, we proceeded to lift him up to put him in the chair. We didn't use the lift because it was being used on somebody else. A review of the Nurse's Notes dated 02/06/2023 revealed the following, in part: 06:19 a.m. S10LPN entered: Resident #2 came to the nurse's station with a complaint of right knee pain and reported his toes won't move. Resident #2 stated it happened while CNA's were transporting him from his bed to his wheelchair this a.m. and he heard a pop in his knee. S5MD notified and instructed S10LPN to have Resident #2 go to the ER when he returns from dialysis. Resident #2 verbalized agreement. A review of the medical records from the local dialysis center dated 02/06/2023 revealed the following, in part: 6:30 a.m. - Prior to arrival, Resident #2 called and reported that his knee got hurt this morning when he was moved to his wheelchair. He reported the facility didn't use the lift. He said that he was probably going to be taken to the ER. 7:09 a.m., Resident #2 in wheelchair, late for treatment. Resident #2 reported that the nursing home didn't use a mechanical lift this morning and hurt his right knee. 7:10 a.m., Noted a large knot below the right knee and broken skin with slight bleeding on the right side of the knee. 9:18 a.m., Resident #2 requested off dialysis early re: right knee/leg hurting. 9:45 a.m., Dialysis Nurse Practitioner rounded. Order noted to send Resident #2 to ER for leg and knee x-rays re: injury this morning. Called for transport. A Review of the Dialysis Nurse Practitioner's note dated 02/06/2023 revealed the following, in part: Seen and examined Resident #2 today. He complained of right knee pain with swelling. He reported that he was being placed in his wheelchair this morning without using a mechanical (Hoyer) lift. 9:30 a.m., Send to ED for x-ray right leg/knee. On 03/22/2023 at 2:55 p.m. an interview was conducted with the dialysis RN Clinic Manager. She stated Resident #2 received dialysis treatments 3 times/week at the dialysis facility. She stated Resident #2 as cognitively intact. She stated Resident #2 arrived to dialysis late on 02/06/2023 and was complaining of pain to the right leg. She stated Resident #2 told her his right knee was injured at the nursing home prior to transportation to dialysis. She said Resident #2 described hearing a pop in his knee while being transferred by 2 CNA's without the use of a mechanical lift. She stated Resident #2's right leg had an obvious deformity with a large knot and a small break in the skin with a small amount of bright red blood near the right knee. She stated Resident #2 was always transferred with a mechanical lift at the dialysis facility due to his paraplegia. On 03/22/2023 at 3:04 p.m. an interview was conducted with the dialysis RN. She stated Resident #2 received dialysis treatments 3 times/week. She stated Resident #2 was cognitively intact. She stated Resident #2 arrived to dialysis late on 02/06/2023, and was complaining of pain to right leg. She stated Resident #2 told her his right knee was injured at the nursing home prior to transportation to dialysis. She said Resident #2 described hearing a pop in his knee while being transferred by 2 CNA's. She said she observed a large hematoma and a small break in skin with a small amount of bloody discharge near the right knee. She stated Resident #2 was always transferred with a mechanical lift at the dialysis facility due to his paraplegia. She stated Resident #2 was noted to have facial grimacing during dialysis treatment, and treatment was stopped early due to pain in right leg. On 03/22/2023 at 3:34 p.m. an interview was conducted with a Certified Hemodialysis Specialist. She stated on 02/06/2023 upon arrival to the dialysis facility, Resident #2 told her he was in pain. She stated Resident #2 told her his right knee was injured at the nursing home prior to transport to dialysis. She said Resident #2 described hearing a pop in his knee while being transferred by 2 CNA's without the use of a mechanical lift. She immediately notified the dialysis RN. She stated Resident #2 was always transferred with a mechanical lift at the dialysis facility due to his paraplegia. On 03/22/2023 at 3:57 p.m. an interview was conducted with the dialysis Nurse Practitioner. She stated Resident #2 was cognitively intact and had sensation to his lower extremities. She stated on 02/06/2023, Resident #2 was complaining of moderate to severe pain in the right leg. She stated Resident #2 conveyed to her that 2 staff at the nursing home transferred him without using the mechanical lift this morning and he felt a pop in his right knee. She stated Resident #2 notified her that his provider was already notified and had given an order for Resident #2 to be sent to ER after completing dialysis. She stated she observed a large hematoma just below the right knee and a skin tear with bloody discharge. She stated during Resident #2's dialysis treatment, she became concerned the resident may have suffered from a vascular injury that required life or limb treatment. She stated she then stopped dialysis treatment early to send him back to the facility in order for him to be evaluated. A review of Resident #2's Nurse's Notes dated 02/06/2023 revealed the following, in part: 10:20 a.m., Resident #2 arrived back from dialysis. S9LPN called report to the ER regarding the resident's right knee pain. EMS called for transport to ER. A review of the Emergency Department's records dated 02/06/2023 revealed the following, in part: Resident #2 arrived to the Emergency Department at 11:41 a.m. with a chief complaint of right knee pain and swelling. Resident #2 is paraplegic with diminished strength to lower extremities (chronic, unchanged). Reports intact sensation to lower extremities. Resident #2 informed the provider that he felt a pop in his knee earlier that day during a transfer at his nursing home facility. Resident #2 had acute onset of severe pain just distal to the right knee with associated swelling. Resident #2 appeared in mild distress secondary to pain. Resident #2 was in significant pain. Significant swelling and tenderness over the right tibial plateau. X-rays revealed an acute (right) tibial plateau fracture with extension into the tibial tuberosity. Orthopedic surgeon was consulted. Orthopedic surgeon did not recommend surgical repair due to comorbidities and being bed-bound. Resident #2 placed in knee immobilizer, then discharged back to nursing home facility with pain medication (Norco). A review of the facility's Nurse's Notes dated 02/06/2023 revealed the following, in part: 9:00 p.m. S10LPN entered: Resident #2 returned from the ER with a new diagnosis of a closed fracture of the right Tibial Plateau. New orders: Do not put weight on leg; Norco 10/325 (hydrocodone-acetaminophen) every 6 hours prn pain, (7-day supply,); Continue previous meds; Refer to orthopedic to be seen within one week. 02/07/2023 at 8:55 a.m. S9LPN entered: Resident #2 complaining of right leg pain uncontrolled. Provider notified. Pain medication increased to every four hours as needed for 48 hours then resume to every six hours as needed for pain. On 03/23/2023 at 12:30 p.m. a telephone interview was conducted with Resident #2. He stated he was paraplegic but has sensation to his lower extremities. He stated on the morning of 02/06/2023 he was transferred from his bed to his wheelchair by 2 CNAs, but he was unable to recall their names. He stated he was always transferred with a mechanical lift, but this day he was told the lift was not working. He stated the mechanical lift sling was placed in his wheelchair prior to transfer. Resident #2 stated during the transfer, his right foot did not pivot, and he heard a pop in his right knee. He said he immediately reported the pop to the CNAs that transferred him and then to S10LPN. He stated S10LPN told him S5MD wanted him to go to dialysis before going to the ER. He stated his pain was a 10/10 at that time. He stated once he got to dialysis he immediately reported his injury to the nurses and the NP assessed his right leg. He stated he had to stop dialysis early due to the severe pain in his right leg. He sent to the ER. He stated he had a fracture to the right lower leg. He stated he felt neglected by the CNAs when they made him transfer without a mechanical lift. He stated he still experiences pain in the right leg. On 03/15/2023 at 3:24 p.m. an interview was conducted with S15CNA. She stated she cared for Resident #2 often. She stated Resident #2 required a mechanical lift with 2 person assistance for all transfers. She stated on 02/06/2023 she and S24CNA transferred Resident #2 from his bed to his wheelchair without using the mechanical lift. She stated one mechanical lift was being used by another resident and the other mechanical lift had a dead battery. She confirmed she had been trained on using the mechanical lift by the facility. She stated she did know how to change the battery in the mechanical lift, but did not attempt to before transferring Resident #2 on 02/06/2023. She confirmed knowing transferring Resident #2 without the mechanical lift was unsafe. On 03/20/2023 at 1:18 p.m., an interview was conducted with S10LPN. She stated Resident #2 could communicate his needs and had sensation to his lower extremities. She stated Resident #2 required 2 staff and mechanical lift for transfers. She stated on 02/06/2023 she was responsible to care for Resident #2. She stated on 02/06/2023 prior to dialysis transport, Resident #2 notified her of right knee pain after CNAs transferred him from bed to wheelchair without the mechanical lift. She stated the CNAs should have used the mechanical lift but they had not on 02/06/2023. She stated. She stated it was neglectful to transfer Resident #2 without a mechanical lift. On 03/20/2023 at 12: 55 p.m., an interview was conducted with S9LPN. She stated Resident #2 could communicate his needs and had sensation to his lower extremities. She stated resident #3 required a mechanical lift for all transfers. She stated upon arrival to work on 02/06/2023 just before 7:00 a.m., Resident #2 was notifying S10LPN of right knee pain. She heard Resident #2 state the right knee pain started immediately after being transferred from bed to wheelchair by 2 CNAs and he heard a pop. She stated S10LPN received an MD order to send Resident #2 to ER after dialysis. She stated Resident #2 returned from dialysis early due to increasing right knee pain. She stated she assessed Resident #2's right leg and observed swelling below the knee with a raised area. She stated Resident #2 was sent to the ER via ambulance. She stated on 02/07/2023 she cared for Resident #2, and he complained of significant pain to the right leg. She stated she notified S5MD and received an order to increase the frequency of pain medication for 48 hours. She stated it was neglectful to transfer Resident #2 without a mechanical lift. On 03/20/2023 at 11:37 a.m., an interview was conducted with S5MD. He stated resident #2 was cognitively intact and required transfers with a mechanical lift. He stated on the morning of 02/06/2023, a nurse from the facility notified him Resident #2 was complaining of being inappropriately transferred and right knee pain. He stated he gave orders to send Resident #2 to the ER for evaluation and treatment after dialysis. He stated the local ER doesn't have dialysis capabilities and the resident was due for his dialysis treatment. He recalled Resident #2 returned from dialysis early due to right knee pain and was then sent to ER. He stated Resident #2 sustained a right tibial plateau fracture. He stated Resident #2 was in a lot of pain and was given Norco by the ER MD. He confirmed Resident #2 was transferred unsafely on 02/06/2023 and the resident suffered harm as a result of this neglect. On 03/20/2023 at 10:29 a.m., an interview was conducted with S8UM. She stated Resident #2 could communicate his needs and he had sensation to lower extremities. She stated the incident involving Resident #2 from 02/06/2023 was discussed in the facility's morning meeting on 02/07/2023. She then initiated an incident report. She recalled getting a statement from S10LPN and Resident #2. She stated Resident #2 was in pain after this incident. She confirmed Resident #2's transfer status was a mechanical lift with 2 staff. She confirmed Resident #2 was care planned for mechanical lift with 2 staff. She confirmed on 02/06/2023 the care plan was not followed for transferring Resident #2. She confirmed on 02/06/2023, Resident #2 should have been transferred using a mechanical lift with 2 staff. She stated this was neglect. On 03/20/2023 at 1:38 p.m. an interview was conducted with S6PTA. She stated Resident #2 could make his needs known and had sensation to lower extremities. She stated Resident #2 should always be transferred with a mechanical lift. She stated the mechanical lift was the safest way to transfer Resident #2 because he could not stand and pivot. On 03/20/2023 at 2:16 p.m., an interview was conducted with S7MDS. She stated she was responsible for MDS assessments and care planning. She confirmed Resident #2 required 2 person assistance with mechanical lift for transfers and was care planned for this. She S15CNA and S24CNA should have used the mechanical lift on 02/06/2023 to transfer Resident #2. She confirmed it was neglect to transfer Resident #2 without a mechanical lift. On 03/22/2023 at 11:30 a.m., an interview was conducted with S2DON. He confirmed if a resident requires a mechanical lift and both are in use, staff should not lift the resident until one is available. He stated if a battery is dead, the charging station has charged batteries at all times. He confirmed Resident #2's transfer status as a mechanical lift with 2 staff. He confirmed Resident #2 was care planned for transfers using a mechanical lift with 2 staff. He confirmed the care plan was not followed by S15CNA and S24CNA on 02/06/2023 when they transferred the resident without using the mechanical lift. He stated the transfer was unsafe, neglectful and resulted in harm to Resident #2. On 03/22/2023 at 12:20 p.m. an interview was conducted with S1ADM. He confirmed on 02/06/2023, staff failed to follow the care plan related to transfers for Resident #2. He confirmed S15CNA and S24CNA neglected Resident #2 on 02/06/2023 when they transferred him without the mechanical lift.

Based on observations, interviews and record reviews, the facility failed to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident by failing to ensure an effective system was implemented for preventing and controlling COVID-19 infections. The facility failed to ensure: 1. A staff member (S5CNA) reported signs and symptoms of COVID-19 prior to providing direct care to the residents residing on Hall C; 2. A staff member (S5CNA) did not care for 3 (#R14, #R15, and #R16) non-positive COVID-19 residents after she tested positive on 02/08/2023 at 11:06 p.m.; 3. COVID-19 testing was being performed and documented on all staff during an outbreak; 4. S10KDM was trained to perform COVID-19 testing accurately on self and kitchen staff (S17RD, S8KC, S7KA); 5. Nursing and kitchen staff (S6KA, S7KA, S8KC, S9CNA, S20LPN, S28DOM, S29ADOM, S30CNA, S31LPN, and S34LPN) wore a face mask during a COVID-19 outbreak; 6. Visitors were notified of active COVID-19 infections, provided a face mask, and educated on hand hygiene and social distancing prior to entering the facility; and 7. Outpatient facilities and transportation providers were notified of a COVID-19 outbreak in the facility. This deficient practice resulted in an Immediate Jeopardy situation with the likelihood of severe injury and/or death to facility residents beginning on 02/08/2023 at 6:59 p.m., when S5CNA entered the facility with signs and symptoms of COVID-19 and began providing direct patient care to non-COVID-19 positive residents on Hall C. On 02/08/2023 at 11:06 p.m., S5CNA tested positive for COVID-19 and continued to provide direct care for 3 non-COVID-19 positive residents (#R14, #R15, and #R16). On 02/08/2023 observations were made of facility staff failing to wear masks while providing resident care and handling resident food. Staff also failed to educate visitors on the facility's COVID-19 outbreak, signs and symptoms of COVID -19, provide masks, or instruct on infection control measures prior to the visitors entering the facility. Interviews with staff revealed staff and visitors had not been screened for signs and symptoms of COVID-19, visitors were not notified of the facility's COVID-19 outbreak and provided education and a face mask, and all staff that worked in the facility were not tested for COVID-19 since the outbreak began on 02/01/2023. Due to the facility failing to implement infection control measures, Residents #R6 and #R7 tested positive for COVID-19 on 02/08/2023 and Resident #R17 tested positive for COVID-19 on 02/09/2023. As of 02/09/2023, there were 102 residents residing in the facility with 10 active resident COVID-19 cases. S1ADM was notified of the immediate jeopardy on 02/09/2023 at 7:18 p.m. The facility presented the following Plan of Removal on 02/10/2023 at 4:20 p.m.: Plan of Removal: Brief Summary of Events: On 2/09/23 at 7:18 PM the State Agency (SA) notified the Executive Director (ED) of an immediate jeopardy related to F-835 Administration. The facility administration failed to ensure an effective system was in place to prevent and control the spread of COVID-19 infections in the facility since an outbreak dated 02/01/2023. An immediate jeopardy (IJ) template was provided to the ED by the SA. Immediate Action started on 02/09/2023 at 7:30 p.m.: - Signage was posted at both entrances on Visitor Infection Control and Stop Notification to notify facility of any symptoms of COVID-19 or COVID-19 Positive results on 02/09/2023. QI Monitoring Tool will be conducted by the ED/designee to ensure signage is posted at both entrances on Visitor Infection Control and Stop Notification to notify facility of any symptoms of COVID -19 or COVID-19 Positive results for three times per week for four weeks and then monthly for two months. - Employee screening log placed at front entrance for staff to begin screening prior to work and was initiated on 02/10/2023 using the Employee Screening form and will continue until facility is no longer in COVID-19 outbreak. QI Monitoring Tool will be conducted by the ED/designee to ensure employee screening logs placed at front entrance for staff to begin screening prior to work for three times per week for four weeks and then monthly for two months. - Employee testing log implemented on 02/10/2023. Infection Control Preventionist will maintain logs to ensure appropriate employees are tested during COVID-19 outbreak. QI monitoring tool will be conducted by DON or designee to ensure appropriate employees are tested two times per week for four weeks and then monthly for two months. - COVID-19 testing competency check-offs were initiated on 02/10/2023 by Regional Director of Clinical Services 2 (RDCS2). QI monitoring tool will be conducted by DON or designee to ensure competency in COVID-19 testing two times per week for four weeks, then weekly for 1 week, and then monthly for two months. - Executive Director education and competency was conducted by Regional [NAME] President of Operations on 02/10/2023 on the aforementioned education. Resident Specific Action: - Resident #R6, #R7 and #R17 room assignments were reassigned to accommodate cohorting positive COVID-19 with positive COVID-19 and exposed negative COVID-19 with exposed negative COVID-19. QAPI: - On 02/09/23 at 7:30PM the Quality Assurance Performance Improvement (QAPI) Committee met to review the F-835 Infection Control IJ template and conduct a Root Cause Analysis (RCA) and review policy and procedures for changes. Attendees were the Executive Director (ED), Interim Director of Nursing (DON), Activities Director (AD), Housekeeping Supervisor (HIC), Regional Director of Clinical Services (RDCS), Director of Therapy (DOR), Assistant Director of Nursing (ADON), Business Office Manager (BOM), and Human Resources Director (HRD). The Medical Director (MD) was notified by phone. - The RCA determined the facility administration failed to ensure an effective system was in place to prevent and control the spread of COVID-19 infections. - The facility failed to alert visitors of active COVID-19 cases, provide education to visitors regarding infection control related to COVID-19, and provide face mask while visiting in the facility. - The facility failed to ensure staff were screened for COVID-19 prior to working in the facility. - The facility failed to maintain tracking and documentation of COVID-19 testing. - The facility failed to ensure staff were knowledgeable and trained to accurately perform point of care COVID-19 testing. Education: - Current Employees including agency and contract, will receive training upon hire and prior to working with emphasis on the following: - Visitors will be alerted to active COVID -19 infections, provided education, screened and provided face mask prior to entering the facility. Signage will be provided at entrance to include Infection Control information regarding COVID-19. Education and competency initiated by Regional Director of Clinical Services 2 (RDCS2) on 02/10/2023. Education and competency will be completed by 02/13/2023. Current staff will be screened prior to working within the facility. Education and competency initiated by Regional Director of Clinical Services 2 (RDCS2) on 02/10/2023. Education and competency will be completed by 02/13/2023. - Tracking and documentation of COVID-19 will be maintained by the infection Control Preventionist. Education and competency initiated by Regional Director of Clinical Services 2 (RDCS2) on 02/10/2023. Education and competency will be completed by 02/13/2023. - Current staff will be knowledgeable and trained to accurately perform point of care COVID-19 testing. Education and competency initiated by Regional Director of Clinical Services 2 (RDCS2) on 02/10/2023. Education and competency will be completed by 02/13/2023. - No current employee or new hire will work without the aforementioned education. - A reconciliation will be completed on education records and current employee list to ensure the aforementioned education is completed by 02/15/2023. The Immediate Jeopardy was removed on 02/10/2023 at 4:20 p.m. when the provider presented an acceptable plan of removal. Through observations, interviews and record review, the surveyors confirmed the above components of the plan of removal had been initiated and/or implemented prior to exit. This deficient practice continued at more than minimal harm for the remaining 92 non-positive COVID-19 residents residing in the facility that were at risk for contracting COVID-19. Findings: Cross Reference F-880 Cross Reference F-882 An interview was conducted with S2IDON on 02/08/2023 at 9:30 a.m. She stated she was currently in charge of the Infection Control Program and she was the facility's Infection Preventionist. She stated her and S27DON were responsible for tracking infections, identifying patterns, monitoring infection practices, and implementing practices to improve quality. She stated she was responsible for implementation of COVID-19 infection control practices. She stated the facility outbreak dated 02/01/2023 began from an employee, S11CNA, who tested positive for COVID-19. She stated she was unsure what the current COVID-19 community transmission rate was. She stated there was a COVID-19 rapid testing document the nurses were supposed to fill out for staff and residents after they were tested for COVID-19, but she did not know how the COVID-19 testing was being tracked. She confirmed all facility staff should have been tested last week. She confirmed the facility provided all COVID-19 tests performed after the start of the outbreak on 02/01/2023 and there were staff members that had been working after the outbreak without a COVID-19 test result. She stated all staff should have been wearing a N95 mask covering their mouth and nose in resident care areas, including during the provision of care and while preparing food for the residents. She stated it was never acceptable for the staff to provide care for a resident unmasked. An interview was conducted on 02/09/2023 at 12:45 p.m. with S2IDON, S3ADON and S4CN. S2IDON stated pre-shift screening on employees was not required and had not been implemented since the start of the outbreak on 02/01/2023. She stated she depended on staff to report if they were experiencing symptoms. She stated she expected an employee with any kind of illness to report that to their supervisor before they reported to work. She stated she would have expected the staff to be educated on reporting symptoms of COVID-19 prior to their shift. She stated on 02/08/2023, after S5CNA tested positive for COVID-19, she was allowed to stay the remainder of her shift. S2IDON confirmed S5CNA should not have been allowed to care for any non-COVID-19 positive residents. S3ADON stated she would have expected the positive COVID-19 employee to separate from the negative COVID-19 employees. S4CN stated S5CNA should not have been allowed to work in the facility after testing positive for COVID-19. S2IDON stated there was no documentation COVID-19 testing was being conducted on all facility and contract staff weekly. She stated the system for tracking COVID-19 testing of staff was to keep the COVID-19 Rapid Test Result sheet for each staff. She confirmed she could not find all COVID-19 test results for all staff. She stated there was not a log or documentation kept by administration to ensure each staff member was tested for COVID-19. She confirmed it was the responsibility of the facility to ensure COVID-19 testing of facility and contract staff was being completed. S2IDON confirmed visitors were not being screened related to COVID-19. She stated she expected the staff to provide each visitor entering the facility with a mask. She stated she would not expect the staff to notify a visitor of an outbreak of COVID-19 in the facility. She stated she would not provide a visitor with any type of education regarding infection control practices if the resident they were visiting was not on isolation. S2IDON and S4CN confirmed any outside facility, day program, and/or transportation company utilized by the facility should have been immediately notified of the facility's COVID-19 Outbreak Status. S2IDON confirmed she did not know if there was a process in place on how the facility handled a COVID-19 outbreak. S2IDON stated any staff could perform COVID-19 testing as long as they had been trained. S2IDON stated she was unsure if staff were trained to perform COVID-19 testing. S2IDON stated the facility should have retained any training for the COVID-19 testing. S2IDON was unable to answer what the contract staff were trained to perform. S2IDON confirmed she had not performed any training or skills check-offs regarding COVID-19 testing or self-swabbing. S2IDON also confirmed she was not aware of and could not put her hands on any documentation to indicate facility or contracted staff had been trained or evaluated via skill check-off for COVID-19 self-swabbing. S2IDON then confirmed she expected all facility and contract staff to have been trained followed by return demonstration to ensure an adequate sample was obtained. S3ADON confirmed she had not performed any training or skills check-offs regarding COVID-19 testing or self-swabbing. S3ADON also confirmed she was not aware of and could not put her hands on any documentation to indicate facility or contracted staff had been trained or evaluated via skill check-off for COVID-19 self-swabbing. S3ADON confirmed any staff member performing COVID-19 testing should have been trained. S4CN confirmed you should wait for 15 minutes after performing a COVID-19 rapid swab and document the result. S4CN confirmed it was not best practice to allow staff to self-swab for COVID-19 testing. S2CN confirmed the test should have been performed by a trained medical professional and not dietary/kitchen staff. S4CN stated if an adequate specimen was not obtained and if the testing procedure was not followed according to manufacturer instructions, the test results could have been inaccurate. S4CN stated when performing the Abbott BinaxNOW (Trademark) COVID-19 Ag CARD test, the results required a minimum of 15 minutes and maximum of 30 minutes to process after the application of the antigen drops to the swab. Both S2IDON and S3ADON verbalized agreement with S4CN's two above statements. A telephone interview was conducted with S27DON on 02/08/2023 at 11:43 a.m. He stated he was responsible for keeping track of staff COVID-19 testing for the week of 02/01/2023 when the COVID-19 outbreak began. He stated he thought all staff had been tested but did not have documentation they had been. He stated he did not track COVID-19 testing for contract staff, which included therapy, housekeeping, laundry, and dietary staff. He stated he notified each department head that their staff needed to be tested for COVID-19 weekly, but did not follow up to ensure the staff were actually being tested . He stated it was the department head's responsibility to ensure each of their staff was being tested weekly. An interview was conducted with S27DON on 02/14/2023 at 12:45 p.m. He confirmed all outside facilities, day programs and/or transportation companies utilized by the facility should have been immediately notified of the COVID-19 Outbreak Status within the facility. An interview was conducted with S1ADM on 02/09/2023 at 11:18 a.m. He confirmed he was notified of S5CNA testing positive for COVID-19 around 11:00 p.m. on 02/08/2023. He stated the decision was made to assign her to the rooms on Hall C that had COVID-19 positive residents in them. He confirmed there were 3 rooms on Hall C that contained a COVID-19 positive and a COVID-19 negative resident. He stated it was not acceptable for S5CNA, a COVID-19 positive employee, to provide direct care to any non-COVID-19 positive residents. An interview was conducted on 02/09/2023 at 1:35 p.m. with S1ADM. He confirmed the current COVID-19 outbreak began on 02/01/2023. He stated he was not sure if he expected staff to screen prior to their shift during a COVID-19 outbreak. He stated if a staff member was in the facility and began having symptoms of COVID-19, he would have expected them be tested and leave the facility immediately. He stated he was not notified S5CNA was symptomatic of COVID-19. He stated the current system the facility had to ensure COVID-19 testing was being completed on all staff was not working. He stated visitors should have been asked to wear a mask. He stated there should have been signage posted to make visitors aware of the facility's COVID-19 outbreak and there was not. He stated outpatient facilities should have been notified of the facility's COVID-19 outbreak. He confirmed he had not reviewed or verified the manufacturer's guidelines and/or instructions to ensure the facility was performing the COVID-19 testing procedure appropriately, to verify if it allowed for self-swabbing or to verify if this type of test could be performed by an unqualified or untrained person. He stated he assumed since the company made a similar test for at home use, it would have been fine for anyone to self-swab. He stated staff should have been trained on rapid swabbing for COVID-19 used in the facility. He confirmed the processing time of the Abbott BinaxNOW (Trademark) COVID-19 Ag CARD test was a minimum of 15 minutes and max of 30 minutes from the time the nasal swabbing was performed. He confirmed a test that was performed incorrectly could yield an inaccurate result. He stated he expected staff to let the rapid COVID-19 test sit for 15 minutes prior to reading a result. He stated he expected masking at all times in the facility. He stated the administrative staff had been inconsistent. He stated training had not been completed on his new administrative staff. He stated the retention of staff should not have affected the quality of care for the residents or the facility's Infection Program An interview was conducted with S18MD on 02/09/2023 at 3:50 p.m. He confirmed he was the Medical Director for the facility. He confirmed staff should have worn a face mask covering their mouth and nose at all times when interacting with residents or during the preparation of food. He confirmed a COVID-19 positive staff member should not have been allowed to continue their shift and care for non-COVID-19 positive residents. He stated he expected the facility to notify visitors of the COVID-19 outbreak status. He confirmed the facility should have notified outside facilities and outside transportation companies of the COVID-19 outbreak status in the facility. He confirmed staff should have been trained prior to performing COVID-19 testing. He confirmed if COVID-19 testing was performed incorrectly it could yield inaccurate results.

Based on observations, interviews, and record review, the facility failed to ensure an effective infection control and prevention program was implemented for preventing and controlling COVID-19 infections for 92 non-positive residents who resided in the facility during a COVID-19 outbreak. The facility failed to ensure: 1. A staff member (S5CNA) reported signs and symptoms of COVID-19 prior to providing direct care to the residents residing on Hall C; 2. A staff member (S5CNA) did not care for 3 (#R14, #R15, and #R16) non-positive COVID-19 residents after she tested positive on 02/08/2023 at 11:06 p.m.; 3. COVID-19 testing was being performed and documented on all staff during an outbreak; 4. S10KDM was trained to perform COVID-19 testing accurately on self and kitchen staff (S17RD, S8KC, S7KA); 5. Nursing and kitchen staff (S6KA, S7KA, S8KC, S9CNA, S20LPN, S28DOM, S29ADOM, S30CNA, S31LPN, and S34LPN) wore a face mask during a COVID-19 outbreak; 6. Visitors were notified of active COVID-19 infections, provided a face mask, and educated on hand hygiene and social distancing prior to entering the facility; and 7. Outpatient facilities and transportation providers were notified of a COVID-19 outbreak in the facility. This deficient practice resulted in an Immediate Jeopardy situation with the likelihood of severe injury and/or death to facility residents beginning on 02/08/2023 at 6:59 p.m., when S5CNA entered the facility with signs and symptoms of COVID-19 and began providing direct patient care to non-COVID-19 positive residents on Hall C. On 02/08/2023 at 11:06 p.m., S5CNA tested positive for COVID-19 and continued to provide direct care for 3 non-COVID-19 positive residents (#R14, #R15, and #R16). On 02/08/2023 observations were made of facility staff failing to wear masks while providing resident care and handling resident food. Staff also failed to educate visitors on the facility's COVID-19 outbreak, signs and symptoms of COVID -19, provide masks, or instruct on infection control measures prior to the visitors entering the facility. Interviews with staff revealed staff and visitors had not been screened for signs and symptoms of COVID-19, visitors were not notified of the facility's COVID-19 outbreak and provided education and a face mask, and all staff that worked in the facility were not tested for COVID-19 since the outbreak began on 02/01/2023. Due to the facility failing to implement infection control measures, Residents #R6 and #R7 tested positive for COVID-19 on 02/08/2023 and Resident #R17 tested positive for COVID-19 on 02/09/2023. As of 02/09/2023, there were 102 residents residing in the facility with 10 active resident COVID-19 cases. S1ADM was notified of the immediate jeopardy on 02/09/2023 at 7:18 p.m. The facility presented the following Plan of Removal on 02/10/2023 at 4:20 p.m.: Brief Summary of Events: On 02/09/2023 at 7:18 p.m., the State Agency (SA) notified the Executive Director (ED) of an immediate jeopardy related to F-880 Infection Control. The facility failed to implement a system for preventing and controlling COVID -19 infections within the facility after a confirmed outbreak on 02/01/2023. An immediate jeopardy (IJ) template was provided to the ED by the SA. Immediate Action started on 02/09/2023 at 7:30 p.m. - Signage was posted at both entrances on Visitor Infection Control and Stop Notification to notify facility of any symptoms of COVID-19 or COVID-19 Positive results on 02/09/2023. QI Monitoring Tool will be conducted by the ED/designee to ensure signage is posted at both entrances on Visitor Infection Control and Stop Notification to notify facility of any symptoms of COVID-19 or COVID-19 Positive results for three times per week for four weeks and then monthly for two months. - Visitor screening placed at entrance for visitor sign in area on 02/10/2023 using the Visitor/Vendor Screening form and will continue until facility is no longer in COVID-19 outbreak. QI Monitoring Tool will be conducted by the ED/designee to ensure visitor screening is placed at the entrance sign in area for three times per week for four weeks and then monthly for two months. - Quality rounds were performed on 02/09/2023 to ensure nursing staff donned face mask while providing direct patient care and kitchen staff donned face mask while prepping/serving meals during COVID-19 outbreak. QI Monitoring Tool will be conducted by the ED/designee to ensure quality rounds are performed to ensure nursing staff donned face mask while providing direct patient care and kitchen staff donned face mask while prepping/serving meals during COVID-19 outbreak for three times per week for four weeks and then monthly for two months. - Facility notified outpatient facilities and outpatient transportation providers on 02/09/2023 and will continue notifying weekly of a current COVID-19 outbreak in the facility and will continue until facility is no longer in COVID-19 outbreak. QI Monitoring Tool will be conducted by the ED/designee to notify outpatient facilities and outpatient transportation providers of a current COVID-19 outbreak in the facility weekly for four weeks and then monthly for two months. - Employee screening log placed at front entrance for staff to begin screening prior to work and initiated on 02/10/2023 using the Employee Screening Form and will continue until facility is no longer in COVID-19 outbreak. QI Monitoring Tool will be conducted by the ED/designee to ensure employee screening logs placed at front entrance for staff to begin screening prior to work for three times per week for four weeks and then monthly for two months. - S5CNA was relieved of duty on 02/09/2023 for a minimum of 10 days related to confirmed positive. Resident Specific Action: Resident #R6, Resident #R7 and Resident #R17 room assignments were reassigned to accommodate cohorting positive COVID-19 with positive COVID-19 and exposed negative COVID-19 with exposed negative COVID-19. QAPI: - On 02/09/2023 at 7:30 p.m. the Quality Assurance Performance Improvement (QAPI) Committee met to review the F-880 Infection Control IJ template and conduct a Root Cause Analysis (RCA) and review policy and procedures for changes. Attendees were the Executive Director (ED), Interim Director of Nursing (IDON), Activities Director (AD), Housekeeping Supervisor (HKS), Regional Director of Clinical Services (RDCS), Director of Therapy (DOR), Assistant Director of Nursing (ADON), Business Office Manager (BOM), and Human Resources Director (HRD). The Medical Director (MD) was notified by phone. - The RCA determined the facility failed to implement infection control measures for Resident R6 and Resident R7 who tested positive for COVID-19 on 02/08/2023 and Resident R17 who tested positive for COVID-19 on 02/09/2023. - The facility failed to alert visitors of active COVID-19 cases, provide education to visitor regarding infection control related to COVID-19, and provide face mask while visiting in the facility. - Direct care nursing staff were not donned in masks while providing direct care. - Kitchen staff were not donned in face mask while prepping and serving meals. - Outpatient facilities and outpatient transportation were not notified of a COVID-19 outbreak in the facility. - A Certified Nursing Assistant (CNA) who became symptomatic during a shift and tested positive for COVID-19 continued to provide care to COVID-19 positive and COVID-19 negative residents. Education: Current Employees including agency and contract, will receive training upon hire and prior to working with emphasis on the following: - Visitors will be alerted to active COVID-19 infections, provided education, screening and provided face mask prior to entering the facility. Signage will be provided at entrance to include Infection Control information regarding COVID-19. Education initiated by Regional Director of Clinical Services 2 (RDCS 2) on 0 2/10/2023 don face mask when prepping and serving meals and to be completed by the receipt date of statement of deficiencies. - Nursing staff will don face mask while providing direct resident care and kitchen staff will don face mask when prepping and serving meals. Education initiated by Interim Director of Nurses (IDON) on 02/10/2023 with nursing staff will don face mask while providing direct resident care and kitchen staff will don face mask when prepping and serving meals and to be completed by the receipt date of statement of deficiencies. - Facility will notify outpatient facilities and outpatient transportation providers of a COVID-19 outbreak in facility. Education initiated by Regional Director of Clinical Services 1 (RDCS 1) on 02/09/2023 with Interdisciplinary Team (IDT) and to be completed by the receipt date of statement of deficiencies. - Staff who test positive for COVID-19 with signs and symptoms of COVID-19 will self-report to their immediate supervisor, be relieved of duties, and exit the facility. Education initiated by IDON on 02/10/2023 with current staff to ensure staff who test positive for COVID-19 with signs and symptoms of COVID-19 will self-report to their immediate supervisor, be relieved of duties, and exit the facility. - No current employee or new hire will work without the aforementioned education. - A reconciliation will be completed on education records and current employee list to ensure the aforementioned education is completed by 02/15/2023. The Immediate Jeopardy was removed on 02/10/2023 at 4:20 p.m. when the provider presented an acceptable plan of removal. Through observations, interviews and record review, the surveyors confirmed the above components of the plan of removal had been initiated and/or implemented prior to exit. This deficient practice continued at more than minimal harm for the remaining 92 non-positive COVID-19 residents residing in the facility that were at risk for contracting COVID-19. Findings: 1. and 2. Review of the facility's policy titled, COVID-19 - Pandemic Plan revealed the following, in part: Employee Health: 28. Practices are in place that addresses the needs of symptomatic staff and facility staffing needs, including: - handling staff members who develop symptoms at work Review of the list of employees with positive COVID-19 test results revealed S5CNA tested positive on 02/08/2023. Review of the Time Card for S5CNA dated 02/08/2023 to 02/09/2023 revealed she clocked in for work at 6:59 p.m. on 02/08/2023 and clocked out at 5:51 a.m. on 02/09/2023. An interview was conducted with S42HR on 02/09/2023 at 9:56 a.m. S42HR reviewed S5CNA's time stamps and confirmed S5CNA worked in the facility from 6:59 p.m. on 02/08/2023 to 5:51 a.m. on 02/09/2023. A telephone interview was conducted with S5CNA on 02/09/2023 at 10:24 a.m. She stated when she entered the facility on 02/08/2023 for her night shift, she was feeling very tired, had body aches, and a headache. She stated the staff did not have to screen for signs and symptoms of COVID-19 prior to starting their shift. She stated she was assigned to care for the residents on Hall C at the beginning of her shift on 02/08/2023. She stated she took a COVID-19 test at the facility around 11:06 p.m. after realizing she could not taste her food and the results were positive. She stated she did not want to leave the facility short staffed and worked until around 6:00 a.m. on 02/09/2023. She further explained after testing positive, the night shift supervisor changed her room assignments so she cared for the isolation rooms on Hall C the remainder of her shift. She stated she was assigned to 5 isolation rooms with 2 residents in each. She stated she did not know if there were COVID-19 negative residents in the isolation rooms she cared for. She stated she did not limit her movement within the facility during her shift. An interview was conducted with S1ADM on 02/09/2023 at 11:18 a.m. He confirmed he was notified of S5CNA testing positive for COVID-19 around 11:00 p.m. on 02/08/2023. He stated the decision was made to assign her to the rooms on Hall C that had COVID-19 positive residents in them. He confirmed there were 3 rooms on Hall C that contained a COVID-19 positive and a COVID-19 negative resident. He stated it was not acceptable for S5CNA, a COVID-19 positive employee, to provide direct care to any non-COVID-19 positive residents. An interview was conducted with S36LPN on 02/09/2023 at 11:25 a.m. She stated there was a total of five COVID-19 isolation rooms on Hall C. She stated out of the 5 rooms there were 3 rooms that housed a COVID-19 positive resident with a non-COVID-19 positive resident. She stated the residents that were not COVID-19 positive and were housed with a COVID-19 positive resident were Residents #R14, #R15, and #R16. An interview was conducted with S30CNA on 02/08/2023 at 5:08 a.m. She confirmed staff were not required to perform screening for signs or symptoms of COVID-19 prior to their shift. An interview was conducted with S20LPN on 02/08/2023 at 5:16 a.m. She stated the staff were not required to screen for signs and symptoms of COVID-19 prior to their shift. An interview was conducted with S31LPN on 02/08/2023 at 5:20 a.m. She stated she did not screen for signs and symptoms of COVID-19 prior to beginning her shift and could not recall the last time she had done so. She explained staff were no longer required to screen for signs and symptoms of COVID-19 prior to the start of their shift. An interview was conducted with S9CNA on 02/08/2023 at 5:30 a.m. She stated she was not required to screen for signs or symptoms of COVID-19 prior to working in the facility An interview was conducted with S32CNA on 02/08/2023 at 5:35 a.m. She stated staff were no longer required to self-screen for signs and symptoms of COVID-19 prior to beginning their shift. She confirmed she did not self-screen prior to the start of her shift tonight and could not recall the last time she had done so. An interview was conducted of S6KA on 02/08/2023 at 6:10 a.m. She confirmed staff were no longer being screened for signs and symptoms of COVID-19 prior to entering the facility to start her shift. An interview was conducted with S35CNA on 02/08/2023 at 6:15 a.m. She stated she was not required to screen for signs and symptoms of COVID-19 prior to starting her shift. An interview was conducted with S36LPN on 02/08/2023 at 7:37 a.m. She confirmed she was not screened for signs and symptoms of COVID-19 prior to entry into the facility. An interview was conducted with S37LPN on 02/08/2023 at 7:51 a.m. She confirmed since the start of the facility's COVID-19 outbreak staff were not required to screen for signs and symptoms of COVID-19 prior to starting their shift. An interview was conducted with S38CNA on 02/08/2023 at 9:56 a.m. She confirmed she was not screened for signs and symptoms of COVID-19 prior to the start of her shift this morning and had not been screened since the start of the current COVID-19 outbreak. A telephone interview was conducted with S12LPN on 02/08/2023 at 11:16 a.m. She stated there was not a screening process for staff prior to entering the facility. An interview was conducted with S39HKLS on 02/08/2023 at 1:37 p.m. She stated the staff were not required to screen for signs or symptoms of COVID-19 prior to their shift. An interview was conducted with S2IDON, S3ADON and S4CN on 02/09/2023 at 12:45 p.m. S2IDON stated pre-shift screening on employees was not required and had not been implemented since the start of the outbreak on 02/01/2023. S2IDON stated she depended on staff to report if they were experiencing symptoms. S2IDON stated she expected an employee with any kind of illness to report that to their supervisor before they reported to work. S2IDON stated she would have expected the staff to be educated on reporting symptoms of COVID-19 prior to their shift. S2IDON stated on 02/08/2023, after S5CNA tested positive for COVID-19, she was allowed to stay the remainder of her shift. S2IDON confirmed S5CNA should not have been allowed to care for any non-COVID-19 positive residents. S3ADON stated she would have expected the positive COVID-19 employee to separate from the negative COVID-19 employees. S4CN stated S5CNA should not have been allowed to work in the facility after testing positive for COVID-19. An interview was conducted with S1ADM on 02/09/2023 at 1:35 p.m. He stated he was not sure if he expected staff to screen prior to their shift during a COVID-19 outbreak. He stated if a staff member was in the facility and began having symptoms of COVID-19, he would have expected them be tested and leave the facility immediately. He stated he was not notified S5CNA was symptomatic of COVID-19. An interview was conducted with S18MD on 02/09/2023 at 3:50 p.m. He confirmed a COVID-19 positive staff member should not have been allowed to continue their shift and care for non-COVID-19 positive residents. 3. Review of the facility's policy titled, COVID-19 - Pandemic Plan revealed the following, in part: Testing: Outbreak Investigation: iii. Staff and residents who are identified as close contacts or on affected units/floor or specific area of the center, regardless of vaccination status, will be tested . 1. Test immediately but not earlier than 24 hours after exposure, and if negative, a gain in 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. v. If additional cases are identified consider shifting to a broad-based testing approach if not already being performed .As part of the broad based approach, testing should continue on affected unit/floor(s) or facility-wide every 3-7 days until there are not new cases for 14 days. Documentation: Outbreak Investigation includes: -Date case was identified -Date other residents and staff were tested . -Date residents and staff were retested -Results of all tests. Review of the COVID-19 Community Transmission rate for the facility from the week of 02/03/2023 revealed it was high. Review of the COVID-19 test results for the residents that tested positive for COVID-19 since the beginning of the facility's outbreak on 02/01/2023 revealed the following: Date: 02/05/2023, Resident: Resident #R12, COVID - 19 Rapid test result: Positive Date: 02/05/2023, Resident: Resident #5, COVID - 19 Rapid test result: Positive Date: 02/05/2023, Resident: Resident #R11, COVID - 19 Rapid test result: Positive Date: 02/05/2023, Resident: Resident #R8, COVID - 19 Rapid test result: Positive Date: 02/05/2023, Resident: Resident #R10, COVID - 19 Rapid test result: Positive Date: 02/05/2023, Resident: Resident #R13, COVID - 19 Rapid test result: Positive Date: 02/05/2023, Resident: Resident #R9, COVID - 19 Rapid test result: Positive Date: 02/08/2023, Resident: Resident #R6, COVID - 19 Rapid test result: Positive Date: 02/08/2023, Resident: Resident #R7, COVID - 19 Rapid test result: Positive Date: 02/09/2023, Resident: Resident #R17, COVID - 19 Rapid test result: Positive Review of the list of employees with positive COVID-19 infection from 02/01/2023 through 02/13/2023 revealed the following employees tested positive on the following dates: S11CNA - 02/01/2023 S13RHB - 02/01/2023 S12LPN - 02/06/2023 S14COTA - 02/07/2023 S5CNA - 02/08/2023 S15LS - 02/08/2023 S40CNA - 02/08/2023 S41LPN - 02/13/2023 S20LPN - 02/13/2023 Review of the facility's COVID-19 Staff Testing Results for the week of 02/01/2023 compared to the facility's list of 112 active employees revealed 79 active employees did not have a COVID-19 test result during the current outbreak. Review of the list of current contract dietary staff provided by S10KDM revealed no COVID-19 test was conducted on the 9 staff members identified on the list between the dates of 02/01/2023 to 02/09/2023. Review of the current contract therapy staff provided by S13RHB revealed 15 of the 17 staff members on the list were not tested for COVID-19 between the dates of 02/01/2023 to 02/09/2023. Review of the current contract housekeeping and laundry staff provided by S39HKLS revealed 11 of the 12 staff members on the list were not tested for COVID-19 between the dates of 02/01/2023 to 02/09/2023. An interview was conducted with S3ADON on 02/08/2023 at 11:00 a.m. She confirmed the facility provided all documentation for staff COVID-19 testing that began with the outbreak on 02/01/2023. She confirmed she could not provide COVID-19 test results for the above staff members. A telephone interview was conducted with S27DON on 02/08/2023 at 11:43 a.m. He stated he was responsible for keeping track of staff COVID-19 testing for the week of 02/01/2023 when the COVID-19 outbreak began. He stated he thought all staff had been tested but did not have documentation they had been. He stated he did not track COVID-19 testing for contract staff, which included therapy, housekeeping, laundry, and dietary staff. He stated he notified each department head that their staff needed to be tested for COVID-19 weekly, but did not follow up to ensure the staff were actually being tested . He stated it was the department head's responsibility to ensure each of their staff was being tested weekly. An interview was conducted with S2IDON on 02/08/2023 at 9:30 a.m. She stated she was currently in charge of the Infection Control Program and she was the facility's Infection Preventionist. She stated her and S27DON were responsible for tracking infections, identifying patterns, monitoring infection practices, and implementing practices to improve quality. She stated she was responsible for implementation of COVID-19 infection control practices. She stated the facility outbreak dated 02/01/2023 began from an employee (S11CNA) who tested positive for COVID-19. She stated she was unsure what the current COVID-19 community transmission rate was. She stated there was a COVID-19 rapid testing document the nurses were supposed to fill out for staff and residents after they were tested for COVID-19, but she did not know how the COVID-19 testing was being tracked. She confirmed all facility staff should have been tested last week. She confirmed the facility provided all COVID-19 tests performed after the start of the outbreak on 02/01/2023 and there were staff members that had been working after the outbreak without a COVID-19 test result. She stated all staff should have been wearing a N95 mask covering their mouth and nose in resident care areas, including during the provision of care. She stated it was never acceptable for the staff to provide care for a resident unmasked. An interview was conducted with S39HKLS on 02/08/2023 at 1:37 p.m. She confirmed she and her staff were contract employees. She explained housekeeping and laundry staff went to the nurses' station in the facility to be tested for COVID-19 and S2IDON tracked to ensure they were tested . She confirmed she did not track to ensure all of her staff were being tested for COVID-19 weekly. An interview was conducted with S2IDON on 02/09/2023 at 12:45 p.m. S2IDON confirmed she did not know if there was a process in place on how the facility handled a COVID-19 outbreak. S2IDON stated there was no documentation COVID-19 testing was being conducted on all facility and contract staff weekly. She stated the system for tracking COVID-19 testing of staff was to keep the COVID-19 Rapid Test Result sheet for each staff. She confirmed she could not find all COVID-19 test results for all staff. She stated there was not a log or documentation kept by administration to ensure each staff member was tested for COVID-19. She confirmed it was the responsibility of the facility to ensure COVID-19 testing of facility and contract staff was being completed. An interview was conducted with S1ADM on 02/09/2023 at 1:35 p.m. He stated the current system the facility had to ensure COVID-19 testing was being completed on all staff was not working. He stated the administrative staff had been inconsistent. He stated training had not been completed on his new administrative staff. He stated the retention of staff should not have affected the quality of care for the residents or the facility's Infection Program. He confirmed the current COVID-19 outbreak began on 02/01/2023. 4. Review of the facility's policy titled, COVID-19 - Pandemic Plan revealed the following, in part: Testing: Point of Care (POC) Antigen Testing: -Center has identified and trained staff member(s) to utilize the POC device - as designated by the DON Review of the Product Guide for the Abbott BinaxNOW (Trademark) COVID-19 Ag CARD revealed, in part, the following: Frequently Asked Questions: What kind of test and is it accurate? . The visually read test . provides results in 15 minutes. What PPE to use/wear to perform the test? . Change gloves between handling of specimens. How do we dispose of test materials after testing? All components of the . test kit should be discarded as biohazard waste . Review of the FDA's Guide and Instructions For Use for the Abbott BinaxNOW (Trademark) COVID-19 Ag CARD revealed, in part, the following: The BinaxNOW (Trademark) COVID-19 Ag Card is intended for use by medical professionals or trained operators. NOTE: Failure to follow the instructions may result in inaccurate test results. Part 1 - Sample Test Procedure 3. Rotate (twirl) swab shaft 3 times CLOCKWISE (to the right). * Used test cards should be discarded as Biohazard waste . Precautions: 1. Failure to follow the instructions may result in inaccurate test results. 5. Treat all specimens as potentially infectious. Follow universal precautions when handling samples, this kit and its contents. 16. Change gloves between handling of specimens . 17. Do not read test results before 15 minutes . Results read before 15 minutes . may lead to a false positive, false negative, or invalid result. 19. False Negative results can occur if the sample swab is not rotated (twirled) prior to closing the card. An interview was conducted with S10KDM on 02/09/2023 at 9:30 a.m. He confirmed he was responsible for performing the COVID-19 testing of kitchen staff. He confirmed he tested using the Abbott BinaxNOW (Trademark) COVID-19 Ag CARD. He then confirmed the facility had never trained him or performed a competency skills check-off for the performance of COVID-19 testing nor did he have any documentation of completing the training at another facility. He then confirmed he would let the test process for no longer than 5 minutes before reading and documenting the results. He stated he brought the result forms to S2IDON and did not track the results himself. An observation was conducted with S10KDM on 02/09/2023 at 9:50 a.m. S10KDM donned a pair of clear white kitchen gloves then opened the Abbott BinaxNOW (Trademark) COVID-19 Ag CARDs test kit packets. At 10:00 a.m., S17RD, S8KC, S7KA, and S10KDM performed their self-swab. The employees then placed their swabs into their test card, and S10KDM placed the testing drops onto each of the test cards. He was not observed to perform the required swirling motion of the swabs following the application of the drops. At 10:04 a.m., S10KDM verbalized and transcribed all 4 results and stated they needed no longer than 5 minutes to process. At 10:05 a.m., S10KDM gathered the four processed tests and placed them in a coffee cup then placed them into a standard trash bag. An interview was conducted with S10KDM on 02/09/2023 at 10:10 a.m. He confirmed he performed all 4 tests without changing gloves and no one swirled the swab after the application of the testing drops. He confirmed he had allowed the tests to process for a total of 5 minutes from the time the employees performed their self-swab to the time he read the results. He then confirmed he discarded the dirty gloves and processed testing cards/swabs into a regular trashcan. An interview was conducted with S2IDON, S3ADON and S4CN. S2IDON on 02/09/2023 at 12:45 p.m. S2IDOnstated any staff could perform COVID-19 testing as long as they had been trained. S2IDON stated she did not know what staff were trained to perform COVID-19 testing. S2IDON stated the facility should have retained any training for the COVID-19 testing. S4CN confirmed you should wait for 15 minutes after performing a COVID-19 rapid swab and document the result. S4CN confirmed it was not best practice to allow staff to self-swab for COVID-19 testing. S4CN confirmed the test should have been performed by a trained medical professional and not dietary/kitchen staff. S2IDON stated she was unsure if staff were trained on performing swabbing for COVID-19. S2IDON was unable to answer what the contract staff were trained to perform. S2IDON confirmed she had not performed any training or skills check-offs regarding COVID-19 testing or self-swabbing. S2IDON also confirmed she was not aware of and could not put her hands on any documentation to indicate facility or contracted staff had been trained or evaluated via skill check-off for COVID-19 self-swabbing. S2IDON then confirmed she expected all facility and contract staff to have been trained followed by return demonstration to ensure an adequate sample was obtained. S3ADON confirmed she had not performed any training or skills check-offs regarding COVID-19 testing or self-swabbing. S3ADON also confirmed she was not aware of and could not put her hands on any documentation to indicate facility or contracted staff had been trained or evaluated via skill check-off for COVID-19 self-swabbing. S3ADON confirmed any staff member performing COVID-19 testing should have been trained. S4CN stated if an adequate specimen was not obtained and if the testing procedure was not followed according to manufacturer instructions, the test results could have been inaccurate. S4CN stated when performing the Abbott BinaxNOW (Trademark) COVID-19 Ag CARD test, the results required a minimum of 15 minutes and maximum of 30 minutes to process after the application of the antigen drops to the swab. Both S2IDON and S3ADON verbalized agreement with S4CN's two above statements. An interview was conducted with S1ADM on 02/09/2023 at 1:35 p.m. He confirmed he had not reviewed or verified the manufacturer's guidelines and/or instructions to ensure the facility was performing the COVID-19 testing procedure appropriately, to verify if it allowed for self-swabbing or to verify if this type of test could be performed by an unqualified or untrained person. He stated he assumed since the company made a similar test for at home use, it would have been fine for anyone to self-swab. He stated staff should have been trained on rapid swabbing for COVID-19 used in the facility. He confirmed the processing time of the Abbott BinaxNOW (Trademark) COVID-19 Ag CARD test was a minimum of 15 minutes and max of 30 minutes from the time the nasal swabbing was performed. He confirmed a test that was performed incorrectly could yield an inaccurate result. He stated he expected staff to let the rapid COVID-19 test sit for 15 minutes prior to reading a result. An interview was conducted with S18MD on 02/09/2023 at 3:50 p.m. He confirmed he was the Medical Director for the facility. He confirmed staff should have been trained prior to performing COVID-19 testing. He confirmed if COVID-19 testing was performed incorrectly it could yield inaccurate results. 5. An observation was conducted at Entry J prior to entering the facility on 02/08/2023 at 5:00 a.m. The front door and surrounding floor to ceiling windows were noted to be clear glass with an unobstructed line of sight into the facility from the exterior. 4 staff members were observed walking throughout the interior of the facility with no face masks in place. S31LPN was noted on Hall A at a medication cart with no face mask in place. S31LPN and S30CNA opened the door at Entry J for the su [TRUNCATED]

Based on observations, interviews, and record review, the facility failed to ensure the individual designated as the Infection Preventionist established and maintained an effective infection prevention and control program to prevent the spread of COVID-19. This deficient practice resulted in an Immediate Jeopardy situation with the likelihood of severe injury and/or death to facility residents beginning on 02/08/2023 at 6:59 p.m., when S5CNA entered the facility with signs and symptoms of COVID-19 and began providing direct patient care to non-COVID-19 positive residents on Hall C. On 02/08/2023 at 11:06 p.m., S5CNA tested positive for COVID-19 and continued to provide direct care for 3 non-COVID-19 positive residents (#R14, #R15, and #R16). On 02/08/2023 observations were made of facility staff failing to wear masks while providing resident care and handling resident food. Staff also failed to educate visitors on the facility's COVID-19 outbreak, signs and symptoms of COVID -19, provide masks, or instruct on infection control measures prior to the visitors entering the facility. Interviews with staff revealed staff and visitors had not been screened for signs and symptoms of COVID-19, visitors were not notified of the facility's COVID-19 outbreak and provided education and a face mask, and all staff that worked in the facility were not tested for COVID-19 since the outbreak began on 02/01/2023. Due to the facility failing to implement infection control measures, Residents #R6 and #R7 tested positive for COVID-19 on 02/08/2023 and Resident #R17 tested positive for COVID-19 on 02/09/2023. As of 02/09/2023, there were 102 residents residing in the facility with 10 active resident COVID-19 cases. S1ADM was notified of the immediate jeopardy on 02/09/2023 at 7:18 p.m. The facility presented the following Plan of Removal on 02/10/2023 at 4:20 p.m.: Plan of Removal: Brief Summary of Events: On 02/09/2023 at 7:18 p.m. the State Agency (SA) notified the Executive Director (ED) of an immediate jeopardy related to F-882 Infection Preventionist Qualifications/Role. The facility failed to ensure the Infection Preventionist established and maintained an effective infection prevention and control program to prevent the spread of COVID-19. An immediate jeopardy (IJ) template was provided to the ED by the SA. Immediate Action started on 02/09/2023 at 7:30 p.m.: - Signage was posted at both entrances on Visitor Infection Control and Stop notification to notify facility of any symptoms of COVID-19 or COVID-19 Positive results on 02/09/2023. QI Monitoring Tool will be conducted by the ED/designee to ensure signage is posted at both entrances on Visitor Infection Control and Stop Notification to notify facility of any symptoms of COVID-19 or COVID-19 Positive results for three times per week for four weeks and then monthly for two months. - Visitor screening placed at entrance for visitor sign in area on 02/10/2023 using the Visitor/Vendor Screening form and will continue until facility is no longer in COVID-19 outbreak. QI Monitoring Tool will be conducted by the ED/designee to ensure visitor screening is placed at the entrance sign in area for three times per week for four weeks and then monthly for two months. - Quality rounds were performed on 02/09/2023 to ensure nursing staff donned face mask while providing direct patient care and kitchen staff donned face mask while prepping/serving meals during COVID-19 outbreak. QI Monitoring Tool will be conducted by the ED/designee to ensure quality rounds are performed to ensure nursing staff donned face mask while providing direct patient care and kitchen staff donned face mask while prepping/serving meals during COVID-19 outbreak for three times per week for four weeks and then monthly for two months. - Facility notified outpatient facilities and outpatient transportation providers on 02/09/2023 and will continue notifying weekly of a current COVID-19 outbreak in the facility form and will continue until facility is no longer in COVID-19 outbreak. QI Monitoring Tool will be conducted by the ED/designee to notify outpatient facilities and outpatient transportation providers of a current COVID-19 outbreak in the facility weekly for four weeks and then monthly for two months. - Employee screening log placed at front entrance for staff to begin screening prior to work and initiated on 02/10/2023 using the Employee Screening form and will continue until facility is no longer in COVID-19 outbreak. QI Monitoring Tool will be conducted by the ED/designee to ensure employee screening logs placed at front entrance for staff to begin screening prior to work for three times per week for four weeks and then monthly for two months. - S5CNA was relieved of duty on 02/09/2023 for a minimum of 10 days related to confirm positive. - Employee testing log implemented on 02/10/2023. Infection Control Preventionist will maintain log to ensure appropriate employees are tested during COVID-19 outbreak. QI monitoring tool will be conducted by DON or designee to ensure appropriate employees are tested two times per week for four weeks and then monthly for two months. - COVID-19 testing competency check-offs were initiated on 02/10/2023 by Regional Director of Clinical Services 2 (RDCS2). QI monitoring tool will be conducted by DON or designee to ensure competency in COVID-19 testing two times per week for four weeks, then weekly for 1 week, and then monthly for two months. Resident/Staff Specific Action: - Resident R6, Resident R7, and Resident R17 room assignments were reassigned to accommodate cohorting positive COVID-19 with positive COVID-19 and exposed negative COVID-19 with exposed COVID-19. QAPI:| - On 02/09/2023 at 7:30 p.m. the Quality Assurance Performance Improvement (QAPI) Committee met to review the F-882 Infection Preventionist Qualifications/Role IJ template and conduct a Root Cause Analysis (RCA) and review policy and procedures for changes. Attendees were the Executive Director (ED), Interim Director of Nursing (IDON), Activities Director (AD), Housekeeping Supervisor (HO), Regional Director of Clinical Services (RDCS), Director of Therapy (DOR), Assistant Director of Nursing (ADON), Business Office Manager (BOM), Human Resources Director (HRD).The Medical Director (MD) was notified by phone. - The RCA determined the facility failed to ensure the Infection Preventionist established and maintain an effective Infection Control program by failing to provide oversight. - The facility failed to alert visitors of active COVID -19 cases, provide education to visitor regarding infection control related to COVID-19, and provide face mask while visiting in the facility. - Direct care nursing staff were not donned in masks while providing direct care. - Kitchen staff were not donned in face mask while prepping and serving meals. - Outpatient facilities and outpatient transportation was not notified of a COVID19 outbreak in the facility. - A Certified Nursing Assistant (CNA) who became symptomatic during a shift and tested positive for COVID-19 continued to provide care to COVID-19 positive and COVID-19 negative residents. - The facility failed to ensure staff were screened for COVID-19 prior to working in the facility. - The facility failed to maintain tracking and documentation of COVID-19 testing. - The facility failed to ensure staff were knowledgeable and trained to accurately perform point of care COVID-19 testing. Education: Current Infection Control Preventionist received training on 02/10/2023 by the Regional Director of Clinical Services 1 (RDCS1) on Infection Control with emphasis on: - Visitors will be alerted to active COVID -19 infections, provided education, screening and provided face mask prior to entering the facility. Signage will be provided at entrance to include Infection Control information regarding COVID-19. Education initiated by Regional Director of Clinical Services 2 (RDCS 2) on 02/10/2023. - Nursing staff will don face mask while providing direct resident care and kitchen staff will don face mask when prepping and serving meals. Education initiated by Interim Director of Nurses (IDON) on 02/10/2023 with nursing staff will don face mask while providing direct resident care and kitchen staff will don face mask when prepping and serving meats and to be completed by the receipt date of statement of deficiencies. - Facility will notify outpatient facilities and outpatient transportation providers of a COVID -19 outbreak in facility. Education initiated by Regional Director of Clinical Services 1 (RDCS 1) on 02/09/2023 with Interdisciplinary Team (IDT) and to be completed by the receipt date of statement of deficiencies. - Staff who test positive for COVID -19 with signs and symptoms of COVID -19 will self-report to their immediate supervisor, be relieved of duties, and exit the facility. Education initiated by DON on 02/10/2023 with current staff to ensure staff who test positive for COViD-19 with signs and symptoms of COVID-19 will self-report to their immediate supervisor, be relieved of duties, and exit the facility. Current employees including agency and contract, will receive training upon hire and prior to working with emphasis on staff who test positive for COVID-19 with signs and symptoms of COVID -19 will self-report to their immediate supervisor, be relieved of duties, and exit the facility. - Current staff will be screened prior to working within the facility. Education and competency initiated by Regional Director of Clinical Services 2 (RDCS2 2) on 02/10/2023. Educa and competency will be completed by 02/13/2023.Tracking and documentation of COVID-19 will be maintained by the Infection Control Preventionist. Education and competency initiated by Regional Director of Clinical Services 2 (RDCS2 2) on 02/10/2023. Education and competency will be completed by 02/13/2023. - Current staff will be knowledgeable and trained to accurately perform point of care COVID-19 testing. Education and competency initiated by Regional Director of Clinical Services 2 (RDCS2 2) on 02/10/2023. Education and competency will be completed by 02/13/2023. - No current employee or new hire will work without the aforementioned education. - A reconciliation will be completed on education records and current employee list of the aforementioned education is completed by 02/15/2023. The Immediate Jeopardy was removed on 02/10/2023 at 4:20 p.m. when the provider presented an acceptable plan of removal. Through observations, interviews and record review, the surveyors confirmed the above components of the plan of removal had been initiated and/or implemented prior to exit. This deficient practice continued at more than minimal harm for the remaining 92 non-positive COVID-19 residents residing in the facility that were at risk for contracting COVID-19. Findings: Cross Reference F-880 An interview was conducted with S2IDON on 02/08/2023 at 9:30 a.m. She stated she was currently in charge of the Infection Control Program and she was the facility's Infection Preventionist. She stated her and S27DON were responsible for tracking infections, identifying patterns, monitoring infection practices, and implementing practices to improve quality. She stated she was responsible for implementation of COVID-19 infection control practices. She stated the facility outbreak dated 02/01/2023 began from an employee, S11CNA, who tested positive for COVID-19. She stated she was unsure what the current COVID-19 community transmission rate was. She stated there was a COVID-19 rapid testing document the nurses were supposed to fill out for staff and residents after they were tested for COVID-19, but she did not know how the COVID-19 testing was being tracked. She confirmed all facility staff should have been tested last week. She confirmed the facility provided all COVID-19 tests performed after the start of the outbreak on 02/01/2023 and there were staff members that had been working after the outbreak without a COVID-19 test result. She stated all staff should have been wearing a N95 mask covering their mouth and nose in resident care areas, including during the provision of care and while preparing food for the residents. She stated it was never acceptable for the staff to provide care for a resident unmasked. An interview was conducted on 02/09/2023 at 12:45 p.m. with S2IDON, S3ADON and S4CN. S2IDON stated pre-shift screening on employees was not required and had not been implemented since the start of the outbreak on 02/01/2023. She stated she depended on staff to report if they were experiencing symptoms. She stated she expected an employee with any kind of illness to report that to their supervisor before they reported to work. She stated she would have expected the staff to be educated on reporting symptoms of COVID-19 prior to their shift. She stated on 02/08/2023, after S5CNA tested positive for COVID-19, she was allowed to stay the remainder of her shift. S2IDON confirmed S5CNA should not have been allowed to care for any non-COVID-19 positive residents. S3ADON stated she would have expected the positive COVID-19 employee to separate from the negative COVID-19 employees. S4CN stated S5CNA should not have been allowed to work in the facility after testing positive for COVID-19. S2IDON stated there was no documentation COVID-19 testing was being conducted on all facility and contract staff weekly. She stated the system for tracking COVID-19 testing of staff was to keep the COVID-19 Rapid Test Result sheet for each staff. She confirmed she could not find all COVID-19 test results for all staff. She stated there was not a log or documentation kept by administration to ensure each staff member was tested for COVID-19. She confirmed it was the responsibility of the facility to ensure COVID-19 testing of facility and contract staff was being completed. S2IDON confirmed visitors were not being screened related to COVID-19. She stated she expected the staff to provide each visitor entering the facility with a mask. She stated she would not expect the staff to notify a visitor of an outbreak of COVID-19 in the facility. She stated she would not provide a visitor with any type of education regarding infection control practices if the resident they were visiting was not on isolation. S2IDON and S4CN confirmed any outside facility, day program, and/or transportation company utilized by the facility should have been immediately notified of the facility's COVID-19 Outbreak Status. S2IDON confirmed she did not know if there was a process in place on how the facility handled a COVID-19 outbreak. S2IDON stated any staff could perform COVID-19 testing as long as they had been trained. S2IDON stated she was unsure if staff were trained to perform COVID-19 testing. S2IDON stated the facility should have retained any training for the COVID-19 testing. S2IDON was unable to answer what the contract staff were trained to perform. S2IDON confirmed she had not performed any training or skills check-offs regarding COVID-19 testing or self-swabbing. S2IDON also confirmed she was not aware of and could not put her hands on any documentation to indicate facility or contracted staff had been trained or evaluated via skill check-off for COVID-19 self-swabbing. S2IDON then confirmed she expected all facility and contract staff to have been trained followed by return demonstration to ensure an adequate sample was obtained. S3ADON confirmed she had not performed any training or skills check-offs regarding COVID-19 testing or self-swabbing. S3ADON also confirmed she was not aware of and could not put her hands on any documentation to indicate facility or contracted staff had been trained or evaluated via skill check-off for COVID-19 self-swabbing. S3ADON confirmed any staff member performing COVID-19 testing should have been trained. S4CN confirmed you should wait for 15 minutes after performing a COVID-19 rapid swab and document the result. S4CN confirmed it was not best practice to allow staff to self-swab for COVID-19 testing. S2CN confirmed the test should have been performed by a trained medical professional and not dietary/kitchen staff. S4CN stated if an adequate specimen was not obtained and if the testing procedure was not followed according to manufacturer instructions, the test results could have been inaccurate. S4CN stated when performing the Abbott BinaxNOW (Trademark) COVID-19 Ag CARD test, the results required a minimum of 15 minutes and maximum of 30 minutes to process after the application of the antigen drops to the swab. Both S2IDON and S3ADON verbalized agreement with S4CN's two above statements. A telephone interview was conducted with S27DON on 02/08/2023 at 11:43 a.m. He stated he was responsible for keeping track of staff COVID-19 testing for the week of 02/01/2023 when the COVID-19 outbreak began. He stated he thought all staff had been tested but did not have documentation they had been. He stated he did not track COVID-19 testing for contract staff, which included therapy, housekeeping, laundry, and dietary staff. He stated he notified each department head that their staff needed to be tested for COVID-19 weekly, but did not follow up to ensure the staff were actually being tested . He stated it was the department head's responsibility to ensure each of their staff was being tested weekly. An interview was conducted with S27DON on 02/14/2023 at 12:45 p.m. He confirmed all outside facilities, day programs and/or transportation companies utilized by the facility should have been immediately notified of the COVID-19 Outbreak Status within the facility. An interview was conducted with S1ADM on 02/09/2023 at 11:18 a.m. He confirmed he was notified of S5CNA testing positive for COVID-19 around 11:00 p.m. on 02/08/2023. He stated the decision was made to assign her to the rooms on Hall C that had COVID-19 positive residents in them. He confirmed there were 3 rooms on Hall C that contained a COVID-19 positive and a COVID-19 negative resident. He stated it was not acceptable for S5CNA, a COVID-19 positive employee, to provide direct care to any non-COVID-19 positive residents. An interview was conducted on 02/09/2023 at 1:35 p.m. with S1ADM. He confirmed the current COVID-19 outbreak began on 02/01/2023. He stated he was not sure if he expected staff to screen prior to their shift during a COVID-19 outbreak. He stated if a staff member was in the facility and began having symptoms of COVID-19, he would have expected them be tested and leave the facility immediately. He stated he was not notified S5CNA was symptomatic of COVID-19. He stated the current system the facility had to ensure COVID-19 testing was being completed on all staff was not working. He stated visitors should have been asked to wear a mask. He stated there should have been signage posted to make visitors aware of the facility's COVID-19 outbreak and there was not. He stated outpatient facilities should have been notified of the facility's COVID-19 outbreak. He confirmed he had not reviewed or verified the manufacturer's guidelines and/or instructions to ensure the facility was performing the COVID-19 testing procedure appropriately, to verify if it allowed for self-swabbing or to verify if this type of test could be performed by an unqualified or untrained person. He stated he assumed since the company made a similar test for at home use, it would have been fine for anyone to self-swab. He stated staff should have been trained on rapid swabbing for COVID-19 used in the facility. He confirmed the processing time of the Abbott BinaxNOW (Trademark) COVID-19 Ag CARD test was a minimum of 15 minutes and max of 30 minutes from the time the nasal swabbing was performed. He confirmed a test that was performed incorrectly could yield an inaccurate result. He stated he expected staff to let the rapid COVID-19 test sit for 15 minutes prior to reading a result. He stated he expected masking at all times in the facility. He stated the administrative staff had been inconsistent. He stated training had not been completed on his new administrative staff. He stated the retention of staff should not have affected the quality of care for the residents or the facility's Infection Program An interview was conducted with S18MD on 02/09/2023 at 3:50 p.m. He confirmed he was the Medical Director for the facility. He confirmed staff should have worn a face mask covering their mouth and nose at all times when interacting with residents or during the preparation of food. He confirmed a COVID-19 positive staff member should not have been allowed to continue their shift and care for non-COVID-19 positive residents. He stated he expected the facility to notify visitors of the COVID-19 outbreak status. He confirmed the facility should have notified outside facilities and outside transportation companies of the COVID-19 outbreak status in the facility. He confirmed staff should have been trained prior to performing COVID-19 testing. He confirmed if COVID-19 testing was performed incorrectly it could yield inaccurate results.

Based on interviews and record reviews, the facility failed to provide appropriate treatment and services for a resident with fecal incontinence in accordance with professional standards of practice. The facility failed to ensure: 1. Nursing staff assessed, monitored, implemented ordered interventions and communicated bowel status with the physician for 1 (#3) of 9 (#1, #2, #3, #4, #5, R3, R5, R10, and R11) residents reviewed; and 2. Nursing staff reviewed, clarified, and transcribed hospital discharge orders for 1 (#3) of 9 (#1, #2, #3, #4, #5, R3, R5, R10, and R11) residents. This deficient practice resulted in an immediate jeopardy situation for Resident #3, a quadriplegic with [CONDITION(S)] bowel and constipation, on 12/26/2021 when the nursing staff failed to recognize the resident did not have a bowel movement over 3 days and administer PRN Milk of Magnesia or other bowel medications per physicians orders. From 12/23/2021 through 01/03/2021, Resident #3 did not have a bowel movement or receive PRN bowel medications. This resulted in Resident #3 being transferred to the local hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Following the hospitalization , the facility failed to implement the hospital discharge recommendations provided by the GI Specialist for increased fiber, fluid needs and intake/output monitoring. From 01/09/2022 through 01/14/2022, Resident #3 did not have a bowel movement or receive PRN bowel medications, which resulted in him again being transferred to the hospital with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Faecalis Infection. Resident #3 was transferred from the local hospital via helicopter to another hospital on 01/14/2022 to receive a higher level of care due to the deterioration of his condition. S1ED was notified of the Immediate Jeopardy on 03/04/2022 at 6:15 p.m. The Immediate Jeopardy was removed on 03/08/2022 at 4:51 p.m., when the facility submitted an acceptable Plan of Removal. Through observations, interviews and record reviews, the surveyors confirmed the following had been initiated and/or implemented prior to exit: Immediate Action Taken: 1. Administrative staff worked in shifts in the building 24/7 throughout the weekend continuing audits, providing education, etc. 2. Completed 100% audit of resident bowel status and continued to monitor throughout the weekend 3. Completed 100% audit of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 4. Administrative nursing audited to ensure all staff have access to the kiosk to complete documentation monitoring throughout the weekend Resident Specific Action: 1. 03/04/2022 at 6:00 p.m.: Resident #3's current medications were reviewed with physician by the Director of Nursing (DON) to ensure staff can provide services needed to prevent impaction. No new orders were noted. 2. 03/04/2022 at 6:00 p.m.: Resident #3's current bowel movement documentation was reviewed by the Regional Director of Clinical Services. (Regional Director of Clinical Services (RDCS) reviewed Resident # 3's bowel movement documentation and noted resident had a bowel movement documented on 03/02/2022 and 03/04/2022.) 3. 03/04/2022: DON verified Resident #3's gastrointestinal specialist appointment on 03/17/2022 at 9:00 a.m. QAPI: 1. On 03/04/2022 at 6:15 p.m., the Quality Assurance Performance Improvement (QAPI) Committee met to review the F684 Quality of care IJ template and conduct a Root Cause Analysis (RCA) and review policy and procedures for changes. Attendees were the Executive Director (ED) , Director of Nursing (DON), Social Services Director (SSD) , Housekeeping Supervisor (HKS) , RDCS , Activities Director (AD) , Director of Therapy (DOR) , ADON , SDN , MDS nurse , Business Office Manager (BOM) ,Human Resources Director (HRD) , Assistant Business Office Manager (ABOM). The Medical Director (MD) was notified by phone. 2. The RCA determined appropriate treatment and services for residents with fecal incontinence to prevent impaction was not provided due to failure to assess and monitor bowel status, failure to administer PRN bowel medications per physician parameters and failure to provide physician notification regarding change in status and failure to follow through with scheduling specialty consultations. 3. The Notification of Change in Condition and the Medical Consultation policies were reviewed with no change to policy made. Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. 03/04/2022 at 6:00 p.m.: The Unit Manager (UM), SDN and the DON conducted a review of all current residents' orders to ensure there were appropriate orders to provide interventions for the residents to prevent constipation or impaction. The review indicated there was a need for additional PRN orders. The UM contacted the physician and noted the orders. 2. Quality monitoring of residents physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Residents with no Bowel Movements in 3 Days: 1. 03/04/2022: The RDCS and ADON conducted a quality review to determine Residents that had no BM in 3 days. There were three residents identified as having no bowel. All three resident had PRN bowel medications administered with results of a bowel movement within 24 hours. 2. Ongoing monitoring will be conducted 3 times weekly for 1 month then monthly for 3 months by the DON, ADON, SDN, or UM using the daily bowel movement audit form to identify residents with no bowel movement times 3 days. - To ensure physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . - To ensure nurses are communicating change in condition related to bowel movements using the 24 hour report form to the oncoming shift. - To ensure documentation of bowel movements by nurse aides. Review of Medical Specialty Consultations: 1. 03/05/2022: The RDCS and DON conducted a review of resident's specialty consultation orders for last 30 days. There were no medical specialty consults found to be out of compliance. 2. Ongoing quality monitoring will be conducted by the DON or designee weekly for 2 months then monthly for 3 months to ensure specialty medical consultation appointments are scheduled according to physician orders. 1. Nurse obtaining the specialty medical consult order will call the specialty clinic to schedule the appointment and document appointment date and time on 24 hour report. 2. DON or designee will review 24 hour report in morning clinical meeting and verify appointment with specialty clinic and document appointment on appointment calendar 3. Specialty appointment will be noted on the transportation schedule and reviewed by ED or designee weekly to ensure transport availability. 4. Appointment calendar will be reviewed in morning meeting to ensure appointment occurred and consultation report reviewed and reported to physician. Review of Bowel Movement Documentation by the Nurse Aid: 1. 03/04/2022: The RDCS, DON, and ADON conducted a review of the resident's bowel movement documentation for omissions. It was identified that there were omissions in bowel movement documentation by the nurse aides. Ongoing quality monitoring will be conducted by the DON, ADON, SDN, or UM of the resident's bowel movement documentation 3 times weekly for 2 months then monthly times 3 months to ensure nurse aides are documenting bowel movements. Review of Electronic Medical Record: 1. 03/05/2022: RDCS, ADON, and DON conducted a review of all residents electronic medication administration records to ensure routine bowel medications were administered according to the physician orders. 2. Ongoing quality monitoring will be conducted by the DON, ADON, SDN, or UM of the electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Care Plans: 03/06/2022: MDS Team reviewed all current residents care plans to ensure care plans were updated to reflect appropriate interventions for residents to prevent constipation or impaction. 1. Care plans will be updated by the MDS Team in the morning meeting to include change in condition, new interventions, and new physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 2. Upon admission the baseline care plan will reflect appropriate interventions for residents to prevent constipation or impaction. 3. Quality monitoring will be conducted by the MDS Regional or designee with a sample of 10 weekly for 1 month then monthly for 3 months to ensure residents plan of care are implemented and performed. Hospital Discharge Summary: 1. Hospital Discharge documents will be reviewed upon resident's return by the DON, ADON, SDN, or UM and MDS nurse to identify any new recommendations and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Attending physician will be notified by admitting nurse or UM of the return and any recommendations and diagnosis. 3. MDS nurse will update comprehensive care plan to reflect residents new recommendations and diagnosis Education: 1. Nursing staff , including agency and contract, will receive training upon hire, annually and as needed with emphasis on the following: - Nurses using electronic health care record dashboard to identify residents with no bowel movement in last 3 days. (59% education completed) - Implementing the as needed (PRN) physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . (59% education completed) - Evaluating the Resident for signs and symptoms of constipation or impaction. (59% education completed) - Notifying physician if no bowel movement in 24 hours after the implementation of the PRN order. (59% education completed) - Scheduling of specialty consultations. (20% education completed) - Hospital Discharge documents review. 2. Nursing staff , including agency and contract , will receive training upon hire, annually and as needed with emphasis on the following: - Documentation of bowel movements in Point Click Care - If for some reason, the Nurse Aide cannot document in Point Click Care they will document on paper form. 3. Nursing staff will receive training upon hire, annually and as needed with emphasis on the following: - Requesting hospital discharge summaries to identify diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. No nurse will work without education. The deficient practice continued at the potential for more than minimal harm for all 91 of the residents currently residing in the facility. Findings: A review of the facility's Best Practices policy revealed in part, the following: The Licensed Nurse will utilize the 24-hour report to communicate information in order to maintain the continuum of safe patient care. The previous days 24 hour report is reviewed during the Daily Clinical Meeting. Documentation: o Documentation should occur each shift ( either 8 or 12 hours) o Documentation is by exception. Do not list all current residents on the 24 hour report o Documentation should include but is not limited to the following care areas: New Admissions/Re-admissions (should remain on 24 hour report for 72 hours post admission/re-admission), Change in Condition, Physician orders. Resident #3 A Review of Resident #3's clinical record revealed he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #3's quarterly MDS with an ARD of 01/13/2022 revealed the resident had a BIMS of 15, indicating he was cognitively intact. Further review revealed he required total assistance from a minimum of two staff members for all areas of care; bed mobility, transfers, dressing, toileting, and personal hygiene. A review of Resident #3's Care Plan as of 03/04/2022 revealed, in part, the following: Problem: Bowel Incontinence r/t [CONDITION(S)]/[CONDITION(S)] Bowel. Interventions: Administer medications per MD order, observe for effectiveness, check resident every two hours as needed and assist with toileting, observe for constipation, administer medication as per MD order. A review of Resident #3's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 09/09/2021, 11/18/2021, 12/11/2021, 01/21/2022, 03/04/2022, Regular Diet. Regular/Thin Liquid Consistency. Double Portions. 09/09/2021, 11/18/2021, 12/11/2021, Maalox Max Suspension 400-400-40mg/5mL - Give 2400mg by mouth every 4 hours as needed for constipation. 09/09/2021, 11/18/2021, 12/11/2021, Milk of Magnesia Suspension 400mg/5mL - Give 30mL by mouth every 24 hours as needed for constipation or no BM in 3 days. 09/09/2021, 11/18/2021, [MEDICATION(S)] Suppository 10mg - Insert 1 suppository rectally every 24 hours as needed for constipation. 09/09/2021, [MEDICATION(S)] Enema - Insert 19gram rectally every 24 hours as needed for constipation. If no results in the morning after [MEDICATION(S)] suppository. 01/12/2022, Portable X-Ray (XR) of Pelvis/Abdomen and Lumbar Spine r/t Increased Pain (one time only r/t pain, unspecified for 1 day). 01/13/2022, Magnesium [MEDICATION(S)] Solution 1.745gm/10mL - Give 30mL by mouth one time only for constipation for 1 day A review of Bowel and Bladder report for Resident #3 revealed he did not have a bowel movement on the following dates: 12/23/2021, 12/24/2021, 12/25/2021, 12/26/2021, 12/27/2021, 12/29/2021, 12/30/2021, 01/31/2022, 01/01/2022, 01/02/2022, 01/03/2022, 01/09/2022, 01/10/2022, 01/11/2022, 01/12/2022, 01/13/2022 A review of Resident #3's MAR, dated November 2021 through February 2022, revealed the following PRN bowel medications were not administered in the months of November 2021 through February 2022: Maalox Max - Suspension Q4H PRN for Constipation. Milk of Magnesia - Suspension Q24H PRN for Constipation or no BM in 3 days. [MEDICATION(S)] Suppository - Q24h prn constipation. [MEDICATION(S)] Enema - Insert 19 gram rectally every 24 hours as needed for constipation. If no results in the morning after [MEDICATION(S)] Suppository. A review of Resident #3's Nurses Notes, dated November 2021 through March 2022, revealed, in part, the following notes related to his bowel status: 01/12/2022 at 2:57 p.m., New order for portable XR of Pelvis/Abdomen and lumbar spine per resident report of increased pain. 01/13/2022 at 1:57 p.m., new order for Mag [MEDICATION(S)] related to abdominal XR. 01/14/2022 at 5:29 a.m., Resident #3 was admitted to the hospital with [CONDITION(S)], C-Diff, and bowel obstruction. Will be transferred to other facility. A review of Resident #3's Hospital Records dated 01/03/2022 through 01/06/2022 revealed he was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #3's hospital Gastrointestinal Specialist Consultation Note dated 01/04/2022, in part, revealed the following: Patient noted that he did not have a BM over the last two weeks. XR Abdomen performed on 01/03/2022 at 2:21 p.m. Impression: There is a large amount of retained fecal material and gas scattered within the colon, more evident within the right colon and recto-sigmoid colon. Please correlate for possible constipation and Impaction. A review of the Radiology Reports for Resident #3 dated 01/03/2022 through 01/06/2022 in part, revealed: 01/04/2022 at 8:39 a.m. XR of Abdomen Results: There is a large amount of retained fecal material and gas scattered within the colon, more evident within the right colon and rectosigmoid colon Please correlate for possible constipation and fecal impaction. 01/04/2022 at 10:26 a.m. CT without Oral Contrast of Abdomen/Pelvis Results: Large amounts of fecal material within the colon and rectum. This appears more pronounced within the somewhat redundant appearing sigmoid colon and rectum. Please correlate for possible constipation and fecal impaction. A review of the Hospital discharge summary dated 01/06/2022 revealed, in part: This patient needs to remain on a high-fiber diet with at least 30g of soluble fiber in his diet every day. He should also be started on a fiber supplement such as Metamucil, [MEDICATION(S)] or [MEDICATION(S)] daily. He should remain on fiber indefinitely He should also be encouraged to drink and consume at least 2L of water every day. His urinary output per day should be at least 2L. If his urine output drops off his water intake should be increased. This goal to titrate his urinary output to his oral water consumption should continue indefinitely. He should also start on [MEDICATION(S)] 200mg by mouth daily. He is not to be on a stimulant [MEDICATION(S)] such as [MEDICATION(S)] or Senna. New medication orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #3's Dietician Notes, dated November 2022 through current revealed the dietician had not visited the resident since 12/28/2021. Further review revealed there was no evidence Dietician was informed of Resident #3's diet recommendations on 01/06/2022. Review of the facility's radiology report for Resident #3 revealed: 01/12/2022 at 12:00 a.m. XR of Lumbar Spine. Results: Diffuse colonic fecal loading. 01/12/2022 at 12:00 a.m. XR of Abdomen. Results: Marked colorectal loading with fecal fecaloma. A review of Resident #3's Hospital Records dated 01/14/2022 through 01/21/2022 revealed he was admitted with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed a CT of the Abdomen and Pelvis dated 01/20/2022 indicated a stool burden with [CONDITION(S)]. A review of the hospital radiology report for Resident #3 revealed: 01/17/2022 at 10:47 a.m. CT of Abdomen/Pelvis Results: Large stool burden, including that appearing impacted within the rectum. Thickening of the rectosigmoid colon with associated peri-intestinal fat stranding also noted, raising concern for [CONDITION(S)]. On 02/28/2022 at 1:10 p.m., an interview was conducted with S26RN. She stated on 01/14/2022, Resident #3 was found to have a fecal impaction and sent to the local emergency room . She stated Resident #3 was prone to having fecal impactions. On 02/28/2022 at 2:48 p.m., an interview was conducted with S27LPN who stated she was the facility's Unit Manager on 01/06/2022. She stated she signed off on Resident #3's admission/readmission data collection because S25LPN did not sign it prior to leaving the facility. She confirmed she did not know if the data collection was completed when she signed off on it. She confirmed that she did not lay eyes on nor physically assess Resident #3 upon his return to the facility from the hospital on 01/06/2022 and was not told she needed to review the discharge paperwork. On 03/02/2022 at 10:00 a.m., an interview was conducted with S19CNA, who stated she worked with Resident #3 the night of 01/14/2022. She stated the resident's stomach was swollen and she thought he was impacted. She also stated CNAs document bowel movements in the computer but do not verbally inform the nurse because they are able to access the information in the resident's chart. On 03/02/2022 at 11:23 a.m., a telephone interview was conducted with S25LPN. She stated when Resident #3 returned from the hospital on 01/06/2022 she was responsible for checking him back into the facility on ly, which included getting him settled in and taking his vital signs. She denied having completed any other readmission tasks, including head to toe assessment or review of hospital discharge paperwork. On 03/02/2022 at 1:34 p.m., during a telephone interview with S28LPN, she stated she took care of Resident #3 on 01/03/2022 when he was sent out to the ER for abdominal pain. She stated she was made aware in report that Resident #3 was complaining of abdominal pain but there was no mention of bowel status. She stated the resident continued to complain of abdominal pain and pressure during her shift and told her he was not feeling well. She stated the resident began sweating and his skin tone became flush. She stated a few minutes later the resident told her his symptoms had stopped. She confirmed she did not notify the physician at that time. She stated a little later in the shift, the same symptoms returned plus the resident seemed a little out of it and was not acting himself. She stated the resident was transferred to the ER at that time. On 03/02/2022 at 4:03 p.m., an interview was conducted with S6LPN, who confirmed she was the CNA Supervisor and stated it was the CNAs responsibility to document bowel movements during their shift and a blank entry would indicate no bowel movement occurred. She stated she would expect CNAs to verbally communicate with their nurse if a resident did not have a bowel movement during their shift. She stated she would also expect a nurse to inform their CNA if they had administered PRN medications so the CNA would be aware to monitor more closely. She confirmed she was responsible for staff development, which included providing education for all staff. She confirmed no resident should go 3 days or more without having a bowel movement. She also stated if that were to happen, she would expect a nurse to administer the appropriate medications per orders and notify the physician. She denied having trained staff regarding Resident #3's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She also denied having provided staff education following Resident #3's return from the hospital on 01/06/2022 regarding the strict monitoring of his intake and output because she was unaware of the dietary and intake/output suggestions made while he inpatient. She confirmed staff education would need to take place regarding the expectations for care, as well as monitoring of bowel movements for Resident #3. On 03/02/2022 at 5:01 p.m., a telephone interview was conducted with S12LPN, who stated before she sent Resident #3 to the emergency roiagnom on [DATE], he complained of abdominal pain and the abdominal x-ray performed at the facility showed stool. She stated she could not recall when the resident's most recent bowel movement was prior to the date he was sent out. On 03/03/2022 at 1:35 p.m., an interview was conducted with Resident #3. Resident #3 stated he could not feel when he had a bowel movement and could not feel if he was constipated. He stated the only way he would know if he were constipated was if he became sick. He explained he would lose track of how many days he went without a bowel movement and relied on staff to monitor it. He stated he thought they were monitoring them because that was one of the reasons he was admitted to the facility. He stated the nursing staff did not ask him about his bowel movements, possible constipation or offer PRN bowel medication unless he was already sick. He stated when it hits, it hits me really fast and I go down quick. He stated he did not ask for additional PRN bowel medications because he thought the nurses were monitoring his bowel movements to give them when he needed to take them. He stated he did not realize nurses would only give him additional medication if he complained of constipation and/or requested it. He stated if he knew no one was monitoring them, he would have tried to keep up with how often he was having a bowel movement so he would not get sick again. He stated when he was sent to theER on [DATE], he had not had a bowel movement in about 2 weeks. He also said the last time he was impacted, on 01/14/2022, he had to be sent by helicopter to a hospital and the experience was not good. He stated it really took a toll on me. On 03/04/2022 at 1:45 p.m., an interview was conducted with S14CNA and S15CNA. S14CNA and S15CNA confirmed Resident #3 was unable to feel if he needed to have or was having a bowel movement. S14CNA and S15CNA both stated the only time Resident #3 was aware he had a BM was if it had an odor. S14CNA and S15CNA both stated the resident would not know if he were constipated unless he started to feel sick. S14CNA and S15CNA both denied being aware of the need to monitor intake or ask Resident #3 about any bowel movements when he returned to the facility from a pass. S14CNA and S15CNA both confirmed they had not been educated to monitor Resident #3's bowel status closely. S14CNA and S15CNA both stated they chart bowel movements in the computer every shift and nurses are able to review that information so they do not always give them updates. S14CNA and S15CNA both said nurses do not always tell them if they gave anything PRN unless they went to them with concerns and a nurse responded ok let me go get some medicine for them. On 03/04/2022 at 1:58 p.m., an interview was conducted with S16CNA. She stated Resident #3 cannot feel if he is constipated or needs to go to the bathroom. She denied receiving training specifically related to monitoring the bowel status of Resident #3. She stated she charts bowel movements in the computer and nurses are able to access that to review it. She said if she were concerned about something, like a large amount of diarrhea, she would talk to the nurse but not having a BM on her shift would not be something she told the nurse. She stated she does not look at the dashboard to see if it has been a while for a bowel movement so she would not be concerned if there were not one on her shift. On 03/04/2022 at 2:10 p.m., an interview was conducted with S10LPN. She stated due to his [CONDITION(S)], he was not capable of feeling if he was constipated or if he had even had a bowel movement. She stated she was aware Resident #3 had issues with constipation that required hospitalization s in the past. She stated she had not received any specific education from the facility about the resident's condition or need for close bowel monitoring. She stated Resident #3 was cognitive and she relied on him to let her know if he was constipated or needed PRN medication to have a bowel movement. On 03/04/2022 at 3:15 p.m., a telephone interview was conducted with S5MD. He stated Resident #3 was a quadriplegic with a [CONDITION(S)] bowel. He explained Resident #3 had no way of knowing if he had a bowel movement or not. He stated Resident #3 would not know if he was constipated until he had more serious symptoms such as impaction, [CONDITION(S)], headache, or pressure/painful sensations. He stated Resident #3 required bowel medications to have a bowel movement. He stated he had implemented PRN orders with set parameters for bowel medication administration. He confirmed he expected the facility staff to monitor Resident #3's bowel status and administer the medications as needed to prevent complications. He confirmed he was not notified when the Resident #3's bowels were not moving in December 2021 and January 2022. He stated if he had be notified, he would have started him on a different medication months ago. He stated he had been out of the facility for the month of January 2022 due to illness and had conducted telehealth visits during that time. He stated the facility did not communicate the bowel issues identified in each of the resident's hospitalization s. He explained he relied on the facility's medical records nurse and floor nurses to communicate the resident's status, any potential areas of concern, or actual issues taking place. He confirmed Resident #3's repeated hospitalization s were directly related to him not having regular bowel movements. He stated the facility should have been more aggressive with monitoring the resident's bowel status, administering PRN bowel medications as ordered and informing him when the resident was not having routine bowel movements. A review of Resident #3's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] 01/31/2022 Chief Complaint: Recurrent impaction. Upon completion of this visit an order was written for [MEDICATION(S)] with additional adjustments made to previously ordered bowel medications due to the physician now having been made aware of the resident's recurring impactions. On 03/04/2022 at 3:30 p.m., an interview was conducted with S3DON, with S4ADON and S6LPN in attendance. All confirmed Resident #3 was cognitively intact, but due to his diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . S3DON confirmed CNAs were responsible for and expected to document when a resident had a bowel movement in the electronic system. S3DON stated the nurse is expected to monitor and create a note when a resident was overdue for a bowel movement indicating what PRN medication was administered and the outcome, along with any communication to the physician. S3DON also stated they would expect a physician to be notified any time medications were administered and/or interventions implemented that did not work as intended. S3DON stated the electronic charting system had a dashboard to indicate what residents had not had a bowel movement in three days but it would not create a pop up alert, so it was the nurse's responsibility to monitor the dashboard and implement the appropriate interventions, including the administration of medications. S3DON stated CNAs were also able to see the dashboard and ideally, they would expect nurses and CNAs to thoroughly review their dashboards at the start and end of every shift. They stated CNAs should be checking for accuracy or a need to follow up with a resident and nurses should be looking to determine what alerts are present, any intervention(s) that should be implemented and/or if a physician should be contacted to make a notification. S3DON explained the nurse would also be responsible for updating the 24 Hour Report and verbally communicating bowel concerns, implemented interventions and any interventions needing to be implemented when they give shift handoff report. S3DON confirmed all staff are expected to update and utilize the 24 Hour Report during shift handoff and confirmed the report should have been reviewed in the daily meeting of the department heads per the facility's policy. The findings were reviewed with S3DON, S4ADON and S6LPN. S3DON reviewed Resident #3's bowel report for December 2021 and January 2022 and confirmed the dates identified with no bowel movement in the three day window as he should have. S3DON reviewed Resident #3's MAR for December 2021 and January 2022 and confirmed he did not receive any doses of PRN bowel medications as they would have expected him to given his lack of regular bowel movements during that timeframe. Upon completion of the interview, S4ADON and S6LPN verbalized agreement with the information provided by S3DON and denied having any additional information to add. On 03/08/2022 at 8:46 a.m., an interview was conducted with S8LPN, who stated she did not take care of the resident often but when she did it was not reported to her that Resident #3 was constipated and not having bowel movements. She stated she had not administered Resident #3 any PRN bowel medications. She denied knowing she was expected to monitor dashboard alerts in the electronic charting system or utilize a written 24 Hour Report for shift handoff. On 03/08/2022 at 2:30 p.m., all deficient findings related to Resident #3

Based on interviews and record reviews, the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident residing in the facility. The facility failed to ensure an effective system was in place to ensure: 1. Nursing staff assessed, monitored, implemented interventions per physicians orders, and communicated with the physician regarding bowel status and wound care for 1 (#3) of 9 (#1, #2, #3, #4, #5, R3, R5, R10, and R11) residents reviewed; and 2. Nursing staff utilized the facilities processes for communication including the electronic dashboard system and 24 hour report; 3. Consultations were scheduled as ordered by the physician This deficient practice resulted in an immediate jeopardy situation for Resident #3, a quadriplegic with [CONDITION(S)] bowel and constipation, on 12/26/2021 when the facility failed to have a system in place to provide an up to date, individualized plan of care to ensure the monitoring and implementation of interventions. This resulted in Resident #3 being transferred to the local hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Following the hospitalization , the facility failed to have a system in place to ensure the review and implementation of new orders and suggestions from the hospital discharge recommendations provided by the GI Specialist for increased fiber, fluid needs and intake/output monitoring. The facility also failed to notify Resident #3's physician of all diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . From 01/09/2022 through 01/14/2022, the facility still failed to provide an up to date, individualized plan of care that ensured monitoring and implementation of interventions. This resulted in Resident #3 not having a bowel movement or receiving PRN bowel medications leading to another transfer to the hospital with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Faecalis Infection. This hospitalization required Resident #3 to be transferred via helicopter to another hospital on 01/14/2022 to receive a higher level of care due to the deterioration of his condition. S1ED was notified of the Immediate Jeopardy on 03/04/2022 at 6:15 p.m. The Immediate Jeopardy was removed on 03/08/2022 at 5:16 p.m., when the facility submitted an acceptable Plan of Removal. Through interviews and record reviews, the surveyors confirmed the following Plan of Removal had been initiated and/or implemented prior to exit. The Immediate Jeopardy was removed on 03/08/2022 at 4:51 p.m., when the facility submitted an acceptable Plan of Removal. Through observations, interviews and record reviews, the surveyors confirmed the following had been initiated and/or implemented prior to exit: Immediate Action Taken: 1. RDCS (Regional Director of Clinical Services) educated the DON (Director of Nursing), ED (Executive Director) and Assistant Director of Nursing (ADON) on ensuring there is a plan of action for ongoing adequate training and supervision to ensure nursing staff, including agency and contract implement appropriate treatment and services for residents with fecal incontinence. 2. Nursing staff, including agency and contract, will receive training upon hire, annually and as needed. 100% of administration staff have been educated. New hires will be educated in orientation. No administration staff member will work without education. 3. Education and supervision of the nursing staff continued through the weekend on every shift by the RDCS, Director of Nursing (DON), Staff Development Nurse (SDN), Unit Manager (UM) and Assistant Director of Nursing (ADON). QAPI: 1. On 03/04/22 at 6:15 PM the Quality Assurance Performance Improvement (QAPI) Committee met to review the F 835 Quality of care IJ template and conduct a Root Cause Analysis (RCA) and review policy and procedures for changes. Attendees were the ED , DON, Social Services Director (SSD) , Housekeeping Supervisor (HKS) , RDCS , Activities Director (AD) , Director of Therapy (DOR) , ADON , SDN , MDS nurse , Business Office Manager ( BOM ) ,Human Resources Director (HRD) , Assistant Business Office Manager ( ABOM) .The Medical Director (MD) was notified by phone. 2. The RCA determined appropriate treatment and services for residents with fecal incontinence to prevent impaction was not provided due to failure to assess and monitor bowel status, failure to administer as needed (PRN) bowel medications per physician parameters and failure to provide physician notification regarding change in status and failure to follow through with scheduling specialty consultations. 3. In-Service Training policy was reviewed with no change to policy made. Education: Licensed nursing staff, including agency and contract, will receive training upon hire, annually and as needed with emphasis on the following: o Nurses using electronic health care record dashboard to identify residents with no bowel movement in last 3 days. (59% education completed) o Implementing the as needed (PRN) physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . (59% education completed) o Evaluating the Resident for signs and symptoms of constipation or impaction. (59% education completed) o Notifying physician if no bowel movement in 24 hours after the implementation of the PRN order. (59% education completed) o Scheduling of specialty consultations. (20% education completed) o Hospital Discharge documents review. Licensed nursing staff and nurse aides, including agency and contract , will receive training upon hire, annually and as needed with emphasis on the following: 1. Documentation of bowel movements in Point Click Care (PCC) 2. If for some reason, the Nurse Aide cannot document in PCC they will document on paper form Nursing staff will receive training upon hire, annually and as needed with emphasis on the following: 1. Requesting hospital discharge summaries to identify diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] 2. No nurse will work without education. Ongoing Education: SDN will educate licensed nursing staff, including agency and contract upon hire, annually, and as needed to ensure employees are competent in bowel movement management of residents. Competency of the licensed nurses to include will be verified by the SDN by: 1. Observing nurse use the PCC dashboard to identify residents that have been 3 days with no bowel movement 2. Implementing PRN bowel medication orders 3. Notifying physician when appropriate 4. Communicating to oncoming nurses using the 24 hour report form. DON or ADON will educate registered nurses, including agency and contract upon hire, annually, and as needed to ensure employees are competent in bowel movement management of residents. Competency of registered nurses will be verified by the DON or ADON by: 1. Observing nurse use the PCC dashboard to identify residents that have been 3 days with no bowel movement 2. Implementing PRN bowel medication orders 3. Notifying physician when appropriate 4. Communicating to oncoming nurses using the 24 hour report form. Quality monitoring will be conducted by the RDCS or designee every 3 months to ensure nursing administrative staff are: 1. Conducting education upon hire and ongoing education of nursing staff for proper implementation of resident care and needs consistent with their condition and diagnosis Quality Monitoring of Physician Orders: Quality monitoring of residents physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Quality Monitoring of Residents with No Bowel Movement in 3 Days: Ongoing monitoring will be conducted 3 x weekly for 1 month then monthly for 3 months by the DON, ADON, SDN, or UM: 1. Using the daily bowel movement audit form to identify residents with no bowel movement X 3 days. 2. To ensure physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. To ensure nurses are communicating change in condition related to bowel movements using the 24 hour report form to the oncoming shift. 4. To ensure documentation of bowel movements by nurse aides. Quality Monitoring of Medical Specialty Consultations: Ongoing quality monitoring will be conducted by the DON or designee weekly for 2 months then monthly for 3 months to ensure specialty medical consultation appointments are scheduled according to physician orders. 1. Nurse obtaining the specialty medical consult order will call the specialty clinic to schedule the appointment and document appointment date and time on 24 hour report. 2. DON or designee will review 24 hour report in morning clinical meeting and verify appointment with specialty clinic and document appointment on appointment calendar 3. Specialty appointment will be noted on the transportation schedule and reviewed by ED or designee weekly to ensure transport availability. 4. Appointment calendar will be reviewed in morning meeting to ensure appointment occurred and consultation report reviewed and reported to physician. Quality Monitoring of Bowel Movement Documentation by the Nurse Aide: Ongoing quality monitoring will be conducted by the DON, ADON, SDN, or UM of the resident's bowel movement documentation 3 x weekly for 2 months then monthly x 3 months to ensure nurse aides are documenting bowel movements. Quality Monitoring of Electronic Medication Administration Record: [MEDICAL RECORD OR PHYSICIAN ORDER] Ongoing quality monitoring will be conducted by the DON, ADON, SDN, or UM of the electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Quality Monitoring of Care Plans: Quality monitoring will be conducted by the MDS Regional or designee with a sample of 10 weekly for 1 month then monthly for 3 months to ensure residents plan of care are implemented and performed. Cross Reference: F684, F656 Findings: A review of the facility's Best Practices policy revealed in part, the following: The Licensed Nurse will utilize the 24-hour report to communicate information in order to maintain the continuum of safe patient care. The previous days 24 hour report is reviewed during the Daily Clinical Meeting. Documentation: o Documentation should occur each shift ( either 8 or 12 hours) o Documentation is by exception. Do not list all current residents on the 24 hour report o Documentation should include but is not limited to the following care areas: New Admissions/Re-admissions (should remain on 24 hour report for 72 hours post admission/re-admission), Change in Condition, Physician orders. A review of the facility's policy for Notification of Change in Status revealed, in part, the following, the Center to promptly notify the Patient/Resident, the attending physician, and the Resident Representative when there is a change in the status or condition. Procedure: The nurse to notify the attending physician and Resident Representative when there is a(n): o Significant change in the patient/resident's physical, mental, or psychosocial status o Need to alter treatment significantly o New treatment A review of the facility's policy for Medical Consultations revealed, in part, the following: Members of the medical staff will request a medical consultation when appropriate. Procedure: 1. The member of the medical staff requesting a consultation will order the consultation and a Request for Consultation will be initiated by nursing to the consulting physician. Resident #3 A Review of Resident #3's clinical record revealed he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #3's quarterly MDS with an ARD of 01/13/2022 revealed the resident had a BIMS of 15, which indicated he was cognitively intact. Further review revealed he required total assistance from a minimum of 2 staff members for all areas of care; bed mobility, transfers, dressing, toileting, and personal hygiene. A review of Resident #3's Care Plan dated 03/04/2022 revealed, in part, the following: Problem: Bowel Incontinence r/t [CONDITION(S)]/[CONDITION(S)] Bowel. Interventions: Administer medications per MD order, observe for effectiveness, check resident every two hours as needed and assist with toileting, observe for constipation, administer medication as per MD order. Further review of Resident #3's current care plan revealed no care plan for the open wound at his PEG removal site. A review of Resident #3's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 09/09/2021, 11/18/2021, 12/11/2021, 01/21/2022 for the resident's currently ordered diet, as of 03/04/2022, Regular Diet. Regular/Thin Liquid Consistency. Double Portions. 10/08/2021 for GI Consult ASAP r/t unhealed PEG Site. 03/02/2022 for Make appointment with GI, Dr. [NAME], phone # [PHONE NUMBER] r/t previous PEG tube site. A review of Bowel and Bladder report for Resident #3 revealed he did not have a bowel movement on the following dates: 12/23/2021, 12/24/2021, 12/25/2021, 12/26/2021, 12/27/2021, 12/29/2021, 12/30/2021, 01/31/2022, 01/01/2022, 01/02/2022, 01/03/2022, 01/09/2022, 01/10/2022, 01/11/2022, 01/12/2022, 01/13/2022 A review of Resident #3's MAR, dated November 2021 through February 2022, revealed the following PRN bowel medications were not administered in the months of November 2021 through February 2022: Maalox Max - Suspension Q4H PRN for Constipation. Milk of Magnesia - Suspension Q24H PRN for Constipation or no BM in 3 days. [MEDICATION(S)] Suppository - Q24h prn constipation. [MEDICATION(S)] Enema - Insert 19 gram rectally every 24 hours as needed for constipation. If no results in the morning after [MEDICATION(S)] Suppository. A review of Resident #3's Hospital Records dated 01/03/2022 through 01/06/2022 revealed he was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #3's hospital Gastrointestinal Specialist Consultation Note dated 01/04/2022, in part, revealed the following: Patient noted that he did not have a BM over the last two weeks. XR Abdomen performed on 01/03/2022 at 2:21 p.m. Impression: There is a large amount of retained fecal material and gas scattered within the colon, more evident within the right colon and recto-sigmoid colon. Please correlate for possible constipation and Impaction. A review of Resident #3's Patient Rounding Notes from the 01/03/2022 through 01/06/2022 hospitalization , revealed, in part, the following: 01/05/2022 at 09:10 p.m. Barrier cream placed around previous peg tub site due to redness and drainage with gauze placed over barrier cream to absorb small amounts of drainage. A review of the Hospital discharge summary dated 01/06/2022 revealed, in part: This patient needs to remain on a high-fiber diet with at least 30g of soluble fiber in his diet every day. He should also be started on a fiber supplement such as Metamucil, [MEDICATION(S)] or [MEDICATION(S)] daily. He should remain on fiber indefinitely He should also be encouraged to drink and consume at least 2L of water every day. His urinary output per day should be at least 2L. If his urine output drops off his water intake should be increased. This goal to titrate his urinary output to his oral water consumption should continue indefinitely. He should also start on [MEDICATION(S)] 200mg by mouth daily. He is not to be on a stimulant [MEDICATION(S)] such as [MEDICATION(S)] or Senna. New medication orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #3's Dietician Notes, dated November 2022 through current revealed the dietician had not visited the resident since 12/28/2021. Further review revealed there was no evidence Dietician was informed of Resident #3's diet recommendations following discharge on 01/06/2022. A review of Resident #3's Hospital Records dated 01/14/2022 through 01/21/2022 revealed he was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the hospital radiology report for Resident #3 revealed: 01/17/2022 at 10:47 a.m. CT of Abdomen/Pelvis Results: Large stool burden, including that appearing impacted within the rectum. Thickening of the rectosigmoid colon with associated peri-intestinal fat stranding also noted, raising concern for [CONDITION(S)]. Further review of the hospital radiology report for Resident #3 revealed a CT of the Abdomen and Pelvis dated 01/20/2022 indicated a stool burden with [CONDITION(S)]. 1.) On 03/02/2022 at 11:40 a.m., an interview was conducted with S5MD. He verified he was not notified of an old peg site that had opened and was draining. He confirmed if a resident returned from the hospital with no wound care orders, he would expect the nurse to call and let him know about the drainage and obtain wound care orders. On 03/02/2022 at 04:03 p.m., an interview was conducted with S6LPN, who confirmed she was the CNA Supervisor and also responsible for staff development, which included providing education for all staff. She confirmed no training had been provided to staff regarding Resident #3's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She also confirmed no education or training was provided upon Resident #3's return from the hospital on 01/06/2022 regarding the strict monitoring of his intake and output. On 03/04/2022 at 01:45 p.m., an interview was conducted with S14CNA and S15CNA, both denied being aware of a need to monitor intake or ask Resident #3 if he had bowel movements upon his return to the facility from a pass. Both confirmed they had not been educated to monitor Resident #3's bowel status closely. On 03/04/2022 at 01:58 p.m., an interview was conducted with S16CNA, who denied having received training related to monitoring bowel status. On 03/04/2022 at 02:10 p.m., an interview was conducted with S10LPN who stated she was very familiar with Resident #3's care and needs but had not received education from the facility about his condition or need for close monitoring. She confirmed the resident was not capable of feeling if he was constipated or if he had a bowel movement; however, he was cognitive so she relied on him to tell her if he was constipated and to request PRN bowel medications. She confirmed she was aware of his hospitalization s for constipation and impaction and denied having been told of anything that should be implemented after. She denied being aware of who should handle paperwork following discharge or specialist appointment. She stated the paperwork usually went to the front desk when the resident arrived back at the facility. She stated she was not aware of a definitive method for scheduling appointments for residents and was not sure who performed that task. On 03/04/2022 at 03:15 p.m., a telephone interview was conducted with S5MD. He confirmed Resident #3's repeated hospitalization s were directly related to him not having regular bowel movements. He also stated the facility should have been more aggressive with monitoring the resident's bowel status, administering PRN bowel medications as ordered and informing him when the resident was not having routine bowel movements. On 03/04/2022 at 03:30 p.m., an interview was conducted with S3DON, with S4ADON and S6LPN in attendance. S3DON stated the nurse is expected to monitor and create a note when a resident was overdue for a bowel movement indicating what PRN medication was administered and the outcome, along with any communication to the physician. S3DON also stated she would expect a physician to be notified any time medications were administered and/or interventions implemented that did not work as intended. S3DON also confirmed she would expect staff to have addressed and confirmed S5MD was aware of Resident #3's frequent lack of regular bowel movements during his weekly rounds. S3DON stated S5MD's Progress Notes and Orders were handwritten and available to the facility on ce he finished rounds. S3DON stated she would expect the progress notes to be reviewed by the floor nurse with all orders transcribed and implemented on the same day with an additional review and sign off performed by the unit manager to ensure accuracy and verify orders were not missed. Upon completion of the interview, S4ADON and S6LPN verbalized agreement with the information provided by S3DON and denied having any additional information to add. On 03/08/2022 at 02:30 p.m., all deficient findings related to Resident #3 were reviewed and verified by S3DON with S2RCDS and S1ED present. S3DON reviewed and verified Resident #3's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . S3DON confirmed she had been unaware Resident #3's bowel status was not being monitored, which resulted in him frequently going three days or more without a bowel movement and not receiving any of his PRN bowel medications throughout December 2021 and January 2022. S3DON also confirmed S5MD was not notified of Resident #3's on-going lack of regular bowel movements. S3DON confirmed she would have expected better monitoring of the three-day window for bowel movements to ensure Resident #3's PRN bowel medications were given as ordered. S3DON confirmed she would expect nurses to notify S5MD when Resident #3 did not have a bowel movement in 3 days. S3DON also confirmed because of his diagnoses, she would have expected nursing staff to closely monitor Resident #'3's bowel movements instead of relying on him to inform them when he became constipated. S3DON stated if nursing staff did not understand how to provide care for a resident with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . S3DON confirmed upon Resident #3's return to the facility following each hospitalization , she would expect S5MD to be notified of all diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . S3DON verified Resident #3 had been hospitalized on [DATE] and 01/14/2022 related to bowel impaction. S3DON confirmed because they had not been monitoring, they were not aware of the recurring issue so staff had not received education or training regarding the importance of closely monitoring the frequency of Resident #3's bowel movements for administration of his PRN bowel medications. S3DON confirmed she would have liked to implement steps to try and prevent the recurrence. S3DON reviewed and verified Resident #3's current Care Plan. S3DON confirmed they had been unaware there was an issue with Resident #3 having an outdated care plan that was not updated following status changes, onset of new issues, hospitalization s, etc. S3DON confirmed they had been unaware Resident #3's care plan was not accurately individualized to meet his specific needs. S3DON confirmed she would have expected Resident #3's care plan to be updated and individualized to better meet his needs. S3DON further reviewed Resident #3's care plan, and verified he was not care planned for care regarding his PEG tube site. S3DON confirmed Resident #3 should have been care planned for PEG tube site care. Upon completion of the interview, S2RDCS and S1ED verbalized agreement with the information provided by S3DON and denied having any additional information to add. Upon completion of the interview, S2RDCS and S1ED verbalized agreement with the information provided by S3DON and denied having any additional information to add. 2.) On 03/02/2022 at 04:03 p.m., an interview was conducted with S6LPN, who confirmed she was the CNA Supervisor. She stated it was the CNAs responsibility to document bowel movements during their shift and a blank entry would indicate no bowel movement occurred. She stated she would expect CNAs to communicate with nurses if a resident did not have a bowel movement during their shift. She stated she would also expect a nurse to communicate with their CNAs if they had administered PRN medications so they would be aware to monitor more closely. She confirmed she was responsible for staff development, which included providing education for all staff. She confirmed no training had been provided about assessing and monitoring bowel movements on the dashboard then recording that information on the 24 Hour Report for use during shift handoff report. On 03/04/2022 at 01:45 p.m., an interview was conducted with S14CNA and S15CNA, both stated bowel movements are documented in the computer every shift and nurses are able to review the information so they do not need to report it to them. They also denied having nurses inform them when PRN medications were given so they could help monitor. Both confirmed CNAs use verbal report for shift handoff and had not heard of a 24 Hour Report. On 03/04/2022 at 01:58 p.m., an interview was conducted with S16CNA, who stated she charted bowel movements in the computer and nurses were able to access it for review. She said if she were concerned about something, like a large amount of diarrhea, she would talk to the nurse but someone not having a BM on her shift would not automatically be something she told the nurse. She stated she did not know to look at the dashboard to see if it had been a while for a bowel movement so she would not be concerned if there were not one on her shift. 03/04/2022 at 02:10 p.m. Observed shift report and handoff from day shift CNA to oncoming afternoon CNA. Report was provided verbally with no written documentation utilized. There was no observed mention of residents not have bowel movements. 03/04/2022 at 02:05 p.m. Observed shift report and handoff from day shift Nurse to oncoming afternoon Nurse. Report was provided verbally with no written documentation utilized. There was no observed mention of resident s not have bowel movements. On 03/04/2022 at 02:10 p.m., an interview was conducted with S10LPN who stated she used her own written report sheet during shift change because she had only ever received a verbal report and confirmed she was unaware of any expectation for a written report. She confirmed she was not trained on the facility's expectation for use of dashboard alerts. She stated there was nothing in the charting system that required a response to alerts, nurses had to remember to look and she had not seen many people use it. She said CNAs charted bowel movements but did not verbally report to the nurse; however, she hoped she would be made aware if something unusual happened. On 03/04/2022 at 03:30 p.m., an interview was conducted with S3DON, with S4ADON and S6LPN in attendance. S3DON stated the electronic charting system had a dashboard to indicate what residents had not had a bowel movement in three days but it would not create a pop up alert, so it was the nurse's responsibility to monitor the dashboard and implement the appropriate interventions, including the administration of medications. S3DON stated CNAs were also able to see the dashboard and ideally, they would expect nurses and CNAs to thoroughly review their dashboards at the start and end of every shift. They stated CNAs should be checking for accuracy or a need to follow up with a resident and nurses should be looking to determine what alerts are present, any intervention(s) that should be implemented and/or if a physician should be contacted to make a notification. S3DON explained the nurse would also be responsible for updating the 24 Hour Report and verbally communicating bowel concerns, implemented interventions and any interventions needing to be implemented when they give shift handoff report. S3DON confirmed all staff are expected to update and utilize the 24 Hour Report during shift handoff and confirmed the report should have been reviewed in the daily meeting of the department heads per the facility's policy. Upon completion of the interview, S4ADON and S6LPN verbalized agreement with the information provided by S3DON and denied having any additional information to add. On 03/08/2022 at 11:35 a.m., an interview was conducted with S7LPN. She stated she was never trained or instructed to monitor the dashboard for alerts of overdue bowel movements and was unaware staff were expected to utilize a written 24 Hour Report for shift handoff. On 03/08/2022 at 02:30 p.m., all deficient findings related to Resident #3 were reviewed and verified by S3DON with S2RCDS and S1ED present. S3DON confirmed she had been unaware nurses and CNAs were only performing a very brief verbal report at the end of each shift and not utilizing the written 24 Hour Report as expected per the facility's protocol. S3DON also confirmed she had been unaware most nurses and CNAs did not know they should be monitoring dashboard alerts for overdue bowel movements and confirmed she would expect them to review it at least twice per shift. Upon completion of the interview, S2RDCS and S1ED verbalized agreement with the information provided by S3DON and denied having any additional information to add. 3.) On 03/04/2022 at 02:10 p.m., an interview was conducted with S10LPN, who denied being aware of who should handle paperwork following discharge or specialist appointment. She stated the paperwork usually went to the front desk when the resident arrived back at the facility. She stated she was also not aware of a definitive method for scheduling appointments for residents and was not sure who performed that task. On 03/04/2022 at 03:30 p.m., an interview was conducted with S3DON, with S4ADON and S6LPN in attendance. S3DON who confirmed she was not aware Resident #3's hospital discharge summary and orders, dated 01/06/2022, included recommendations for increased fiber in his diet, increased fluid intake, and intake/output monitoring and were unaware the Dietician had not been notified. They also confirmed they were unaware of the outstanding orders for Resident #3 to have a specialist consultation scheduled. S3DON explained upon a resident's arrival back to the facility, she would expect the floor nurse to review the visit notes/discharge summary then communicate and clarify any suggested changes with the physician for transcription and immediate implementation, then update the 24 Hour Report. S3DON further stated she would expect the unit manager to perform a second review of the visit/discharge paperwork to ensure nothing was missed, all orders were transcribed correctly and to confirm the appropriate notifications had been made. S3DON also stated she expect the medical records nurse to be the third review to ensure accuracy and completion of all necessary steps. S3DON stated if the floor nurse were busy, she would expect the unit manager to be the first review and medical records to be the second. S3DON also stated sometimes, the S3DON, S4ADON or S6LPN would perform the review if they were not busy. S3DON confirmed the process for reviewing disc

Based on interviews and record reviews the facility failed to ensure 1 (#28) of 4 (#50, #68, #80, #28) residents reviewed for accidents remained free of accidents by not using the care planned assistive device for transferring the resident from the chair to the bed. The facility failed to have a system of clinical supervision and monitoring in place to ensure that care planned interventions for transfers were implemented by staff. These failed practices resulted in actual harm for resident #28 on 04/19/13 when resident #28 was transferred from a chair to the bed without the use of the care planned Vera lift by one Certified Nursing Assistant (CNA). Resident #28 fell during the transfer and was sent to a local hospital where she was diagnosed with [REDACTED]. Findings: Resident #28 On 05/16/13 a closed record review was conducted for resident #28. She was admitted to the facility on [DATE] and re-admitted on [DATE]. Her [DIAGNOSES REDACTED]. Review of the most recent MDS (Minimum Data Set) ARD (Assessment Reference Date) 02/20/13 revealed she required extensive assistance for transfer- self performance (resident involved in activity, staff provide weight-bearing support and two + persons physical assist for support provided). Further review of the prior MDS Annual Assessment ARD 11/23/12 revealed resident #28's transfer status required the same extensive assistance with two + persons physical assist. Review of the facility document titled, "Activity Participation Record" for the month April 2013 revealed resident #28 enjoyed actively participating in bingo, hospitality hour, television, movies, and videos. On 05/12/13 at 7:00 a.m. a telephone interview was conducted with resident #28's son. He stated his mother was [AGE] years old and would have been 100 next month. When asked if his mother was alert and oriented he stated, "Yes. Sometimes she would be confused what day of the week it was but she could tell you what she needed". He stated, "My mother told that CNA to use the lift". He was asked when his mother made this statement. He stated, "When she was at the hospital after she fell ". He stated, "My mother told me the CNA told her she could do it herself". Review of the document titled, "Care Plan" for resident #28 revealed the following problem identified on 02/11/10: Risk of falls Goal: Will minimize risk of falls/injuries from falls by 06/2013 Approaches included the following assistive device: "Use Vera lift for all transfers". Review of the document titled, "Quarterly Data Collection Tool" dated 02/20/13 revealed a risk for falls assessment was performed for resident #28 and her score was 16. The document also revealed a total score of 10 or above indicated resident #28 was at a high risk for falls. Review of the Nurses Notes dated 04/19/13 at 14:35 (2:35 p.m.) revealed the following: "Called to room per CNA. Resident laying on floor beside bed. CNA states was transferring to bed & bed rolled. CNA then states she lowered resident to floor. Resident was c/o (complaining) pain at left leg. Left leg was noted bent out. Pillow was placed under head for comfort due to resident being in so much pain.....". Further review of the Nurses Notes revealed in part the following: 04/20/13 1000 ".... transferred to (name of hospital) yesterday fx (fracture) hip (Dx) (diagnosis)...." On 05/17/13 at 2:00 p.m. an interview was conducted with S16LPN. She was asked if she worked on 04/19/13 when resident #28 experienced a fall. She stated, "Yes". She stated, "The CNAs called me to the room and the resident was lying on the floor and I tried to find out what was going on. The CNAs told me they were trying to put her to bed. When asked if there were two CNAs transferring resident #28 she stated, "No". S16LPN stated, 'There was one in the room and one at the door. She stated, "S17CNA stated she lowered her to the floor". She stated, "I noticed her left leg was out to the side and her shoe was twisted off of her foot". When asked if there was a lift in the room she stated, "There was no lift in the room at the time of the incident". She was asked if a lift was required. She stated "Yes". She stated, "She (resident #28) required the sit to stand Vera lift". She stated, "This resident required this lift because she would become weak in her legs". On 05/16/13 random interviews were conducted with Certified Nursing Assistants who were on staff throughout the facility. At 3:55 p.m. an interview was conducted with S23CNA. When asked how do you know what type of lift to use for each resident she stated, "We go to the book". When asked what book she took the surveyor to the nurses' station and showed her the book containing the Kardexes for each residents' requirement for transfer assistance. On 05/16/13 at 4:03 p.m. an interview was conducted with S24CNA. She was asked how do you know what type of lift a resident requires. She stated, "You go to the Kardex and find out". On 05/16/13 at 4:05 p.m. an interview was conducted with S25CNA. She was asked how do you know what type of lift a resident requires for transferring. She stated, "You have to go to the book". On 05/16/13 at 4:07 p.m. an interview was conducted with S26CNA. There was a lift observed in the hallway when the interview was conducted. She was asked what type of lift it was. She stated it was a Hoyer Lift. She was asked what this lift was used for. She stated for total assist residents. She was asked how do you know which type of lift to use for each resident. She stated, "There is a book at the nurses' station that tells you". On 05/17/13 at 10:00 a.m. an interview was conducted with S27CNA. She was asked how long she had been employed at the nursing home. She stated 6 months. She was asked how did she know what type of lift a resident requires. She stated, "Let me show you". She took the surveyor to a resident's room and pointed to the resident's name plaque on the outside of the room. She stated, "No, not this one". She asked another staff member, S28RA, who was standing at the doorway to the resident's room, where the lift information was located. S28RA stated, "On the Kardex". Review of the Online Tracking and Incident System (OTIS) Client Incident Report involving resident #28 revealed in part the following documentation: Occurred: 04/19/2013 01:45 pm Accused / Allegation (S17CNA) Finding Substantiated Victim (Resident #28) Injury Fracture Case Notes Description: "(Resident #28) was being transferred from chair to bed by aide (S17CNA). (S17CNA) should of been using a sit to stand lift instead was transferring her by herself and the resident went down to the floor. When DON arrived (resident #28) was lying on the floor in supine position with left leg rotated inward. The CNA stated the bed moved when she went to transfer (resident #28). The DON asked if she had locked the bed back and she stated yes., when the DON asked for her to show her she could not. (Resident #28) was sent to ER and diagnosed with [REDACTED]. Review of the statement provided by S17CNA dated 04/19/13 regarding the OTIS Client Incident Report revealed in part the following documentation: ".... not aware to use a sit-to-stand lift on her". On 05/17/13 at 12:19 p.m. an interview was conducted with S3DON. She was asked to review the Online Tracking and Incident System (OTIS) Report involving the accident that occurred on 04/19/13 involving resident #28 and S17CNA. S3DON was asked to describe how the accident occurred. She stated, "The aide transferred the resident from the chair to the bed and the CNA stated the bed moved". She stated, "My observation was the bed did not move". She stated, "The resident required a sit to stand lift". S3DON was asked why S17CNA did not use a lift. She stated, "I have no idea why she transferred the resident by herself". She was asked if she asked S17CNA why she didn't use the lift. She stated, "The CNA stated she didn't review the Kardex". When asked to review the written statement provided by S17CNA, S3DON confirmed the written statement contained documentation that S17CNA did not know she was supposed to use a lift. S3DON was asked should S17CNA have known to use the lift. S3DON stated, "When they are hired they are educated about the Kardex". On 05/17/13 at 12:25 p.m. an interview was conducted with S3DON. She was asked what the facility did following this accident involving a CNA transferring a resident without a lift. She stated, "The facility educated the staff on the Kardex, transfer, and use of equipment". She stated, "We reviewed all residents for their transfer status, updated the charts, care plans, and Kardexes.". S3DON was asked what the facility did after the training was conducted. She stated, "It is a part of our QA (Quality Assurance)". The surveyor requested documentation of any quality assurance and follow up to include monitoring the staff following the inservices. The facility was not able to provide documentation that staff were monitored for using the correct mode of transfer on residents. On 05/17/13 at 12:31 p.m. an interview was conducted with S2Adm in the presence of S3DON. He was asked to discuss the QA conducted following the accident that occurred on 04/19/13 involving resident #28. He stated, "The QA Committee meets every 4th Thursday of every month". He stated, "We have Clinical Meetings every day". He stated, "During these meetings we follow up on falls, hospital returns, and new admits" He stated, "This information is collected during April and May and we identify any trends that need to be added to our quality assurance program". S2Adm was asked again how the facility ensured the inservice education was effective. He stated, "We follow up daily at our clinical meetings".

Based on observation, interview and record review the facility failed to conduct initially and periodically a comprehensive and accurate assessment of each resident's functional capacity for 1 (#5) of 9 (#1, #2, #3, #4, #5, #6, #7, #8, #9) residents reviewed for assessments. The facility failed to: 1. follow the facility's care plan to inspect the skin daily 2. perform weekly skin assessments 3. document the presence of a splint to the resident's (R) arm 4. assess the neurovascular status of the resident's (R) arm 5. perform quarterly Braden scale assessments 6. consult an orthopedist to assess a fracture to the (R) arm Resident #5 was placed in Immediate Jeopardy on 11/29/12 when she returned to the facility from the hospital with a fracture to the (R) humerus and a long arm splint to the fractured arm. The facility did not consult an orthopedist as ordered. The resident's (R) arm, covered by the splint, was not assessed for neurovascular status or skin integrity from 11/29/12 - 01/18/13. Braden scale assessments were not done quarterly. On 01/18/13, fifty-one days after the application of the splint, the splint was removed and a stage IV pressure ulcer was found to the resident's (R) elbow. The Administrator was notified of the Immediate Jeopardy on 03/26/13 at 2:05 p.m. A plan of removal was presented by the Administrator which read as follows: Failure to transcribe orders: 1. Notify attending physician to determine need for follow up of resident with Orthopedist (completed 03/26/13). 2. Review residents medical records from 11/29/12 to present to ensure that appointments have been made and physician orders [REDACTED]. 3. Nurses will be re-educated on accurately transcribing physician orders [REDACTED]. (will be completed upon returning to work, before being allowed to go to work, on next scheduled shift). 4. Unit managers will monitor physician orders [REDACTED]. DSC (Director of Clinical Services)/designee will conduct random audits weekly, utilizing the same QI tool, and report results monthly to the PI committee to ensure ongoing substantial compliance. 5. Date of Compliance 03/26/13. Failure to Assess Properly, resulting in a stage IV Pressure Ulcer 1. Assess current status of healing wound and notify physician if needed (done 03/26/13) 2. Head to toe assessments on residents to determine current status (done 03/26/13). Wounds will be assessed to determine need for further physician/responsible party notification. Physician orders [REDACTED]. Documentation will reflect notification and current status of wounds (in progress, will be completed 03/27/13). 3. Nurses will be educated on completing weekly head to toe assessments as scheduled with the appropriate follow through of any of any identified areas of skin breakdown. Education of nurses will include how to properly assess by checking for adequate circulation for those residents with an apparatus (such as immobilizers, splints, casts). CNAs will be re-educated on completing bath and body audits including reporting findings to charge nurses. Physicians/responsible party will be notified as needed. Care plans will be updated as needed. (upon returning to work, before being allowed to go to work, on next scheduled shift). 4. Unit Managers will monitor for compliance during the Morning Clinical Meeting, utilizing the same QI Data Collection Form. Director of Clinical Services/designee will conduct random audits weekly, utilizing the same QI tool, and report results monthly to the PI committee to ensure ongoing substantial compliance. 5. Date of compliance 03/26/13. The Immediate Jeopardy was removed on 03/27/13 at 2:55 p.m. when the surveyor confirmed all residents' records were reviewed for correct transcription of physicians' orders and appointments; all nurses were reeducated on transcribing orders with appropriate follow up; head to toe assessments were done on all residents; all nurses were reeducated on completing weekly head to toe assessments and follow through of any identified areas of skin breakdown and all nurses were educated on the proper assessment of adequate circulation for residents with apparatuses. The deficient practice remains at a level 3 for actual harm to Resident #5. Findings: Resident #5 was a [AGE] year old woman admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed the resident's cognitive skills for daily decision making were (3) severely impaired - never/rarely made decisions The resident was totally dependent for bed mobility, transfers, and all aspects of activities of daily living. Section M (skin conditions) M015: Is resident at risk for developing a pressure ulcer (Yes) M0210: Resident has Stage 1 or higher pressure ulcer (No) Review of the Minimum Data Set ((MDS) dated [DATE] revealed the resident's cognitive skills for daily decision making were (3) severely impaired - never/rarely made decisions The resident was totally dependent for bed mobility, transfers, and all aspects of activities of daily living. Section M (skin conditions) M015: Is resident at risk for developing a pressure ulcer (Yes) M0210: Resident has Stage 1 or higher pressure ulcer (Yes) M0300D1: Stage 4 pressure ulcers: number present (1) Review of the care plan revealed the following: Problem Onset: 06/05/2009: At risk for pressure ulcers/skin tears secondary to bladder/bowel incontinence. Goal & Target Date: Will minimize risk of skin breakdown/pressure ulcers qd (everyday) by 11/27/12 and again by 02/13 Approaches: inspect skin daily while performing care and notify nurse of any redness, irritation or skin tears. Review of the clinical record's nurses' notes dated 11/29/12 and timed 1:55 p.m., revealed the resident fell and expressed discomfort when her (R) arm was touched. She was sent to_______ Medical Center for an evaluation. At 4:00 p.m. the facility received a report from _______ Medical Center the resident had sustained a fractured to the right humerus and was being transferred to ________hospital. The resident returned to the facility on [DATE] at 8:40 p.m. The General Instructions Form from _____Medical Center dated 11/29/12, documented the following: Fracture proximal right humerus. Displacement of fracture is present (Patient is neurovascularly intact). Procedures: Long arm splint. The Exitcare Patient Information form from _______hospital dated 11/29/12 and timed 7:08 p.m., revealed the following: Please follow up with Dr._____(orthopedic surgeon) in 7 days for further evaluation. Review of the facility's physician's orders [REDACTED]. Review of the facility's nurses' notes dated 11/29/12 through 01/08/13 revealed no documentation the resident had a splint to the (R) arm. Review of the facility's Weekly Nursing Progress Notes dated 11/22/12; 12/06/12; 12/13/12; 12/20/12; 12/27/12; 01/03/13; 01/10/13; and 01/17/13 revealed no documentation of the neurovascular status of the resident's (R) arm or assessments of the skin on her (R) arm. The section on the weekly nurses' notes titled "Contractures" has a check list that includes hand splint. Hand splint was never marked on any of the weekly nurses' notes. Review of the resident's Medication Administration Records (MAR) for the months of November 2012 and December 2012 revealed no documentation of circulatory checks to the resident's (R) arm. The first documentation of circulatory checks to the resident's (R) arm is dated January 21, 2013. Review of a nurse's note dated 01/18/13 revealed the following: 10:45 a.m. Upon assessing Rt arm & splint noted an open area on Rt elbow - entire area 44 cm (discolored area) 2.1 x .3 cm open area in center, 0.5 cm depth with brownish yellow drainage and odor noted.... On 01/18/13 the resident's physician was notified and the following orders were given: Consult Dr._____(orthopedic surgeon ). A Request for physician's orders [REDACTED]. ______(orthopedic surgeon) refused to see resident secondary to the fracture being old. The resident was then referred to _________wound center on 01/22/13. On 01/22/13 orders were written to begin wound care with normal saline and Arginate daily until healed, Keflex 500 mg TID (three times a day) X 10 days, consult____wound care, culture & sensitivity of wound drainage, x-ray ? arm. The resident was initially seen at the wound care center on 01/30/13 with the following [DIAGNOSES REDACTED]. She continued with weekly visits until 03/13/13 when she was discharged from the wound care center. Review of the wound care center records revealed, in part, the following: Wound Location Type/Stage Measurements (cm) 01/30/13 (R) elbow Pressure Wound IV 0.3 x 0.7 x 0.8 Pack Tunneling/Undermining Lightly with: [MEDICATION NAME] AG Rope 2 x a week *wound debrided today Additional orders: Bone Culture sent today 02/06/13 (R) elbow Pressure Wound IV 0.2 x 0.2 x 0.5 Pack Tunneling/Undermining Lightly with: [MEDICATION NAME] AG Rope 2 x a week *removed nonviable/necrotic tissue from wound bed Additional orders: no pressure to wound area-no splint for one week 02/13/13 (R) elbow Pressure Wound IV 0.2 x 0.4 x 0.6 Apply to Wound Bed: [MEDICATION NAME] AG 2 x a week Additional orders: Keflex 250 mg po (by mouth) q12h (every 12 hours);[MEDICATION NAME] 3 x a day 02/20/13 (R) elbow Pressure Wound IV 0.2 x 0.2 x 0.3 Apply to Wound Bed: [MEDICATION NAME] 2 x a week *surgical removal non-viable tissue/slough Additional orders: Resume Keflex one more week 02/27/13 (R) elbow Pressure Wound IV 0.2 x 0.2 x 0.3 Apply to Wound Bed: [MEDICATION NAME] 2 x a week *surgical removal muscle &/or fascial tissue; surgical removal of bone Additional orders: Keflex 250 mg po q12h x 10 days; [MEDICATION NAME] TID (3 times a day) Wound deteriorated today, [MEDICATION NAME] - Palliative care, patient DNR (Do Not Resuscitate) 03/06/13 (R) elbow Pressure Wound IV 0.4 x 0.3 x 0.1 Apply to Wound Bed: Elta Silvergel/[MEDICATION NAME] 2 x a week *surgical removal/scissors non-viable tissue/slough Additional orders: Keep dressing on at all times; follow up in one week Wound deteriorated today, [MEDICATION NAME] - Palliative care, patient DNR (Do Not Resuscitate) 03/13/13 (R) elbow Pressure Wound IV 0.1 x 0.1 x 0.1 Apply to Wound Bed: [MEDICATION NAME] only 2 X a week *exudate removed, essentially healed Additional orders: Essentially healed, foam for offloading On 03/25/13 at 11:30 a.m. an observation was made of the resident sitting in her geri chair in the assisted dining room. When spoken to she did not respond. A CNA nearby stated the resident does not speak. A small dressing was noted to her (R) elbow. On 3/25/13 at 4:45 p.m. an interview was conducted with S2DON. She was asked to review the weekly nursing progress notes dated 11/22/12; 12/06/12; 12/13/12; 12/20/12; 12/27/12; 01/03/13; 01/10/13; 01/17/13 and all other nurses' notes written on Resident #5 from 11/29/12 to 01/17/13. She was asked if the section to indicate the resident had a splint was ever checked. S2DON verified there was no documentation the resident had on a splint when she returned to the facility on [DATE] or any time after until it was removed on 01/18/13. She was asked if neurovascular checks had been done on the resident's (R) arm from 11/29/12 to 01/17/13. S2DON verified there was no documentation of neurovascular checks to the resident's (R) arm. She was asked who should have been assessing the resident's arm. S2DON stated the assigned treatment nurse, who is no longer employed with the facility, should have been doing weekly skin assessments and the floor nurses should have also assessed the arm and splint daily. She was asked why the orthopedist was not consulted. S2DON verified the orthopedic consult was not done because the floor nurse did not write the need for the consult on the 24 form, which then is discussed in the morning meeting and would have been scheduled by social services. S2DON verified that when the consult was finally made on 01/22/13, the orthopedic surgeon refused to see the resident because the fracture was old. She was asked when was the stage IV pressure ulcer to the resident's (R) arm discovered. S2DON verified the wound was discovered at a stage IV on 01/18/13 when the splint was removed for the first time since her return to the facility on [DATE]. On 04/01/13 at 8:30 a.m. an interview was conducted with S4LPN, MDS Coordinator. S2DON was present during the interview with S4LPN, MDS. S4LPN was asked how often are the Braden Scale assessments to be done on residents. S4LPN stated on admit and quarterly. She was asked if any Braden Scale assessments had been done on the resident. S4LPN provided Braden scales done on the resident on 06/08/12 and 03/05/13. S4LPN verified there was no documentation of assessments done in September 2012 or December 2012. S4LPN was asked to review the resident's care plan. She was asked if the resident's skin was to be inspected daily for any changes. S4LPN stated "yes". On 04/01/13 at 8:45 a.m. an interview was conducted with S2DON. She was asked how often are skin assessments done and by whom. S2DON stated weekly skin assessments are done on all residents by the treatment nurse. She stated the nurses on the floor are responsible for daily skin assessments on their residents. She was asked if there was documentation of daily skin assessments. S2DON stated "No". She was asked if she had any documentation weekly skin assessments had been done on Resident #5. She stated she would check. On 04/01/13 at 9:40 a.m. S2DON returned to the surveyor and provided forms titled Weekly Skin Integrity Checks. Review of the weekly skin assessments for Resident #5 revealed weekly skin integrity checks were done on the resident for the months of June 2012 and July 2012. There was no documentation of weekly skin integrity checks for August 2012, September 2012, October 2012, November 2012 or December 2012. The first weekly skin integrity check for 2013 was done on 01/18/13, the day the stage IV wound was discovered. S2DON verified the facility's wound care nurse had not performed weekly skin integrity checks on Resident #5. S2DON was asked for the facility's policy and procedure for weekly and daily skin assessments. S2DON provided the surveyor a policy titled Assessment and Documentation of Wounds. She stated she did not have a policy for weekly skin sweeps or daily skin checks, but verified it was the facility's practice for the wound care nurses to perform weekly skin assessments and for the nurses on the floor to check their residents skin daily. She was asked to review the Braden Scale for Resident #5. S2DON verified the last Braden Scales done on the resident were done on 06/08/12 and 03/05/13. She was asked how often are Braden scale assessments to be done on residents. S2DON stated "Quarterly". She was asked if Braden scale assessments had been done on Resident #5 quarterly. She stated "No".

Based on interviews, record reviews, and review of Louisiana Administrative code, Title 46, Professional and Occupation Standards Practice XLVII, Nurse Subpart I Practical Nurse, the facility failed to ensure that care and services were provided to 3 (#1, #5, #6) of 9 (#1, #2, #3, #4, #5, #6) residents in accordance with professional standards of quality by failing to: Residents: #1- Follow a physician's orders [REDACTED]. This resulted in an Immediate Jeopardy situation began when resident #1 was admitted to the facility on [DATE]. S1Adm and S2DON was notified of the Immedicate Jeopardy siutation on [DATE] at 10:12 a.m. and removed at 3:04 p.m. Resident #1 had a history and [DIAGNOSES REDACTED]. The facility failed to have the daily PT/INR laboratory values performed and administer the anticoagulant medication [MEDICATION NAME] as needed based on the laboratory values throughout resident #1's length of stay. The Immediate Jeopardy situation continued for resident #1 until he expired on [DATE]. Resident #5 The facility failed to: 1. Ensure nursing staff follow the physician's orders [REDACTED]. 2. Ensure nursing staff document the presence of a splints or other apparatuses on residents 3. Ensure nursing staff assess residents neurovascular status 4. Ensure nursing staff perform weekly skin assessments 5. Ensure nursing staff follow the facility's care plans 6. ensure nursing staff perform quarterly Braden scale assessments Resident #5 was placed in Immediate Jeopardy on [DATE] when she returned to the facility from the hospital with a fracture to the (R) humerus and a long arm splint to the fractured arm. The facility did not consult an orthopedist as ordered. The resident's (R) arm, covered by the splint, was not assessed for neurovascular status or skin integrity from [DATE] - [DATE]. Braden scale assessments were not done quarterly. On [DATE], fifty-one days after the application of the splint, the splint was removed and a stage IV pressure ulcer was found to the resident's (R) elbow. The Administrator was notified of the Immediate Jeopardy on [DATE] at 2:05 p.m. A plan of removal was presented by the Administrator which read as follows: Failure to transcribe orders: 1. Notify attending physician to determine need for follow up of resident with Orthopedist (completed [DATE]). 2. Review residents medical records from [DATE] to present to ensure that appointments have been made and physician orders [REDACTED]. 3. Nurses will be re-educated on accurately transcribing physician orders [REDACTED]. (will be completed upon returning to work, before being allowed to go to work, on next scheduled shift). 4. Unit managers will monitor physician orders [REDACTED]. DSC (Director of Clinical Services)/designee will conduct random audits weekly, utilizing the same QI tool, and report results monthly to the PI committee to ensure ongoing substantial compliance. 5. Date of Compliance [DATE]. Failure to Assess Properly, resulting in a stage IV Pressure Ulcer 1. Assess current status of healing wound and notify physician if needed (done [DATE]) 2. Head to toe assessments on residents to determine current status (done [DATE]). Wounds will be assessed to determine need for further physician/responsible party notification. Physician orders [REDACTED]. Documentation will reflect notification and current status of wounds (in progress, will be completed [DATE]). 3. Nurses will be educated on completing weekly head to toe assessments as scheduled with the appropriate follow through of any of any identified areas of skin breakdown. Education of nurses will include how to properly assess by checking for adequate circulation for those residents with an apparatus (such as immobilizers, splints, casts). CNAs will be re-educated on completing bath and body audits including reporting findings to charge nurses. Physicians/responsible party will be notified as needed. Care plans will be updated as needed. (upon returning to work, before being allowed to go to work, on next scheduled shift). 4. Unit Managers will monitor for compliance during the Morning Clinical Meeting, utilizing the same QI Data Collection Form. Director of Clinical Services/designee will conduct random audits weekly, utilizing the same QI tool, and report results monthly to the PI committee to ensure ongoing substantial compliance. 5. Date of compliance [DATE]. The Immediate Jeopardy was removed on [DATE] at 2:55 p.m. when the surveyor confirmed all residents' records were reviewed for correct transcription of physicians' orders and appointments; all nurses were reeducated on transcribing orders with appropriate follow up; head to toe assessments were done on all residents; all nurses were reeducated on completing weekly head to toe assessments and follow through of any identified areas of skin breakdown and all nurses were educated on the proper assessment of adequate circulation for residents with apparatuses. The deficient practice remains at a level 3 for actual harm to Resident #5. Resident #6 The facility failed to: 1. Ensure nursing staff accurately transcribe physician's orders [REDACTED]. Resident #6 was placed in Immediate Jeopardy on [DATE] when she returned from an office visit with physician's orders [REDACTED]. The facility did not obtain the ultrasound until [DATE] after the resident complained of leg pain. The results of the ultrasound revealed the resident had 4 occlusive thrombus and 1 nonocclusive thrombus to the left lower leg. The Administrator was notified of the Immediate Jeopardy on [DATE] at 10:12 a.m. A plan of removal was presented by the Administrator which read as follows: 1. Review of physicians orders on current residents including transfer records from hospital, ER, office visits, progress notes, consults, in residents records from [DATE] to present was completed to ensure physician orders [REDACTED]. 2. All nurses will be re-educated on accurately transcribing physician orders [REDACTED]. 3. Unit Managers will monitor physicians orders along with appointments ordered Monday - Friday during the Morning Clinical Meeting, utilizing the QI data Collection Form, for ongoing compliance. Weekend supervisor will monitor Saturday and Sunday. DCS (Director of Clinical Services)/designee will conduct random audits weekly, utilizing same tool, and report results monthly to the PI committee to ensure on-going substantial compliance. The Immediate Jeopardy was removed on [DATE] at 3:04 p.m. when the surveyor confirmed all physician's orders [REDACTED]. The deficient practice remains at a level 3 for actual harm to Resident #6 Findings: Review of the Louisiana Administrative Code, Title 46, Professional and Occupational Standard, Part. XLVII, Nurses: Practical Nurses and Registered Nurses (As amended through December, 2009) Subpart, I. Practical Nurse, under subchapter E. Curriculum Requirements revealed in part ..."3. development of those qualities and personal characteristics needed to practice practical nursing safely, effectively and with [MEDICATION NAME], including increased and ongoing development of self awareness, sound judgement, prudence, ethical thing and behaviors, problem solving and critical thinking abilities...7. Principles and Practice of Nursing-presenting the application of concepts which will provide basic principles of nursing care and correlated experiences to develop competency in medical-surgical nursing, geriatric nursing, obstetrical nursing, pediatric nursing, and mental health. Clinical experience shall include, but not be limited to, the performance of basic and advanced nursing skills, general health and physical assessment, critical thinking and critical problem solving, medication administration, IV therapy, patient education, health screening, health promotion, health restoration and maintenance, supervision and management, safety and infection control, communication and documentation, and writing as member of the interdisciplinary health care team..." Resident #1 On [DATE] at 9:35 a.m. an interview was conducted with S2DON. She was asked to review the physician orders [REDACTED]. Review of the orders revealed resident was admitted to the facility with admission orders [REDACTED]. S2DON confirmed this admission order. She was asked to obtain resident #1's admission orders [REDACTED]. S2DON was asked to review the Medication Administration Record (MAR) dated [DATE] with the surveyor. She reviewed [DATE] MAR and confirmed [MEDICATION NAME] was transcribed to the MAR as a medication to be administered. Asked DON if the [MEDICATION NAME] medication for this resident was still in the building. Stated she would check. S2DON was asked to also obtain the pharmacy records indicating when the medication [MEDICATION NAME] for resident #1 was received at the facility. On [DATE] at 3:30 p.m. an interview was conducted with S2DON. She presented a copy of a document entitled, "(Name of Hospital) CPOE Discharge Orders" for resident #1 dated [DATE]. She verified this document was the transferring hospital's discharge and admission orders [REDACTED]. Review of the Discharge Orders revealed in part the following: "Diagnostic Studies Check PT/INR q (every) AM (morning) and start [MEDICATION NAME] 1.5 mg (milligram) per body weight q day when INR less than 2.0". S2DON confirmed the admission order for PT/INR and [MEDICATION NAME]. She was asked again to review the MAR dated [DATE] with the surveyor. She reviewed [DATE] MAR and confirmed the medication [MEDICATION NAME] was never administered. When asked if there was any of resident #1's [MEDICATION NAME] remaining in the facility. She stated no. S2DON presented a document entitled, "Order Search by Resident". She confirmed this document listed all the medications the facility ordered from the pharmacy for resident #1. S2DON verified at this time the medication [MEDICATION NAME] was never ordered. S2DON was asked if there was any documentation of PT/INR results for resident #1. She stated, "I can check the hospital's records". S2DON was informed by the surveyor she requested the facility's PT/INR laboratory records for resident #1 following admission. S2DON verified there was no documented evidence the facility had ever requested laboratory values for PT/INR for resident #1. On [DATE] at 3:45 p.m. an interview was conducted with S18LPN. She stated she worked in Medical Records and verified she transcribed the admission orders [REDACTED]. She was asked to review the hospital's discharge and admission orders [REDACTED]. She confirmed the PT/INR was transcribed correctly to the [DATE] Physician Orders. She confirmed the medication order for [MEDICATION NAME] was transcribed correctly to the [DATE] Physician Orders. She was asked what was the facility's procedure and nurse's responsibility to ensure a resident received laboratory orders. She stated the nurse that does the admitting packet should enter the lab order in the lab book for each day. She stated laboratory services were received and performed by (Name of hospital) Hospital Monday -Friday. She stated Medical Records would in turn fax the required labs to notify them what labs need to be drawn. She was asked what does the facility do on weekends. She stated, "The nurses put in in the calendar at the stations". She was asked to locate the Lab Book at the Nurses Station and bring it to the surveyor. S18LPN reviewed the Lab Book with the surveyor and confirmed there was no documented evidence of any PT/INR labs scheduled to be drawn for resident #1. S18LPN stated, "(Resident #1) should have had the first PT/INR drawn [DATE]. Further review of the Lab Book confirmed there were no labs drawn for resident #1 during his entire length of stay at the facility from [DATE] - [DATE]. Findings: Resident #5 was a [AGE] year old woman admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed the resident's cognitive skills for daily decision making were (3) severely impaired - never/rarely made decisions The resident was totally dependent for bed mobility, transfers, and all aspects of activities of daily living. Section M (skin conditions) M015: Is resident at risk for developing a pressure ulcer (Yes) M0210: Resident has Stage 1 or higher pressure ulcer (No) Review of the Minimum Data Set ((MDS) dated [DATE] revealed the resident's cognitive skills for daily decision making were (3) severely impaired - never/rarely made decisions The resident was totally dependent for bed mobility, transfers, and all aspects of activities of daily living. Section M (skin conditions) M015: Is resident at risk for developing a pressure ulcer (Yes) M0210: Resident has Stage 1 or higher pressure ulcer (Yes) M0300D1: Stage 4 pressure ulcers: number present (1) Review of the care plan revealed the following: Problem Onset: [DATE]: At risk for pressure ulcers/skin tears secondary to bladder/bowel incontinence. Goal & Target Date: Will minimize risk of skin breakdown/pressure ulcers qd (everyday) by [DATE] and again by ,[DATE] Approaches: inspect skin daily while performing care and notify nurse of any redness, irritation or skin tears. Review of the clinical record's nurses' notes dated [DATE] and timed 1:55 p.m., revealed the resident fell and expressed discomfort when her (R) arm was touched. She was sent to _______ Medical Center for an evaluation. At 4:00 p.m. the facility received a report from _______ Medical Center the resident had sustained a fractured to the right humerus and was being transferred to ________hospital. The resident returned to the facility on [DATE] at 8:40 p.m. The General Instructions Form from _____Medical Center dated [DATE], documented the following: Fracture proximal right humerus. Displacement of fracture is present (Patient is neurovascularly intact). Procedures: Long arm splint. The Exitcare Patient Information form from _______hospital dated [DATE] and timed 7:08 p.m., revealed the following: Please follow up with Dr._____(orthopedic surgeon) in 7 days for further evaluation. Review of the facility's physician's orders [REDACTED]. Review of the facility's nurses' notes dated [DATE] through [DATE] revealed no documentation the resident had a splint to the (R) arm. Review of the facility's Weekly Nursing Progress Notes dated [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; and [DATE] revealed no documentation of the neurovascular status of the resident's (R) arm or assessments of the skin on her (R) arm. The section on the weekly nurses' notes titled "Contractures" has a check list that includes hand splint. Hand splint was never marked on any of the weekly nurses' notes. Review of the resident's Medication Administration Records (MAR) for the months of [DATE] and [DATE] revealed no documentation of circulatory checks to the resident's (R) arm. The first documentation of circulatory checks to the resident's (R) arm is dated [DATE]. Review of a nurse's note dated [DATE] revealed the following: 10:45 a.m. Upon assessing Rt arm & splint noted an open area on Rt elbow - entire area 44 cm (discolored area) 2.1 x .3 cm open area in center, 0.5 cm depth with brownish yellow drainage and odor noted.... On [DATE] the resident's physician was notified and the following orders were given: Consult Dr._____(orthopedic surgeon ). A Request for physician's orders [REDACTED]. ______(orthopedic surgeon) refused to see resident secondary to the fracture being old. The resident was then referred to _________wound center on [DATE]. On [DATE] orders were written to begin wound care with normal saline and Arginate daily until healed, Keflex 500 mg TID (three times a day) X 10 days, consult____wound care, culture & sensitivity of wound drainage, x-ray ? arm. The resident was initially seen at the wound care center on [DATE] with the following [DIAGNOSES REDACTED]. She continued with weekly visits until [DATE] when she was discharged from the wound care center. Review of the wound care center records revealed, in part, the following: Wound Location Type/Stage Measurements (cm) [DATE] (R) elbow Pressure Wound IV 0.3 x 0.7 x 0.8 Pack Tunneling/Undermining Lightly with: [MEDICATION NAME] AG Rope 2 x a week *wound debrided today Additional orders: Bone Culture sent today [DATE] (R) elbow Pressure Wound IV 0.2 x 0.2 x 0.5 Pack Tunneling/Undermining Lightly with: [MEDICATION NAME] AG Rope 2 x a week *removed nonviable/necrotic tissue from wound bed Additional orders: no pressure to wound area-no splint for one week [DATE] (R) elbow Pressure Wound IV 0.2 x 0.4 x 0.6 Apply to Wound Bed: [MEDICATION NAME] AG 2 x a week Additional orders: Keflex 250 mg po (by mouth) q12h (every 12 hours);[MEDICATION NAME] 3 x a day [DATE] (R) elbow Pressure Wound IV 0.2 x 0.2 x 0.3 Apply to Wound Bed: [MEDICATION NAME] 2 x a week *surgical removal non-viable tissue/slough Additional orders: Resume Keflex one more week [DATE] (R) elbow Pressure Wound IV 0.2 x 0.2 x 0.3 Apply to Wound Bed: [MEDICATION NAME] 2 x a week *surgical removal muscle &/or fascial tissue; surgical removal of bone Additional orders: Keflex 250 mg po q12h x 10 days; [MEDICATION NAME] TID (3 times a day) Wound deteriorated today, [MEDICATION NAME] - Palliative care, patient DNR (Do Not Resuscitate) [DATE] (R) elbow Pressure Wound IV 0.4 x 0.3 x 0.1 Apply to Wound Bed: Elta Silvergel/[MEDICATION NAME] 2 x a week *surgical removal/scissors non-viable tissue/slough Additional orders: Keep dressing on at all times; follow up in one week Wound deteriorated today, [MEDICATION NAME] - Palliative care, patient DNR (Do Not Resuscitate) [DATE] (R) elbow Pressure Wound IV 0.1 x 0.1 x 0.1 Apply to Wound Bed: [MEDICATION NAME] only 2 X a week *exudate removed, essentially healed Additional orders: Essentially healed, foam for offloading On [DATE] at 11:30 a.m. an observation was made of the resident sitting in her geri chair in the assisted dining room. When spoken to she did not respond. A CNA nearby stated the resident does not speak. A small dressing was noted to her (R) elbow. On [DATE] at 4:45 p.m. an interview was conducted with S2DON. She was asked to review the resident's clinical record with the surveyor. She was asked to review the exitcare patient information form from _______hospital dated [DATE]. She was asked if the facility's nurses had ever consulted the orthopedic doctor. S2DON stated "No". She was asked should they have. S2DON stated "Yes". She was asked to review the weekly nursing progress notes dated [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; and [DATE]. She was asked if the section to indicate the resident had a splint was ever checked. S2DON verified there was no documentation the resident had on a splint when she returned to the facility on [DATE] or any time after until it was removed on [DATE]. She was asked if neurovascular checks had been done on the resident's (R) arm from [DATE] to [DATE]. S2DON verified there was no documentation of neurovascular checks to the resident's (R) arm. She was asked who should have been assessing the resident's arm. S2DON stated the assigned treatment nurse, who is no longer employed with the facility, should have been doing weekly skin assessments and the floor nurses should have also assessed the arm and splint daily. She was asked why the orthopedist was not consulted. S2DON verified the orthopedic consult was not done because the floor nurse did not write the need for the consult on the 24 form, which then is discussed in the morning meeting and would have been scheduled by social services. S2DON verified that when the consult was finally made on [DATE], the orthopedic surgeon refused to see the resident because the fracture was old. She was asked when was the stage IV pressure ulcer to the resident's (R) arm discovered. S2DON verified the wound was discovered at a stage IV on [DATE] when the splint was removed for the first time since her return to the facility on [DATE]. On [DATE] at 9:20 a.m. an interview was conducted with S2DON. She was asked why the resident was not seen at the wound care center until [DATE] when the consult was ordered on [DATE]. She stated the center only sees patients on Wednesdays and [DATE] was the next available Wednesday. On [DATE] at 10:45 a.m. an interview was conducted with S12LPN, treatment nurse, as she performed wound care for Resident #5. She was asked what did she know about the history of the resident's wound. S12LPN stated she was not the wound care nurse at the time the wound was discovered, but she stated the previous wound care nurse discovered the wound when she removed the splint. She stated the resident was recently discharged from the wound care center. Observation of the wound revealed a small closed area to the (R) elbow. Review of the last measurement taken of the wound on [DATE], was (L) 0.1 cm x (W) 0.1 cm with no measurable depth. On [DATE] at 10:55 a.m. an interview was conducted with S28RN, who was working on the hall where the resident resided. She was asked what did she know about the development of the resident's pressure ulcer to her (R) elbow. S28RN stated the "splint was wrapped in an ace wrap and the treatment nurse at the time, thought the floor nurses were taking care of it". On [DATE] at 8:30 a.m. an interview was conducted with S4LPN, MDS Coordinator. S2DON was present during the interview with S4LPN, MDS. S4LPN was asked how often are the Braden Scale assessments to be done on residents. S4LPN stated on admit and quarterly. She was asked if any Braden Scale assessments had been done on the resident. S4LPN provided Braden scales done on the resident on [DATE] and [DATE]. S4LPN verified there was no documentation of assessments done in [DATE] or [DATE]. S4LPN was asked to review the resident's care plan. She was asked if the resident's skin was to be inspected daily for any changes. S4LPN stated "yes". On [DATE] at 8:45 a.m. an interview was conducted with S2DON. She was asked how often are skin assessments done and by whom. S2DON stated weekly skin assessments are done on all residents by the treatment nurse. She stated the nurses on the floor are responsible for daily skin assessments on their residents. She was asked if there was documentation of daily skin assessments. S2DON stated "No". She was asked if she had any documentation weekly skin assessments had been done on Resident #5. She stated she would check. On [DATE] at 9:40 a.m. S2DON returned to the surveyor and provided forms titled Weekly Skin Integrity Checks. Review of the weekly skin assessments for Resident #5 revealed weekly skin integrity checks were done on the resident for the months of [DATE] and [DATE]. There was no documentation of weekly skin integrity checks for [DATE], [DATE], [DATE], [DATE] or [DATE]. The first weekly skin integrity check for 2013 was done on [DATE], the day the stage IV wound was discovered. S2DON verified the facility's wound care nurse had not performed weekly skin integrity checks on Resident#5. S2DON was asked for the facility's policy and procedure for weekly and daily skin assessments. S2DON provided the surveyor a policy titled Assessment and Documentation of Wounds. She stated she did not have a policy for weekly skin sweeps or daily skin checks, but verified it was the facility's practice for the wound care nurses to perform weekly skin assessments and for the nurses on the floor to check their residents skin daily. She was asked to review the Braden Scale for Resident #5. S2DON verified the last Braden Scales done on the resident were done on [DATE] and [DATE]. She was asked how often are Braden scale assessments to be done on residents. S2DON stated "Quarterly". She was asked if Braden scale assessments had been done on Resident #5 quarterly. She stated "no". Resident #6 Resident #6 was a [AGE] year old woman admitted to the facility on [DATE] after an ORIF (Open Reduction Internal Fixation) of the (L) Hip. Other [DIAGNOSES REDACTED]. She was readmitted on [DATE] after a hospitalization for [MEDICAL CONDITION]. Review of the (MDS) Minimum (MDS) data set [DATE] revealed the resident had a BIMS (Brief Interview for Mental Status) score of 11 (moderate impairment) Review of the care plan revealed the following: Problem Onset: [DATE] [MEDICATION NAME] therapy related to status [REDACTED]. Goal & Target Date: will have no abnormal bleeding by [DATE] Approaches: monitor for [MEDICAL CONDITION]: warmth, redness, swelling to extremity, positive Homans sign. Review of the nurses' notes dated [DATE] - [DATE] revealed the following: On [DATE] the resident went out to a scheduled office visit with Dr._____. Review of the physician's office notes revealed the following: Chief Complaint: some c/o (complaints) of weakness and pain and leg swelling, on walker/[MEDICATION NAME], PWB (partial weight bearing). ROS (review of systems): Patient reports joint pain and difficulty walking but reports no joint stiffness or swelling, no weakness of muscles or joints, no muscle pain or cramps, no back pain, and no cold extremities. Assessment /Plan: d/c (discontinue) staples, PT (physical therapy)/WBAT (weight bearing as tolerated) check u/s (ultrasound) LLE (left lower extremity), walker, finish course of [MEDICATION NAME]. Review of the clinical record revealed the following: Physician's progress note dated [DATE]: Plan (P) check u/s - leg swelling. physician's orders [REDACTED]. Nurses' Notes: [DATE] 3:50 p.m Returned from appointment with Dr.______ per nursing home van with orders for WBAT with walker PT/ROM (range of motion), u/s (L) leg r/o [MEDICAL CONDITION].signed by S17LPN. Physician's Telephone Orders dated [DATE]: WBAT with walker/PT/hip and knee ROM, u/s (L) leg-r/o [MEDICAL CONDITION] by S16RN. Review of the clinical record's nurses' notes dated [DATE] and timed at 8:15 a.m. documented the following: Resident up working with therapy. Resident complained of pain to her (L) leg, lower. MD (medical doctor) ordered u/s of lower extremity. Facility van will transport her to appointment this am......signed by S3RN. Nurses' notes continued: [DATE] 6:00 p.m. resident was admitted to ______Medical Center with [DIAGNOSES REDACTED]. [DATE] 7:30 p.m. readmit assessment done with resident and daughter. Orders from ____Medical Center/Dr._____for readmit to ________Nursing home. [DIAGNOSES REDACTED]. Review of the u/s done on [DATE] at ______Medical Center revealed the u/s was completed at 10:11 a.m. and the resident's physician was notified by the Radiologist at 10:22 a.m. of the following results: Findings: There is nonocclusive thrombus demonstrated within the left common femoral vein. Partial flow is demonstrated. There is occlusive thrombus noted within the profunda femoral, superficial femoral, popliteal, and anterior tibial veins. No flow demonstrated within these veins. The posterior vein demonstrates no thrombus. Impression: Occlusive thrombus within the profunda femoral, superficial femoral, popliteal, and anterior tibial veins on the left with nonocclusive thrombus within the common femoral vein. On [DATE] at 4:30 p.m. an interview conducted with S2DON and S3RN. They were asked to review the clinical record and MD orders on [DATE] for an u/s to the lower leg and the u/s report of [DATE] positive for thrombus. S3RN was asked if she was the nurse on duty the morning of [DATE] when the resident complained of leg pain. She stated "yes". S3RN was asked why did she send Resident #6 for the ultrasound. S3RN stated on the morning of [DATE] the resident complained of pain to her left lower leg. She stated she realized the ultrasound ordered on [DATE] had not been done, so she called_______Medical Center and the resident was seen for the ultrasound. S2DON was asked if an ultrasound had been ordered on [DATE] by the physician to rule out [MEDICAL CONDITION]. She stated "yes". She was asked if the resident received an ultrasound on [DATE] as ordered. S2DON stated "no". She was asked if the order written on [DATE] had been followed. S2DON verified the order had not been followed by nursing. She was asked what is the process for scheduling tests. S2DON stated the nurse takes off the order and writes it on the outpatient appointments schedule sheet. S5SSD then schedules the appointments. On [DATE] at 10:30 a.m. S25RN, Corporate Nurse presented the surveyor with a form titled Outpatient Appointments to be Scheduled and a copy from the appointment book of S5SSD dated [DATE]th, 12th and 13th of 2013. The resident's name was listed on the appointments to be scheduled form with the date [DATE] written under the heading "Date Of Order". On the appointment book the resident's name was written near the top of the page for [DATE] with no time next to it. On [DATE] at 10:40 a.m. S1ADM approached the surveyor, and referring to the forms presented by S25RN, Corporate Nurse, stated the facilty had tried to schedule the ultrasound on [DATE], but _______Medical Center had scheduled the ultrasound for [DATE]. On [DATE] at 11:20 a.m. an interview was conducted with S15RAD, the Director of Radiology services at ________ Medical Center. He was asked if the resident had ever been scheduled for an u/s on [DATE]. After reviewing the radiology schedule for [DATE], he stated "she was never scheduled; the first time we were contacted was on [DATE] when they called and asked to bring her over ". He was asked how did he know the resident was never scheduled on [DATE] by the nursing facility. S15RAD stated "because she was never placed on our schedule". He went on to state "she was put into our system at 9:40 a.m. on [DATE] when she arrived and the ultrasound was completed at 10:11 a.m. Dr._____(radiologist) called the results to Dr.____(resident's physician)". He was asked if the resident could have been seen on Friday, [DATE], if the facility had scheduled the u/s. S15RAD stated "yes, we have techs here until 11:30 p.m. and then someone is on call ". He went on to state "we don't really schedule ultrasounds for [MEDICAL CONDITION] (deep vein thrombus)

I. Based on observation, interview and record review the facility failed to ensure services were provided by qualified persons in accordance with each resident's written plan of care for 3 (#1,#5, #6) of 9 (#1, #2, #3, #4, #5, #6, #7, #8, #9 ) residents. The facility failed to: 1. consult an orthopedist, assess neurovascular status, perform weekly skin assessments, follow the facility's care plan to inspect the skin daily and perform quarterly Braden scale assessments for Resident #5. 2. Follow the physician's orders [REDACTED].#6 3.Follow a physician's orders [REDACTED].#1. II. Based on observation, interview and record review the facility failed to ensure services were provided by qualified persons in accordance with each resident's written plan of care for 4 (#3, #4, #5, #7) of 9 (#1, #2, #3, #4, #5, #6, #7, #8, #9 ) sampled residents and for 57 random residents. The facility failed to ensure medications were administered timely for a total sample of 62 residents who received a total of 237 doses late out of a total facility census of 118 as documented on Resident Census and Conditions of Residents form CMS-672. Findings: I. Resident #5 Resident #5 was placed in immediate jeopardy on 11/29/12 when she returned to the facility from the hospital with a fracture to the (R) humerus and a long arm splint to the fractured arm. The facility did not consult an orthopedist as ordered. The resident's (R) arm, covered by the splint, was not assessed for neurovascular status or skin integrity from 11/29/12 - 01/18/13. Braden scale assessments were not done quarterly. On 01/18/13, fifty-one days after the application of the splint, the splint was removed and a stage IV pressure ulcer was found to the resident's (R) elbow. The Administrator was notified of the immediate jeopardy on 03/26/13 at 2:05 p.m. A plan of removal was presented by the Administrator which read as follows: Failure to transcribe orders: 1. Notify attending physician to determine need for follow up of resident with Orthopedist (completed 03/26/13). 2. Review residents medical records from 11/29/12 to present to ensure that appointments have been made and physician orders [REDACTED]. 3. Nurses will be re-educated on accurately transcribing physician orders [REDACTED]. (will be completed upon returning to work, before being allowed to go to work, on next scheduled shift). 4. Unit managers will monitor physician orders [REDACTED]. DSC (Director of Clinical Services)/designee will conduct random audits weekly, utilizing the same QI tool, and report results monthly to the PI committee to ensure ongoing substantial compliance. 5. Date of Compliance 03/26/13. Failure to Assess Properly, resulting in a stage IV Pressure Ulcer 1. Assess current status of healing wound and notify physician if needed (done 03/26/13) 2. Head to toe assessments on residents to determine current status (done 03/26/13). Wounds will be assessed to determine need for further physician/responsible party notification. Physician orders [REDACTED]. Documentation will reflect notification and current status of wounds (in progress, will be completed 03/27/13). 3. Nurses will be educated on completing weekly head to toe assessments as scheduled with the appropriate follow through of any of any identified areas of skin breakdown. Education of nurses will include how to properly assess by checking for adequate circulation for those residents with an apparatus (such as immobilizers, splints, casts). CNAs will be re-educated on completing bath and body audits including reporting findings to charge nurses. Physicians/responsible party will be notified as needed. Care plans will be updated as needed. (upon returning to work, before being allowed to go to work, on next scheduled shift). 4. Unit Managers will monitor for compliance during the Morning Clinical Meeting, utilizing the same QI Data Collection Form. Director of Clinical Services/designee will conduct random audits weekly, utilizing the same QI tool, and report results monthly to the PI committee to ensure ongoing substantial compliance. 5. Date of compliance 03/26/13. The immediate jeopardy was removed on 03/27/13 at 2:55 p.m. when the surveyor confirmed all residents' records were reviewed for correct transcription of physicians' orders and appointments; all nurses were reeducated on transcribing orders with appropriate follow up; head to toe assessments were done on all residents; all nurses were reeducated on completing weekly head to toe assessments and follow through of any identified areas of skin breakdown and all nurses were educated on the proper assessment of adequate circulation for residents with apparatuses. The deficient practice remains at a level 3 for actual harm to Resident #5. Findings: Resident #5 was a [AGE] year old woman admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed the resident's cognitive skills for daily decision making were (3) severely impaired - never/rarely made decisions The resident was totally dependent for bed mobility, transfers, and all aspects of activities of daily living. Section M (skin conditions) M015: Is resident at risk for developing a pressure ulcer (Yes) M0210: Resident has Stage 1 or higher pressure ulcer (No) Review of the Minimum Data Set ((MDS) dated [DATE] revealed the resident's cognitive skills for daily decision making were (3) severely impaired - never/rarely made decisions The resident was totally dependent for bed mobility, transfers, and all aspects of activities of daily living. Section M (skin conditions) M015: Is resident at risk for developing a pressure ulcer (Yes) M0210: Resident has Stage 1 or higher pressure ulcer (Yes) M0300D1: Stage 4 pressure ulcers: number present (1) Review of the care plan revealed the following: Problem Onset: 06/05/2009: At risk for pressure ulcers/skin tears secondary to bladder/bowel incontinence. Goal & Target Date: Will minimize risk of skin breakdown/pressure ulcers qd (everyday) by 11/27/12 and again by 02/13 Approaches: inspect skin daily while performing care and notify nurse of any redness, irritation or skin tears. Review of the clinical record's nurses' notes dated 11/29/12 and timed 1:55 p.m., revealed the resident fell and expressed discomfort when her (R) arm was touched. She was sent to _______ Medical Center for an evaluation. At 4:00 p.m. the facility received a report from _______ Medical Center the resident had sustained a fractured to the right humerus and was being transferred to ________hospital. The resident returned to the facilty on 11/29/12 at 8:40 p.m. The General Instructions Form from _____Medical Center dated 11/29/12, documented the following: Fracture proximal right humerus. Displacement of fracture is present (Patient is neurovascularly intact). Procedures: Long arm splint. The Exitcare Patient Information form from _______hospital dated 11/29/12 and timed 7:08 p.m., revealed the following: Please follow up with Dr._____(orthopedic surgeon) in 7 days for further evaluation. Review of the facility's physician's orders [REDACTED]. Review of the facility's nurses' notes dated 11/29/12 through 01/08/13 revealed no documentation the resident had a splint to the (R) arm. Review of the facility's Weekly Nursing Progress Notes dated 11/22/12; 12/06/12; 12/13/12; 12/20/12; 12/27/12; 01/03/13; 01/10/13; and 01/17/13 revealed no documentation of the neurovascular status of the resident's (R) arm or assessments of the skin on her (R) arm. The section on the weekly nurses' notes titled "Contractures" has a check list that includes hand splint. Hand splint was never marked on any of the weekly nurses' notes. Review of the resident's Medication Administration Records (MAR) for the months of November 2012 and December 2012 revealed no documentation of circulatory checks to the resident's (R) arm. The first documentation of circulatory checks to the resident's (R) arm is dated January 21, 2013. Review of a nurse's note dated 01/18/13 revealed the following: 10:45 a.m. Upon assessing Rt arm & splint noted an open area on Rt elbow - entire area 44 cm (discolored area) 2.1 x .3 cm open area in center, 0.5 cm depth with brownish yellow drainage and odor noted.... On 01/18/13 the resident's physician was notified and the following orders were given: Consult Dr._____(orthopedic surgeon ). A Request for physician's orders [REDACTED]. ______(orthopedic surgeon) refused to see resident secondary to the fracture being old. The resident was then referred to _________wound center on 01/22/13. On 01/22/13 orders were written to begin wound care with normal saline and Arginate daily until healed, Keflex 500 mg TID (three times a day) X 10 days, consult____wound care, culture & sensitivity of wound drainage, x-ray ? arm. The resident was initially seen at the wound care center on 01/30/13 with the following [DIAGNOSES REDACTED]. She continued with weekly visits until 03/13/13 when she was discharged from the wound care center. Review of the wound care center records revealed, in part, the following: Wound Location Type/Stage Measurements (cm) 01/30/13 (R) elbow Pressure Wound IV 0.3 x 0.7 x 0.8 Pack Tunneling/Undermining Lightly with: [MEDICATION NAME] AG Rope 2 x a week *wound debrided today Additional orders: Bone Culture sent today 02/06/13 (R) elbow Pressure Wound IV 0.2 x 0.2 x 0.5 Pack Tunneling/Undermining Lightly with: [MEDICATION NAME] AG Rope 2 x a week *removed nonviable/necrotic tissue from wound bed Additional orders: no pressure to wound area-no splint for one week 02/13/13 (R) elbow Pressure Wound IV 0.2 x 0.4 x 0.6 Apply to Wound Bed: [MEDICATION NAME] AG 2 x a week Additional orders: Keflex 250 mg po (by mouth) q12h (every 12 hours);[MEDICATION NAME] 3 x a day 02/20/13 (R) elbow Pressure Wound IV 0.2 x 0.2 x 0.3 Apply to Wound Bed: [MEDICATION NAME] 2 x a week *surgical removal non-viable tissue/slough Additional orders: Resume Keflex one more week 02/27/13 (R) elbow Pressure Wound IV 0.2 x 0.2 x 0.3 Apply to Wound Bed: [MEDICATION NAME] 2 x a week *surgical removal muscle &/or fascial tissue; surgical removal of bone Additional orders: Keflex 250 mg po q12h x 10 days; [MEDICATION NAME] TID (3 times a day) Wound deteriorated today, [MEDICATION NAME] - Palliative care, patient DNR (Do Not Resuscitate) 03/06/13 (R) elbow Pressure Wound IV 0.4 x 0.3 x 0.1 Apply to Wound Bed: Elta Silvergel/[MEDICATION NAME] 2 x a week *surgical removal/scissors non-viable tissue/slough Additional orders: Keep dressing on at all times; follow up in one week Wound deteriorated today, [MEDICATION NAME] - Palliative care, patient DNR (Do Not Resuscitate) 03/13/13 (R) elbow Pressure Wound IV 0.1 x 0.1 x 0.1 Apply to Wound Bed: [MEDICATION NAME] only 2 X a week *exudate removed, essentially healed Additional orders: Essentially healed, foam for offloading On 03/25/13 at 11:30 a.m. an observation was made of the resident sitting in her geri chair in the assisted dining room. When spoken to she did not respond. A CNA nearby stated the resident does not speak. A small dressing was noted to her (R) elbow. On 3/25/13 at 4:45 p.m. an interview was conducted with S2DON. She was asked to review the resident's clinical record with the surveyor. She was asked to review the exitcare patient information form from _______hospital dated 11/29/12. She was asked if the facility's nurses had ever consulted the orthopedic doctor. S2DON stated "No". She was asked should they have. S2DON stated "Yes". She was asked to review the weekly nursing progress notes dated 11/22/12; 12/06/12; 12/13/12; 12/20/12; 12/27/12; 01/03/13; 01/10/13; and 01/17/13. She was asked if the section to indicate the resident had a splint was ever checked. S2DON verified there was no documentation the resident had on a splint when she returned to the facility on [DATE] or any time after until it was removed on 01/18/13. She was asked if neurovascular checks had been done on the resident's (R) arm from 11/29/12 to 01/17/13. S2DON verified there was no documentation of neurovascular checks to the resident's (R) arm. She was asked who should have been assessing the resident's arm. S2DON stated the assigned treatment nurse, who is no longer employed with the facility, should have been doing weekly skin assessments and the floor nurses should have also assessed the arm and splint daily. She was asked why the orthopedist was not consulted. S2DON verified the orthopedic consult was not done because the floor nurse did not write the need for the consult on the 24 form, which then is discussed in the morning meeting and would have been scheduled by social services. S2DON verified that when the consult was finally made on 01/22/13, the orthopedic surgeon refused to see the resident because the fracture was old. She was asked when was the stage IV pressure ulcer to the resident's (R) arm discovered. S2DON verified the wound was discovered at a stage IV on 01/18/13 when the splint was removed for the first time since her return to the facility on [DATE]. On 03/26/13 at 9:20 a.m. an interview was conducted with S2DON. She was asked why the resident was not seen at the wound care center until 01/30/13 when the consult was ordered on [DATE]. She stated the center only sees patients on Wednesdays and 01/30/13 was the next available Wednesday. On 03/26/13 at 10:45 a.m. an interview was conducted with S12LPN, treatment nurse, as she performed wound care for Resident #5. She was asked what did she know about the history of the resident's wound. S12LPN stated she was not the wound care nurse at the time the wound was discovered, but she stated the previous wound care nurse discovered the wound when she removed the splint. She stated the resident was recently discharged from the wound care center. Observation of the wound revealed a small closed area to the (R) elbow. Review of the last measurement taken of the wound on 03/18/13, was (L) 0.1 cm x (W) 0.1 cm with no measurable depth. On 03/26/13 at 10:55 a.m. an interview was conducted with S28RN, who was working on the hall where the resident resided. She was asked what did she know about the development of the resident's pressure ulcer to her (R) elbow. S28RN stated the "splint was wrapped in an ace wrap and the treatment nurse at the time, thought the floor nurses were taking care of it". On 04/01/13 at 8:30 a.m. an interview was conducted with S4LPN, MDS Coordinator. S2DON was present during the interview with S4LPN, MDS. S4LPN was asked how often are the Braden Scale assessments to be done on residents. S4LPN stated on admit and quarterly. She was asked if any Braden Scale assessments had been done on the resident. S4LPN provided Braden scales done on the resident on 06/08/12 and 03/05/13. S4LPN verified there was no documentation of assessments done in September 2012 or December 2012. S4LPN was asked to review the resident's care plan. She was asked if the resident's skin was to be inspected daily for any changes. S4LPN stated "yes". On 04/01/13 at 8:45 a.m. an interview was conducted with S2DON. She was asked how often are skin assessments done and by whom. S2DON stated weekly skin assessments are done on all residents by the treatment nurse. She stated the nurses on the floor are responsible for daily skin assessments on their residents. She was asked if there was documentation of daily skin assessments. S2DON stated "No". She was asked if she had any documentation weekly skin assessments had been done on Resident #5. She stated she would check. On 04/01/13 at 9:40 a.m. S2DON returned to the surveyor and provided a forms titled Weekly Skin Integrity Checks. Review of the weekly skin assessments for Resident #5 revealed weekly skin integrity checks were done on the resident for the months of June 2012 and July 2012. There was no documentation of weekly skin integrity checks for August 2012, September 2012, October 2012, November 2012 or December 2012. The first weekly skin integrity check for 2013 was done on 01/18/13, the day the stage IV wound was discovered. S2DON verified the facility's wound care nurse had not performed weekly skin integrity checks on Resident#5. S2DON was asked for the facility's policy and procedure for weekly and daily skin assessments. S2DON provided the surveyor a policy titled Assessment and Documentation of Wounds. She stated she did not have a policy for weekly skin sweeps or daily skin checks, but verified it was the facility's practice for the wound care nurses to perform weekly skin assessments and for the nurses on the floor to check their residents skin daily. She was asked to review the Braden Scale for Resident #5. S2DON verified the last Braden Scales done on the resident were done on 06/08/12 and 03/05/13. She was asked how often are Braden scale assessments to be done on residents. S2DON stated "Quarterly". She was asked if Braden scale assessments had been done on Resident #5 quarterly. She stated "no". I. Resident #6 The facility failed to follow the physician's orders [REDACTED]. Resident #6 was placed in immediate jeopardy on 03/08/13 when she returned from an office visit with physician's orders [REDACTED]. The facility did not obtain the ultrasound until 03/11/13 after the resident complained of leg pain. The results of the ultrasound revealed the resident had 4 occlusive thrombus and 1 nonocclusive thrombus to the left lower leg. The Administrator was notified of the immediate jeopardy on 03/28/13 at 10:12 a.m. A plan of removal was presented by the Administrator which read as follows: 1. Review of physicians orders on current residents including transfer records from hospital, ER, office visits, progress notes, consults, in residents records from 03/08/13 to present was completed to ensure physician orders [REDACTED]. 2. All nurses will be re-educated on accurately transcribing physician orders [REDACTED]. 3. Unit Managers will monitor physicians orders along with appointments ordered Monday - Friday during the Morning Clinical Meeting, utilizing the QI data Collection Form, for ongoing compliance. Weekend supervisor will monitor Saturday and Sunday. DCS (Director of Clinical Services)/designee will conduct random audits weekly, utilizing same tool, and report results monthly to the PI committee to ensure on-going substantial compliance. The immediate jeopardy was removed on 03/28/13 at 3:04 p.m. when the surveyor confirmed all physician's orders [REDACTED]. The deficient practice remains at a level 3 for actual harm to Resident #6 Resident #6 Resident #6 was a [AGE] year old woman admitted to the facility on [DATE] after an ORIF (Open Reduction Internal Fixation) of the (L) Hip. Other [DIAGNOSES REDACTED]. She was readmitted on [DATE] after a hospitalization for [MEDICAL CONDITION]. Review of the (MDS) Minimum (MDS) data set [DATE] revealed the resident had a BIMS (Brief Interview for Mental Status) score of 11 (moderate impairment) Review of the care plan revealed the following: Problem Onset: 02/21/13 [MEDICATION NAME] therapy related to status [REDACTED]. Goal & Target Date: will have no abnormal bleeding by 05/01/13 Approaches: monitor for [MEDICAL CONDITION]: warmth, redness, swelling to extremity, positive Homans sign. Review of the nurses' notes dated 02/21/13 - 03/25/13 revealed the following: On 03/08/13 the resident went out to a scheduled office visit with Dr._____. Review of the physician's office notes revealed the following: Chief Complaint: some c/o (complaints) of weakness and pain and leg swelling, on walker/[MEDICATION NAME], PWB (partial weight bearing). ROS (review of systems): Patient reports joint pain and difficulty walking but reports no joint stiffness or swelling, no weakness of muscles or joints, no muscle pain or cramps, no back pain, and no cold extremities. Assessment /Plan: d/c (discontinue) staples, PT (physical therapy)/WBAT (weight bearing as tolerated) check u/s (ultrasound) LLE (left lower extremity), walker, finish course of [MEDICATION NAME]. Review of the clinical record revealed the following: Physician's progress note dated 03/08/13: Plan (P) check u/s - leg swelling. physician's orders [REDACTED]. Nurses' Notes: 03/08/13 3:50 p.m Returned from appointment with Dr.______ per nursing home van with orders for WBAT with walker PT/ROM (range of motion), u/s (L) leg r/o [MEDICAL CONDITION].signed by S17LPN. Physician's Telephone Orders dated 03/08/13: WBAT with walker/PT/hip and knee ROM, u/s (L) leg-r/o [MEDICAL CONDITION] by S16RN. Review of the clinical record's nurses' notes dated 03/11/13 and timed at 8:15 a.m. documented the following: Resident up working with therapy. Resident complained of pain to her (L) leg, lower. MD (medical doctor) ordered u/s of lower extremity. Facility van will transport her to appointment this am......signed by S3RN. Nurses' notes continued: 03/11/13 6:00 p.m. resident was admitted to ______Medical Center with [DIAGNOSES REDACTED]. 03/15/13 7:30 p.m. readmit assessment done with resident and daughter. Orders from ____Medical Center/Dr._____for readmit to ________Nursing home. [DIAGNOSES REDACTED]. Review of the u/s done on 03/11/13 at ______Medical Center revealed the u/s was completed at 10:11 a.m. and the resident's physician was notified by the Radiologist at 10:22 a.m. of the following results: Findings: There is nonocclusive thrombus demonstrated within the left common femoral vein. Partial flow is demonstrated. There is occlusive thrombus noted within the profunda femoral, superficial femoral, popliteal, and anterior tibial veins. No flow demonstrated within these veins. The posterior vein demonstrates no thrombus. Impression: Occlusive thrombus within the profunda femoral, superficial femoral, popliteal, and anterior tibial veins on the left with nonocclusive thrombus within the common femoral vein. On 03/27/13 at 4:30 p.m. an interview conducted with S2DON and S3RN. They were asked to review the clinical record and MD orders on 03/08/13 for an u/s to the lower leg and the u/s report of 03/11/13 positive for thrombus. S3RN was asked if she was the nurse on duty the morning of 03/11/13 when the resident complained of leg pain. She stated "yes". S3RN was asked why did she send Resident #6 for the ultrasound. S3RN stated on the morning of 03/11/13 the resident complained of pain to her left lower leg. She stated she realized the ultrasound ordered on [DATE] had not been done, so she called_______Medical Center and the resident was seen for the ultrasound. S2DON was asked if an ultrasound had been ordered on [DATE] by the physician to rule out [MEDICAL CONDITION]. She stated "yes". She was asked if the resident received an ultrasound on 03/08/13 as ordered. S2DON stated "no". She was asked if the order written on 03/08/13 had been followed. S2DON verified the order had not been followed by nursing. She was asked what is the process for scheduling tests. S2DON stated the nurse takes off the order and writes it on the outpatient appointments schedule sheet. S5SSD then schedules the appointments. On 03/28/13 at 10:30 a.m. S25RN, Corporate Nurse presented the surveyor with a form titled Outpatient Appointments to be Scheduled and a copy from the appointment book of S5SSD dated March 11th, 12th and 13th of 2013. The resident's name was listed on the appointments to be scheduled form with the date 03/08/13 written under the heading "Date Of Order". On the appointment book the resident's name was written near the top of the page for 03/11/13 with no time next to it. On 03/28/13 at 10:40 a.m. S1ADM approached the surveyor, and referring to the forms presented by S25RN, Corporate Nurse, stated the facilty had tried to schedule the ultrasound on 03/08/12, but _______Medical Center had scheduled the ultrasound for 03/11/13. On 03/28/13 at 11:20 a.m. an interview was conducted with S15RAD, the Director of Radiology services at ________ Medical Center. He was asked if the resident had ever been scheduled for an u/s on 03/08/13. After reviewing the radiology schedule for 03/08/13, he stated "she was never scheduled; the first time we were contacted was on 03/11/13 when they called and asked to bring her over ". He was asked how did he know the resident was never scheduled on 03/08/13 by the nursing facility. S15RAD stated "because she was never placed on our schedule". He went on to state "she was put into our system at 9:40 a.m. on 03/11/13 when she arrived and the ultrasound was completed at 10:11 a.m. Dr._____(radiologist) called the results to Dr.____(resident's physician)". He was asked if the resident could have been seen on Friday, 03/08/13, if the facility had scheduled the u/s. S15RAD stated "yes, we have techs here until 11:30 p.m. and then someone is on call ". He went on to state "we don't really schedule ultrasounds for [MEDICAL CONDITION] (deep vein thrombus) or PEs (pulmonary embolisms) because those are done immediately ". S15RAD stated if the facility would have called on 03/08/13 the resident would have been seen immediately. Copies of the radiology schedule revealed Resident #6's name was not listed on the radiology schedule for 03/08/13 or 03/11/13. On 04/01/13 at 9:45 a.m. a telephone interview was conducted with S17LPN, who was on duty 03/08/13, when the resident returned from her office visit with orders for an ultrasound. She was asked if she wrote the note on Resident #6 on 03/08/13 that documented an u/s was to be done to r/o [MEDICAL CONDITION]. S17LPN stated "yes". She was asked if it was the facility's practice for the nurse to write the consults on the outpatient appointment to be scheduled form. She stated "yes". She was asked if she scheduled or attempted to schedule the u/s. She stated "no". She was asked if she had written the resident's name on the outpatient appointment form. S17LPN stated "I don't remember". On 04/01/13 at 9:50 a.m. a telephone interview was conducted with S16RN, who was on duty the evening the resident returned to the facility with orders for an u/s, on 03/08/13. She was asked if she had signed off the order for the u/s. She stated "yes". S16RN stated 03/08/13 was her first day out of orientation. She was asked if she had written the resident's name on the outpatient appointment sheet. S16RN stated "I'm not sure". She was asked if the u/s had been scheduled. S16RN stated she had not scheduled it and was depending on what she was being told by the other nurse. S16RN stated she wished she would have ensured it was done. On 04/01/13 At 10:10 a.m. an interview was conducted with S5SSD. She was asked what is her role in scheduling appointments. She stated the nurses place the request for a test/consult on the outpatient schedule form, she then makes daily rounds to see if any request are written. If so she then schedules the appointment or consults, informs the resident and the responsible party, and writes the appointment or consult date and time in her appointment book and then someone from medical records writes the appointment in one of the appointment books at each nursing station ...depending on where the resident resides. She was asked to review her records for Resident #6. S5SSD reported on the morning of 03/11/13, during the morning meeting, someone who she can't remember came in to the meeting and asked could she schedule an u/s for Resident #6. She reported she remembers them saying the resident's family was asking if the test had ever been done. S5SSD reported she was not aware the resident needed an u/s until that moment. She stated she called _____(scheduler) in the x-ray department at _______Medical Center and Resident #6 was seen immediately. S5SSD stated for tests to rule out [MEDICAL CONDITION] she doesn't schedule those, instead she calls the hospital and gets it done right then. Review of the Station 1 appointment book, where the resident was residing on 03/08/13 and 03/11/13, revealed no u/s scheduled for 3/11/13. S5SSD verified it was not in the Station 1 book because she had not scheduled it until the morning of 03/11/13 when someone requested she get an u/s for Resident #6. S5SSD was asked to explain the entry on her appointment book listing Resident #6 for an ultrasound on 03/11/13. S5SSD stated she wrote that in at the top of the page so she would have a record of the resident's appointments. She reiterated she was not made aware of the u/s until the morning of 03/11/13 and that is when she called ________Medical Center. On 04/01/13 at 10:40 a.m. an interview was conducted with S6MR, who is currently the CNA scheduler, but verified she worked in medical records at the time Resident #6 went for the u/s. She was asked to review the appointment book from Station 1. She was asked why the u/s had not been put in the Station 1 appointment book on 03/08/13. S6MR stated" it was not in S5SSD's appointment book for the 11 th, or I would have put in the Station 1 book " . On 04/01/13 at 11:05 a.m an interview was conducted with S8COTA. She was asked if she worked with Resident #6 on 03/11/13. S8COTA stated "yes" and reported on 03/11/13 while in therapy, the resident complained of pain in both legs. She stated she notified nursing and the resident was sent out to the hospital. S8COTA stated the resident resumed therapy on 03/18/13. On 04/01/13 At 12:50 p.m. an interview was conducted with S3RN. She was asked to review the Station 1 appointment book dated 03/11/13. S3RN verified the resident was not listed for an ultrasound on the schedule book for 03/11/13. On 04/01/13 at 4:00 p.m. a telephone call was placed to the office of Dr.______, the resident's physician who ordered the ultrasound on 03/08/13. The physician was unavailable, so the surveyor spoke to S13LPN, the physician's nurse. She verified she was familiar with Resident #6. She was asked if Dr.______had ordered an u/s on 03/08/13 to rule out deep vein thrombus. S13LPN stated "yes". She was asked when should the test have been done. S13LPN stated "Dr._____requires the results of all ultrasounds to be reported to him within 24 hours". I. Resident #1 This resulted in an Immediate Jeopardy situation which began when resident #1 was admitted to the facility on [DATE]. S1Adm and S2DON was notified of the Immedicate Jeopardy siutation on 03/28/13 at 10:12 a.m. and removed at 3:04 p.m. Resident #1 had a history and [DIAGNOSES REDACTED]. The facility failed to have the daily PT/INR laboratory values performed and administer the anticoagul

Based on interviews and record reviews the facility failed to ensure 3 (Resident #1, #5, and #6) of 9 (#1, #2, #3, #4, #5, #6, #7, #8, #9) residents received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care by failing to: Resident #1- follow a physician's orders [REDACTED]. This resulted in an Immediate Jeopardy situation which began when resident #1 was admitted to the facility on [DATE]. S1Adm and S2DON was notified of the Immedicate Jeopardy siutation on [DATE] at 10:12 a.m. and removed at 3:04 p.m. Resident #1 had a history and [DIAGNOSES REDACTED]. The facility failed to have the daily PT/INR laboratory values performed and administer the anticoagulant medication [MEDICATION NAME] as needed based on the laboratory values throughout resident #1's length of stay. The Immediate Jeopardy situation continued for resident #1 until he expired on [DATE]. Resident #5 The facility failed to: 1. follow the physician's orders [REDACTED]. 2. document the presence of a splint to the resident's (R) arm 3. assess the neurovascular status of the resident's (R) arm 4. perform weekly skin assessments 5. follow the facility's care plan to inspect the skin daily 6. perform quarterly Braden scale assessments Resident #5 was placed in Immediate Jeopardy on [DATE] when she returned to the facility from the hospital with a fracture to the (R) humerus and a long arm splint to the fractured arm. The facility did not consult an orthopedist as ordered. The resident's (R) arm, covered by the splint, was not assessed for neurovascular status or skin integrity from [DATE] - [DATE]. Braden scale assessments were not done quarterly. On [DATE], fifty-one days after the application of the splint, the splint was removed and a stage IV pressure ulcer was found to the resident's (R) elbow. The Administrator was notified of the Immediate Jeopardy on [DATE] at 2:05 p.m. A plan of removal was presented by the Administrator which read as follows: Failure to transcribe orders: 1. Notify attending physician to determine need for follow up of resident with Orthopedist (completed [DATE]). 2. Review residents medical records from [DATE] to present to ensure that appointments have been made and physician orders [REDACTED]. 3. Nurses will be re-educated on accurately transcribing physician orders [REDACTED]. (will be completed upon returning to work, before being allowed to go to work, on next scheduled shift). 4. Unit managers will monitor physician orders [REDACTED]. DSC (Director of Clinical Services)/designee will conduct random audits weekly, utilizing the same QI tool, and report results monthly to the PI committee to ensure ongoing substantial compliance. 5. Date of Compliance [DATE]. Failure to Assess Properly, resulting in a stage IV Pressure Ulcer 1. Assess current status of healing wound and notify physician if needed (done [DATE]) 2. Head to toe assessments on residents to determine current status (done [DATE]). Wounds will be assessed to determine need for further physician/responsible party notification. Physician orders [REDACTED]. Documentation will reflect notification and current status of wounds (in progress, will be completed [DATE]). 3. Nurses will be educated on completing weekly head to toe assessments as scheduled with the appropriate follow through of any of any identified areas of skin breakdown. Education of nurses will include how to properly assess by checking for adequate circulation for those residents with an apparatus (such as immobilizers, splints, casts). CNAs will be re-educated on completing bath and body audits including reporting findings to charge nurses. Physicians/responsible party will be notified as needed. Care plans will be updated as needed. (upon returning to work, before being allowed to go to work, on next scheduled shift). 4. Unit Managers will monitor for compliance during the Morning Clinical Meeting, utilizing the same QI Data Collection Form. Director of Clinical Services/designee will conduct random audits weekly, utilizing the same QI tool, and report results monthly to the PI committee to ensure ongoing substantial compliance. 5. Date of compliance [DATE]. The Immediate Jeopardy was removed on [DATE] at 2:55 p.m. when the surveyor confirmed all residents' records were reviewed for correct transcription of physicians' orders and appointments; all nurses were reeducated on transcribing orders with appropriate follow up; head to toe assessments were done on all residents; all nurses were reeducated on completing weekly head to toe assessments and follow through of any identified areas of skin breakdown and all nurses were educated on the proper assessment of adequate circulation for residents with apparatuses. The deficient practice remains at a level 3 for actual harm to Resident #5. Resident #6 The facility failed to follow the physician's orders [REDACTED]. Resident #6 was placed in immediate jeopardy on [DATE] when she returned from an office visit with physician's orders [REDACTED]. The facility did not obtain the ultrasound until [DATE] after the resident complained of leg pain. The results of the ultrasound revealed the resident had 4 occlusive thrombus and 1 nonocclusive thrombus to the left lower leg. The Administrator was notified of the Immediate Jeopardy on [DATE] at 10:12 a.m. A plan of removal was presented by the Administrator which read as follows: 1. Review of physicians orders on current residents including transfer records from hospital, ER, office visits, progress notes, consults, in residents records from [DATE] to present was completed to ensure physician orders [REDACTED]. 2. All nurses will be re-educated on accurately transcribing physician orders [REDACTED]. 3. Unit Managers will monitor physicians orders along with appointments ordered Monday - Friday during the Morning Clinical Meeting, utilizing the QI data Collection Form, for ongoing compliance. Weekend supervisor will monitor Saturday and Sunday. DCS (Director of Clinical Services)/designee will conduct random audits weekly, utilizing same tool, and report results monthly to the PI committee to ensure on-going substantial compliance. The Immediate Jeopardy was removed on [DATE] at 3:04 p.m. when the surveyor confirmed all physician's orders [REDACTED]. The deficient practice remains at a level 3 for actual harm to Resident #6 Findings: Resident #1 On [DATE] a closed record review was conducted for resident #1. Review of a document entitled, "History and Physical" dated [DATE] from a recent admission to a local hospital revealed in part the following: "Chief Complaint: Per ED (Emergency Department) Triage "transfer from (name of hospital) with c/o (complaints of) sob (shorteners of breath) onset x 6 wks. (weeks) dx (diagnosis) with right lung pe (pulmonary embolism)....". "Impression: 1. Lung Mass 2. Suspected liver metastases 3. Tobacco abuse 4. [MEDICAL CONDITION] Embolism". "Plan: .... 4. [MEDICAL CONDITION] Embolism. Patient has [MEDICAL CONDITION] embolism in the setting of [MEDICAL CONDITION]. Patient will need subcutaneous injection for life. Will place on [MEDICATION NAME] drip at this time in place of [MEDICATION NAME].". Review of the Minimum Data Set (MDS) Assessment Reference Date (ARD) [DATE] revealed resident #1's cognitive skills for daily decision making was coded 3. severely impaired-never/rarely made decisions. On [DATE] at 9:35 a.m. an interview was conducted with S2DON. She was asked to review the physician orders [REDACTED]. Review of the orders revealed resident was admitted to the facility with admission orders [REDACTED]. S2DON confirmed this admission order. She was asked to obtain resident #1's admission orders [REDACTED]. S2DON was asked to review the Medication Administration Record (MAR) dated [DATE] with the surveyor. She reviewed [DATE] MAR and confirmed [MEDICATION NAME] was transcribed to the MAR as a medication to be administered. Asked DON if the [MEDICATION NAME] medication for this resident was still in the building. Stated she would check. S2DON was asked to also obtain the pharmacy records indicating when the medication [MEDICATION NAME] for resident #1 was received at the facility. On [DATE] at 3:30 p.m. an interview was conducted with S2DON. She presented a copy of a document entitled, "(Name of Hospital) CPOE Discharge Orders" for resident #1 dated [DATE]. She verified this document was the transferring hospital's discharge and admission orders [REDACTED]. Review of the Discharge Orders revealed in part the following: "Diagnostic Studies Check PT/INR q (every) AM (morning) and start [MEDICATION NAME] 1.5 mg (milligram) per body weight q day when INR less than 2.0". S2DON confirmed the admission order for PT/INR and [MEDICATION NAME]. She was asked again to review the MAR dated [DATE] with the surveyor. She reviewed [DATE] MAR and confirmed the medication [MEDICATION NAME] was never administered. When asked if there was any of resident #1's [MEDICATION NAME] remaining in the facility. She stated no. S2DON presented a document entitled, "Order Search by Resident". She confirmed this document listed all the medications the facility ordered from the pharmacy for resident #1. S2DON verified at this time the medication [MEDICATION NAME] was never ordered. S2DON was asked if there was any documentation of PT/INR results for resident #1. She stated, "I can check the hospital's records". S2DON was informed by the surveyor she requested the facility's PT/INR laboratory records for resident #1 following admission. S2DON verified there was no documented evidence the facility had ever requested laboratory values for PT/INR for resident #1. On [DATE] at 3:45 p.m. an interview was conducted with S18LPN. She stated she worked in Medical Records and verified she transcribed the admission orders [REDACTED]. She was asked to review the hospital's discharge and admission orders [REDACTED]. She confirmed the PT/INR was transcribed correctly to the [DATE] Physician Orders. She confirmed the medication order for [MEDICATION NAME] was transcribed correctly to the [DATE] Physician Orders. She was asked what was the facility's procedure and nurse's responsibility to ensure a resident received laboratory orders. She stated the nurse that does the admitting packet should enter the lab order in the lab book for each day. She stated laboratory services were received and performed by (Name of hospital) Hospital Monday -Friday. She stated Medical Records would in turn fax the required labs to notify them what labs need to be drawn. She was asked what does the facility do on weekends. She stated, "The nurses put in in the calendar at the stations". She was asked to locate the Lab Book at the Nurses Station and bring it to the surveyor. S18LPN reviewed the Lab Book with the surveyor and confirmed there was no documented evidence of any PT/INR labs scheduled to be drawn for resident #1. S18LPN stated, "(Resident #1) should have had the first PT/INR drawn [DATE]. Further review of the Lab Book confirmed there were no labs drawn for resident #1 from [DATE] - [DATE]. Resident #1 was transferred to a local hospital on [DATE]. Review of a document entitled, "General Instructions with ExitWriter" from the hospital dated [DATE] revealed in part the following: "You have been evaluated today by (Name of Physician) for the following conditions: Changed mental status with stupor. Subdural Hematoma. Severe Dehydration. [MEDICAL CONDITION]. Metastases present. (end stage). Further review of this document revealed a PT ([MEDICATION NAME]) with INR was performed. Review of the PT ([MEDICATION NAME]) with INR results revealed resident #1's [MEDICATION NAME] was 27.9. (Normal Reference 9.30 - 13.20)". Findings: Resident #5 was a [AGE] year old woman admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed the resident's cognitive skills for daily decision making were (3) severely impaired - never/rarely made decisions The resident was totally dependent for bed mobility, transfers, and all aspects of activities of daily living. Section M (skin conditions) M015: Is resident at risk for developing a pressure ulcer (Yes) M0210: Resident has Stage 1 or higher pressure ulcer (No) Review of the Minimum Data Set ((MDS) dated [DATE] revealed the resident's cognitive skills for daily decision making were (3) severely impaired - never/rarely made decisions The resident was totally dependent for bed mobility, transfers, and all aspects of activities of daily living. Section M (skin conditions) M015: Is resident at risk for developing a pressure ulcer (Yes) M0210: Resident has Stage 1 or higher pressure ulcer (Yes) M0300D1: Stage 4 pressure ulcers: number present (1) Review of the care plan revealed the following: Problem Onset: [DATE]: At risk for pressure ulcers/skin tears secondary to bladder/bowel incontinence. Goal & Target Date: Will minimize risk of skin breakdown/pressure ulcers qd (everyday) by [DATE] and again by ,[DATE] Approaches: inspect skin daily while performing care and notify nurse of any redness, irritation or skin tears. Review of the clinical record's nurses' notes dated [DATE] and timed 1:55 p.m., revealed the resident fell and expressed discomfort when her (R) arm was touched. She was sent to _______ Medical Center for an evaluation. At 4:00 p.m. the facility received a report from _______ Medical Center the resident had sustained a fractured to the right humerus and was being transferred to ________hospital. The resident returned to the facility on [DATE] at 8:40 p.m. The General Instructions Form from _____Medical Center dated [DATE], documented the following: Fracture proximal right humerus. Displacement of fracture is present (Patient is neurovascularly intact). Procedures: Long arm splint. The Exitcare Patient Information form from _______hospital dated [DATE] and timed 7:08 p.m., revealed the following: Please follow up with Dr._____(orthopedic surgeon) in 7 days for further evaluation. Review of the facility's physician's orders [REDACTED]. Review of the facility's nurses' notes dated [DATE] through [DATE] revealed no documentation the resident had a splint to the (R) arm. Review of the facility's Weekly Nursing Progress Notes dated [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; and [DATE] revealed no documentation of the neurovascular status of the resident's (R) arm or assessments of the skin on her (R) arm. The section on the weekly nurses' notes titled "Contractures" has a check list that includes hand splint. Hand splint was never marked on any of the weekly nurses' notes. Review of the resident's Medication Administration Records (MAR) for the months of [DATE] and [DATE] revealed no documentation of circulatory checks to the resident's (R) arm. The first documentation of circulatory checks to the resident's (R) arm is dated [DATE]. Review of a nurse's note dated [DATE] revealed the following: 10:45 a.m. Upon assessing Rt arm & splint noted an open area on Rt elbow - entire area 44 cm (discolored area) 2.1 x .3 cm open area in center, 0.5 cm depth with brownish yellow drainage and odor noted.... On [DATE] the resident's physician was notified and the following orders were given: Consult Dr._____(orthopedic surgeon ). A Request for physician's orders [REDACTED]. ______(orthopedic surgeon) refused to see resident secondary to the fracture being old. The resident was then referred to _________wound center on [DATE]. On [DATE] orders were written to begin wound care with normal saline and Arginate daily until healed, Keflex 500 mg TID (three times a day) X 10 days, consult____wound care, culture & sensitivity of wound drainage, x-ray ? arm. The resident was initially seen at the wound care center on [DATE] with the following [DIAGNOSES REDACTED]. She continued with weekly visits until [DATE] when she was discharged from the wound care center. Review of the wound care center records revealed, in part, the following: Wound Location Type/Stage Measurements (cm) [DATE] (R) elbow Pressure Wound IV 0.3 x 0.7 x 0.8 Pack Tunneling/Undermining Lightly with: [MEDICATION NAME] AG Rope 2 x a week *wound debrided today Additional orders: Bone Culture sent today [DATE] (R) elbow Pressure Wound IV 0.2 x 0.2 x 0.5 Pack Tunneling/Undermining Lightly with: [MEDICATION NAME] AG Rope 2 x a week *removed nonviable/necrotic tissue from wound bed Additional orders: no pressure to wound area-no splint for one week [DATE] (R) elbow Pressure Wound IV 0.2 x 0.4 x 0.6 Apply to Wound Bed: [MEDICATION NAME] AG 2 x a week Additional orders: Keflex 250 mg po (by mouth) q12h (every 12 hours);[MEDICATION NAME] 3 x a day [DATE] (R) elbow Pressure Wound IV 0.2 x 0.2 x 0.3 Apply to Wound Bed: [MEDICATION NAME] 2 x a week *surgical removal non-viable tissue/slough Additional orders: Resume Keflex one more week [DATE] (R) elbow Pressure Wound IV 0.2 x 0.2 x 0.3 Apply to Wound Bed: [MEDICATION NAME] 2 x a week *surgical removal muscle &/or fascial tissue; surgical removal of bone Additional orders: Keflex 250 mg po q12h x 10 days; [MEDICATION NAME] TID (3 times a day) Wound deteriorated today, [MEDICATION NAME] - Palliative care, patient DNR (Do Not Resuscitate) [DATE] (R) elbow Pressure Wound IV 0.4 x 0.3 x 0.1 Apply to Wound Bed: Elta Silvergel/[MEDICATION NAME] 2 x a week *surgical removal/scissors non-viable tissue/slough Additional orders: Keep dressing on at all times; follow up in one week Wound deteriorated today, [MEDICATION NAME] - Palliative care, patient DNR (Do Not Resuscitate) [DATE] (R) elbow Pressure Wound IV 0.1 x 0.1 x 0.1 Apply to Wound Bed: [MEDICATION NAME] only 2 X a week *exudate removed, essentially healed Additional orders: Essentially healed, foam for offloading On [DATE] at 11:30 a.m. an observation was made of the resident sitting in her geri chair in the assisted dining room. When spoken to she did not respond. A CNA nearby stated the resident does not speak. A small dressing was noted to her (R) elbow. On [DATE] at 4:45 p.m. an interview was conducted with S2DON. She was asked to review the resident's clinical record with the surveyor. She was asked to review the exitcare patient information form from _______hospital dated [DATE]. She was asked if the facility's nurses had ever consulted the orthopedic doctor. S2DON stated "No". She was asked should they have. S2DON stated "Yes". She was asked to review the weekly nursing progress notes dated [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; and [DATE]. She was asked if the section to indicate the resident had a splint was ever checked. S2DON verified there was no documentation the resident had on a splint when she returned to the facility on [DATE] or any time after until it was removed on [DATE]. She was asked if neurovascular checks had been done on the resident's (R) arm from [DATE] to [DATE]. S2DON verified there was no documentation of neurovascular checks to the resident's (R) arm. She was asked who should have been assessing the resident's arm. S2DON stated the assigned treatment nurse, who is no longer employed with the facility, should have been doing weekly skin assessments and the floor nurses should have also assessed the arm and splint daily. She was asked why the orthopedist was not consulted. S2DON verified the orthopedic consult was not done because the floor nurse did not write the need for the consult on the 24 form, which then is discussed in the morning meeting and would have been scheduled by social services. S2DON verified that when the consult was finally made on [DATE], the orthopedic surgeon refused to see the resident because the fracture was old. She was asked when was the stage IV pressure ulcer to the resident's (R) arm discovered. S2DON verified the wound was discovered at a stage IV on [DATE] when the splint was removed for the first time since her return to the facility on [DATE]. On [DATE] at 9:20 a.m. an interview was conducted with S2DON. She was asked why the resident was not seen at the wound care center until [DATE] when the consult was ordered on [DATE]. She stated the center only sees patients on Wednesdays and [DATE] was the next available Wednesday. On [DATE] at 10:45 a.m. an interview was conducted with S12LPN, treatment nurse, as she performed wound care for Resident #5. She was asked what did she know about the history of the resident's wound. S12LPN stated she was not the wound care nurse at the time the wound was discovered, but she stated the previous wound care nurse discovered the wound when she removed the splint. She stated the resident was recently discharged from the wound care center. Observation of the wound revealed a small closed area to the (R) elbow. Review of the last measurement taken of the wound on [DATE], was (L) 0.1 cm x (W) 0.1 cm with no measurable depth. On [DATE] at 10:55 a.m. an interview was conducted with S28RN, who was working on the hall where the resident resided. She was asked what did she know about the development of the resident's pressure ulcer to her (R) elbow. S28RN stated the "splint was wrapped in an ace wrap and the treatment nurse at the time, thought the floor nurses were taking care of it". On [DATE] at 8:30 a.m. an interview was conducted with S4LPN, MDS Coordinator. S2DON was present during the interview with S4LPN, MDS. S4LPN was asked how often are the Braden Scale assessments to be done on residents. S4LPN stated on admit and quarterly. She was asked if any Braden Scale assessments had been done on the resident. S4LPN provided Braden scales done on the resident on [DATE] and [DATE]. S4LPN verified there was no documentation of assessments done in [DATE] or [DATE]. S4LPN was asked to review the resident's care plan. She was asked if the resident's skin was to be inspected daily for any changes. S4LPN stated "yes". On [DATE] at 8:45 a.m. an interview was conducted with S2DON. She was asked how often are skin assessments done and by whom. S2DON stated weekly skin assessments are done on all residents by the treatment nurse. She stated the nurses on the floor are responsible for daily skin assessments on their residents. She was asked if there was documentation of daily skin assessments. S2DON stated "No". She was asked if she had any documentation weekly skin assessments had been done on Resident #5. She stated she would check. On [DATE] at 9:40 a.m. S2DON returned to the surveyor and provided forms titled Weekly Skin Integrity Checks. Review of the weekly skin assessments for Resident #5 revealed weekly skin integrity checks were done on the resident for the months of [DATE] and [DATE]. There was no documentation of weekly skin integrity checks for [DATE], [DATE], [DATE], [DATE] or [DATE]. The first weekly skin integrity check for 2013 was done on [DATE], the day the stage IV wound was discovered. S2DON verified the facility's wound care nurse had not performed weekly skin integrity checks on Resident #5. S2DON was asked for the facility's policy and procedure for weekly and daily skin assessments. S2DON provided the surveyor a policy titled Assessment and Documentation of Wounds. She stated she did not have a policy for weekly skin sweeps or daily skin checks, but verified it was the facility's practice for the wound care nurses to perform weekly skin assessments and for the nurses on the floor to check their residents skin daily. She was asked to review the Braden Scale for Resident #5. S2DON verified the last Braden Scales done on the resident were done on [DATE] and [DATE]. She was asked how often are Braden scale assessments to be done on residents. S2DON stated "Quarterly". She was asked if Braden scale assessments had been done on Resident #5 quarterly. She stated "no". Resident #6 The facility failed to follow the physician's orders [REDACTED]. Resident #6 was a [AGE] year old woman admitted to the facility on [DATE] after an ORIF (Open Reduction Internal Fixation) of the (L) Hip. Other [DIAGNOSES REDACTED]. She was readmitted on [DATE] after a hospitalization for [MEDICAL CONDITION]. Review of the (MDS) Minimum (MDS) data set [DATE] revealed the resident had a BIMS (Brief Interview for Mental Status) score of 11 (moderate impairment) Review of the care plan revealed the following: Problem Onset: [DATE] [MEDICATION NAME] therapy related to status [REDACTED]. Goal & Target Date: will have no abnormal bleeding by [DATE] Approaches: monitor for [MEDICAL CONDITION]: warmth, redness, swelling to extremity, positive Homans sign. Review of the nurses' notes dated [DATE] - [DATE] revealed the following: On [DATE] the resident went out to a scheduled office visit with Dr._____. Review of the physician's office notes revealed the following: Chief Complaint: some c/o (complaints) of weakness and pain and leg swelling, on walker/[MEDICATION NAME], PWB (partial weight bearing). ROS (review of systems): Patient reports joint pain and difficulty walking but reports no joint stiffness or swelling, no weakness of muscles or joints, no muscle pain or cramps, no back pain, and no cold extremities. Assessment /Plan: d/c (discontinue) staples, PT (physical therapy)/WBAT (weight bearing as tolerated) check u/s (ultrasound) LLE (left lower extremity), walker, finish course of [MEDICATION NAME]. Review of the clinical record revealed the following: Physician's progress note dated [DATE]: Plan (P) check u/s - leg swelling. physician's orders [REDACTED]. Nurses' Notes: [DATE] 3:50 p.m Returned from appointment with Dr.______ per nursing home van with orders for WBAT with walker PT/ROM (range of motion), u/s (L) leg r/o [MEDICAL CONDITION].signed by S17LPN. Physician's Telephone Orders dated [DATE]: WBAT with walker/PT/hip and knee ROM, u/s (L) leg-r/o [MEDICAL CONDITION] by S16RN. Review of the clinical record's nurses' notes dated [DATE] and timed at 8:15 a.m. documented the following: Resident up working with therapy. Resident complained of pain to her (L) leg, lower. MD (medical doctor) ordered u/s of lower extremity. Facility van will transport her to appointment this am......signed by S3RN. Nurses' notes continued: [DATE] 6:00 p.m. resident was admitted to ______Medical Center with [DIAGNOSES REDACTED]. [DATE] 7:30 p.m. readmit assessment done with resident and daughter. Orders from ____Medical Center/Dr._____for readmit to ________Nursing home. [DIAGNOSES REDACTED]. Review of the u/s done on [DATE] at ______Medical Center revealed the u/s was completed at 10:11 a.m. and the resident's physician was notified by the Radiologist at 10:22 a.m. of the following results: Findings: There is nonocclusive thrombus demonstrated within the left common femoral vein. Partial flow is demonstrated. There is occlusive thrombus noted within the profunda femoral, superficial femoral, popliteal, and anterior tibial veins. No flow demonstrated within these veins. The posterior vein demonstrates no thrombus. Impression: Occlusive thrombus within the profunda femoral, superficial femoral, popliteal, and anterior tibial veins on the left with nonocclusive thrombus within the common femoral vein. On [DATE] at 4:30 p.m. an interview conducted with S2DON and S3RN. They were asked to review the clinical record and MD orders on [DATE] for an u/s to the lower leg and the u/s report of [DATE] positive for thrombus. S3RN was asked if she was the nurse on duty the morning of [DATE] when the resident complained of leg pain. She stated "yes". S3RN was asked why did she send Resident #6 for the ultrasound. S3RN stated on the morning of [DATE] the resident complained of pain to her left lower leg. She stated she realized the ultrasound ordered on [DATE] had not been done, so she called_______Medical Center and the resident was seen for the ultrasound. S2DON was asked if an ultrasound had been ordered on [DATE] by the physician to rule out [MEDICAL CONDITION]. She stated "yes". She was asked if the resident received an ultrasound on [DATE] as ordered. S2DON stated "no". She was asked if the order written on [DATE] had been followed. S2DON verified the order had not been followed by nursing. She was asked what is the process for scheduling tests. S2DON stated the nurse takes off the order and writes it on the outpatient appointments schedule sheet. S5SSD then schedules the appointments. On [DATE] at 10:30 a.m. S25RN, Corporate Nurse presented the surveyor with a form titled Outpatient Appointments to be Scheduled and a copy from the appointment book of S5SSD dated [DATE]th, 12th and 13th of 2013. The resident's name was listed on the appointments to be scheduled form with the date [DATE] written under the heading "Date Of Order". On the appointment book the resident's name was written near the top of the page for [DATE] with no time next to it. On [DATE] at 10:40 a.m. S1ADM approached the surveyor, and referring to the forms presented by S25RN, Corporate Nurse, stated the facilty had tried to schedule the ultrasound on [DATE], but _______Medical Center had scheduled the ultrasound for [DATE]. On [DATE] at 11:20 a.m. an interview was conducted with S15RAD, the Director of Radiology services at ________ Medical Center. He was asked if the resident had ever been scheduled for an u/s on [DATE]. After reviewing the radiology schedule for [DATE], he stated "she was never scheduled; the first time we were contacted was on [DATE] when they called and asked to bring her over ". He was asked how did he know the resident was never scheduled on [DATE] by the nursing facility. S15RAD stated "because she was never placed on our schedule". He went on to state "she was put into our system at 9:40 a.m. on [DATE] when she arrived and the ultrasound was completed at 10:11 a.m. Dr._____(radiologist) called the results to Dr.____(resident's physician)". He was asked if the resident could have been seen on Friday, [DATE], if the facility had scheduled the u/s. S15RAD stated "yes, we have

Based on observations, interviews, and record reviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to maintain the highest practicable physical well being for 3 (#1, #5, #6) of 9 (#1, #2, #3, #4, #5, #6, #7, #8, #9) sampled residents. The Administrative staff failed to: 1. Have an efficient system in place to ensure comprehensive assessments were performed on Resident #5, physician orders [REDACTED].#5 2. Have an efficient system in place to ensure physician orders [REDACTED]. Have an efficient system in place to ensure physician orders [REDACTED]. Findings: Resident #5 The facility failed to: 1. follow the facility's care plan to inspect the skin daily 2. perform weekly skin assessments 3. document the presence of a splint to the resident's (R) arm 4. assess the neurovascular status of the resident's (R) arm 5. perform quarterly Braden scale assessments 6. consult an orthopedist to assess a fracture to the (R) arm Resident #5 was placed in Immediate Jeopardy on 11/29/12 when she returned to the facility from the hospital with a fracture to the (R) humerus and a long arm splint to the fractured arm. The facility did not consult an orthopedist as ordered. The resident's (R) arm, covered by the splint, was not assessed for neurovascular status or skin integrity from 11/29/13 - 01/18/13. Braden scale assessments were not done quarterly. On 01/18/13, fifty-one days after the application of the splint, the splint was removed and a stage IV pressure ulcer was found to the resident's (R) elbow. The Administrator was notified of the Immediate Jeopardy on 03/26/13 at 2:05 p.m. A plan of removal was presented by the Administrator which read as follows: Failure to transcribe orders: 1. Notify attending physician to determine need for follow up of resident with Orthopedist (completed 03/26/13). 2. Review residents medical records from 11/29/12 to present to ensure that appointments have been made and physician orders [REDACTED]. 3. Nurses will be re-educated on accurately transcribing physician orders [REDACTED]. (will be completed upon returning to work, before being allowed to go to work, on next scheduled shift). 4. Unit managers will monitor physician orders [REDACTED]. DSC (Director of Clinical Services)/designee will conduct random audits weekly, utilizing the same QI tool, and report results monthly to the PI committee to ensure ongoing substantial compliance. 5. Date of Compliance 03/26/13. Failure to Assess Properly, resulting in a stage IV Pressure Ulcer 1. Assess current status of healing wound and notify physician if needed (done 03/26/13) 2. Head to toe assessments on residents to determine current status (done 03/26/13). Wounds will be assessed to determine need for further physician/responsible party notification. Physician orders [REDACTED]. Documentation will reflect notification and current status of wounds (in progress, will be completed 03/27/13). 3. Nurses will be educated on completing weekly head to toe assessments as scheduled with the appropriate follow through of any of any identified areas of skin breakdown. Education of nurses will include how to properly assess by checking for adequate circulation for those residents with an apparatus (such as immobilizers, splints, casts). CNAs will be re-educated on completing bath and body audits including reporting findings to charge nurses. Physicians/responsible party will be notified as needed. Care plans will be updated as needed. (upon returning to work, before being allowed to go to work, on next scheduled shift). 4. Unit Managers will monitor for compliance during the Morning Clinical Meeting, utilizing the same QI Data Collection Form. Director of Clinical Services/designee will conduct random audits weekly, utilizing the same QI tool, and report results monthly to the PI committee to ensure ongoing substantial compliance. 5. Date of compliance 03/26/13. The Immediate Jeopardy was removed on 03/27/13 at 2:55 p.m. when the surveyor confirmed all residents' records were reviewed for correct transcription of physicians' orders and appointments; all nurses were reeducated on transcribing orders with appropriate follow up; head to toe assessments were done on all residents; all nurses were reeducated on completing weekly head to toe assessments and follow through of any identified areas of skin breakdown and all nurses were educated on the proper assessment of adequate circulation for residents with apparatuses. The deficient practice remains at a level 3 for actual harm to Resident #5. Findings: Resident #5 was a [AGE] year old woman admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed the resident's cognitive skills for daily decision making were (3) severely impaired - never/rarely made decisions The resident was totally dependent for bed mobility, transfers, and all aspects of activities of daily living. Section M (skin conditions) M015: Is resident at risk for developing a pressure ulcer (Yes) M0210: Resident has Stage 1 or higher pressure ulcer (No) Review of the Minimum Data Set ((MDS) dated [DATE] revealed the resident's cognitive skills for daily decision making were (3) severely impaired - never/rarely made decisions The resident was totally dependent for bed mobility, transfers, and all aspects of activities of daily living. Section M (skin conditions) M015: Is resident at risk for developing a pressure ulcer (Yes) M0210: Resident has Stage 1 or higher pressure ulcer (Yes) M0300D1: Stage 4 pressure ulcers: number present (1) Review of the care plan revealed the following: Problem Onset: 06/05/2009: At risk for pressure ulcers/skin tears secondary to bladder/bowel incontinence. Goal & Target Date: Will minimize risk of skin breakdown/pressure ulcers qd (everyday) by 11/27/12 and again by 02/13 Approaches: inspect skin daily while performing care and notify nurse of any redness, irritation or skin tears. Review of the clinical record's nurses' notes dated 11/29/12 and timed 1:55 p.m., revealed the resident fell and expressed discomfort when her (R) arm was touched. She was sent to _______ Medical Center for an evaluation. At 4:00 p.m. the facility received a report from _______ Medical Center the resident had sustained a fractured to the right humerus and was being transferred to ________hospital. The resident returned to the facility on [DATE] at 8:40 p.m. The General Instructions Form from _____Medical Center dated 11/29/12, documented the following: Fracture proximal right humerus. Displacement of fracture is present (Patient is neurovascularly intact). Procedures: Long arm splint. The Exitcare Patient Information form from _______hospital dated 11/29/12 and timed 7:08 p.m., revealed the following: Please follow up with Dr._____(orthopedic surgeon) in 7 days for further evaluation. Review of the facility's physician's orders [REDACTED]. Review of the facility's nurses' notes dated 11/29/12 through 01/08/13 revealed no documentation the resident had a splint to the (R) arm. Review of the facility's Weekly Nursing Progress Notes dated 11/22/12; 12/06/12; 12/13/12; 12/20/12; 12/27/12; 01/03/13; 01/10/13; and 01/17/13 revealed no documentation of the neurovascular status of the resident's (R) arm or assessments of the skin on her (R) arm. The section on the weekly nurses' notes titled "Contractures" has a check list that includes hand splint. Hand splint was never marked on any of the weekly nurses' notes. Review of the resident's Medication Administration Records (MAR) for the months of November 2012 and December 2012 revealed no documentation of circulatory checks to the resident's (R) arm. The first documentation of circulatory checks to the resident's (R) arm is dated January 21, 2013. Review of a nurse's note dated 01/18/13 revealed the following: 10:45 a.m. Upon assessing Rt arm & splint noted an open area on Rt elbow - entire area 44 cm (discolored area) 2.1 x .3 cm open area in center, 0.5 cm depth with brownish yellow drainage and odor noted.... On 01/18/13 the resident's physician was notified and the following orders were given: Consult Dr._____(orthopedic surgeon ). A Request for physician's orders [REDACTED]. ______(orthopedic surgeon) refused to see resident secondary to the fracture being old. The resident was then referred to _________wound center on 01/22/13. On 01/22/13 orders were written to begin wound care with normal saline and Arginate daily until healed, Keflex 500 mg TID (three times a day) X 10 days, consult____wound care, culture & sensitivity of wound drainage, x-ray ? arm. The resident was initially seen at the wound care center on 01/30/13 with the following [DIAGNOSES REDACTED]. She continued with weekly visits until 03/13/13 when she was discharged from the wound care center. Review of the wound care center records revealed, in part, the following: Wound Location Type/Stage Measurements (cm) 01/30/13 (R) elbow Pressure Wound IV 0.3 x 0.7 x 0.8 Pack Tunneling/Undermining Lightly with: [MEDICATION NAME] AG Rope 2 x a week *wound debrided today Additional orders: Bone Culture sent today 02/06/13 (R) elbow Pressure Wound IV 0.2 x 0.2 x 0.5 Pack Tunneling/Undermining Lightly with: [MEDICATION NAME] AG Rope 2 x a week *removed nonviable/necrotic tissue from wound bed Additional orders: no pressure to wound area-no splint for one week 02/13/13 (R) elbow Pressure Wound IV 0.2 x 0.4 x 0.6 Apply to Wound Bed: [MEDICATION NAME] AG 2 x a week Additional orders: Keflex 250 mg po (by mouth) q12h (every 12 hours);[MEDICATION NAME] 3 x a day 02/20/13 (R) elbow Pressure Wound IV 0.2 x 0.2 x 0.3 Apply to Wound Bed: [MEDICATION NAME] 2 x a week *surgical removal non-viable tissue/slough Additional orders: Resume Keflex one more week 02/27/13 (R) elbow Pressure Wound IV 0.2 x 0.2 x 0.3 Apply to Wound Bed: [MEDICATION NAME] 2 x a week *surgical removal muscle &/or fascial tissue; surgical removal of bone Additional orders: Keflex 250 mg po q12h x 10 days; [MEDICATION NAME] TID (3 times a day) Wound deteriorated today, [MEDICATION NAME] - Palliative care, patient DNR (Do Not Resuscitate) 03/06/13 (R) elbow Pressure Wound IV 0.4 x 0.3 x 0.1 Apply to Wound Bed: Elta Silvergel/[MEDICATION NAME] 2 x a week *surgical removal/scissors non-viable tissue/slough Additional orders: Keep dressing on at all times; follow up in one week Wound deteriorated today, [MEDICATION NAME] - Palliative care, patient DNR (Do Not Resuscitate) 03/13/13 (R) elbow Pressure Wound IV 0.1 x 0.1 x 0.1 Apply to Wound Bed: [MEDICATION NAME] only 2 X a week *exudate removed, essentially healed Additional orders: Essentially healed, foam for offloading On 03/25/13 at 11:30 a.m. an observation was made of the resident sitting in her geri chair in the assisted dining room. When spoken to she did not respond. A CNA nearby stated the resident does not speak. A small dressing was noted to her (R) elbow. On 3/25/13 at 4:45 p.m. an interview was conducted with S2DON. She was asked to review the weekly nursing progress notes dated 11/22/12; 12/06/12; 12/13/12; 12/20/12; 12/27/12; 01/03/13; 01/10/13; 01/17/13 and all other nurses' notes written on Resident #5 from 11/29/12 to 01/17/13. She was asked if the section to indicate the resident had a splint was ever checked. S2DON verified there was no documentation the resident had on a splint when she returned to the facility on [DATE] or any time after until it was removed on 01/18/13. She was asked if neurovascular checks had been done on the resident's (R) arm from 11/29/12 to 01/17/13. S2DON verified there was no documentation of neurovascular checks to the resident's (R) arm. She was asked who should have been assessing the resident's arm. S2DON stated the assigned treatment nurse, who is no longer employed with the facility, should have been doing weekly skin assessments and the floor nurses should have also assessed the arm and splint daily. She was asked why the orthopedist was not consulted. S2DON verified the orthopedic consult was not done because the floor nurse did not write the need for the consult on the 24 form, which then is discussed in the morning meeting and would have been scheduled by social services. S2DON verified that when the consult was finally made on 01/22/13, the orthopedic surgeon refused to see the resident because the fracture was old. She was asked when was the stage IV pressure ulcer to the resident's (R) arm discovered. S2DON verified the wound was discovered at a stage IV on 01/18/13 when the splint was removed for the first time since her return to the facility on [DATE]. On 04/01/13 at 8:30 a.m. an interview was conducted with S4LPN, MDS Coordinator. S2DON was present during the interview with S4LPN, MDS. S4LPN was asked how often are the Braden Scale assessments to be done on residents. S4LPN stated on admit and quarterly. She was asked if any Braden Scale assessments had been done on the resident. S4LPN provided Braden scales done on the resident on 06/08/12 and 03/05/13. S4LPN verified there was no documentation of assessments done in September 2012 or December 2012. S4LPN was asked to review the resident's care plan. She was asked if the resident's skin was to be inspected daily for any changes. S4LPN stated "yes". On 04/01/13 at 8:45 a.m. an interview was conducted with S2DON. She was asked how often are skin assessments done and by whom. S2DON stated weekly skin assessments are done on all residents by the treatment nurse. She stated the nurses on the floor are responsible for daily skin assessments on their residents. She was asked if there was documentation of daily skin assessments. S2DON stated "No". She was asked if she had any documentation weekly skin assessments had been done on Resident #5. She stated she would check. On 04/01/13 at 9:40 a.m. S2DON returned to the surveyor and provided forms titled Weekly Skin Integrity Checks. Review of the weekly skin assessments for Resident #5 revealed weekly skin integrity checks were done on the resident for the months of June 2012 and July 2012. There was no documentation of weekly skin integrity checks for August 2012, September 2012, October 2012, November 2012 or December 2012. The first weekly skin integrity check for 2013 was done on 01/18/13, the day the stage IV wound was discovered. S2DON verified the facility's wound care nurse had not performed weekly skin integrity checks on Resident#5. S2DON was asked for the facility's policy and procedure for weekly and daily skin assessments. S2DON provided the surveyor a policy titled Assessment and Documentation of Wounds. She stated she did not have a policy for weekly skin sweeps or daily skin checks, but verified it was the facility's practice for the wound care nurses to perform weekly skin assessments and for the nurses on the floor to check their residents skin daily. She was asked to review the Braden Scale for Resident #5. S2DON verified the last Braden Scales done on the resident were done on 06/08/12 and 03/05/13. She was asked how often are Braden scale assessments to be done on residents. S2DON stated "Quarterly". She was asked if Braden scale assessments had been done on Resident #5 quarterly. She stated "no". Resident #6 The facility failed to follow the physician's orders [REDACTED]. Resident #6 was placed in Immediate Jeopardy on 03/08/13 when she returned from an office visit with physician's orders [REDACTED]. The facility did not obtain the ultrasound until 03/11/13 after the resident complained of leg pain. The results of the ultrasound revealed the resident had 4 occlusive thrombus and 1 nonocclusive thrombus to the left lower leg. The Administrator was notified of the Immediate Jeopardy on 03/28/13 at 10:12 a.m. A plan of removal was presented by the Administrator which read as follows: 1. Review of physicians orders on current residents including transfer records from hospital, ER, office visits, progress notes, consults, in residents records from 03/08/13 to present was completed to ensure physician orders [REDACTED]. 2. All nurses will be re-educated on accurately transcribing physician orders [REDACTED]. 3. Unit Managers will monitor physicians orders along with appointments ordered Monday - Friday during the Morning Clinical Meeting, utilizing the QI data Collection Form, for ongoing compliance. Weekend supervisor will monitor Saturday and Sunday. DCS (Director of Clinical Services)/designee will conduct random audits weekly, utilizing same tool, and report results monthly to the PI committee to ensure on-going substantial compliance. The Immediate Jeopardy was removed on 03/28/13 at 3:04 p.m. when the surveyor confirmed all physician's orders [REDACTED]. The deficient practice remains at a level 3 for actual harm to Resident #6 Resident #6 Resident #6 was a [AGE] year old woman admitted to the facility on [DATE] after an ORIF (Open Reduction Internal Fixation) of the (L) Hip. Other [DIAGNOSES REDACTED]. She was readmitted on [DATE] after a hospitalization for [MEDICAL CONDITION]. Review of the (MDS) Minimum (MDS) data set [DATE] revealed the resident had a BIMS (Brief Interview for Mental Status) score of 11 (moderate impairment) Review of the care plan revealed the following: Problem Onset: 02/21/13 [MEDICATION NAME] therapy related to status [REDACTED]. Goal & Target Date: will have no abnormal bleeding by 05/01/13 Approaches: monitor for [MEDICAL CONDITION]: warmth, redness, swelling to extremity, positive Homans sign. Review of the nurses' notes dated 02/21/13 - 03/25/13 revealed the following: On 03/08/13 the resident went out to a scheduled office visit with Dr._____. Review of the physician's office notes revealed the following: Chief Complaint: some c/o (complaints) of weakness and pain and leg swelling, on walker/[MEDICATION NAME], PWB (partial weight bearing). ROS (review of systems): Patient reports joint pain and difficulty walking but reports no joint stiffness or swelling, no weakness of muscles or joints, no muscle pain or cramps, no back pain, and no cold extremities. Assessment /Plan: d/c (discontinue) staples, PT (physical therapy)/WBAT (weight bearing as tolerated) check u/s (ultrasound) LLE (left lower extremity), walker, finish course of [MEDICATION NAME]. Review of the clinical record revealed the following: Physician's progress note dated 03/08/13: Plan (P) check u/s - leg swelling. physician's orders [REDACTED]. Nurses' Notes: 03/08/13 3:50 p.m Returned from appointment with Dr.______ per nursing home van with orders for WBAT with walker PT/ROM (range of motion), u/s (L) leg r/o [MEDICAL CONDITION].signed by S17LPN. Physician's Telephone Orders dated 03/08/13: WBAT with walker/PT/hip and knee ROM, u/s (L) leg-r/o [MEDICAL CONDITION] by S16RN. Review of the clinical record's nurses' notes dated 03/11/13 and timed at 8:15 a.m. documented the following: Resident up working with therapy. Resident complained of pain to her (L) leg, lower. MD (medical doctor) ordered u/s of lower extremity. Facility van will transport her to appointment this am......signed by S3RN. Nurses' notes continued: 03/11/13 6:00 p.m. resident was admitted to ______Medical Center with [DIAGNOSES REDACTED]. 03/15/13 7:30 p.m. readmit assessment done with resident and daughter. Orders from ____Medical Center/Dr._____for readmit to ________Nursing home. [DIAGNOSES REDACTED]. Review of the u/s done on 03/11/13 at ______Medical Center revealed the u/s was completed at 10:11 a.m. and the resident's physician was notified by the Radiologist at 10:22 a.m. of the following results: Findings: There is nonocclusive thrombus demonstrated within the left common femoral vein. Partial flow is demonstrated. There is occlusive thrombus noted within the profunda femoral, superficial femoral, popliteal, and anterior tibial veins. No flow demonstrated within these veins. The posterior vein demonstrates no thrombus. Impression: Occlusive thrombus within the profunda femoral, superficial femoral, popliteal, and anterior tibial veins on the left with nonocclusive thrombus within the common femoral vein. On 03/27/13 at 4:30 p.m. an interview conducted with S2DON and S3RN. They were asked to review the clinical record and MD orders on 03/08/13 for an u/s to the lower leg and the u/s report of 03/11/13 positive for thrombus. S3RN was asked if she was the nurse on duty the morning of 03/11/13 when the resident complained of leg pain. She stated "yes". S3RN was asked why did she send Resident #6 for the ultrasound. S3RN stated on the morning of 03/11/13 the resident complained of pain to her left lower leg. She stated she realized the ultrasound ordered on [DATE] had not been done, so she called_______Medical Center and the resident was seen for the ultrasound. S2DON was asked if an ultrasound had been ordered on [DATE] by the physician to rule out [MEDICAL CONDITION]. She stated "yes". She was asked if the resident received an ultrasound on 03/08/13 as ordered. S2DON stated "no". She was asked if the order written on 03/08/13 had been followed. S2DON verified the order had not been followed by nursing. She was asked what is the process for scheduling tests. S2DON stated the nurse takes off the order and writes it on the outpatient appointments schedule sheet. S5SSD then schedules the appointments. On 03/28/13 at 10:30 a.m. S25RN, Corporate Nurse presented the surveyor with a form titled Outpatient Appointments to be Scheduled and a copy from the appointment book of S5SSD dated March 11th, 12th and 13th of 2013. The resident's name was listed on the appointments to be scheduled form with the date 03/08/13 written under the heading "Date Of Order". On the appointment book the resident's name was written near the top of the page for 03/11/13 with no time next to it. On 03/28/13 at 10:40 a.m. S1ADM approached the surveyor, and referring to the forms presented by S25RN, Corporate Nurse, stated the facilty had tried to schedule the ultrasound on 03/08/12, but _______Medical Center had scheduled the ultrasound for 03/11/13. On 03/28/13 at 11:20 a.m. an interview was conducted with S15RAD, the Director of Radiology services at ________ Medical Center. He was asked if the resident had ever been scheduled for an u/s on 03/08/13. After reviewing the radiology schedule for 03/08/13, he stated "she was never scheduled; the first time we were contacted was on 03/11/13 when they called and asked to bring her over ". He was asked how did he know the resident was never scheduled on 03/08/13 by the nursing facility. S15RAD stated "because she was never placed on our schedule". He went on to state "she was put into our system at 9:40 a.m. on 03/11/13 when she arrived and the ultrasound was completed at 10:11 a.m. Dr._____(radiologist) called the results to Dr.____(resident's physician)". He was asked if the resident could have been seen on Friday, 03/08/13, if the facility had scheduled the u/s. S15RAD stated "yes, we have techs here until 11:30 p.m. and then someone is on call ". He went on to state "we don't really schedule ultrasounds for [MEDICAL CONDITION] (deep vein thrombus) or PEs (pulmonary embolisms) because those are done immediately ". S15RAD stated if the facility would have called on 03/08/13 the resident would have been seen immediately. Copies of the radiology schedule revealed Resident #6's name was not listed on the radiology schedule for 03/08/13 or 03/11/13. On 04/01/13 at 9:45 a.m. a telephone interview was conducted with S17LPN, who was on duty 03/08/13, when the resident returned from her office visit with orders for an ultrasound. She was asked if she wrote the note on Resident #6 on 03/08/13 that documented an u/s was to be done to r/o [MEDICAL CONDITION]. S17LPN stated "yes". She was asked if it was the facility's practice for the nurse to write the consults on the outpatient appointment to be scheduled form. She stated "yes". She was asked if she scheduled or attempted to schedule the u/s. She stated "no". She was asked if she had written the resident's name on the outpatient appointment form. S17LPN stated "I don't remember". On 04/01/13 at 9:50 a.m. a telephone interview was conducted with S16RN, who was on duty the evening the resident returned to the facility with orders for an u/s, on 03/08/13. She was asked if she had signed off the order for the u/s. She stated "yes". S16RN stated 03/08/13 was her first day out of orientation. She was asked if she had written the resident's name on the outpatient appointment sheet. S16RN stated "I'm not sure". She was asked if the u/s had been scheduled. S16RN stated she had not scheduled it and was depending on what she was being told by the other nurse. S16RN stated she wished she would have ensured it was done. On 04/01/13 At 10:10 a.m. an interview was conducted with S5SSD. She was asked what is her role in scheduling appointments. She stated the nurses place the request for a test/consult on the outpatient schedule form, she then makes daily rounds to see if any request are written. If so she then schedules the appointment or consults, informs the resident and the responsible party, and writes the appointment or consult date and time in her appointment book and then someone from medical records writes the appointment in one of the appointment books at each nursing station ...depending on where the resident resides. She was asked to review her records for Resident #6. S5SSD reported on the morning of 03/11/13, during the morning meeting, someone who she can't remember came in to the meeting and asked could she schedule an u/s for Resident #6. She reported she remembers them saying the resident's family was asking if the test had ever been done. S5SSD reported she was not aware the resident needed an u/s until that moment. She stated she called _____(scheduler) in the x-ray department at _______Medical Center and Resident #6 was seen immediately. S5SSD stated for tests to rule out [MEDICAL CONDITION] she doesn't schedule those, instead she calls the hospital and gets it done right then. Review of the Station 1 appointment book, where the resident was residing on 03/08/13 and 03/11/13, revealed no u/s scheduled for 3/11/13. S5SSD verified it was not in the Station 1 book because she had not scheduled it until the morning of 03/11/13 when someone requested she get an u/s for Resident #6. S5SSD was asked to explain the entry on her appointment book listing Resident #6 for an ultrasound on 03/11/13. S5SSD stated she wrote that in at the top of the page so she would have a record of the resident's appointments. She reiterated she was not made aware of the u/s until the morning of 03/11/13 and that is when she called ________Medical Center. On 04/01/13 at 10:40 a.m. an interview was conducted with S6MR, who is currently the CNA scheduler, but verified she worked in medical records at the time Resident #6 went for the u/s. She was asked to review the appointment book from Station 1. She was asked why the u/s had not been put in the Station 1 appointment book on 03/08/13. S6MR stated" it was not in S5SSD's appointment book for the 11 th, or I would have put in the Station 1 book " . On 04/01/13 at 11:05 a.m an interview was conducted with S8COTA. She was asked if she worked with Resident #6 on 03/11/13. S8COTA stated "yes" and reported on 03/11/13 while in therapy, the resident complained of pain in both legs. She stated she notified nursing and the resident was sent out to the hospital. S8COTA stated the resident resumed therapy on 03/18/13. On 04/01/13 At 12:50 p.m. an interview was conducted with S3RN. She was asked to review the Station 1 appointment book dated 03/11/13. S3RN verified the resident was not listed for an ultrasound on the schedule book for 03/11/13. On 04/01/13 at 4:00 p.m. a telephone call was placed to the office of Dr.______, the resident's physician who ordered the ultrasound on 03/08/13. The physician was unavailable, so the surveyor spoke to S13LPN, the physician's nurse. She verified she was familiar with Resident #6. She was asked if Dr.______had ordered an u/s on 03/08/13 to rule out deep vein thrombus. S13LPN stated "yes". She was asked when should the test have been done. S13LPN stated "Dr._____requires the results of all ultrasounds to be reported to him within 24 hours". Resident #1 The facility failed to follow a physician's orders [REDACTED]. This resulted in an Immediate Jeopardy situation which began when resident #1 was admitted to the facility on [DATE]. S1Adm and S2DON was notified of the Immedicate Jeopardy siutation on 03/28/13 at 10:12 a.m. and removed at 3:04 p.m. Resident #1 had a history and [DIAGNOSES REDACTED]. The facility failed to have the daily PT/INR laboratory values performed and administer the anticoagulant medication [MEDICATION NAME] as needed based on the laboratory values throughout resident #1's length of stay. The Immediate Jeopardy situation continued for resident #1 until he was discharged on [DATE].

Based on interviews and record reviews the facility failed to ensure the Quality Assessment and Assurance Committee identified actual quality deficiencies and implement appropriate plans of action for quality of care issues necessary to correct quality deficiencies (cross reference F272, F281, F282, F309 F314, F323, F333) Findings: On 04/01/13 at 5:43 p.m. an interview was conducted with S1ADM and S2DON to review the facility's quality assessment and assurance. S1Adm was asked if he was the staff person responsible for quality assessment and assurance (QA&A). He stated, "I guess I am". He was asked how does the QA&A committee identify issues to be addressed by the QA&A program. S1Adm requested S2DON respond to the question asked. S2DON stated, "Quality issues are discovered during the morning meetings, activities of the facility, complaints, and changes in residents' conditions". She was asked what methods the facility utilizes to develop action plans to correct quality deficiencies identified. She stated the facility has a 4 point plan that develops a plan of correction to correct the problems, conduct audits, perform required education and follow up. S2DON was asked how are the current action plans being implemented. She confirmed the last quarterly meeting was held on 01/21/13 and stated, "we also have monthly meetings". She stated, "We use the same 4 point plan on any problems identified". When asked if she felt the 4 point plan was effective in resolving quality issues identified she stated, "Typically we find the 4 point plan to be effective". S2DON was asked what quality issues was the QA&A committee currently reviewing. She stated, "The skin assessment policy, physician follow through with treatment orders, apparatus orders for splints, and physician orders". She stated, "We are also working on assessments and physician notification since the last complaint survey exited on 02/14/13. S2DON stated, "We have an open 4 point plan in place to correct the medication pass times with the addition of staff". She was asked if this 4 point plan was put in place following the medication pass conducted by the surveyors from 6:45 p.m. - 9:30 p.m. on 03/25/13. S2DON verified additional staff were not present during the medication pass conducted with the surveyors on 03/25/13. She stated, "A meeting was held following this medication pass and we identified the need to add additional staff to perform the medication pass". S2DON was asked if the current action plan to correct these quality deficiencies was effective. She verified and stated, "It is not working". S2DON was asked if environmental accident hazards were part of the facility's QA&A review. S1Adm responded and stated, "Are you talking about the screws on the toilets? It was not an issue before". When asked how does he ensure the facility's environment remained free of accident hazards he stated, "Maintenance makes rounds weekly and maintenance logs are maintained at each station". S2DON was asked how are the action plans implemented. She stated we conduct audits and reviews of any findings of the audits to ensure they are corrected. She stated the facility identifies trends, patterns, educate and re-educate and continue with the audits. She was asked for the facility's policy and procedure for QA activities. S2DON stated, "We don't have a policy". She stated, "This would have to be addressed with corporate for any changes needed". She was asked if any of the QA &A issues identifed have not been achieved. She stated, "The skin issue found in January was not achieved and brought to QA Committee and we redeveloped a 4 point plan". S2DON was asked if the facility should have known about the quality deficiencies identifed during this survey. She stated, "We should hve known about the narcotic medicines on the MAR". She stated, "Some of the issues that the facility has developed QA to identify corrective action plans and 4 point plans are based on the complaint survey exit date: 02/14/13 and we are currently working on these issues". When asked if there have been any concerns regarding residents not receiving their medications she stated, "There was some concerns from some residents regarding medication pass but the facility has not QA'd the issue of nurses signing out narcotics and not documenting the medication as given". S1Adm stated, "Tomorrow we are having a meeting to review the Plan Of Correction from the last complaint survey". The surveyor explained to S2DON and S1Adm the facility's QA should not be based on the surveyors' findings. S2DON stated, "Based on the results of this survey our QA&A plan will need to be revamped".

Based on interviews and record reviews the facility failed to ensure 1 (#28) of 4 (#50, #68, #80, #28) residents reviewed for accidents remained free of accidents and received the required assistive device for transfers by failing to ensure the resident was transferred using the designated lift and failing to ensure staff were trained and knowledgeable to provide care to a resident and prevent an accident from occurring. This failed practice resulted in actual harm on 04/19/13 when resident #28 was transferred from a chair to the bed without the use of the designated lift by one Certified Nursing Assistant (CNA). Subsequently, resident #28 fell and was sent to a local hospital where she was diagnosed with [REDACTED]. Findings: Resident #28 On 05/16/13 a closed record review was conducted for resident #28. She was admitted to the facility on [DATE] and re-admitted on [DATE]. Her [DIAGNOSES REDACTED]. Review of the most recent MDS (Minimum Data Set) ARD (Assessment Reference Date) 02/20/13 revealed she required extensive assistance for transfer- self performance (resident involved in activity, staff provide weight-bearing support and two + persons physical assist for support provided). Further review of the prior MDS Annual Assessment ARD 11/23/12 revealed resident #28's transfer status required the same extensive assistance with two + persons physical assist. Review of the facility document titled, "Activity Participation Record" for the month April 2013 revealed resident #28 enjoyed actively participating in bingo, hospitality hour, television, movies, and videos. Review of the Nurses Notes dated 04/26/13 revealed resident #28 returned to the facility following hospitalization for her fractured left hip. Further review of the Nurses Notes the following day on 04/27/13 revealed in part the following: "1030 .... New Orders Admit to (name of hospice agency) for routine home care Dx (Diagnosis) Failure to thrive.... Activity: up to w/c (wheelchair) as tolerated.... 1120.... Resident awake at 0850 (8:50 a.m.) c/o (complaining of) leg pain and general agitation.... 1310 (1:10 p.m.) Resident having agitation again.... 1330 (1:30 p.m.).... Resident c/o leg pain... 1513 (3:13 p.m.) Called to room by Family. Resident has no pulse.... Laying in bed eyes closed.... 1920 (7:20 p.m.) (Name of funeral home) picked up resident. On 05/12/13 at 7:00 a.m. a telephone interview was conducted with resident #28's son. He stated his mother was [AGE] years old and would have been 100 next month. When asked if his mother was alert and oriented he stated, "Yes. Sometimes she would be confused what day of the week it was but she could tell you what she needed". He stated, "My mother told that CNA to use the lift". He was asked when did his mother make this statement. He stated, "When she was at the hospital after she fell ". He stated, "My mother told me the CNA told her she could do it herself". Review of the document titled, "Care Plan" for resident #28 revealed the following problem identified on 02/11/10: Risk of falls Goal: Will minimize risk of falls/injuries from falls by 06/2013 Approaches included the following assistive device: "Use Vera lift for all transfers". Review of the document titled, "Quarterly Data Collection Tool" dated 02/20/13 revealed a risk for falls assessment was performed for resident #28 and her score was 16. The document also revealed a total score of 10 or above indicated resident #28 was at a high risk for falls. Review of the Nurses Notes dated 04/19/13 at 14:35 (2:35 p.m.) revealed the following: "Called to room per CNA. Resident laying on floor beside bed. CNA states was transferring to bed & bed rolled. CNA then states she lowered resident to floor. Resident was c/o (complaining) pain at left leg. Left leg was noted bent out. Pillow was placed under head for comfort due to resident being in so much pain.....". Further review of the Nurses Notes revealed in part the following: 04/20/13 1000 ".... transferred to (name of hospital) yesterday fx (fracture) hip (Dx) (diagnosis)...." On 05/17/13 at 2:00 p.m. an interview was conducted with S16LPN. She was asked if she worked on 04/19/13 when resident #28 experienced a fall. She stated, "Yes". She stated, "The CNAs called me to the room and the resident was lying on the floor and I tried to find out what was going on. The CNAs told me they were trying to put her to bed. When asked if there were two CNAs transferring resident #28 she stated, "No". S16LPN stated, 'There was one in the room and one at the door. She stated, "S17CNA stated she lowered her to the floor". She stated, "I noticed her left leg was out to the side and her shoe was twisted off of her foot". When asked if there was a lift in the room she stated, "There was no lift in the room at the time of the incident". She was asked if a lift was required. She stated "Yes". She stated, "She (resident #28) required the sit to stand Vera lift". She stated, "This resident required this lift because she would become weak in her legs". On 05/16/13 random interviews were conducted with Certified Nursing Assistants who were on staff throughout the facility. At 3:55 p.m. an interview was conducted with S23CNA. When asked how do you know what type of lift to use for each resident she stated, "We go to the book". When asked what book she took the surveyor to the nurses station and showed her the book containing the Kardexes for each residents' requirement for transfer assistance. At 4:03 p.m. an interview was conducted with S24CNA. She was asked how do you know what type of lift a resident requires. She stated, "You go to the Kardex and find out". At 4:05 p.m. an interview was conducted with S25CNA. She was asked how do you know what type of lift a resident requires for transferring. She stated, "You have to go to the book". At 4:07 p.m. an interview was conducted with S26CNA. There was a lift observed in the hallway when the interview was conducted. She was asked what type of lift it was. She stated it was a Hoyer Lift. She was asked what was this lift used for. She stated for total assist residents. She was asked how do you know which type of lift to use for each resident. She stated, "There is a book at the nurses station that tells you". On 05/17/13 at 10:00 a.m. an interview was conducted with S27CNA. She was asked how long she had been employed at the nursing home. She stated 6 months. She was asked how did she know what type of lift a resident requires. She stated, "Let me show you". She took the surveyor to a resident's room and pointed to the resident's name plaque on the outside of the room. She stated, "No, not this one". She asked another staff member, S28RA, who was standing at the doorway to the resident's room, where the lift information was located. S28RA stated, "On the Kardex". On 05/17 13 at 10:15 a.m. an interview was conducted with S18Adm.Assist. She was asked for employee records for S17CNA, S19CNA, S20CNA, S21CNA, and S22CNA. She was asked if the employees' records included training. She verified they did. She was asked what staff member was responsible for the CNA training. She stated S6WC. On 05/17/13 a record review was conducted of the following employee files: S17CNA- Date of hire: 04/08/13- Review of the document titled, "Certified Nursing Assistant Skill Review revealed no documented evidence of a return demonstration validated by another employee for the following areas: vital signs, weights, daily resident/patient care, clinical programs, restorative nursing, change in condition, communication, and equipment management. S19CNA- Date of hire: 04/12/13- Review of the document titled, "Certified Nursing Assistant Skill Review revealed S19CNA signed the return demonstrations. There was no documented evidence of a return demonstration validated by another employee for the following areas: vital signs, weights, daily resident/patient care, clinical programs, restorative nursing, change in condition, communication, and equipment management. S20CNA- Date of hire 03/28/13- Review of the document titled, "Certified Nursing Assistant Skill Review revealed S20CNA signed some of her own return demonstrations. There was no documented evidence of a return demonstration validated by another employee for the following areas: vital signs, weights, daily resident/patient care, clinical programs, restorative nursing, change in condition, communication, and equipment management. employee signed their own evaluation. S21CNA- Date of hire: 04/11/13- Review of the document titled, "Certified Nursing Assistant Skill Review revealed S21CNA signed some of her own return demonstrations. There was no documented evidence of a return demonstration validated by another employee for the following areas: vital signs, weights, daily resident/patient care, clinical programs, restorative nursing, change in condition, communication, and equipment management. employee signed their own evaluation. S22CNA- Date of hire: 04/12/13- Review of the document titled, "Certified Nursing Assistant Skill Review revealed S22CNA signed some of her own return demonstrations. There was no documented evidence of a return demonstration validated by another employee for the following areas: vital signs, weights, daily resident/patient care, clinical programs, restorative nursing, change in condition, communication, and equipment management. employee signed their own evaluation. On 05/17/13 at 11:47 a.m. an interview was conducted with S6WC. She was asked what was her job description. She stated she was a Ward Clerk and also worked in Medical Records. She stated she had been providing orientation for the CNAs since April 1, 2013. She was asked how long was the orientation. She stated 1 day. She stated, "Following orientation the CNAs will have further orientation for 2 days with another CNA". When asked if she was finished with the CNAs after the first day of orientation she stated, "I check up on them for the next 2 weeks". She was asked when are the skills orientation checklists completed. She stated, "After orientation we do skills checklists". She was asked where do you document this. S6WC stated in the employee's folder. She was asked to review S17CNA's employee folder and presented a copy of a document titled, "Low Lift Program Employee Education Checklist". She was asked what type of training was provided for this program. She stated she did not have a copy of the Low Lift Program. Review of the document titled, "Low Lift Program Employee Education Checklist" in S17CNA's employee file revealed an Acknowledgment signed by the employee that read "I have received training and understand the policy and procedures that have been implemented in this facility to prevent back injuries....". S6WC was asked to review the document titled, "Certified Nursing Assistant Skill Review" in S17CNA's employee file with the surveyor. She verified there was no documented evidence of skill reviews and demonstrations validated by another employee. She stated she did not know if she should sign the skill review and demonstration validation because the form required a nurse to sign it. Review of the Online Tracking and Incident System (OTIS) Client Incident Report involving resident #28 revealed in part the following documentation: Occurred: 04/19/2013 01:45 pm Accused / Allegation (S17CNA) Finding Substantiated Victim (Resident #128) Injury Fracture Case Notes Description: "(Resident #28) was being transferred from chair to bed by aide (S17CNA). (S17CNA) should of been using a sit to stand lift instead was transferring her by herself and the resident went down to the floor. When DON arrived (resident #28) was lying on the floor in supine position with left leg rotated inward. The CNA stated the bed moved when she went to transfer (resident #28). The DON asked if she had locked the bed back and she stated yes., when the DON asked for her to show her she could not. (Resident #28) was sent to ER and diagnosed with [REDACTED]. Review of the statement provided by S17CNA dated 04/19/13 regarding the OTIS Client Incident Report revealed in part the following documentation: ".... not aware to use a sit-to-stand lift on her". On 05/17/13 at 12:19 p.m. an interview was conducted with S3DON. She was asked to review the Online Tracking and Incident System (OTIS) Report involving the accident that occurred on 04/19/13 involving resident #28 and S17CNA. S3DON was asked to describe how the accident occurred. She stated, "The aide transferred the resident from the chair to the bed and the CNA stated the bed moved". She stated, "My observation was the bed did not move". She stated, "The resident required a sit to stand lift". S3DON was asked why did S17CNA not use a lift. She stated, "I have no idea why she transferred the resident by herself". She was asked if she asked S17CNA why she didn't use the lift. She stated, "The CNA stated she didn't review the Kardex". When asked to review the written statement provided by S17CNA, S3DON confirmed the written statement contained documentation that S17CNA did not know she was supposed to use a lift. S3DON was asked should S17CNA have known to use the lift. S3DON stated, "When they are hired they are educated about the Kardex". S3DON was asked what did the facility do following this accident involving a CNA transferring a resident without a lift. She stated, "The facility educated the staff on the Kardex, transfer, and use of equipment". She stated, "We reviewed all residents for their transfer status, updated the charts, care plans, and Kardexes. S3DON was asked what did the facility do after the training was conducted. She stated, "It is a part of our QA (Quality Assurance)". The surveyor requested documentation of any quality assurance and follow up to include monitoring the staff following the inservices. On 05/17/13 at 12:31 p.m. an interview was conducted with S2Adm in the presence of S3DON. He was asked to discuss the QA conducted following the accident that occurred on 04/19/13 involving resident #28. He stated, "The QA Committee meets every 4 th Thursday of every month". He stated, "We have Clinical Meetings every day". He stated, "During these meetings we follow up on falls, hospital returns, and new admits" He stated, "This information is collected during April and May and we identify any trends that need to be added to our quality assurance program". S2Adm was asked again how does the facility ensure the inservice education was effective. He stated, "We followup daily at our clinical meetings". On 05/17/13 at 12:45 p.m. an interview and record review was conducted with S3DON. She was asked to review the CNA employee records with the surveyor. She verified S6WC was responsible for conducting CNA orientation. She was asked how did the facility ensure the CNAs are competent to perform skills. She stated S3WC goes over the skills with the employees and makes sure they are competent. She was asked to review the documents in the employee files titled, "Certified Nursing Assistant Skill Review". She verified there was no documented evidence another staff member validated the skill reviews and demonstrations. She stated, "Did you already talk to (S3WC) about this?" The surveyor stated yes.

Based on interviews and record reviews the facility failed to ensure that the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision to prevent accidents for 1 (#1) of 9 (#1, #2, #3, #4, #5, #6, #7, #8, #9) residents by failing to conduct a fall risk assessment as innidiated, ensure resident #1 received increased supervision, and ensure the toilets in the facility were free of an accident hazard. Findings: On 03/25/13 at 10:30 a.m. during the initial tour of the facility an observation was conducted of Room "a". Upon entering the residents' bathroom there was a large screw coming out of the base of the toilet, exposed and not covered. On 03/25/13 at 10:35 a.m. an observation was conducted of Room "b". Upon entering the residents' bathroom there was a large screw coming out of the base of the toilet, exposed and not covered. On 03/25/13 at 10:53 a.m. an observation was conducted of Room "c". Upon entering the residents' bathroom there was a large screw coming out of the base of the toilet, exposed and not covered. Resident #1 On 03/25/13 a record review was conducted for resident #1. Review of his accumulative [DIAGNOSES REDACTED]. Review of a document entitled, "Admission - Data Collection Form" dated 03/08/13 revealed in part the following:"Cognitive /Communication /Mood & Behavior: drowsy, verbal expressions of distress, sleep cycle issues. Functional Status: Transfers- 1 person assist Ambulation: able to stand uses wheelchair Risk for Falls: total score 7 (Indicating resident #1 was not at a high risk for falls). Total score of 10 or above deems resident at high risk. Side Rail Assessment: Has the resident demonstrated poor bed mobility or difficulty moving to a sitting position on the side of the bed? Yes. Does the resident have difficulty with balance or poor trunk control? Yes. Resident tried to get out of bed". Review of the document entitled, "Admission Care Plan" revealed in part the following problem identified for resident #1 upon admission: "Falls / Safety / Elopement Risks Goal: Resident will remain free of injuries and falls. Evaluate for unsteady gait. Instruct resident on appropriate safety measures." Further review of the Care Plan revealed no documented evidence of any interventions added until resident #1 experiences a fall on 03/16/13 sustaining a laceration to the back of his head. Review of the documents entitled Skilled Nursing Progress Notes revealed in part the following: "03/08/13 0445 (4:45 a.m.)- Resident found by CNA (Certified Nursing Assistant) sitting on toilet bleeding. Resident pulled out indwelling foley catheter w (with) / balloon intact.... Resident transferred to (Name of hospital)"...."03/09/13- ....alert and oriented to person only. Getting out of bed unassisted. Reeducated on using call light. Pressure pad alarm on bed in place & working".... "03/09/13 1933 (7:33 p.m.) Resident continues to get out of bed to use toilet. Educated resident on importance of calling for help when getting up". "03/10/13 0100 (1:00 a.m.) ... was trying to get out of bed unassisted earlier in evening was educated on call light bed alarm in place and working"... "03/10/13 1500 (3:00 p.m.) Resident confused. Reported to me resident was attempting to open the door. MD (Physician) notified. Order for wanderguard bracelet"... "03/10/13 2300 (11:00 p.m.) Resident found by CNA sitting in w/c (wheelchair). Resident pulled out indwelling catheter.... Primary MD notified gave order to DC (Discontinue)catheter". "03/10/13- 1500 (3:00 p.m.) Resident confused. Reported to me resident was attempting to open the door. Order for wanderguard bracelet"... "03/12/13- 0800 (8:00 a.m.) ...Needs redirection often. Walks around in room to bathroom. Encouraged to use call light".... "03/16/13 1810 (6:10 p.m.)- Called to residents room per CNA (name of CNA). Appears that resident went to the bathroom without assist and fell and hit his head on toilet. Small amount of bright red blood on the floor. Upon exam a small cut was noted to the back of his head. I notified the resident's nurse (name of nurse) of the incident". On 03/26/13 at 11:15 a.m. an interview was conducted with S2DON. She was asked if she was familiar with resident #1. She stated he had lung cancer and metastatic cancer of the liver. She stated he was recently placed on hospice prior to expiring. When asked if this resident had experienced and falls she stated yes. She stated he was ambulatory but in a weakened condition. She stated, "He could communicate with you some but didn't communicate well". She stated, "He could not voice all his needs". S2DON was asked when do the nurses perform fall risk assessments. She stated the nurse does an initial admit fall risk assessment and the MDS nurse does one quarterly. She stated the nurse receiving a resident following a hospitalization will also do a fall risk assessment. She stated, "I don't think they do a fall risk assessment if the resident is not hospitalized ". On 03/26/13 at 11:30 a.m. an interview was conducted with S7PT. He was asked of her was familiar with resident #1. He stated yes. He stated, "The first day we saw him for an evaluation on 03/10/13 he had a bed alarm in the bed". He stated, "We added a wheelchair alarm also to his wheelchair". He stated, "The first week he was ambulatory in his room, to the bathroom, and required contact guard assistance". When asked if this resident was at a high risk for falls upon admission he stated, "Safety was the biggest concern for this resident". When asked if he was at a high risk for falls he stated, "Yes, especially after the first fall". Review of the document entitled, "Physical Therapy PT Initial Evaluation" Start of Care 03/101/3 revealed in part the following: "Fall Risk Fall Predictors: Balance Impairment, Gait Impairment, History of Falls, Impaired ADL (Activities of Daily Living), Impaired Cognition, Impaired Strength, Pain and 5 or more medications". "Assessment Summary Risk Factors: Due to the documented physical impairments and associated functional deficits, the patient is at risk for: decreased circulatory function, falls, depression, further decline in function, increased dependency upon caregivers and pneumonia. Clinical Impressions/Summary of Findings: Pt (Patient) presents with weakness and debility, decreased balance and functional endurance; impairing all functional activities and placing pt at high risk for falls". On 03/26/13 at 1:50 p.m. a telephone interview was conducted with S19LPN. She was asked if she was familiar with resident #1. She stated yes. She was asked if she was working on 03/16/13 when resident #1 experienced a fall. She stated yes. S10LPN stated she was called to the resident's room by (Name of CNA). She stated resident #1 hit his head on the toilet. She was asked what part of the toilet. She stated, "The base of the toilet had blood on it where the exposed screws are located". She stated resident #1 cut the back of his head. When asked if this resident would get up without assistance she stated, "When I took care of him he tried to get out of bed constantly". She stated she worked nights. On 03/26/13 at 2:10 p.m. a telephone interview was conducted with S20LPN. She stated she employed prn (as needed). She verified she was working when resident #1 was found in the bathroom on 03/16/13. She stated, "I was in the dining room when S19LPN came and got me and said (resident #1) was found in the bathroom and there was blood on floor". She stated, "I looked at his head and told S19LPN it was coming from his head". She was asked if resident #1 had increased supervision at the time. She stated, "Every 2 hours the aides were checking on him". When asked what did the wound look like she stated, "It was a gash on the back of his head. It looked like a "circular wound". She stated, "There's a screw that comes out of the bottom of the toilet and the wound resembled the screw. She was asked if she reported the exposed screw on the bottom of the toilet to anyone. S20LPN stated she reported it to S19LPN. Review of the document entitled, "Post Incident Management & Investigation Checklist / Resident" for resident #1 dated 03/16/13 and completed by S20LPN revealed the following documentation in part, "Environment not a factor". On 03/26/13 at 3:50 p.m. an interview and record review was conducted with S2DON. She was asked to review the Fall Risk Initial assessment dated [DATE] for resident #1. She verified resident's fall risk score was 7 upon admission. She was asked when resident #1 was found on the toilet on 03/08/13 how did he get there. She stated he got there by himself. She was asked if this resident required assistance with ambulation. S2DON stated she did not know. She was asked if she was aware resident #1 continued to get up unassisted following admission to the facility. S2DON stated yes. She was asked if she was familiar with the fall resident #1 experienced on 03/16/13. She stated yes. She stated, "He received a gash in his head". When asked if she assessed the gash in his head she stated, "Yes. I couldn't find anything. She was asked if she was aware of the exposed screw on the bottom of the toilet. S2DON stated, "Someone told me about the possibility it could have been from the toilet and there was a screw exposed on the bottom of the toilet". She was asked what did she do about the exposed screw. She stated she reported this to S1Adm. She stated he had S21Maint. saw them off throughout the building. When asked what interventions have been added to this resident's plan of care she stated, "On 03/16/13 he was placed on the falling star program. Review of the facility's policy and procedure entitled, "Falling Stars Program" revealed in part the following:Policy To decrease the number of resident falls in the facility, the Falling Star program is designed to facilitate recognition of residents who are at risk for falls.... Procedure 1. A fall risk assessment will be initiated by the Clinical Nurse and completed on admission, quarterly, and as needed,.... On 03/25/13 at 4:30 p.m. an interview was conducted with S21Maint. He was asked if he was aware of the exposed screws on the bases of the toilets. He stated yes. He stated he ordered some caps for the exposed screws but they didn't come in. He stated he finally received 3 sets and was able to cover the screws on 3 toilets. S21Maint. was asked if the screws could pose a hazard for residents. He stated, " Yes". He stated, "Residents can hurt themselves, it is a safety hazard, and an accident hazard " . He was asked when were you first aware of the exposed screws. He stated, "S1Adm brought it to my attention on 03/19/13". He stated he was told to get his helper to get toilet bolts off and get covers. He was asked how many toilets have been taken care of since 03/19/13. He stated there were 6 completed. S21Maint was asked how many more do you have left to do He stated, "Approximately 22". On 03/28/13 at 2:46 p.m. an interview was conducted with S22CNA outside the room where resident #1 resided prior to discharge. He was asked if he remembered resident #1. He stated yes. He verified he was one of the CNAs responsible for this resident's care. When asked if this resident would get up unassisted he stated, "He would constantly get up out of the bed or wheelchair". He stated, "I even asked his roomates to press their call light if (resident #1) got up". S22CNA was asked if resident #1 had any falls. He stated yes. He stated, "In that bathroom right there". He pointed to the bathroom located outside the room where resident #1 resided. When asked to describe what happened he stated, "I found him on the bathroom floor". He was asked to describe the approximate location where resident #1 was found on the floor. He stated, "(Resident #1's) head was close to the base of the toilet". He was asked if there was blood on the floor. He stated yes. He was asked if there was blood on the base of the toilet. He stated, "Yes. By the cap on the bottom of the base". He was asked if the resident sustained [REDACTED]. He stated, "Yes I think so".