Every finding on record at Fairfield Nursing & Rehabilitation Center

Based on observations, interviews, and record reviews, the facility failed to properly store, prepare, and distribute food under sanitary conditions in accordance with standards for food service safety for 1 of 1 kitchen. 1. The facility failed to ensure Dietary Aide A wore proper hair restraint when holding clean plates in the dishwashing room.2. The facility failed to ensure the Dietary Manager wore a beard guard when standing next to the food prep table. 3. The facility failed to ensure Dietary Aide A sanitized his hands prior to donning gloves after touching his clothes.Findings include: Observations on 12/16/2025 at 9:05 AM, Dietary Aide A was wearing a baseball cap when he was holding clean plates in the dishwasher room in the kitchen. He had approximately 12 inches of hair in a ponytail not covered by the baseball cap. Interview on 12/16/2025 at 9:09 AM, Dietary Aide A stated he was informed by the Dietary Manager to cover his ponytail with a hair net. He stated he forgot, and he was expected to have all of his hair covered when in the kitchen. Dietary Aide A stated there was a possibility a resident may become ill with stomach issues such as vomiting, if a resident swallowed hair. He stated food was placed on the clean plate and the hair may get into the food. Dietary Aide A stated he had been in-serviced on wearing hair nets and ensuring all of his hair was covered when he wore a baseball cap. He did not recall the date and time of the in-service. Observation on 12/16/2025 at 9:15 AM, Dietary Manager was standing near food prep area, and he was not wearing a beard guard. He had facial hair approximately 10 inches around his chin. Interview on 12/16/2025 at 9:18 AM, Dietary Manager stated he was not wearing a beard guard. He stated there was a potential hair may fall from his face onto the food prep table or any clean dishes. He stated if there was hair on the food preparation table there was a potential hair may transfer to a resident plate of food. He stated he had gone through training about wearing hair nets and beard guards. Dietary Manager stated hair was considered contaminated and he was expected to wear a beard guard when in the kitchen. He did not recall the date of the training. Dietary Manager stated the Dietary Aide A was expected to wear hair net over his ponytail. He stated Dietary Aide A was allowed to wear a baseball cap; however, all of his hair was expected to be covered. He stated a resident may become physically ill with stomach issues such as nausea or vomiting if dietary staff did not wear a beard guard or hair net in the kitchen and hair fell on food or dishes. Dietary Manager stated he was responsible for monitoring the dietary staff and all aspects of the kitchen. Observation on 12/17/2025 at 10:40 AM Dietary Aide A was walking to the dishwashing room to obtain a clear container from a shelf. He touched right side of his shirt with his middle, ring and forefinger on his right hand when he was exiting the dishwashing room and entering the kitchen area. Dietary Aide A also touched the right side of his pants with all fingers on his right hand when he placed the clear container on the food prep table. Dietary Aide moved from on food prep table to another food prep table and obtained a large can of apple jelly. He placed this large can of apple jelly beside the clear container. Dietary Aide A obtained gloves and used his fingers on his right hand and touched the fourchettes on the left and right glove as he pulled the gloves from the glove box. He donned the gloves on both hands and did not sanitize or wash his hands. Dietary Aide A returned to the food preparation table and began placing apple jelly in plastic small souffle cups. His middle finger and forefinger on his right hand touched inside 3 of the cups as he was placing the apple jelling into the cups. Interview on 12/17/2025 at 10:50 AM Dietary Aide A stated he did not sanitize or wash his hands as he touched the gloves and placed the gloves on his hands. He stated he did touch his shirt and probably touched his pants. Dietary Aide stated clothes were considered contaminated. He stated his fingers on his right hand did touch inside the cups as he poured the apple jelly into the cups. He stated the apple jelly and cups was considered contaminated. Dietary Aide A stated he would discard the contaminated jelly. Dietary Aide A stated if a resident ate the jelly there was a possibility a resident may become ill with some type of stomach issues such as diarrhea from the apple jelly being contaminated. He stated he was expected to wash his hands prior to placing gloves on his hands. He stated the gloves was contaminated. Dietary Aide A stated he had been in-service on hand hygiene but did not recall the date of the in-service. He stated he learned during the in-service to always wash his hands prior to placing gloves on his hands, in between tasks and if he touched anything considered contaminated. Interview on 12/18/2025 at 10:15 AM Dietary Manager stated all staff was expected to wash their hands when they enter the kitchen. He stated all dietary staff was expected to wash their hands when they change tasks, touch anything considered contaminated, and prior to donning gloves. He stated Dietary Aide A did not follow the facility protocol of hand hygiene. He stated the Dietary Aide A was expected to wash hands after touching his shirt and pants. Dietary Manager stated Dietary Aide A did contaminate the apple jelly in the cups. He stated the few cups he touched with his contaminated gloves was discarded. Dietary Manager stated he had in-service staff on hand hygiene, and he did not recall the date or time. He stated he was responsible for overseeing all aspects of the kitchen and the dietary staff. Interview on 12/18/2025 at 11:15 AM The Administrator stated all dietary staff was expected to wear a beard guard and hair net when in the kitchen. She stated there was a potential hair that may fall into food or onto clean plates. The Administrator stated if hair was in residents' food or on a plate served to a resident, there was a potential that the resident may ingest the hair and according to what type of bacteria was on the hair a resident may become ill with some type of foodborne illness such as vomiting or diarrhea. She stated all staff was to wash hands prior to donning gloves. The Administrator stated clothes was considered contaminated and dietary staff was expected to wash hands prior to touching anything contaminated. She stated the Dietary Manger was responsible for overseeing the dietary department and she was responsible for supervising the Dietary Manager. Review of Facility's Inservice on hand hygiene, dated 12/06/2025, reflected the Infection Control Policy was reviewed with staff and Dietary Aide A was in attendance and the Dietary Manager was the instructor of the in-service. Requested Facility's Inservice on 12/18/2025 at 10:15 AM from the Dietary Manager and this was not provided at time of exit. Review of Facility's Infection Control Policy for Dietary Staff, dated 2012, reflected We will ensure that all employees practice infection control in the Food and Nutrition Services Department, and maintain sanitary food preparation. All dietary service employees will follow infection control policies as established and approved by the Infection Control committee.Procedure:1. Clean hair is required. It is to be covered with an effective hair restraint. Facial hair is to be closely trimmed and is to be covered with a hair restraint.2. Careful hand washing by personnel will be done in the following situations:a. Prior to entering the work area and reporting to the workstation.b. Between handling dirty dishes, boxes or equipment and handling clean food or utensils.c. Between handling of cooked and uncooked food.d. After each instance of coughing, sneezing, touching face and/or hair. Review of the Facility's Protocol for Hand Hygiene is from the Texas Food Establishment Rules, not dated, reflected S228.38. Hands and Arms.(a) Clean Condition. Food employees shall keep their hands and exposed portions oftheir arms clean.(b) Cleaning Procedure.(1) except as specified in subsection (d) of this section, food employees shallclean their hands and exposed portions of their arms, including surrogate prosthetic devices forhands or arms for at least 20 seconds, using a cleaning compound in a handwashing sink that isequipped as specified under S228.146 and S228.175.(2) food employees shall use the following cleaning procedure in the order statedto clean their hands and exposed portions of their arms, including surrogate prosthetic devicesfor hands and arms:(A) rinse under clean, running warm water.(B) apply an amount of cleaning compound recommended by the cleaningcompound manufacturer.(C) rub together vigorously for at least 10 to 15 seconds while:(i) paying particular attention to removing soil from underneath thefingernails during the cleaning procedure,and(ii) creating friction on the surfaces of the hands and arms orsurrogate prosthetic devices for hands and arms, fingertips, and areas between the fingers.(D) thoroughly rinse under clean, running warm water.and(E) immediately follow the cleaning procedure with thorough drying usinga method as specified under S228.175(c). S228.38 (b)(3) S228.38 (d)(9)(3) to avoid re-contaminating their hands or surrogate prosthetic devices, foodemployees may use disposable paper towels or similar clean barriers when touching surfacessuch as manually operated faucet handles on a handwashing sink or the handle of a restroomdoor.(4) if approved and capable of removing the types of soils encountered in the foodoperations involved, an automatic handwashing facility may be used by food employees to cleantheir hands or surrogate prosthetic devices.(c) Special Handwash Procedures. Employees not utilizing suitable utensils or single usegloves when handling ready-to-eat foods shall wash hands using the cleaning proceduresspecified in subsection (b)(2) of this section and follow the approved procedures specified inS228.65(a)(5) of this title.(d) When to Wash. Food employees shall clean their hands and exposed portions of theirarms as specified under subsection (b) immediately before engaging in food preparationincluding working with exposed food, clean equipment and utensils, and unwrapped single serviceand single-use articlesand:(1) after touching bare human body parts other than clean hands and clean,exposed portions of arms.(2) after using the toilet room.(3) after caring for or handling service animals or aquatic animals as specified inS228.44(2);(4) except as specified in S228.42(b) after coughing, sneezing, using ahandkerchief or disposable tissue, using tobacco, eating, or drinking.(5) after handling soiled equipment or utensils.(6) during food preparation, as often as necessary to remove soil andcontamination and to prevent cross contamination when changing tasks.(7) when switching between working with raw food and working with ready-to-eatfood.(8) before donning gloves to initiate a task that involves working with food.and(9) after engaging in other activities that contaminate the hands.

Based on interviews and record reviews, the facility failed to consider the views of the resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility or to demonstrate their response and rationale for such response for 1 of 1 resident council reviewed.The facility failed to follow up on concerns and requests expressed in resident council meetings from July 2025 through November 2025. This failure placed residents at risk of not having their preferences honored.Review of Resident Council minutes from 07/05/2025 to 12/09/2025 reflected the following Resident council grievances did not have a facility's responses: *7/05/ 2025 minutes reflected: Nursing review concerns: When getting showers, beds still not getting stripped. When answering call lights aides come & leave without helping, not putting call lights in reach.It was reported residents did not receive scheduled showers. Staff completed showers at their convenience, and residents had to ask for showers. Fresh water not provided regularly, maybe once a day Snacks are still not provided. Beds are being left unmade, preventing taking naps & getting rest. Residents are making own beds.Staff have been observed using personal cell phones while on duty, while seated behind the nurses station and while feeding residents. Nutrition Services review concerns: Are you receiving the correct meal ordered? Hardly ever matches the main menu. Meal tickets are still coming out blank. Residents are not getting the meal of the month. Maintenance *8/12/2025 minutes reflected: Nursing review concerns: Disinfect between showersStaff observed on their personal cell phones while working. Nutrition Services review concerns:Meals have not been served on time and have been cold.Meal portions are too small. *9/9/2025 minutes reflected: Nursing review concerns: Residents from St one voiced concerns of shower chairs and showers being disinfected after showers.Scheduled showers not received for ST one residents.Fresh water was only received once in the morning, not refreshed throughout the day. Making their own beds, bed sheets not being changed.Evening snacks not being received on hall ST one. Nutrition Services review concerns: Coffee machine running out and would like coffee after hours. Cleaning in the dining room while they are still eating. Maintenance:Showers on the 400 hall did not have hot water; and a resident said it was high priority. *10/14/2025 minutes reflected: Nursing review concerns: Evening snacks not received, we must A solution. Beds are still not being made. Nutrition Services review concerns:Once or twice a week, the meal has not matched the menu.Did not receive meal of the month; the dietary manager stopped listening to them. *11/14/2025 minutes reflected: Nursing review concerns: Take time to dry residents' hair and do hair. Aides wearing ear buds around residents and talking their personal business in their presence. Not cleaning showers between residents. Maintenance: Sinks on 300 water don't get hot *12/09/2025 minutes reflected: Nursing review concerns: No one is rounding every 2 hours. Some aides are not residents for showers. Not giving fresh water. During a confidential group interview meeting on 12/17/2025 at 2:00 PM, 6 anonymous residents stated the AD helps to document the minutes for each monthly Resident Council meeting. They all stated when there is a concern, they address it in the Resident Council meeting monthly, but the concerns are not being addressed. They all stated they were not aware of any method by which the facility management provided resolutions to the concerns that came up in the resident council minutes. They all stated most of the complaints were about the menu, staff on cell phones, bed linen changes, and the maintenance of the showers. They stated they have discussed the meal of the month in several monthly meetings. They all stated that they discuss their resident rights during meetings, but feel they are not being taken seriously. They stated they had never seen any kind of written paper or grievance form that reflected their concerns and requests during resident council or explained any resolution. Some stated their concerns appear to be ignored. In an interview conducted 12/18/2025 at 10:09 AM, the ADM stated she and the Social Worker were the Grievance Officials for the facility. In an interview conducted 12/18/2025 at 1:11 PM, the AD stated she has worked at the facility for three years. She reported that designated residents take their own minutes during Resident Council meetings, while she maintained the official set of minutes. She stated that she takes the residents' concerns and complaints to each department head and communicates this information, typically the morning after the meeting. She explained that some departments conduct in-services and notify her that they have done so; however, they do not provide her with copies of the in-service documentation. The AD stated that information was relayed back to residents once departments provide updates to her, and she communicated this information at the next Resident Council meeting. She also reported that she has personally invited department heads to attend meetings to speak directly with residents. The AD stated that department heads request the concerns and complaints from Resident Council meetings and then take responsibility for correcting them. The AD said she never filled out a grievance sheet and she said she was not aware she needed to fill out a grievance sheet. The AD stated that approximately two months ago, the Administrator informed her that some items documented in the meeting minutes may constitute grievances and asked how those grievances were being handled and whether they were forwarded to the Social Worker. The AD stated she informed the Administrator that she had not been trained to identify or process concerns as grievances and had been told that Resident Council meetings were residents' private meetings and that concerns were to be shared with department heads. The AD stated she provided copies of the Resident Council minutes to the Social Worker. The Activity Director stated that when residents do not see their concerns addressed, it may cause them to feel unimportant, not cared for, or that their needs are not being met, or prioritized. She stated this may result in residents feeling more tense and angry. In an interview conducted 12/18/2025 at 2:02 PM, SW stated she has been employed at the facility for three years, as of December. She stated she was the designated contact for grievances. She reported that concerns and complaints from Resident Council meetings are forwarded to the Administrator. She stated she does not resolve those concerns. The Social Worker stated that minutes from Resident Council meetings are not provided to her and that she has never resolved any issues originating from Resident Council meetings. She stated that the potential impact on residents who do not feel their voices are heard may be upsetting and may cause them to feel as though they do not have a voice. She stated that some residents may withdraw, feel defeated, and choose not to speak up again, which defeats the purpose of the Resident Council process. The Social Worker stated that the previous Administrator handled concerns from Resident Council meetings. In an interview conducted 12/18/2025 at 2:12 PM, ADM stated she was the facility's designated grievance official, along with the Social Worker. She stated that copies of Resident Council meeting concerns are provided to all department heads and that each department was responsible for their area. The ADM stated she had just become aware that the Social Worker was not receiving copies of the Resident Council meeting notes. She stated this process would be corrected. The Administrator further stated that documentation of Resident Council meetings would be made more specific. The ADM stated she expected immediate communication from the AD regarding concerns or complaints raised during Resident Council meetings so the concerns can be addressed through the interdisciplinary team process. She stated that some concerns raised during Resident Council meetings constitute valid complaints. The ADM stated the potential harm was that residents may feel their concerns are not as important to facility staff as they are to the residents. She further stated that corrective training would be provided regarding the process of addressing Resident Council concerns. Review of the facility grievances dated 7/08/2025-11/25/2025 did not reflect any of the concerns/complaints mentioned in Resident Council. Review of facility policy on 12/18/2025, titled Resident Advisory Council reflected the following: 8.The health care center listens and seriously attempts, to the extent practicable, to accommodate all Resident Advisory Council recommendations and respond to the Resident Advisory Council in writing of facility action taken. 10. Minutes of Resident Advisory Council meetings are: A. Written to maintain as much confidentiality as possible. B. Reflect feedback/ response of the facility to concerns or recommendations. Review of facility policy on 12/18/2025 titled Resident Rights reflected the following: The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this policy.Self-determination- The resident has the right to, and the facility must promote and facilitate resident self-determination throughsupport of resident choice.5. The resident has a right to organize and participate in resident groups in the facility. c. The facility must provide a designated staff person who is approved by the resident or family group and the facility and who is responsible for providing assistance and responding to written requests that result from group meetings. d. The facility must consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility.i. The facility must be able to demonstrate their response and rationale for such response.

Based on interview and record review the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete and accurately documented for 1 of 5 residents (Resident #1) for complete and accurate records. The facility failed to ensure Resident #1's weight was documented in PCC for July 2025. This failure could place residents at risk for the possibility of not verifying the needed care and services to meet their needs. Findings include:A record review of Resident #1's face sheet, dated 07/26/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1's had diagnoses which included unspecified dementia (memory loss), major depressive disorder (sadness), diabetes (too much sugar in the blood) and hypertension (high blood pressure) A record review of Resident #1's Quarterly MDS assessment, dated 06/23/2025, reflected the resident had a BIMS score of 8, which indicated moderate cognitive impairment. A record review of Resident #1's weight in PCC for July 2025 did not reflect a weight for Resident #1. During an interview with the ADON on 07/28/2025 at 3:48 PM, the ADON stated she was responsible for placing and making sure Resident #1's weight, taken on 07/08/2025, was documented in PCC. The ADON stated Resident #1's weight was 148 pounds, and she failed to enter it in PCC and when she realized Resident # 1's weight did not get entered was when Resident #1 discharged on 07/19/2025. The ADON states she knew how important it was to document the weights in PCC and without the weights documented, the system would not be able to flag any weight loss or gains.During an interview with the DON on 07/28/2025 at 4:12 PM, the DON stated it was expected for the ADON to document Resident #1's July weight by 07/10/2025. The DON stated if it was not documented it did not happen. The DON stated if the weight was not documented in the system, it would not trigger weight loss or gain to identify if interventions needed to be set in place.During an interview with the ADM on 07/28/2025 at 4:28 PM, the ADM stated it was expected for the ADON to have documented Resident #1's weight in PCC by 07/10/2025. The ADM stated it was important for the July 2025 weight to be entered to make sure there was not any weight loss or gains. The ADM stated when weights were not documented in PCC, staff would not be able to identify weight loss or gain to be able to put an intervention in place Record review of the facility's, undated, policy titled documentation reflected Documentation is the recording of all information, both objective and subjective, in the clinical record of an individual resident and or soft resident file. It may include observations, investigations, and communications of the resident involving care and treatments. It has legal requirements regarding accuracy and completeness legibility and timing. Special forms on the clinical record are utilized in nursing documentation, such as assessment, care plan, nursing progress notes, flow sheets, medication sheets, incident reports, and summary sheets (daily, weekly, monthly, discharge). Documentation also occurs in the clinical software Point Click Care (PCC). All documentation and clinical records are confidential and can be released with signed permission of the resident legal representative.

Based on interview and record review, the resident has the right to be informed of, and participate in, his or her treatment including the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers for 1 of 5 (Resident #1) reviewed for resident rights. The facility failed to ensure Resident #1 was sent out to the hospital when Resident #1 complained of pain in her lower back on 07/17/2025. This failure could place residents at risk of their rights to have their medical needs met . Findings include:A record review of Resident #1's face sheet, dated 07/26/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1's diagnoses which included unspecified dementia (memory loss), major depressive disorder (sadness), diabetes (too much sugar in the blood) and hypertension (high blood pressure). A record review of Resident #1's Quarterly MDS assessment, dated 06/23/2025, reflected the resident had a BIMS score of 8, which indicated moderate cognitive impairment. A record review of Resident #1's progress note, dated 07/17/2025 written by LVN A at 10:39 AM, reflected Patient c/o increased pain to her lower back. UA was obtained early this AM and sent to the lab R/T malodorous (smelling very unpleasant) urine. Patient lower pubic area is distended and firm to palpitation. IN and OUT cath performed using sterile supplies and sterile technique. Once urine returned a small amount of blood returned an no more urine noted. Bladder appears to be having spasms during procedure. Cath. Removed and MD was contacted. Patient stated that she wants to go to ER at this time. She remains Afebrile (free from fever) and has received PRN medications for pain. MD gave verbal order for Rocephin 1GM now, and he will come visit patient and check bladder for retention. LVN A, charge nurse contacted RP for patient. She is aware of plan of care at this time and agrees. Care ongoing. During an interview with Resident #1's RP on 07/26/2025 at 10:35 AM, the RP stated LVN A did not send Resident # 1 to the hospital on [DATE], when Resident # 1 requested to go to the hospital when she had experienced pain in the lower back. Resident #1's RP stated LVN A did collect a sample of urine and Resident #1 received pain medication, but the LVN A should had sent Resident #1 out to the hospital when she requested to go. The RP stated when LVN A did not send Resident #1 out to the hospital per her request her medical needs would not have been addressed. The RP stated Resident #1 was no longer at the facility as she transferred her to another facility on 07/22/2025. During an interview with LVN A on 07/26/2025 at 1:27 PM, LVN A stated on 07/17/2025, can't recall the time around 11:00 AM to 12:00 PM, she went in to check on Resident # 1 and she told her that her lower back was hurting, and she wanted to go to the hospital. LVN A asked Resident #1 if she could help her with anything before sending her out and she said okay and she was fine. LVN A stated she assessed Resident #1 and she did not fail to send Resident #1 out to the hospital because she wanted to see what she could do before Resident # 1 would be sent out. LVN A stated she knew it was expected to send Resident #1 out per her request, but she assessed Resident # 1 and also had contacted Resident # 1's RP. LVN A stated not sending Resident #1 out when she requested, Resident #1's medical needs may have not been met. During an interview with the DON on 07/28/2025 at 4:12 PM, the DON stated it was expected for LVN A to send Resident #1 to the hospital per her request. The DON stated when residents were not sent out to the hospital when they requested their medical need would not have been met. During an interview with the ADM on 07/28/2025 at 4:28 PM, the ADM stated it was expected for LVN A to have sent Resident #1 when she requested to be sent out to the hospital on [DATE] when she experienced lower back pain. The ADM stated if Resident #1 was not sent out when she requested her needs would not have been met. Record review of facility's policy titled Resident Rights, dated 11/28/2016, reflected The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility.

Based on observation, interview, and record review, the facility failed to ensure all allegations of abuse are reported immediately, but not later than 2 hours after the allegation is made, to the Administrator of the facility and to HHSC for one (Resident #4) of five residents reviewed for abuse. The facility staff failed to immediately report an allegation of abuse to the Administrator and to HHSC as required when Resident #4 was struck in the face by Resident #3 on 08/20/2024 at 8:30 p.m This failure could place residents at risk for unreported allegations of abuse. Findings included: Record review of the facility EHR reflected nurses note dated 08/20/24 at 8:30p.m. stated that Resident #3 struck Resident #4 in the face at 8:30 p.m. on 08/20/24. The facility staff was present in the area and intervened. The residents were separated and assessed for injuries. Resident #3 was placed on 1:1 supervision by staff. Resident #4 was monitored as part of the assessment. The facility Administrator was not made aware of the incident until a 6:45 a.m. on 08/21/2024. The report was made at that time. Record review of Resident #3 MDS record reflected a current BIMS score of 5, indicating severe impairment, and the following partial diagnosis Unspecified Dementia, Major Depressive Disorder, Alzheimer's Disease and Bipolar Disorder. Record review of resident #4 MDS record reflected a current BIMS of 0 indicating severe impairment and partial diagnosis including Cerebral Infarction, Depression, Adjustment Disorder, and Aphasia. Interview with Resident#3 09/24/2024 at 1:30 p.m. Resident observed in bed eyes open, no marks or bruises were observed. Resident did not respond to questions. Interview with Resident #4 on 09/24/2024 at 2:30 p.m. Resident #4 was observed sitting in the common area where the incident occurred. Resident #4 was sitting in a wheelchair watching television. Resident #4 acknowledged the surveyor's presence but did not speak when spoken to. Resident #4 motioned for the surveyor to come closer but did not speak in an understandable manner. Resident#4 was observed with no visible marks or bruising. In an interview with RN A on 09/24/24 at 3:15 p.m. RN A stated she is aware of the incident involving Resident #4. She stated it happened on the other side of the building. RN A stated that she had provided care for Resident #3 before. Resident #3 was known to be aggressive with staff, but RN A stated she is unaware of any issues with other residents. RN A stated that they had to complete an in-service regarding reporting incidents to Administrator who is the Abuse Coordinator. She stated that all incidents of abuse or neglect must be reported immediately to the Administrator. She stated that residents could be negatively impacted by abuse and neglect. Injuries may be unnoticed or the abuse or neglect it could continue to happen. In an interview on 9/24/2024 at 3:40 p.m. with CNA C. CNA C stated that Resident #3 was resistive to care and at times could be aggressive to staff. She would come after staff in her wheelchair. CNA C stated she had never observed Resident #3 being aggressive with the other residents. She stated that neither of residents seemed to be bothered or upset by the incident. She stated that she completed the in-service for reporting abuse to the Administrator. In an interview with LVN B on 09/25/2024 at 11:25 am. LVN B stated that she primarily cares for Resident #1 she stated that she has no issues with her behaviors as she will just spend a little more time with her. She stated that there were no previous issues with Resident #3 and Resident #4. She stated that after the incident they had in-service for Abuse Neglect, Reporting and Residents Rights. She stated that staff must inform the Administrator of any suspected abuse immediately and she must report it to the State. She stated that they must protect the residents from any abuse or neglect whether it be staff, other residents or outside family or others. In an interview on 9/25/2024 at 3:25 with the DON. The DON stated that the Administrator found out about the incident when she was reviewing the overnight reports. She stated that the Administrator reported the incident to the HHSC desk immediately on 08/21/2024 at 6:45 a.m. She stated after the report was made, they spoke to the staff involved the ADON and LVN D about reporting and they found that LVN D did not call either of them. She then told them she informed the ADON. She stated that they conferenced both the ADON and LVN D. She stated at that point they in-serviced the whole building on when to report incidents of abuse and neglect to, that being both the DON and the Administrator. She stated that she conducted the in-service for staff on abuse, neglect and resident rights, the Administrator completed the in-service for reporting abuse neglect. Record review of the provider investigation dated 08/29/2024 reflected that LVN D stated that she did inform the Administrator, DON, and ADON. Both LVN D and ADON were provided with 1 on 1 in-service with the self-reporting protocol. Review of in-service records reflected that all staff completed the resident's rights in-service conducted by the Administrator on 08/21/2024. The abuse and neglect in-service were conducted by DON and completed by all staff on 08/21/2024. The self-reporting protocol/Ad Hoc QAPI resident to resident physical aggression in-service was conducted by the Administrator and completed by all staff on 08/21/2024.

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 (Residents #1) of 3 residents reviewed for infection control in that: 1. CNA A failed to change their soiled gloves and wash hands during incontinent care for Resident #1. These failures could place residents at-risk of cross contamination which could result in infections or illness. Findings included: Review of Resident #1's EHR on 09/24/24 revealed the resident was a [AGE] year-old female that was admitted to the facility on [DATE] with diagnoses including Polyarthritis (arthritis that affects all joints),and mixed incontinence (both urine and bowel incontinence). Review of Resident #1's quarterly MDS assessment, dated 7/02/24, reflected a BIMS score of 9, indicating the resident was moderately impaired cognitively, and able to make decisions. Her functional status indicated she needed two staff to complete her activities of daily living, to include incontinent of bowel and bladder. Observation on 04/24/24 at 11:44 a.m., revealed CNA A and NA B donned clean gloves. CNA A, with the help of NA B, positioned Resident #1 on her back. CNA A unfastened the resident's brief tabs and wiped the pubic area with a disposable wipe, discarded the wipe, then she wiped the folds of the groin inguinal (abdomen) area using wipes. CNA A, with assistance of NA B, repositioned Resident #1 on her left side and cleaned her buttocks area, which was soiled with urine, then removed the brief and placed it in a trash bag. CNA A placed a clean brief on Resident #1 and fastened it. CNA A continued with care for Resident #1 without discarding her soiled gloves. She pulled the resident's dress down and pulled the cover up over the resident. CNA A and NA B then removed their dirty gloves disposing of them in the trash bag, leaving the room after washing their hands. Interview on 09/24/24 at 12:00 p.m., CNA A stated she never changed her gloves between dirty and clean, while performing incontinent care on Resident #1. CNA A stated she just washed her hands before and after care. NA B stated she was being trained and she did touch the resident only to repositioned her, but she knew to change gloves and wash her hands but did not say anything to CNA A. CNA A and NA B stated by not changing their gloves and sanitizing their hands they could spread germs to other residents. Interview on 09/25/24 at 10:45 a.m., the DON stated that her expectation was that staff would sanitize their hands prior to putting on and after taking off gloves. She stated the staff should be changing their gloves when they go from dirty to clean and sanitizing in between. If the staff changes gloves multiple times, they must sanitize their hands with soap and water or hand gel between each time. The DON stated she thought she would have to do some further training. Review of facility's Policies and Procedure titled: Perineal Care, dated May 2022, reflected the following: .The purpose: aims to maintain the resident's dignity and self-worth and reduce embarrassment by providing cleanliness and comfort to the resident, preventing infections and skin irritation, and observing the resident's skin condition . procedure content: .10) perform .hand hygiene, 11) [NAME] gloves, instructions on performing incontinent care provided .24) doff gloves, 25) perform hand hygiene, placing on new gloves if necessary, 26) provide resident comfort and safety by reclothing . straightening bedding, adjusting the bed . important points: doffing and discarding of gloves are required if visible soiled, always perform hand hygiene before and after glove use

Based on observation, interview, and record review, the facility failed to ensure residents were free from physical restraints, not required to treat the resident's symptoms, for 1 of 9 residents (Resident #1) reviewed for physical restraints. The facility failed to ensure RP #2 was educated on physical restraint policy and refrained from having tied Resident #1's right hand/wrist to her bed's assist bar with a blanket. This failure placed residents at risk of physical harm, psychosocial harm, and having their needs gone unmet. Findings included: Record review of Resident #1's AR, dated 8/14/2024, reflected an [AGE] year-old female admitted to the facility on [DATE]. She was diagnosed with Dementia (which was a disease that affected memory, thought, and interfered with daily life,) Cerebral infarction (which was a pathologic process that resulted in necrotic tissue in the brain, caused by disrupted oxygen and blood supply,) and Bullous Pemphigoid (which was a rare skin condition that caused blisters on the skin.) Record review of Resident #1's Quarterly MDS assessment, dated 7/19/2024 reflected Resident #1 had a BIMS Score of 8. A BIMS Score of 8 indicated Resident #1 had moderate cognitive impairment. Resident #1 used a wheelchair for ambulation; she was dependent upon staff for eating, oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/talking off shoes, and personal hygiene. Dependent meant the helper did all the effort. Resident did none of the effort to complete the activity; Or the assistance of 2 or more helpers was required for the resident to complete the activity. Resident #1 had a catheter and was frequently incontinent of bowel. Record review of Resident #1's CP reflected a focus area for potential/actual impairment to skin integrity, initiated on 5/01/2024 and revised on 8/5/2024, evidenced by self-inflicted scratches; revised focus area R/T diagnosis of Bullous Pemphigoid. The goal was to have no complications by the target date of 10/10/2024. The interventions for nursing staff were to administer treatments as ordered, initiated 5/17/2024; avoid scratching and keep hands and body parts from excessive moisture, keep fingernails short, initiated 5/17/2024; Educate resident and responsible parties of causative factors to prevent skin injury, initiated 5/1/2024; Follow facility protocols for treatments of injury, initiated 5/1/2024; Identify potential causative factors and eliminate where possible, initiated 5/1/2024; Keep skin dry and clean/use lotion on dry skin, initiated 5/1/2024. Resident #1's CP reflected a second focus area for skin integrity, initiated on 5/30/2024, evidenced by scratching skin and skin breaks. The goal was to have fewer episodes of scratching by target date of 10/10/2024. The interventions for nursing staff were to administer medications as ordered, initiated 5/30/2024; anticipate needs of resident, initiated 5/30/2024; Apply Geri-sleeves on both upper extremities, initiated 8/12/2024. Record review of Resident #1's Order Summary Report reflected an order for hydroxyzine; (1) .25 MG tablet by mouth every 6 hours for itching. The order was written on 7/9/2024 and started on 7/9/2024.The Order Summary Report reflected an order for prednisone; (7) 10 MG tablets given via peg tube one time a day R/T Bullous Pemphigoid. The order was written 8/5/2024 and started on 8/6/2024. Record review of Resident #1's July 2024 MAR, viewed in PCC, reflected Resident #1's medication list. The July 2024 MAR indicated Resident #1 received hydroxyzine; .25 MG tablet by mouth every 6 hours. The MAR reflected medication administration started on 7/9/2024 at 11:00 PM. The July 2024 MAR indicated administration of hydroxyzine .25 MG tablet by mouth every 6 hours through 7/31/2024 (continuous.) Record review of Resident #1's August 2024 MAR, viewed in PCC, reflected Resident #1's medication list. The August 2024 MAR indicated Resident #1 received hydroxyzine; .25 MG tablet by mouth every 6 hours. The MAR reflected medication administration continued from 8/1/2024 at 5:00 AM until 8/14/2024 (continuous.) The August 2024 MAR indicated administration of prednisone; (7) 10 MG tablets given via peg tube one time a day R/T Bullous Pemphigoid. The August 2024 MAR indicated Resident #1 received prednisone; (7) 10 MG tablets given via peg tube one time a day R/T Bullous Pemphigoid 1 time daily from 8/6/2024 until 8/14/2024 (continuous.) Record review of Resident #1's Admission Contract, signed and dated 3/25/2024, reflected Section 21. Rules on Restraints, Resident's Behavior, and Health Care Center Practice. The Admission Contract indicated: It was the policy of the facility to have maintained an environment that prohibited the use of restraints for discipline or convenience. Restraint usage would have been limited to circumstances in which the resident had medical symptoms that warranted the use of restraints. The restraint assessment committee would have evaluated and established the need for restraint use or restrain reduction for residents in the health care center. The health care center was committed to nurturing the autonomy and independence of the residents by having attempted to provide a restraint free environment. A physical restraint was defined as any manual restraint method, such as physical, mechanical, material, or the use of adjacent equipment, that the individual could not remove easily, which would have restricted a resident's freedom of movement, or normal access to one's body. The Admission Contract's Notice of Rights and Services, located in Section 21, indicated: the facility must have informed the resident, or the residents next of kin/guardian, both orally and in an understandable language the rights and rules governing resident conduct and responsibilities during the resident's stay at the facility. The facility's policy related to the use of restraints and involuntary seclusion must have also been given to the resident's legally authorized representative if the resident had one. Record review of a legal document, notarized on 4/10/2024, named RP #2 as Resident #1's Medical Power of Attorney. Record review of Resident #1's incident report dated 8/3/2024 at 8:35 PM; written by the ADON, reflected an unwitnessed event in the room of Resident #1 (201-B); resident not taken to hospital; no injuries observed. Record review of Resident #1's progress notes dated 8/3/2024 at 8:35 PM; written by LVN A, reflected an entry having indicated: Resident was found with her right hand tied to the grab bar after RP #2 had left for the night, reported it to the administrator. Hand was untied and assessed resident's wrist for any marks or bruising and none where found. Record review of a written statement by LVN B, dated 8/3/2024 at 7:30 PM, reflected LVN B ad LVN A entered Resident #1's room just after RP #2 left Resident #1's room. LVN A and LVN B discovered Resident #1's right hand had been tied to the bed's assist bar. The two LVN's immediately released Resident #1's hand/wrist and assessed for trauma. No marks were noted to her wrist. Resident #1 did not appear to be in any distress. Record review of a written statement by LVN A, dated 8/5/2024, reflected LVN A entered Resident #1's room (8/3/2024) with LVN B having discovered Resident #1's right hand had been tied to the bed's assist bar with a small blanket. LVN A released Resident #1's right hand. A visual inspection of Resident #1's right hand resulted with no visible trauma. LVN A reported the incident to the ADM. Record review of Resident #1's weekly skin assessment, dated 8/5/2024, reflected Resident #1's skin color was normal, no bruises, no skin tears, no abrasions, and no lacerations. There were no areas that had not been reported to the facility medical provider. Assessment performed by LVN F. Record review of a local police report, # 2400220, written on 8/14/2024 by Officer #3 reflected an incident, which occurred at the facility on 8/3/2024. The report indicated: On 08/05/2024 at approximately 3:30 PM, I, Officer #3 responded to a call at the Nursing and Rehab. When I arrived, I met with the ADM. The ADM stated that she was notified by a charge nurse, LVN A, that Resident #1 had her hand tied to the assist bar, by RP #2. The ADM stated LVN A reported having untied Resident #1 arms, bound by a blanket to the bed's mobility assist bar. The ADM stated LVN A reported no red marks, bruises, lacerations of any kind. The ADM stated that the facility staff had spoken with RP #2, and he explained he did not mean any harm, but was only trying to keep Resident #1 from scratching herself. Resident #1 had recently been diagnosed with an autoimmune skin condition, which caused severe itching. RP #2 did not know his actions were wrong and said he would never do it again. The ADM stated that she believed it was not a malicious intent. The ADM stated RP #2 was really good to Resident #1 and visited with her daily, and only wanted the best for her. Officer #3 went to Resident #1's room and looked at her arm. There were no signs of any bruising or any other marks. Resident #1's hand was in a sock when having arrived at her room. Record review of Resident #1's progress notes dated 8/5/2024 at 7:58 PM; written by the ADM, reflected an entry having indicated: The Administrator had a care plan with RP #2. The ADM discussed using restraints and explained that this was not allowed in the facility and was considered to be a form of abuse. RP #2 became very upset as he did not know and was very sorry, having explained all he tried to do was to keep Resident #1 from having scratched herself. RP #2 explained all he wanted was to take good care of Resident #1 and that he had devoted the last several years of his life doing that. Resident #1 had a new diagnosis of Bullous Pemphigoid, 7/23/2024, and it did cause her to scratch. The facility's MD had prescribed hydroxyzine. RP #2 was glad to hear this and promised he would never restrain Resident #1 again. Record review of Resident #1's progress notes dated 8/8/2024 at 4:57 PM; written by the SW, reflected an entry having indicated: The SW followed up with Resident #1 for the incident having regarded to RP #2 securing Resident #1's wrist to the bed rails to prevent Resident #1 from scratching herself. Resident #1 stated she was not in any distress from the incident or upset with RP #2. Resident #1 stated RP #2 had good intentions and tried his best to help her from scratching, which had caused her skin to bleed. Resident #1 stated RP #2 understood why he should not have tied her right hand/wrist to the bed side rail and that it was a mistake, an error. Resident #1 was calm, alert, and oriented to self, place, and time. Record review of a facility self-reported intake reflected an email, dated 8/5/2024. The email indicated [To Whom it May Concern, please find attached a late-self report on abuse that occurred on the evening of 8/3/2024. Attached were the following: Initial self-report, resident face sheet, witness statements, heat to toe assessment completed 8/5/2024. If you have any questions, please feel free to contact the ADM. Observation on 8/13/2024 at 10:15 AM of Resident #1 reflected the resident seated /reclined in her Geri-chair (a large wheelchair with a padded back/seat and leg stirrups) in the television area near the facility's nurse's station. Resident #1 was covered up to her torso with a white sheet, her head was supported with a horseshoe shaped pillow around her neck, and she did not appear to be in any distress. Resident #1 had her eyes closed and was non-responsive to verbal prompts. Interview on 8/14/2024 at 8:43 AM with RP #2 revealed he was at the facility the night of 8/3/2024 to see Resident #1. To keep Resident #1 from having scratched her skin, he stated he used the material from the softest material he could find, which was a blanket, and tied Resident #1's right hand/wrist to the support bar on the side of the bed. He stated he did not try to hide what he had done, and left the knotted blanket exposed for anyone who had entered the room to see. He did not know, at the time, that having tied Resident #1's hand/wrist to the support bar was a form of abuse through restraint. He stated he was seen by the ADM, a couple of days later, and learned that physical restraints were not allowed at the facility. He was only trying to help Resident #1 and promised he would never do it again. Observation and interview on 8/14/2024 at 9:55 AM of Resident #1 revealed the resident seated /reclined in her Geri-chair in the television area near the facility's nurse's station. Through verbal responses and facial features, Resident #1 affirmed that she was feeling ok and denied any pain. She recalled RP #2 tying her right arm to the bedside assist bar on 8/3/2024 but denied that it caused her any pain. The itching was just about the same. Resident was observed wearing Geri-gloves (which were mesh gloves worn to protect skin without having sacrificed comfort or mobility.) Phone interview on 8/14/2024 at 10:22 AM with Officer #3 revealed she was called out to the facility on [DATE] for an allegation described as RP #2 having allegedly tied Resident #1's right arm/wrist to the bed side support bar on 8/3/2024. When she arrived at the facility, the RP #2 was in the room. Officer #3 reported RP #2 told her he did not know he could not tie Resident #1's hand/wrist to the bed's support bar. RP #2 was only trying to have helped Resident #1. Officer #3 performed a visual inspection of Resident #1's right hand/wrist for injuries and did not observe any. Officer #3 stated that the local police department did not receive the call about the allegation, which occurred on 8/3/2024, until 8/5/2024. Interview on 8/14/2024 at 2:25 PM with the facility SW revealed the facility addressed the incident (allegation of abuse,) which occurred on 8/3/2024, with both Resident #1 and RP #2. The SW stated she had reviewed Resident #1's assessments and CP. The SW stated any future risk of abuse from RP #2 towards Resident #1 had been removed. Interview on 8/14/2024 at 2:35 PM with the ADON revealed staff was trained to report allegations, or suspicions, of abuse immediately to the abuse coordinator, who was the ADM. Some examples of abuse were described as physical, such as hitting residents and being too rough. Some examples of abuse were described as verbal/emotional such calling resident names or cursing them. Staff was trained the facility had a no restraint policy. Some examples of restraint were described as chemical, such as medications. Some examples of restraint were described as physical, such as blocking a resident in bed or a chair, tying one up, or holding one down. Family members, responsible parties, or authorized representatives were held to the same standard of restraints and abuse, and any observations, or suspicions, were to be reported to the abuse coordinator immediately. Interview on 8/14/2024 at 2:45 with NA C revealed she had been trained on restraints and abuse. Any observations, or suspicions, were supposed to be reported to the abuse coordinator, who was the ADM, immediately. Some examples of abuse were described as physical, such as slapping, pulling, holding down, or being rough with a resident. Some examples of abuse were described as emotional/verbal, such as telling a resident to shut up or calling them names. Restraints were not allowed at the facility. Some examples of restraints were described as belting a client in a chair or tying one up in their bed. Staff had been trained that resident's significant others could be abusive towards residents and instances of suspected abuse, or the use of restraints, was supposed to be reported to the abuse coordinator immediately. Interview on 8/14/2024 at 3:04 PM with LVN D revealed she had been trained on abuse, neglect, exploitation, and the use of restraints. Some examples of abuse were described as physical, such as hitting, pushing, and pinching a resident. Some examples of abuse were described as emotional/verbal, such as name calling, putting down, or being made to feel bad. The facility was a no restraint facility. It was not ok for staff, or guests, to restrain residents. Some restraints were described as physical, such as tying a resident to a bed, or inhibiting their natural body movements; Some examples of restraints were described as chemical, such as overmedication for a resident to make a staff's job easier. Allegations of abuse and restraints, or suspicions of, were supposed to be reported to the abuse coordinator, who was the ADM, immediately. Interview on 8/14/2024 at 3:10 with CNA E revealed she had recently received training on abuse, restraints, and resident's rights recently. She stated she was trained to report allegations, or suspicions, or abuse to the abuse coordinator, who was the ADM. Some examples of abuse were described as physical, such as jerking a resident during a transfer or being rough while having provided care. Some examples of abuse were described as emotional/verbal, such as name calling, yelling, venting frustrations, or having dismissed a resident's feelings. The facility was restraint free. Some examples of restraints were described as forcing a resident to wear gloves, raising full bed rails, and locking chair belts. Family members, and guests, were not allowed to be abusive, or to restrain residents, so allegations or suspicions of family member abuse or restraints were supposed to be reported to the ADM immediately. Interview on 8/14/2024 at 3:30 PM with the DON revealed staff was trained to identify and report instances, allegations, or suspicions of abuse to the abuse coordinator, who was the ADM, immediately. Some examples of abuse were described as physical, such as gripping resident's too hard, dropping residents during a transfer, hitting, or slapping, a resident. Some examples of abuse were described as emotional/verbal, such as lashing out at a resident, making a resident cry, having called them names, or having used derogatory remarks. The facility was a restraint free facility. Some examples of restraints were physical, such as having tightly tucked residents in their sheets, having tied them to a bed rail, or having had restricted their body movements. Some examples of restraints were described as chemical, such as having purposefully medicated a resident to make staff's jobs easier. Any allegations or suspicions, such as abuse or the use of a restraints, were supposed to be reported to the ADM immediately. The DON stated she had reviewed Resident #1's CP, and assessments, and the risk of abuse by RP #2 towards Resident #1 had been removed. RP #2 had been educated that restraints were not allowed. Resident #1 had received new medications for her itching, has had her fingernails continually trimmed short, and had been provided Geri-gloves for her upper extremities to help protect her exposed skin. The DON stated a measure in place to inform residents, and family members, about the use of restraints was in the admissions packet. Residents who were placed in the situation to have been restrained against their will risked psychosocial harm, physical injuries, or the development of distrust and fearfulness of staff. Interview on 8/14/2024 at 3:39 PM with the ADM revealed her staff was trained to recognize instances of abuse and expected her staff to report allegations, or suspicions, of abuse, to her immediately. As well, the ADM stated her staff was trained on the facility's policy on restraints and expected her staff to report allegations of resident restraint, or suspicions, to her immediately. The facility's Admission Contract, which discussed the facility's no restraint policy, was signed by Resident #1 on 3/25/2024. The Admission Contract was a failsafe in place for residents, and significant others, to learn that restraints were not allowed at the facility; however, Resident #1 had was her own responsible party at the time of admittance but had chosen a significant other, RP #2, to become their Medical Power of Attorney on 4/10/2024. The ADM was not aware, and could not state with certainty, if the facility forwarded RP #2 a copy of Resident #1's Admission Agreement, which discussed the facility's no restraint policy. Residents who were abused in the form of having been restrained, were placed at risk of physical harm, such as injuries, and psychosocial harm, such as trauma related emotions. The reporting time for allegations of abuse, per the facility's Abuse and Neglect policy, indicated the allegation of abuse was supposed to have been reported to Health and Human Services within 2 hours of the report; however, the ADM did not report the allegation of abuse, which was initially reported to her by staff on 8/3/2024 at 8:35 PM, through the reporting website until 8/5/2024 at 3:11 PM. The ADM did not try to rationalize why the report was made late and acknowledged she was not in compliance and had no excuse. Record review of the ADM's one-on-one in-service, dated 8/5/2024, addressed the Long-Term Care Regulatory Provider Letter, PL 19-17, titled: Abuse, Neglect, Exploitation, Misappropriation of Resident Property and Other incident that a Nursing Facility Must Report to the Health and Human Services Commission; Provider types: Nursing Facilities; Date Issued: 7/10/2019. The provider letter indicated abuse, with or without serious bodily injury, was supposed to be reported immediately, but not less than two hours after the incident occurred or was suspected. The instructor was RRN. Record review of the facility's in-service, dated 8/5/2024, addressed the facility's Abuse and Neglect Policy, dated 11/15/2016. The policy indicated that facility employees must report all allegations of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury on unknown source to the facility administrator. The facility administrator or designee will report the allegation to HHSC. If the allegations involved abuse, or resulted in serious bodily injury, the report was to have been made within 2 hours of the allegation. If the allegation did not involve abuse or serious bodily injury, the report must have been made within 24 hours. The in-service recorded 40 staff members in attendance. Record review of the facility in-service, dated 8/5/2024, addressed the importance of timely reporting (undated document.) The document indicated to please ensure that you were reporting any suspected or confirmed incidents, abuse/neglect, misappropriation of funds of anything that you are unsure that could be of harm to any resident immediately to your charge nurse. These events were very sensitive events and needed to be immediately investigated and reported to Texas HHSC. The in-service recorded 40 staff members in attendance. Record review of the facility's in-service, dated 8/5/2024, addressed the facility's Resident Rights Policy, dated 2003. The policy indicated each resident was free from mental and physical abuse and free from chemical and physical restraint except when authorized in writing by a physician for a specified and limited period of time, or when necessary, in an emergency to protect the patient from injury to themselves or others. The in-service recorded 39 staff members in attendance. Record review of the facility's in-service, dated 8/5/2024, addressed the facility's Restraint Policy, dated 2/1/2007. The policy indicated the facility was supposed to have maintained an environment that prohibited the use of restraints for discipline or convenience. Restraint usage would have been limited to circumstances in which the resident had medical symptoms that warranted the use of restraints. The restraint assessment committee would have evaluated and established the need for restraint use or had used restrain reduction for residents in the health care center. The health care center was committed to have nurtured the autonomy and independence of the residents by having attempted to provide a restraint free environment. A physical restraint was defined as any manual restraint method, such as physical, mechanical, material, or the use of adjacent equipment, that the individual could not remove easily, which would have restricted a resident's freedom of movement or normal access to one's body. Physical restraints included, but were not limited to, leg restraints, arm restraints, hand mitts, soft ties or vests, wheelchair safety bars, Geri-chairs, lap cushions, and trays that the resident could not move. Restraints would only be used with informed consent from the resident, and or, the resident's representative/ responsible party and the resident's physician. The in-service recorded 40 staff members in attendance.

Based on observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, for 1 of 9 residents (Resident #1) reviewed for reporting abuse allegations. The facility failed to report an incident involving the use of a restraint on Resident #1 by RP #2, that occurred on 8/3/2024 at 8:35 PM, until 8/5/2024 to Health and Human Service. This failure placed residents at risk of physical harm, psychosocial harm, lack of regulatory oversite, and having their needs gone unmet. Findings included: Record review of Resident #1's AR, dated 8/14/2024, reflected an [AGE] year-old female admitted to the facility on [DATE]. She was diagnosed with Dementia (which was a disease that affected memory, thought, and interfered with daily life,) Cerebral infarction (which was a pathologic process that resulted in necrotic tissue in the brain, caused by disrupted oxygen and blood supply,) and Bullous Pemphigoid (which was a rare skin condition that caused blisters on the skin.) Record review of Resident #1's Quarterly MDS assessment, dated 7/19/2024 reflected Resident #1 had a BIMS Score of 8. A BIMS Score of 8 indicated Resident #1 had moderate cognitive impairment. Resident #1 used a wheelchair for ambulation; she was dependent upon staff for eating, oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/talking off shoes, and personal hygiene. Dependent meant the helper did all the effort. Resident did none of the effort to complete the activity; Or the assistance of 2 or more helpers was required for the resident to complete the activity. Resident #1 had a catheter and was frequently incontinent of bowel. Record review of Resident #1's CP reflected a focus area for potential/actual impairment to skin integrity, initiated on 5/01/2024 and revised on 8/5/2024, evidenced by self-inflicted scratches; revised focus area R/T diagnosis of Bullous Pemphigoid. The goal was to have no complications by the target date of 10/10/2024. The interventions for nursing staff were to administer treatments as ordered, initiated 5/17/2024; avoid scratching and keep hands and body parts from excessive moisture, keep fingernails short, initiated 5/17/2024; Educate resident and responsible parties of causative factors to prevent skin injury, initiated 5/1/2024; Follow facility protocols for treatments of injury, initiated 5/1/2024; Identify potential causative factors and eliminate where possible, initiated 5/1/2024; Keep skin dry and clean/use lotion on dry skin, initiated 5/1/2024. Resident #1's CP reflected a second focus area for skin integrity, initiated on 5/30/2024, evidenced by scratching skin and skin breaks. The goal was to have fewer episodes of scratching by target date of 10/10/2024. The interventions for nursing staff were to administer medications as ordered, initiated 5/30/2024; anticipate needs of resident, initiated 5/30/2024; Apply Geri-sleeves on both upper extremities, initiated 8/12/2024. Record review of Resident #1's Order Summary Report reflected an order for hydroxyzine; (1) .25 MG tablet by mouth every 6 hours for itching. The order was written on 7/9/2024 and started on 7/9/2024.The Order Summary Report reflected an order for prednisone; (7) 10 MG tablets given via peg tube one time a day R/T Bullous Pemphigoid. The order was written 8/5/2024 and started on 8/6/2024. Record review of Resident #1's July 2024 MAR, viewed in PCC, reflected Resident #1's medication list. The July 2024 MAR indicated Resident #1 received hydroxyzine; .25 MG tablet by mouth every 6 hours. The MAR reflected medication administration started on 7/9/2024 at 11:00 PM. The July 2024 MAR indicated administration of hydroxyzine .25 MG tablet by mouth every 6 hours through 7/31/2024 (continuous.) Record review of Resident #1's August 2024 MAR, viewed in PCC, reflected Resident #1's medication list. The August 2024 MAR indicated Resident #1 received hydroxyzine; .25 MG tablet by mouth every 6 hours. The MAR reflected medication administration continued from 8/1/2024 at 5:00 AM until 8/14/2024 (continuous.) The August 2024 MAR indicated administration of prednisone; (7) 10 MG tablets given via peg tube one time a day R/T Bullous Pemphigoid. The August 2024 MAR indicated Resident #1 received prednisone; (7) 10 MG tablets given via peg tube one time a day R/T Bullous Pemphigoid 1 time daily from 8/6/2024 until 8/14/2024 (continuous.) Record review of Resident #1 Admission Contract, signed and dated 3/25/2024, reflected Section 21. Rules on Restraints, Resident's Behavior, and Health Care Center Practice. The Admission Contract indicated: It was the policy of the facility to have maintained an environment that prohibited the use of restraints for discipline or convenience. Restraint usage would have been limited to circumstances in which the resident had medical symptoms that warranted the use of restraints. The restraint assessment committee would have evaluated and established the need for restraint use or restrain reduction for residents in the health care center. The health care center was committed to nurturing the autonomy and independence of the residents by having attempted to provide a restraint free environment. A physical restraint was defined as any manual restraint method, such as physical, mechanical, material, or the use of adjacent equipment, that the individual could not remove easily, which would have restricted a resident's freedom of movement, or normal access to one's body. The Admission Contract's Notice of Rights and Services, located in Section 21, indicated: the facility must have informed the resident, or the residents next of kin/guardian, both orally and in an understandable language the rights and rules governing resident conduct and responsibilities during the resident's stay at the facility. The facility's policy related to the use of restraints and involuntary seclusion must have also been given to the resident's legally authorized representative if the resident had one. Record review of a legal document, notarized on 4/10/2024, named RP #2 as Resident #1's Medical Power of Attorney. Record review of Resident #1's incident report dated 8/3/2024 at 8:35 PM; written by the ADON, reflected an unwitnessed event in the room of Resident #1 (201-B); resident not taken to hospital; no injuries observed. Record review of Resident #1's progress notes dated 8/3/2024 at 8:35 PM; written by LVN A, reflected an entry having indicated: Resident was found with her right hand tied to the grab bar after RP #2 had left for the night, reported it to the administrator. Hand was untied and assessed resident's wrist for any marks or bruising and none where found. Record review of a written statement by LVN B, dated 8/3/2024 at 7:30 PM, reflected LVN B ad LVN A entered Resident #1's room just after RP #2 left Resident #1's room. LVN A and LVN B discovered Resident #1's right hand had been tied to the bed's assist bar. The two LVN's immediately released Resident #1's hand/wrist and assessed for trauma. No marks were noted to her wrist. Resident #1 did not appear to be in any distress. Record review of a written statement by LVN A, dated 8/5/2024, reflected LVN A entered Resident #1's room (8/3/2024) with LVN B having discovered Resident #1's right hand had been tied to the bed's assist bar with a small blanket. LVN A released Resident #1's right hand. A visual inspection of Resident #1's right hand resulted with no visible trauma. LVN A reported the incident to the ADM. Record review of Resident #1's weekly skin assessment, dated 8/5/2024, reflected Resident #1's skin color was normal, no bruises, no skin tears, no abrasions, and no lacerations. There were no areas that had not been reported to the facility medical provider. Assessment performed by LVN F. Record review of a local police report, # 2400220, written on 8/14/2024 by Officer #3 reflected an incident, which occurred at the facility on 8/3/2024. The report indicated: On 08/05/2024 at approximately 3:30 PM, I, Officer #3 responded to a call at the Nursing and Rehab. When I arrived, I met with the ADM. The ADM stated that she was notified by a charge nurse, LVN A, that Resident #1 had her hand tied to the assist bar, by RP #2. The ADM stated LVN A reported having untied Resident #1 arms, bound by a blanket to the bed's mobility assist bar. The ADM stated LVN A reported no red marks, bruises, lacerations of any kind. The ADM stated that the facility staff had spoken with RP #2, and he explained he did not mean any harm, but was only trying to keep Resident #1 from scratching herself. Resident #1 had recently been diagnosed with an autoimmune skin condition, which caused severe itching. RP #2 did not know his actions were wrong and said he would never do it again. The ADM stated that she believed it was not a malicious intent. The ADM stated RP #2 was really good to Resident #1 and visited with her daily, and only wanted the best for her. Officer #3 went to Resident #1's room and looked at her arm. There were no signs of any bruising or any other marks. Resident #1's hand was in a sock when having arrived at her room. Record review of Resident #1's progress notes dated 8/5/2024 at 7:58 PM; written by the ADM, reflected an entry having indicated: The Administrator had a care plan with RP #2. The ADM discussed using restraints and explained that this was not allowed in the facility and was considered to be a form of abuse. RP #2 became very upset as he did not know and was very sorry, having explained all he tried to do was to keep Resident #1 from having scratched herself. RP #2 explained all he wanted was to take good care of Resident #1 and that he had devoted the last several years of his life doing that. Resident #1 had a new diagnosis of Bullous Pemphigoid, 7/23/2024, and it did cause her to scratch. The facility's MD had prescribed hydroxyzine. RP #2 was glad to hear this and promised he would never restrain Resident #1 again. Record review of Resident #1s progress notes, dated 8/8/2024 at 4:57 PM; written by the SW, reflected an entry having indicated: The SW followed up with Resident #1 for the incident having regarded to RP #2 securing Resident #1's wrist to the bed rails to prevent Resident #1 from scratching herself. Resident #1 stated she was not in any distress from the incident or upset with RP #2. Resident #1 stated RP #2 had good intentions and tried his best to help her from scratching, which had caused her skin to bleed. Resident #1 stated RP #2 understood why he should not have tied her right hand/wrist to the bed side rail and that it was a mistake, an error. Resident #1 was calm, alert, and oriented to self, place, and time. Record review of a facility self-reported intake reflected an email, dated 8/5/2024. The email indicated [To Whom it May Concern, please find attached a late-self report on abuse that occurred on the evening of 8/3/2024. Attached are the following: Initial self-report, resident face sheet, witness statements, heat to toe assessment completed 8/5/2024. If you have any questions, please feel free to contact the ADM. Observation on 8/13/2024 at 10:15 AM of Resident #1 reflected the resident seated /reclined in her Geri-chair (a large wheelchair with a padded back/seat and leg stirrups) in the television area near the facility's nurse's station. Resident #1 was covered up to her torso with a white sheet, her head was supported with a horseshoe shaped pillow around her neck, and she did not appear to be in any distress. Resident #1 had her eyes closed and was non-responsive to verbal prompts. Interview on 8/14/2024 at 8:43 AM with RP #2 revealed he was at the facility the night of 8/3/2024 to see Resident #1. To keep Resident #1 from having scratched her skin, he stated he used the material from the softest material he could find, which was a blanket, and tied Resident #1's right hand/wrist to the support bar on the side of the bed. He stated he did not try to hide what he had done, and left the knotted blanket exposed for anyone who had entered the room to see. He did not know, at the time, that having tied Resident #1's hand/wrist to the support bar was a form of abuse through restraint. He stated he was seen by the ADM, a couple of days later, and learned that physical restraints were not allowed at the facility. He was only trying to help Resident #1 and promised he would never do it again. Observation and interview on 8/14/2024 at 9:55 AM of Resident #1 revealed the resident seated /reclined in her Geri-chair in the television area near the facility's nurse's station. Through verbal responses and facial features, Resident #1 affirmed that she was feeling ok and denied any pain. She recalled RP #2 tying her right arm to the bedside assist bar on 8/3/2024 but denied that it caused her any pain. The itching was just about the same. Resident was observed wearing Geri-gloves (which were mesh gloves worn to protect skin without having sacrificed comfort or mobility.) Interview on 8/14/2024 at 3:39 PM with the ADM revealed her staff was trained to recognize instances of abuse and expected her staff to report allegations, or suspicions, of abuse, to her immediately. As well, the ADM stated her staff was trained on the facility's policy on restraints and expected her staff to report allegations of resident restraint, or suspicions, to her immediately. Residents who were abused in the form of having been restrained, were placed at risk of physical harm, such as injuries, and psychosocial harm, such as trauma related emotions. The reporting time for allegations of abuse, per the facility's Abuse and Neglect policy, indicated the allegation of abuse was supposed to have been reported to Health and Human Services within 2 hours of the report; however, the ADM did not report the allegation of abuse, which was initially reported to her by staff on 8/3/2024 at 8:35 PM, through the reporting website until 8/5/2024 at 3:11 PM. The ADM did not try to rationalize why the report was made late and acknowledged she was not in compliance and had no excuse. Record review of the ADM's one-on-one in-service, dated 8/5/2024, addressed the Long-Term Care Regulatory Provider Letter, PL 19-17, titled: Abuse, Neglect, Exploitation, Misappropriation of Resident Property and Other incident that a Nursing Facility Must Report to the Health and Human Services Commission; Provider types: Nursing Facilities; Date Issued: 7/10/2019. The provider letter indicated abuse, with or without serious bodily injury, was supposed to be reported immediately, but not less than two hours after the incident occurred or was suspected. The instructor was RRN.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assures the accurate acquiring, receiving, dispensing, and administering of medications for 1 of 3 medication carts (nurse cart hall 300) and failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation for 7 of 9 months (October 2022, February 2023, March 2023, April 2023, May 2023, June 2023, and July 2023) reviewed for pharmacy services. 1. The facility failed to remove expired insulin from the nurse medication cart on hall 300 for Resident #36. 2. The facility failed to remove expired medications from the nurse medication cart on hall 300 for Resident #64. 3. The facility failed have a licensed pharmacist and two witnesses initial the attached pages of the controlled medication destruction inventory sheets. These failures could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications and put residents at risk for misappropriation and drug diversion. Findings: 1. Record review of facility face sheet dated 7/26/2023 indicated Resident #36 was an [AGE] year-old female admitted to the facility on [DATE] with diagnosis of dementia (impaired cognition) and diabetes mellitus (abnormal blood sugar levels). Record review of physician order dated 12/28/2022 indicated an order for Novolog insulin 100 units/ml per a sliding scale before meals and at bedtime. Record review of comprehensive care plan dated 07/04/2023 indicated Resident #36 had diabetes mellitus and required diabetes medications as ordered by the doctor. Record review of annual MDS dated [DATE] indicated a BIMS of 06 indicated severe impaired cognition and required insulin daily. During an observation on 07/25/2023 at 9:30 am with LVN D the medication cart located on hall 300 revealed expired Novolog insulin for Resident # 36 with an open date of 6/25/2023 and should have been discarded after 28 days of opening. 2. Record review of facility face sheet dated 7/26/2023 indicated Resident #64 was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis of COPD (chronic obstructive pulmonary disease, breathing impairment). Record review of physician orders dated 12/16/2022 indicated an order for atropine sulfate solution 1% place 2 drops buccally every 2 hours as needed for increased secretions, furosemide solution 10mg/ml 4 m inhale orally via nebulizer every 6 hours as needed for shortness of breath, and glycopyrrolate capsule 14 mcg inhale orally via nebulizer every 4 hours as needed for increased secretions. Record review of comprehensive care plan dated 07/04/2023 indicated Resident # 64 had altered respiratory status related to COPD and to administer medications as ordered. Record review of quarterly MDS dated [DATE] indicated BIMS of 06 indicating severely impaired cognition. During an observation on 07/25/2023 at 9:30 am with LVN D the medication cart located on hall 300 revealed Resident # 64 had furosemide 10mg/ml inhalation solution with discard date of 7/20/2023, atropine sulfate 90 mcg inhaler with expiration date of 6/2023, and glycopyrrolate 14 mcg inhalation capsule with discard by date of 5/14/2023. 3. During a record review of the facility's drug destruction log for the last 9 months (October 2022, February 2023, March 2023, April 2023, May 2023, June 2023, and July 2023), revealed the drug destructions for controlled drugs dated 10/10/2022, 02/06/2023, 03/01/2023, 04/10/2023, 05/08/2023, 06/14/2023, and 07/10/2023 indicated that the attached pages of medication destruction did not include the initials of the consultant pharmacist and two witnesses. During an interview on 07/25/2023 at 9:45 am LVN D stated she had worked at the facility for 8 years and just moved to hall 300 located at station 1 a week ago. She stated she had been working on the medication cart to get it cleaned up but had not been able to get it done. She stated the nurses check the carts for expired medications when they could but there was no specific schedule. She stated she had not told anyone about the cart having expired medicine. She stated the nurses used a chart that helped with medication expiration dates or use by dates for knowing when medications like insulin would expire. She stated the risk of a resident receiving expired medications could be the medicine not working correctly. During an interview on 7/25/2023 at 10:04 am the ADON stated the nurses were responsible for checking the medicine carts for expired medicine and prior to administering any medicine. She stated she and the DON also checked the carts periodically but there was no actual system in place. She stated the risk of not removing expired medications or a resident receiving expired medication could be ineffective medication. During an interview on 7/25/2023 at 10:09 am the DON stated the medication carts were to be checked by the nurses and all medicine should be checked prior to administering. She stated she and the ADON performed audits monthly and removed expired medicines as needed but there was no formal documentation. She stated the pharmacist checked all medication carts monthly and would document the findings for her to review. She stated the risk to the resident receiving expired medication could be ineffective medication and going forward she would put in place a new monitoring system to ensure expired medications were removed from medication carts. She stated she was not aware that the medication destruction log pages had to be initialed by the pharmacist and 2 witnesses and thought the cover sheet was enough documentation. She stated she expected going forward the rule for proper documentation was followed and the risk could be a drug diversion. During an interview on 7/26/2023 at 10:14 am the pharmacist stated she came to the facility monthly and the medications carts were audited a few months ago. She stated when she found expired medications on the medication carts she removed those medications and the ADON or DON were given the audit for review. She stated the medication carts storing expired medications could place residents at risk of receiving medications that were of poor quality. She stated she came to the facility monthly and that she completed drug destructions with the DON, ADON and/or Administrator at least quarterly but usually monthly. She stated she was not aware that each attached page to the drug destruction cover sheet had to be initialed by the pharmacist and 2 witnesses but would see that it was corrected on the next destruction. She stated she did not see a risk because she knew the medicines were destroyed. During an interview on 7/26/2023 at 10:45 am the administrator stated that the medication carts were the responsibility of the charge nurses and all expired medications should be removed timely to prevent a resident from receiving an expired medicine. She stated the DON and ADON were responsible for oversight of the medication chart audits and expected all medication carts to be free of expired medicine in order to prevent a resident from receiving medicine that could be ineffective. She stated that she was not aware of the need for initials on each attached page of the drug destruction but going forward expected the medication destruction rules to be followed to prevent a drug diversion. Record review of facility policy titled Recommended Medication Storage dated 7/2012 indicated, .Novolog expires 28 days after initial use regardless of product storage . No other policy provided by the facility in regard to medication storage. Record review of 22 TAC S303.1 Destruction of Dispensed Drugs (a) Drugs dispensed to patients in health care facilities or institutions. (1) Destruction by the consultant pharmacist. The consultant pharmacist, if in good standing with the Texas State Board of Pharmacy, is authorized to destroy dangerous drugs dispensed to patients in health care facilities or institutions. A consultant pharmacist may destroy controlled substances as allowed to do so by federal laws or rules of the Drug Enforcement Administration. Dangerous drugs may be destroyed provided the following conditions are met. (A) A written agreement exists between the facility and the consultant pharmacist. (B) The drugs are inventoried, and such inventory is verified by the consultant pharmacist. The following information shall be included on this inventory: (i) name and address of the facility or institution. (ii) name and pharmacist license number of the consultant pharmacist. (iii) date of drug destruction. (iv) date the prescription was dispensed; (v) unique identification number assigned to the prescription by the pharmacy; (vi) name of dispensing pharmacy; (vii) name, strength, and quantity of drug; (viii) signature of consultant pharmacist destroying drugs; (ix) signature of the witness(es); and (x) method of destruction. C) The signature of the consultant pharmacist and witness(es) to the destruction and the method of destruction specified in subparagraph (B) of this paragraph may be on a cover sheet attached to the inventory and not on each individual inventory sheet, provided the cover sheet contains a statement indicating the number of inventory pages that are attached and each of the attached pages are initialed by the consultant pharmacist and witness(es). v) any two individuals working in the following capacities at the facility: (I) facility administrator; (II) director of nursing; (III) acting director of nursing; or (IV) licensed nurse. Record review of facility policy and procedure titled Drug Destruction dated July 10, 2013, indicated, .2. Drugs to be destroyed under the supervision of a consultant pharmacist and at least one of the following DON, ADON, or Administrator and this policy failed to meet the standards of the regulation under 22 TAC 303.1.

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent. There were 3 errors out of 42 opportunities, resulting in a 7.14 percent medication error involving 3 of 9 residents (Resident #17, Resident #19, and Resident #70) reviewed for medication pass. LVN C failed to administer the ordered dose of Vitamin D3 to Resident # 17. LVN D failed to administer the ordered water flush with medication administration through a feeding tube for Resident # 19. LVN C failed to administer the ordered dose of Vitamin D3 to Resident # 70. These failures could place residents at risk for not receiving the intended therapeutic benefit of their medications or receiving them as prescribed, per physician orders Findings: 1. Record review of facility face sheet dated 7/26/2023 indicated Resident #17 was a [AGE] year-old female admitted to facility on 09/25/2022 with diagnosis of schizophrenia (mental illness). During a medication pass observation on 7/25/2023 at 8:15 am LVN C administered Resident # 17 Vitamin D 3 25 mcg 1 tablet by mouth. Record review of physician order dated 09/29/2022 revealed an order for cholecalciferol (Vitamin D3) 25 mcg give 2 capsules by mouth one time a day. Record review of comprehensive care plan dated 06/21/2023 indicated resident with nutritional problem and to administer medications as ordered. Record review of quarterly MDS dated [DATE] indicated a BIMS of 03 indicating severe impaired cognition. 2. Record review of facility face sheet dated 7/26/2023 indicated Resident #19 was a [AGE] year-old male admitted to the facility on [DATE] with diagnosis of quadriplegia (paralyzed from the neck down). During a medication pass observation on 7/25/2023 at 3:15 pm LVN D administered Resident # 19 medication via a gastrostomy tube. LVN D did not flush gastrotomy tube before administering medication and flushed the gastrostomy tube with 30 ml of water after medication administration. Record review of physician order dated 05/10/2023 revealed an order to flush gastrostomy tube with 60 cc of water before and after medication administration. Record review of comprehensive care plan dated 5/30/2023 indicated Resident #19 had potential fluid deficit related to tube feeding and required gastrostomy tube and to administer fluids and medicines as ordered. Record review of quarterly MDS dated [DATE] indicated a BIMS of 00 indicating severe impaired cognition and required a feeding tube. 3. Record review of facility face sheet dated 7/26/2023 indicated Resident #70 was an [AGE] year-old female admitted to the facility on [DATE] with diagnosis of fracture of left femur (broken left leg). During a medication pass observation on 7/25/23 at 8:10 AM LVN C administered Resident # 70 Vitamin D3 25mcg 1 tab by mouth. Record review of physician order dated 10/20/2022 revealed an order for cholecalciferol (Vitamin D3) 25 mcg give 2 capsules by mouth one time a day. Record review of comprehensive care plan dated 4/28/2023 indicated a risk for malnourishment and weight loss. Record review of quarterly MDS dated [DATE] indicated a BIMS of 05 indicating severely impaired cognition. During an interview on 7/25/2023 at 3:37 pm LVN D stated she had been at the facility for four years as the weekend charge nurse and had been a nurse for [AGE] years. She stated she should have flushed Resident #19's gastrotomy tube as ordered before and after giving his medication. She stated she had been trained on administering medicines through a gastrostomy tube but it had been a while and she was nervous. She stated the risk to the resident could be occluded tube or medication interactions. During an interview on 7/25/2023 at 10:01 am LVN C stated she had been a nurse 1 year and on hire she did receive training on medication administration and each order was to be checked before administering medications to each resident. She stated regarding Resident #17 and Resident #70 she just overlooked the Vitamin D3 order was for 2 tablets not 1 tablet. She stated the risk to resident receiving the incorrect dose of medicine could be the resident would not receive the full benefit of the medicine. During an interview on 7/26/2023 at 10:30 am the DON stated nurses are trained on hire and annually through a proficiency audit regarding medication administration. She stated the seasoned nurses on the floor oversee the new nurses orientation regarding different nursing task and then the ADON or herself ensure the checkoff's are done and each nurse was proficient. She stated she expected each nurse to administer medications correctly per the physician order. She stated the risk of medicines being given incorrectly could vary depending on what each medication was. During an interview on 7/26/2023 at 10:45 am the Administrator stated the DON and ADON were responsible for ensuring medications were given as ordered. She stated she oversees the in-service program and monitors the DON's audits she puts in place. She stated going forward she expected medications were to be administered as ordered and per policy and procedure to decrease the risk of medication errors. Record review of facility policy and procedure titled Enteral Medication Administration dated 1/25/13 indicated, .7. flush the tube with 30 ml water or according to physician order, 9. once all medications have been administered, flush the tube with 30 ml water or according to physician order. Record review of facility policy and procedure titled Medication Administration procedure dated 2003 indicated, .20.the five rights of medication should always be adhered to 2. right dose . Record review of facility policy and procedure titled Ordering Medications dated 2003 indicated, .other functions that must be performed or verified by nursing staff include doses charted accurately on the MAR as ordered and as administered, medication dispensed accurately with proper handling.

Based on observation interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure food items in the refrigerator were not expired. The facility failed to ensure food item in the dry storage area that required refrigeration was refrigerated. These failures could place residents at risk for food-borne illness, and food contamination. Findings included: Observations of the refrigerator in the kitchen on [DATE] beginning at 12:00 PM revealed that the following items were expired: 1.One plastic bag labelled turkey had sliced meat in it. The packed date written on it was [DATE] and 'use by date' was [DATE]. DM stated it was Turkey Ham 2.One plastic bag contains four sandwiches with prepared date [DATE] and 'use by date' [DATE] written on it. 3.One plastic bag containings 11 small containers with yellow creamy substance in it. Mayo, [DATE] was written on the bag. DM stated it was mayonnaise repacked from a large container, for day-to-day use. DM said they were supposed to be used within 7 days from the date of packing. 4.Observations of the storage area in the kitchen on [DATE] beginning at 12:00 PM revealed a jar of strawberry jam that was in use, stored in the dry storage area. On the label it was written Refrigerate after opening During an interview on [DATE] at 12:30 PM the DM stated the expired food items should not have been in the refrigerator. DM said the food item that required refrigeration after opening should be stored in the refrigerator. When the investigator asked about the consequences of these deficiencies, DM stated inappropriate storage of food items might promote the growth of microorganisms. He added, this created opportunity for cross contamination of fresh food items in the refrigerator. DM stated the facility follows Texas Food Establishment Rules (TFER) for storing, preparing, distributing, and serving food. He said the expectation was, prepared and repacked items were disposed within 7 days and the food items that needed refrigeration should be refrigerated at the correct temperature and every staff member who worked in the kitchen was responsible for it. When the investigator asked about the training conducted regarding safe storage of food items DM stated there were in-services (training) on food safety however he did not remember any training conducted specific to safe storage of food items. Review of facility in-service records on [DATE] revealed there were no in- services (training) on safe storage of food products since [DATE]. The DON stated the facility administrator was on leave. She said following proper protocol for food handling was necessary to ensure food safety of the residents. Review on [DATE] of facility undated policy titled Dietary Services Policy and Procedure Manual 2012: Food storage and Supplies reflected: All facility storage areas will be maintained in an orderly manner that preserves the condition of food and supplies. We will ensure storage areas are clean, organized, dry and protected from vermin, and insects . . 4. Open packages of food are stored in closed containers with covers or in sealed bags and dated as to when opened . .6. When items are received from the vendor, they should be first examined for expiration date, and if an expiration date is present, it is beneficial to mark it by circling it, so it is readily visible and noticeable. It is important to distinguish between an expiration date and a production date, or a best by or use by date. Production dates indicate when the product was manufactured, not when it expires, and should not be interpreted as a best by or use by date. Best by or use by dates indicate when a product will have best flavor or quality and are not an indicator of the product's safety. As the quality may deteriorate after the date passes, the dietary manager should closely inspect any products that are past the best by date to determine if they are still good quality. . 8. On perishable foods, microorganisms such as molds, yeasts, and bacteria can multiple and cause food to spoil. Spoiled foods will develop an off odor, flavor, or texture due to naturally occurring spoilage bacteria. If a food has developed such spoilage characteristics, it should not be eaten. There are two types of bacteria that can be found on food: pathogenic bacteria, which cause food borne illness, and spoilage bacteria, which causes foods to deteriorate and develop unpleasant characteristics such as an undesirable taste or odor making the food not wholesome, but do not cause illness. Perishable foods have been processed/treated and sealed to eliminate pathogenic bacteria, but spoilage bacteria can multiply, and this is what causes the food to deteriorate in quality and taste. If perishable food items are not stored at the proper temperature, spoilage bacteria can grow faster than anticipated and food becomes spoiled and should not be served. Food items such as loaves of bread or dairy products with a stamped best-by or use by date do not need to be labeled when opened as this will not affect the date by which they should be used. However, if possible, food spoilage is observed p1ior to the best by date, the product will be discarded .

Based on interviews and record reviews the facility failed to provide education regarding the benefits and potential side effects of influenza and pneumococcal immunizations to the resident or resident's representative for residents that refused the vaccines for two (Resident #67 and Resident #276) of five residents reviewed for influenza and pneumococcal immunizations. This failure could place residents at risk of being uniformed on the risks and benefits of vaccination and a potential decline in health. Findings included: Record Review of face sheet for Resident #67 on 6/8/22 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and was subsequently readmitted most recently on 3/4/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record Review of the immunization record on 6/8/22 for Resident #67 revealed she was offered the influenza vaccine 4 times and refused each time and she was offered the pneumonia vaccine 4 times and refused each time. There were no dates documented on any offering or refusals, and no declination forms regarding education on the benefits and potential side effects of immunization. Record Review of face sheet on 6/8/22 for Resident #276 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record Review of the immunization record for Resident #276 revealed she was offered a pneumonia vaccination but refused. There no date of offering or refusal documented, nor was there a declination form regarding education on the benefits and potential side effects of immunization. In an interview on 06/07/22 at 5:02 PM the DON stated the only documentation that had been happening regarding vaccine refusals was the documentation of the refusal in the immunization tab in the electronic charting system The DON stated that she cannot produce any documentation regarding education regarding risks and benefits, declination forms, or documentation of any kind other than that the refusal is put in the immunization tab in the residents' charts. The DON said not educating residents or representatives could cause them to decline vaccines without fully understanding the benefits and potential side effects of immunizations.

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessments for 1 of 6 residents reviewed for care plans. (Resident #58). The facility failed to update Resident #58's care plan to reflect her DNR code status This failure could place residents at risk for inappropriate interventions by staff when reading information in the clinical record, (that is inaccurate or incomplete) which could delay emergency treatment or incur unwanted treatment. Findings: Record review of an Admission Record for Resident #58 dated [DATE] indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of a signed Out of Hospital DNR by Resident #58, dated [DATE] indicated it was witnessed by a notary and her physician. Record review of an Admission MDS Assessment for Resident #58 dated [DATE] indicated she had moderate impairment in thinking with a BIMS score of 12. Her functional status indicated she required limited assistance with bed mobility, eating, toilet use and personal hygiene. She required extensive assistance with transfers, and dressing. Record review of a Care Plan for Resident #58 dated [DATE] indicated she was a full code and request for CPR to be initiated will be followed. Interventions included to initiate BLS (basic life support) CPR (cardiopulmonary resuscitation) if the resident is without a heartbeat or not breathing. Record review of a Care Plan Conference dated [DATE] for Resident #58 indicated the resident, RP, DON, MDS nurse, Food Service Staff, Physician, Activity Director and Social Worker. Other information indicated the resident's plan is to rehab to home. Resident was independent, living alone, driving prior to fall and fracture. If unsuccessful with skilled services. There was no documentation of Resident #58's code status. During an interview on [DATE] at 3:45 PM, the MDS Nurse said she had been employed at the facility since 2014. She said Resident #58 code status should be a DNR. She said the resident admitted on [DATE] and her care plan was a baseline care plan. She said on admission if a resident came in and did not have a DNR in place, the electronic charting system automatically populated the resident as a full code. She said the MDS Nurse, and the entire IDT (interdisciplinary) team was responsible for entering information in the care plans which included the DON, ADON, SW, Dietary and Therapy. She said notification of code status should be entered the same day the information was received. She said the comprehensive care plans should be completed within 21 days of admission. She said Resident #58's initial care plan meeting was held on [DATE]. She said if a resident had a DNR in place and their care plan indicated a full code that the facility would not be adhering to their plan of care or the resident's wishes. She said she would update Resident #58's care plan to reflect her code status of DNR. During an interview on [DATE] at 9:35 AM, the DON said she had been employed at the facility for 5 years with the last 2 years as the DON. She said the responsibility of the care plans was the charge nurses who admits the residents, they will initiate a care plan. The care plan is then updated by MDS nurse, ADON and DON. She said they tried to make sure the Social worker received the DNR initially and coordinated with the MDS nurse who was responsible for updating the care plans to reflect the code status. She said the risks of not following the care plan include not following the care needed for the resident or their wishes regarding code status. She said going forward the care plans would be up to date to match the current orders of the residents. She said they would form a system to prevent it from happening again. She said an in-service was conducted at the facility on yesterday with nursing staff on when a code status was changed the MDS team would be notified so that the care plan could be updated. Record review of a facility In-service dated [DATE] on Code status was conducted and nursing staff was in attendance. Record review of a facility policy titled, Resident Care Plan with a revision date of [DATE] indicated, 1. A written resident care plan initiated upon admission is coordinated by Nursing Services in cooperation with Dietary, Activities, Social Services, Wound Care and pharmaceutical services. Medical input, as well as resident and family input, into the care planning process will be sought. 2. The plan of care provides us with a profile of the needs of each resident, identifies the role of each service in meeting these needs, and the supporting measures each service will use to accomplish these goals

Based on observation, interviews, and record reviews the facility failed to ensure the resident environment remained free of accidents hazards and residents received adequate supervision to prevent accidents for one of four (Resident #1) residents reviewed for accidents hazards and supervision. CNA A failed to close and lock the cabinet in the shower room which contained chemicals used for cleaning and failed to close and lock the door entering the shower room on the secure unit (500 hall) after she exited. This failures could place residents at risk of injuries, illness, and hospitalization s. The findings include: Record review of Resident #1's face sheet, dated 12/29/2021, reflected a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included: Alzheimer's disease, unspecified, generalized anxiety disorder, cognitive communication deficit, need for assistance with personal care and major depressive disorder. Record review of Resident #1's Quarterly MDS, dated [DATE], reflected the resident had a BIMS score of two which indicated her cognition was severely impaired. Resident #1 had difficulty concentrating. Resident #1 required supervision with locomotion on the unit. Resident #1 was also assessed as not steady with walking but was able to walk without staff assistance. Record review of Resident #1's Comprehensive Care Plan, dated 11/18/2021 and last revision was on 12/17/2021, reflected the resident had an anxiety disorder. Resident #1 was to be monitored for impaired thinking and judgement, forgetfulness, pacing and wandering. Resident #1 was required to reside on the secure unit related to wandering and lack of safety awareness. According to the care plan, Resident #1 had impaired cognitive function and impaired thought process. Resident #1 was to be provided with supervision as needed when walking . Resident #1 was at risk for wandering. Identify if Resident #1 was looking for something. Record review of Resident #1's Physician Orders, dated 12/29/2021, reflected Resident #1 may remain on the secure unit due to wandering. Observation on 12/29/2021 at 11:20 AM revealed when entering the secure unit Resident #1 walked in the shower room, near the entrance door to the secure unit. LVN B was near the dining room and a portion of the hall approximately 10 feet from the room Resident #1 entered. LVN B was looking into her medication cart. No other facility staff could be seen. Resident #1 was approximately 3 feet inside the shower room. The shower door was opened and propped against the wall. There were no facility staff inside the shower room and the cabinet which contained chemicals and toiletries was opened. The chemicals in the cabinet were accessible to Resident #1. The chemicals in the cabinet were all purpose cleaner, air freshener and neutral disinfectant cleaner. There were also three large containers of toiletries such as shampoo, shaving cream, deodorant, aftershave, body wash and lotions. The cabinet had a key and the key was located inside the lock. Observation on 12/29/2021 at 11:24 AM revealed CNA A entered the shower room . In an interview on 12/29/2021 at 11:26 AM, CNA A stated she forgot to lock the shower room door when she left to assist a resident to the tv area (approximately 20 feet from the shower room and could not see the shower room from the TV area ). CNA A stated she could not view the shower room from where she was standing in the TV area. She stated she had been away from the shower room several minutes. She stated she did not know exactly how many minutes. She stated she was away long enough for a resident to enter the shower room and possibly take some of the chemicals. She stated if a resident had swallowed a chemical which was hazardous it could have caused physical harm to the resident and possibly caused skin [CONDITION(S)]. She also stated a resident could require hospitalization and if the chemical had a severe reaction to the resident it could result in death. She stated she knew the cabinet had to be locked when she was not in the shower room. She stated the shower room door was required to be locked when staff were not present in the shower room. She stated there was a key to lock the cabinet and the key was in the lock . She stated they lock the shower room door from the inside, and she did have a key to unlock the shower room door. She also stated the Administrator and the Director of Nurses had verbally expressed the importance of keeping all chemicals locked and to lock the shower room door . She stated there was only one shower room on the secure unit. In an interview on 12/29/2021 at 11:45 AM, LVN B stated she did not see Resident #1 approach the shower room and did not know CNA A left the shower room and cabinet with chemicals unlocked. She stated she was looking in her medication cart at the time the shower room was observed being left open. She also stated she did not see CNA A exit the shower room. She stated she was concentrating on medications. She stated the shower room door was always to be locked when staff were not using the shower. She also stated the cabinet in the shower room needed to be locked. She stated a resident could drink or get chemicals on their skin and could cause physical harm. She stated the physical harm could result in hospitalization and serious injury such as skin [CONDITION(S)] and problems with swallowing and other internal injuries. She stated the Administrator and Director of Nurses had explained the importance of locking the shower room door and keeping the chemical cabinet locked . In an interview on 12/29/2021 at 11:58 AM, CNA C stated she did not view the shower room door being open or witness CNA A exit the shower room without locking the door. She stated she was making rounds to monitor the residents in their rooms. She stated if a resident drank some of the chemicals it could cause death. She stated the Administrator and Director of Nurses had explained the importance of keeping the shower door and chemicals locked. In an interview on 12/29/2021 at 12:10 PM, the Director of Nurses stated the nursing staff had been informed verbally to keep all chemicals in the shower rooms locked and to keep the shower room door locked. She stated if staff was were not in shower room, the door was expected to be locked. She stated it was very important for the shower door to be locked and chemicals to be locked in the cabinet due to residents on the secure unit being diagnosis diagnosed of with either Alzheimer's or Dementia. She stated there were several residents on the unit who wandered in the hall and different areas and some of the residents were usually looking for something. She stated if a resident inhaled a chemical, the resident had the potential to have serious physical harm which could result in death. She stated if a resident accidentally had the chemicals on their skin, the resident had the potential of receiving serious skin [CONDITION(S)]. She stated it was the responsibility of nursing supervisors and all nursing staff to monitor shower rooms and chemicals in the showers rooms. In an interview on 12/29/2021 at 12:30 PM, the Administrator stated he was shocked the shower room door and cabinet which stored chemicals on the secure unit was opened for a resident to enter the shower room without supervision. He stated it was the nursing staff's responsibility to ensure the shower rooms were locked and chemicals were locked when not in use . Record Review of the Safety Data Sheet for the all-purpose cleaner, revised on 11/11/2013, provided by the Housekeeping Supervisor reflected Causes serious eye irritation, may cause an allergic skin reaction. Harmful if swallowed. If eye irritation persists, get medical attention. If skin irritation or rash occurs, seek medical advice/ attention. If swallowed call poison center or doctor. Record Review of the Safety Data Sheet for the air freshener, revised on 11/11/2013, provided by the Housekeeping Supervisor reflected Causes serious eye irritation, may cause an allergic skin reaction, harmful if swallowed. If eye irritation persists, get medical attention. If skin irritation or rash occurs, seek medical advice/ attention. If swallowed call poison center or doctor. Record Review of the Safety Data Sheet neutral disinfectant cleaner, revised on 11/13/2013, provided by the Housekeeping Supervisor reflected May be harmful if inhaled, harmful if swallowed, causes eye irritation and mild skin irritation. If eye and skin irritation occur get medical advice/ attention. Inhalation of high concentration may cause central nervous system effects characterized by nausea, headache, dizziness, unconsciousness, and coma. May cause respiratory tract irritation. If ingested may cause gastrointestinal irritation with nausea, vomiting and diarrhea. Advanced stages may cause collapse, unconsciousness, coma, and possible death due to respiratory failure. Record Review of the Facility Policy Hazardous Areas, Devices and Equipment, dated July 2017, reflected A hazard is defined as anything in the environment that has potential to cause injury or illness. Examples of environmental hazards include but are not limited to: Access to toxic chemicals and disabled locks, latches, or alarms. Any element of the resident environment that has potential to cause injury and that is accessible to a vulnerable resident is considered hazardous. Resident vulnerability is based on risk factors including the individual resident's functional status, medical condition, cognitive abilities and mood.

Based on interview and record review, the facility failed to ensure the activities program was directed by a qualified professional who was qualified therapeutic recreation specialist or and activity professional for one (1) of one (1) facility. The facility failed to designate a qualified activity professional to direct the activities programs. The facility did not have a qualified activity professional since 11/23/2020. This failure could place resident at risk for reduced quality of life and experience a decline in their psychosocial wellbeing. Findings Include: Record Review of Activity Director's A personnel file on 07/19/2020 at 4:30 PM revealed, hire date was 11/23/2020. On her application indicated there was not any experience working in a nursing home or as an Activity Director or Activity Assistant. She initialed a form stating she reviewed the activity job description. She did not have any type of certification. Record Review of Activity Job Description on 07/19/2020 at 4:40 PM reflected: Knowledge Base: * High school graduate with certification where required by state regulations. * Must be certified Activity Director. * Experience with creating and implementing effective resident care plans. *Ability to develop, organize and implement a program of activities for the social, emotional, physical and other therapeutic needs of the residents within specified budget. * Conduct resident activity histories and assessments as required by state and federal standards * Maintain detailed records of activity programs and participation of individual residents, identifying progress toward established care plan goals. Applicant Declaration: I have read the qualifications and requirements of the position of Activity Director. To the best of my knowledge, I confirm and certify that I can perform these duties. In an interview on 07/19/2021 at 2:05 PM Activity Director A stated I do not have my certification to be an activity director. This is my first time working at a nursing home. I did not have any experience being an activity director or an activity assistant until I was hired at this facility in November 2020. I enrolled for the activity online course. This is required by the state of Texas. I have only taken one or two weeks of the course. I registered in February of this year (2021). I did view some of the course. I do not know the date I reviewed the course. I have been the Activity Director since I was hired. Record Review of correspondence with a professional at MEPAP (Modular Education Program for Activity Professionals) on 07/19/2021 at 3:02 PM reflected the Activity Director A did register for the online MEPAP course, however, there was no payment rendered to enroll in the course to become an activity professional. In an interview on 07/19/2021 at 3:15 PM Activity Director A stated she did not have any other information about the activity course. She stated the on-line MEPAP course registration/ no payment form was all the proof she had that she had registered for the course. She stated she did receive a job description when she was hired. She stated she did review it upon hire date. In a (phone) interview on 07/20/2021 at approximately 11:00 AM the Life Enrichment Coordinator F (Consultant of the Activity Director) stated Activity Director A received the virtual onboarding and training with her in December 2020 and when she visited Activity Director A in February 2021. She stated she discussed care plans, MDS, Participation records and all documentation pertaining to activity department. She stated Activity Director A did receive a visit from Ambassador G in June with further training and any questions Activity Director A had were answered during that visit. She stated Activity Director A had access to call her or Ambassador G anytime she had questions In an interview on 07/20/2021 at 12:15 pm Activity Director A stated when she was hired, she did not have any experience working as an activity director. She stated she had received training from the Life Enrichment Coordinator (Nurse Consultant) in December 2020 during the virtual onboarding. She stated she was trained on what was in the activity manual in February 2021. In an interview on 07/20/2021 at 1:15 pm the Interim Administrator stated Activity Director A wasn't certified. He stated the Activity Director A was the only person in the activity department. He state he did review her application and she wasn't qualified upon her hire date. He stated he would need to review other reports before he answered any other questions.

Based on observation, interview and record review the facility failed to provide ongoing activity programs to support residents in their choice of activities, both facility sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental and psychosocial well-being for five (5) of eighteen (18) residents reviewed for activities on one (1) of (1) secure hall of the facility. (Resident #s 1, 2, 3, 4 and 5) The facility failed to consistently provide activities for Resident #1, Resident #2, Resident #3, Resident #4 and Resident #5. This failure could place residents who have impaired mobility and cognition and need assistance to attend activities or require in-room activities at risk for a decline in social, mental, psychosocial well-being and decreased quality of life. Findings included: Resident #1 Record review of Resident #1's Face Sheet undated reflected a [AGE] year old male resident with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's Annual MDS dated [DATE] reflected Resident #1 has a BIMS score of 5. He feels tired and had little energy. Resident does wander. Activity Preferences for Resident #1: Very Important- have books, newspapers and magazines to read, listen to favorite music, do things in group of people, do favorite activities, go outside when weather is good and participate in religious services or practices Record review of Resident #1's Care Plan dated 07/08/2021 reflected Provide in room activities of choice, as able. Resident has impaired cognitive function/ dementia or impaired thought processes. The resident will maintain current level of cognitive function. Engage the resident in simple, structured activities that avoid over demanding tasks. The resident needs out of room social, spiritual and stimulus activities and mental stimulation. Resident has impaired visual function: Intervention: the activity director will provide the resident reading material for mental stimulation. The activity director will praise the resident for attending group activities of their choices. Resident has nutritional problem or potential for nutritional problem related to Dementia Cerebral Infarction. Intervention: Develop an activity program that included exercise, mobility. Offer activities of choice to help divert attention from food. Record review of Resident #1's Activity assessment dated [DATE] reflected Resident #1 participates in activities 3-5 times per week. Prefers to be with people, requires reminding to attend activities. He is an active participant. Vision and Hearing is poor. He is forgetful. Resident's psychosocial needs are the following: intellectual stimulation, spiritual growth and sensory stimulation. In an interview with Activity Director A on 07/19/2021 at 4:30 PM stated Resident #1 doesn't have any participation records. I have not provided him with any reading material. I don't know if any of the staff on the secure unit has provided him with any activity items. It is activity department responsibility to provide activity items for all residents on the secure unit. I don't know his activity preferences. I read what is on his MDS. If his activity level or interest change, we could do another MDS. I did not contact family or talk to staff on the secure unit about his activity level or his activity preferences. Resident #2 Record review of Resident #2's Face Sheet dated 11/28/2020 reflected a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #2's current Activity Quarterly assessment dated [DATE] reflected the resident required to be reminded to attend activities. Resident participated in 6 or more activities per week. Vision, hearing is poor and disoriented times 3 (three). Resident has short attention span. Needs intellectual stimulation, spiritual growth and sensory stimulation. Unable to make needs known. Review of participation records reflected activities on the secure unit from November 2020 until July 2021 had not been documented. Record review of Resident #2's Annual MDS dated [DATE] reflected BIMS score of 4 indicating severe cognitive impairment. Activity Preferences: Very Important includes keeping up with the news, doing things with groups of people, doing favorite activities and going outside to get fresh air when the weather is good. Somewhat Important includes listening to music, being around animals such as pets and participating in religious services. Not very important have books, newspapers and magazines to read. Record review of Resident #2's Care Plan dated 05/27/2021 reflected encourage food related activities history of weight loss. Provide in room activities of choice, as able. Resident needs to be out of room social, spiritual and stimulus activities and mental stimulation. The resident will attend activities of her choice, will watch tv, read and socialize with other residents at least 2 times weekly. The activity director will encourage and remind the resident of current activities. The activity director will provide the resident reading material for mental stimulation. Resident enjoys listening to Hispanic music, snacks and exercise class. Resident at risk for wandering. Distract resident from wandering by offering structured activities, food, conversation, television and book. Provide structured activities walking inside/ outside, pictures and memory boxes. Resident has impaired visual function. Record review of Resident #2's Activity Quarterly assessment dated [DATE] reflected resident has attended 3-5 activities per week. Resident requires to be reminded of group activities. She is an active participant in activities. She prefers to be with others and prefers to be out of room. Resident is forgetful and requires reminders/ cues of activities. Her vision and hearing are poor. Resident needs sensory stimulation. Record review of Resident #2's Activity Quarterly assessment dated [DATE] reflected resident has attended six or more activities. Prefers to be around people. Her vision and hearing are poor. She requires to be reminded to attend activities. Resident #1 Psychosocial needs are the following: group interaction, intellectual stimulation, adjustment to placement and sensory stimulation. In an interview on 07/19/2021 at 4:30 PM the Activity Director A stated Resident #2 wasn't provided with any Hispanic music. I did not realize she preferred this type of music. The care plan was completed by someone else. I don't always review the care plan unless a family member attends the care plan meeting. Before I complete an assessment on a resident residing on the secure unit, I look at their past quarterly assessment for information. If I need to know the resident's interests, I would interview the resident. If the resident is non-interviewable I would speak to the family and/or other staff. I did not speak to any staff on the unit or any families prior to completing her quarterly assessment. The staff on the unit could have provided information about her daily routine. I was not aware I should follow what her preferences documented on the MDS. Resident #3 Record review of Resident #3's Face Sheet dated 09/25/2020 reflected a [AGE] year-old female admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #3's Admission MDS dated [DATE] reflected resident sometimes understands others and sometimes makes self-understood. Resident has poor short- and long-term memory recall. Her decision-making skills is severely impaired. Resident unable to complete BIMS related to her Dementia. Resident has difficulty concentrating on reading or watching tv. She wanders 1-3 days of week. Activity Preferences indicated: Very Important included listen to music, keeping up with the news, do things with group of people, do favorite activities and participate in religious activities. Somewhat Important included be around animals such as pets and going outside for fresh air when weather is good. Not very important included have books, newspapers and magazines to read. Record review of Resident #3's Care Plan dated 07/08/2021 reflected Resident needs out of room social, spiritual and stimulus activities and mental stimulation. Resident enjoys nail care, dancing, daily exercises. Resident requires frequent cueing and redirection to participate in activities. The activity director will encourage and remind the resident of current activities. The activity director will provide the resident reading material for mental stimulation. Residents Care Plan further reflects, Provide in room activities of choice, as able. Engage the resident in simple, structured activities that avoid overly demanding tasks. Provide a program of activities that accommodates the resident's abilities. Resident risk for falls - Dementia. Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility. Resident has a communication problem related to unspecified dementia without behavioral disturbance. Provide a program of activities that accommodates the resident's communication abilities. Resident is at risk for wandering. Distract resident from wandering by offering diversions, structured activities, television, book and memory boxes. Record review of Resident #3's Activity Quarterly assessment dated [DATE] reflected Resident #3 participates in 6 or more activities per week. She also participates in one to one program. In an interview on 07/20/2021 at 12:30 PM the Activity Director stated I have not updated Resident #3's preferences since her admission MDS. I understand all residents' activities are planned according to their preferences. I would consider the preferences listed on the admission MDS to be correct. It is documented she doesn't like books and it is on her care plan to offer her books. I have not developed memory box or provided any activity items for her. If a resident doesn't prefer to do a particular activity it should not be offered to them. I do not have any participation records for Resident #3. Resident #4 Record Review of Resident #4's Face Sheet dated 01/24/2021 reflected [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record Review of Resident #4's Annual MDS dated [DATE] reflected a BIMS score of two. Cognitive Patterns did not indicate resident was rarely/ never understood. Wandering occurred one (1) to three (3) days per week. Activity Preferences for Customary Routine and Activities indicated resident is rarely/ never understood and she doesn't have any activity interests or preferences. Record Review of Resident #4's Care Plan dated 07/20/2021 reflected Provide in room activities of choice, as able. Resident has impaired cognitive function/ dementia or impaired thought process related to Alzheimer's Disease unspecified Dementia without Behavioral Disturbances. Engage the resident in simple, structured activities that avoid overly demanding tasks. Provide a program of activities that accommodate the resident's abilities- use task segmentation to support short term memory deficits. Resident risk for falls- encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility. Care plan further reflects, the Resident needs out of room social, spiritual and stimulus activities and mental stimulation. Resident enjoys group activities nail care and exercises. The activity director will encourage and remind the resident of current activities. The activity director will provide the resident reading material for mental stimulation. Resident is at risk for wandering. Provide Structure activities walking inside and outside, pictures and memory boxes. Record Review of Resident #4's Activity Quarterly assessment dated [DATE] reflected participated in 6 or more activities per week. Psychosocial needs: intellectual, stimulation, spiritual growth and sensory stimulation. In an interview on 07/20/2021 at 12:30 PM the Activity Director A stated I cannot explain why I didn't document any of resident's on the secure unit preferences on the MDS. I didn't review her mental capabilities. I don't know if she was able to understand. There isn't a memory box for her. I have not documented anything on residents' activities. Participation records was never completed from November 2020 until today on this resident. Resident #5 Record review of Resident #5's Face Sheet dated 01/06/2021 reflected a [AGE] year old female admitted on [DATE] with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #5's Admission MDS dated [DATE] reflected Resident usually makes self-understood and sometimes understands. She has a BIMS score of 2. Cognitive status doesn't reflect she is rarely or never understood. She has difficulty concentrating on things such as reading or watching television. Resident wandered daily. Preferences for Customary Routine and Activities reflect resident is rarely/ never understood. Also reflects she has not activity preferences. Record review of Resident #5's Care plan dated 04/26/2021 reflected Provide in room activities of choice, as able. Resident needs out of room social, spiritual and stimulus activities and mental stimulation. Resident enjoys interacting with other resident's nail care, crafts and exercise. The activity director will encourage and remind the resident of current activities. The activity director will provide the resident reading material for mental stimulation. Resident has impaired cognitive function/ dementia or impaired thought process related to unspecified dementia with behavioral disturbance. Provide a program of activities that accommodates the resident's abilities. Resident at risk for wandering. Distract resident from wandering by offering pleasant diversions, structured activities, television and book. Provide structured activities pictures and memory boxes. Record review of Resident #5's Activity Quarterly Progress Note dated 04/08/2021 reflected Resident #5 attended 3-5 activities a week. She requires reminding to attend group activities. She is an active participant. Prefers to be with people and out of room. Her vision and hearing are poor. Her psychosocial needs are the following: adjustment to placement and intellectual stimulation. Record review of Resident #5's Activity Quarterly Progress Note dated 07/09/2021 reflected Resident #5 attended 6 or more activities. She required assistance to attend activities and was an active participant. She prefers to be around people and prefers to be out of room. Her hearing and vision are poor. Resident Psychosocial Needs are the following: adjustment to placement, intellectual activities, spiritual growth and sensory stimulation. Observation of the 18 residents residing in the secure unit on 07/19/2021 at 10:00 AM revealed the parachute ball group activity scheduled at 10:00 AM was not being conducted on the secure unit. There were residents sitting in the common area. The television was on, however, the residents weren't watching the television. Some of the residents were asleep and some residents were leaning on the arm of the couch and chairs. Residents were not engaged in any individual activities. Observation of the secure unit on 07/19/2021 at 10:10 AM revealed Resident # 3 pacing from the television area into the hall and back. LVN B attempted to redirect Resident #3 by conversing with her and offering something to drink. Resident # 3 increased pacing and put her arm up where LVN A could not come near her. Observation of the secure unit on 07/19/2021 at 10:15 AM revealed Resident #1, #2, #4 and #5 were asleep in the television area. These residents were sitting in chairs. In an interview on 07/19/2021 at 10:25 AM LVN B stated there aren't ' any activity items for the staff to use when interacting with residents. I asked the therapy department if they would provide us with a beach ball for the residents. The beach ball, a few puzzles and dominoes were all the activity items they had to offer the residents LVN B stated the activity director did not come on the secure unit to do any group or individual activities. She stated, when residents had any type of behavior problems, whether it was exit seeking or wandering into other residents' rooms, they did not have access to any activity items. She stated if the staff on secure unit had activity items, it would help divert resident's attention. She stated the AD had not asked her about interests of the residents (on secure unit) or their daily routine. Observation on 07/19/2021 at 10:30 AM of the closet where activity items were located on the secure unit revealed very few activity items. There was a beach ball, a balloon, a few puzzles and a few craft items. In an interview on 07/19/2021 at 10:40 AM CNA C (6:00 AM-2:00 PM shift) stated the staff on this unit (secure unit) were unable to do activities. She stated staff were giving baths, giving care and having to monitor the residents. She stated if residents needed to be re-directed, when they are wandering toward the door, into other residents' rooms or attempting to stand up when they cannot walk, the staff did not have any activity items to provide for these residents. She stated if residents had group activities as scheduled, there would be less behaviors and it would help residents with their happiness. CNA C stated staff never saw the AD unless she was coming to get two of the residents to go to the general population area to play bingo approximately once a week. She stated the activities listed on the calendar were never followed by activity staff and staff on the secure wing were responsible for doing group activities. She stated the nursing staff would do some things with the residents but they couldn't follow the exact times on the calendar and may not have time to do what is on the activity calendar. She stated it was the activity directors responsibility to have residents in some type of activity. She stated the activity director had not asked here any questions about the residents on the unit. She stated the AD would have a party on the general population side of the facility and would not bring food for the residents on the unit (secure unit). Observation of the secure unit on 07/19/2021 at 2:00 PM revealed eight residents sitting in the television area. The residents were not watching the television. Four of the residents were asleep and four residents were looking around the room. There were three residents in the dining room area and they were talking to one another. There were not any one on one activities or group activities occurring with the residents. The group daiquiri and music group activity listed on the activity calendar wasn't being followed by the activity department. The activity department didn't provide any items for the staff on the unit to do any of the activities. In an interview on 07/19/2021 at 2:10 PM CNA D (2:00 PM- 10:00 PM) stated she didn't ever see the AD. She stated it was very difficult to attempt to re direct residents when they were wandering into other residents' rooms or they were anxious and would not sit still. She stated there were not any activity items for the staff to offer the residents when they had sun down behavior issues. She stated the activity director didn't have group activities on this unit, and she had never seen her do any individual activities. She stated the AD had not asked her any questions about the residents on this unit. Observation of the secure unit on 07/20/2021 at 10:30 AM revealed eight residents sitting in dining room and staff were passing out something for them to drink. There were six residents in the tv area not watching tv. They were staring around the room. Resident #3 was pacing and staff attempting to re-direct her and she became agitated. When they attempted to offer her something to drink or assist her to sit in a chair she refused. In an interview on 07/20/2021 at 10:40 a.m., NA E stated I have been working on the secure unit approximately a month and didn't know there was an activity director until now He stated he hadn't witnessed residents participating in group activities or individual activities. He stated the only activity item he knew about was a beach ball. He state he had not seen any memory boxes or heard any Hispanic music being played. In an interview on 07/20/2021 at 2:10 PM CNA F (2:00 PM -10:00 PM shift) stated there isn't any activity items on the secure unit to offer the residents except a beach ball. The AD never comes on the unit (secure unit) unless it's to get one or two residents to play bingo in the non secure area of the facility. She stated the AD didn't interact with any of the residents when she comes and assists two of the residents off the unit. She stated there were not any memory boxes or any Hispanic music for the residents. She stated the AD didn't follow the activity calendar and never held any group or individual activities on this unit. She stated we had a gentleman who lived on this unit and he liked books and different types of magazines. CNA F stated she would bring books from home and go to store and buy him magazines. She stated there were some ladies at one time that liked to do crafts. She stated the few craft items in the closet were items she purchased personally and brought to the facility. She stated the AD hadn't discussed any residents with her. She stated she had requested activity items from the AD but had not received any. In an interview on 7/19/2021 at 2:05 PM the AD stated she does not have any participation records for the secure unit. She stated there was not any documentation of activity items being offered to residents on the secure unit. She stated the activity department is responsible for providing activity items for residents. The AD stated she had not created any memory boxes for any of the residents. She stated when was the only activity staff in the activity department. She stated when she completed an assessment of the residents on the secure unit she guessed the activities they had attended. She stated if residents were unable to be interviewed, the activity interests/preferences would be provided by the families. She stated she did not ask staff working on the secure unit any questions about the residents prior to completing their assessment. The AD stated she had not received any training on any documentation since she began working in November of 2020. The AD stated she was informed by Ambassador G in June of this year (2021), every activity for secure unit was required to be documented on a participation record. The AD stated she did not have any participation records for June or July of this year (2021) for the secure unit. She stated the only time she went on the secure unit was to assist two or three residents off the unit to play bingo or dominoes. She stated she did this maybe once a week. She agreed the activities on the care plans did not meet the resident's preferences or abilities. She stated the activity department was responsible for one on one activities for residents on secure unit. She stated she had not organized a one on one activity program for any of the residents (Resident #1, #2, #3, #4 and #5). She stated she did not have access to an Activity Manual. In a (phone) interview on 07/20/2021 at approximately 11:00 AM the Life Enrichment Coordinator G (Consultant of the Activity Director) stated the participation records for the entire facility were discussed with the AD during the onboarding training in December 2020. She stated when she visited in February they were discussed again. She stated they discussed care plans, MDS, participation records and all documentation pertaining to the activity department. She stated the AD did receive a visit from an Ambassador H in June. She stated Ambassador H reviewed documentation and activity programming. She stated she did discuss creating Secure Unit calendars beginning in March 2021 with the AD in February 2021. She stated the AD had not been using a calendar for the secure unit. She stated the AD was given all the information she would need to develop activity programs, complete all documentation including participation records. In an interview on 07/20/2021 at 1:15 PM the Interim Administrator stated the activity director did have access to an activity manual and after information shared by the Life Enrichment Consultant G, it was apparent the activity director did have training of her job duties in December 2020. He stated activities were required on the secure unit and to be documented on the proper participation forms. He stated he had only been interim at this facility few months. He stated he was learning all the staff and the operations of this facility. He stated he was not aware the calendar was not being followed on the secure unit. He stated he would need to review documents to answer any further questions. Record Review of onboarding document used in the virtual class in December 2020 provided by the Life Enrichment Coordinator (Activity Consultant) revealed Activity Expectations: Documentation, Activity Program Review, Utilization of Resources and Monthly Calendar. The class explained all documentation including participation records. It also explained where to locate the Activity Manual on the computer. The following are some of the information can be found in the Activity Manual: 1. Activity Programming 2. Activity Program Calendar 3. Individual Activity Programs 4. Supplies and Equipment 5. Activity Assessment 6. Activity Care Planning 7. Activity Progress Notes 8. Activity Participation Records Record Review of the facility policy on Activity Programming dated 2011 reflected: 1. Recreation programs are based on the interest and needs of the residents expressed through the activity assessment. 2. Resident's or family's expressed needs and interests are included in the development of programs. 3. Activity programs are to be designed based on resident's leisure interests and implemented to meet the needs (physical, cognitive, creative, social, spiritual, independent and sensory) of the residents. 4. Programs will be geared to maintain functional ADL's, provide social interaction and, at the same time, protect residents from environmental over stimulation. 5. Those who cannot participate in group settings are provided individual programming. Inability to participate could include those who refuse to participate in activities, those who are in isolation or physician ordered bed rest. 6. Programming includes large groups, small groups, individual and independent opportunities. 7. Programs may take place in mornings, afternoons, and/ or evenings that span throughout the entire week. 8. Programs various areas available in and out of the health care center. 9. The resident population is cognitively assessed routinely to determine the number of functional level programs needed.

Based on observation, interview and record review, the facility failed to maintain an effective pest control program to keep the facility free of pests and rodents. The facility failed to keep flies out of the facility. This facility failure could place residents at risk for spread of infection, cross-contamination, food-borne illness, and decreased quality of life. Findings include: Observation on 1/6/2020 at 11:50 AM revealed several flies flying around in the dining room. Resident #184 had a fly swatter on the dining table. Observation on 1/6/2020 at 2:57 PM of Resident #21 sitting in Geri-chair as a fly was flying around and landing on resident #21. A family member continued to wave fly away. Observation on 1/6/2020 at 3:17 PM of Resident #68 where there were two flies, in his room, flying around him, and landing on his stomach and arm. Observation and Interview on 1/6/2020 at 03:19 PM revealed Resident #12 has flies in her room. She had a fly swatter in the seat of her wheelchair next to her. Two flies are flying around her and landing on her while she's talking and she continued to wave them off. She said, Oh these flies are BAD. Observation on 1/7/2020 at 9:00 AM revealed Resident #42 sitting in the day area near the nurse's station, on the secured unit. Surveyor noted three flies landing on his hands and face. He was observed by surveyor batting the flies away. Interview on 01/07/2020 at 9:05 AM where LVN A stated that the facility occasionally has problems with flies, especially during warm weather. She said there is a fan over the door going outside that helps keep the flies from coming into the building. She said the residents complain of being cold when the fan is on. She said there is also a light that helps keep the flies away. Observation on 01/07/2020 at 9:05 AM revealed a fan hanging above the door leading to outside patio area on the secure unit. The fan was not turned on. Surveyor observed a light hanging on the wall near the door leading to outside patio area on the secure unit. The light was not turned on. Observation on 1/7/2020 at 10:08 AM revealed a fly swatter on the nightstand of Resident #234. Observation on 1/7/2020 at 10:32 AM revealed two flies on the refrigerator in the kitchen. Surveyor also observed one fly on the tray rack. This rack was used as cart to transport meals. Observation on 1/7/209 at 10:51 AM revealed two flies landing on the prep table in the kitchen while dessert was being prepared by kitchen staff. Interview on 01/07/2020 at 11:50 AM, the Maintenance Director stated that the fans above the doors are designed to keep flies and other flying insects out of the building. He said the residents complain they are cold, when the fans are on. He stated the light on the wall of the dining room is a bug light. He then stated, the bulb is out. Observation on 01/07/2020 at 11:50 AM, revealed a fan hanging above the door leading outside, across the hall from the dining room. The fan was not turned on. There was a sign attached to the fan instructing: the fan is to be on at all times. Surveyor also observed a bug light on the wall in the dining area. This bug light was not turned on. Observation on 1/7/2020 at 12:16 PM, revealed Resident #34 in dining area with a fly crawling on her bowl of food. Observation on 1/7/2020 at 12:17 PM, revealed Resident #44 at table in dining room. A fly was crawling on her dessert. Interview on 1/7/2020 at 12:18 PM, Resident #44 stated the flies are usually bothering her about half the time. Observation and Interview, on 1/7/2020 at 12:20 PM, in the dining area, Resident #12 had a fly swatter on her table. When asked about the fly swatter, she stated, to fight off the flies when they get bad. Observation on 1/7/2020 at 12:36 PM, revealed a fly swatter on the bedside table, in the room of Resident #10. Interview on 1/7/2020 at 12:36 PM, Resident #10 stated, while pointing to her fly swatter, when the flies get bad sometimes, I have to use it. She also stated she had a fly that landed on her nose. Observation on 01/07/2020 at 12:40 PM, revealed a bug light, on the wall at the Number Two Nurses Station, was not plugged in. On 01/07/2020 at 1:20 PM, during a confidential meeting with 6 alert and oriented residents, all attendees revealed they keep a fly swatter in their rooms. They reported to surveyor they had frequent problems with flies in the facility. Interview on 01/07/2019 at 1:45 PM, of Dietary staff, revealed flies in the kitchen were occasionally a problem. He said the flies come in from the door leading to the outside, located directly across from the dining room. He said they try to keep food covered when flies are in the kitchen. He said there was a light in the kitchen that helps with the flies. The light was not currently working. He said the light was flickering so he turned it off this morning. Observation on 01/07/2020 at 2:05 PM, revealed an air-curtain type fan hanging over the entrance/exit door, near the staff lounge. Surveyor observed the fan was not turned on. Interview on 1/8/2020 at 11:05 AM, with the Dietary Manager, she reported they do not normally have a fly control problem at this time of year. She stated there are flies in the kitchen that come from the dining area. DM reported there are lights and fans to help with flies and they also have dumpster clean up to attempt to reduce the number of flies in the area. Interview on 1/8/20 at 1:21 PM, with Administrator, revealed she had not noticed any insect problems. She stated they have air curtains, big lights and pest control contracts to control pests in the facility. She stated there are air curtains and lights at most entrances. She noted there had been an in-service with all staff, to keep air curtains turned on and not to unplug the lights. Record review of the undated facility policy titled Insect and Rodent Control revealed: The facility will maintain an effective pest control program in order to provide an insect and vermin free food service department. Arrangements are made with a reputable company for regular spraying for insects which includes rodent control when required. Facility will maintain appropriate screens, close fitting doors. Properly sealed water/sewer pipes, structurally maintained walls, baseboards, etc. to prevent entrance access of insects and rodents. Sanitation of facility will be maintained per other stated sanitation policies to prevent food sources, breeding places, etc. for insects or rodents. Deliveries of food and supplies will be monitored for prevention of insect and rodent access. Record review of a contract with Perfect Pest Control dated 01/05/2011 revealed pest control services are to be provided monthly/bi-monthly. Contract states pest control work shall conform to Federal, State and local ordinances and laws and shall be performed in a safe manner and in accordance with the most modern and effective scientific pest control procedures. Record review of Service tickets for pest control reveal treatments shall be performed the 2nd Wednesday of every month. Service Ticket dated 10/8/19 indicates treatment for [REDACTED]. Service Ticket dated 11/12/19 indicates treatment for [REDACTED]. Service ticket dated 12/10/19 indicates Catchmaster fly light glueboard (6 each) for hallways and kitchen to target flies, PT Alpine pressurized fly bait for kitchen.

Based on observation, interview and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 1 of 1 resident reviewed for incontinent care (Resident #47). Licensed Vocational Nurse (LVN B) failed to properly change gloves and wash or sanitize hands when moving from a soiled area to a clean area on Resident #47 when providing incontinent care. This deficient practice placed all residents identified as incontinent of bladder and/or bowel at risk for cross contamination, spread of infection and urinary tract infections. Findings include: Review of resident #47's face sheet reflected resident #47 was a [AGE] year-old male admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set ((MDS) dated [DATE] reflected resident #47 had a Brief Interview for Mental Status (BIMS) score of 11 indicating Resident #47 had moderately impaired cognition. The MDS assessment for bowel and Bladder reflected Resident #47 was always incontinent of bowel and bladder. Review of the care plan initiated 11/10/2013 with a goal date of 02/26/2020 reflected Resident #47 was susceptible to urinary tract infections. He had an activity of daily living self-care deficit, he was totally dependent on staff for toilet use. During an observation on 01/07/2020 at 03:45 PM LVN B provided incontinent care to resident # 47 with assistance from CNA [NAME] LVN B used hand sanitizer then donned gloves. While resident # 47 was supine LVN B unfastened the wet brief and folded it back and away from resident #47 toward his legs, LVN B then used disposable wipes to clean the resident's groin and pubic area. With assistance from CNA A he rolled Resident #47 onto their left side, LVN B then removed the wet brief, placing the wet brief at the end of the resident's bed near his feet. LVN B used disposable wipes to clean the resident's buttocks and rectal area. LVN B failed to remove gloves and sanitize hands prior to applying barrier cream to the resident's buttocks. LVN B unfolded a clean disposable brief placing it under the resident's buttocks, then with assistance from CNA A rolled Resident #47 onto the brief, LVN B then pulled the clean brief up between the residents' legs and fastened the tape. LVN B placed the wet brief into a trash bag provided by CNA A, LVN B pulled the blankets up over the resident, removed gloves placing the soiled gloves into the trash bag, and tied the bag closed. LVN B then pulled back the privacy curtain and took the trash to the soiled linen/trash closet in the hallway. LVN B came back to the resident's room and washed hands. LVN B did not sanitize his hands or change gloves when moving from a dirty area to a clean area while performing incontinent care to Resident #47, LVN B placed a wet disposable brief onto Resident #47's bedding during incontinent care. During an interview on 01/07/2020 at 3:55 PM LVN B and CNA A stated they usually wash hands or use hand sanitizer and change gloves when moving from a dirty area to a clean area while performing incontinent care but were nervous when being observed by a state surveyor. During an interview on 01/07/2020 at 4:00 PM the DON stated it was her expectation nursing staff would perform hand hygiene when moving from a dirty area to a clean area, including removing gloves, use of hand sanitizer or washing hands with soap and water and donning clean gloves. Review of a document provided by the DON, titled Perineal Care of Male dated (MONTH) 14, 2007 revealed the following: [NAME] wash hands and put on clean gloves for perineal care. H. Gently wash perineal area, wiping from clean urethral area toward dirty' rectal area. e. Change gloves. H. pat dry the urethral and perineal area, working in the same direction until dry. [NAME] Change gloves. I. Cleaning the rectal and buttocks area. a. Assist resident to turn onto side. b. Gently wash the rectal and buttocks area c. Change gloves. d. If using a no-rinse perineal cleaner, pat dry the rectal and buttocks area. f. Change gloves g. Apply moisture barrier h. remove gloves. [NAME] Closing steps a. Clean and store reusable items and discard disposables per facility policy. b. If gloved, remove and discard gloves. Wash hands. Review of the facility infection control policy titled Fundamentals of Infection Control Precautions dated (YEAR) revealed the following: Gloving, Wearing Gloves does not replace the need for hand washing because gloves may have small inapparent defects or be torn during use, and hands can become contaminated during removal of gloves.

Based on observation, interview and record review, the facility failed to ensure nursing staff were able to demonstrate competency in skills and techniques necessary to care for resident's needs as identified through resident assessment and described in the plan of care for 1 of 1 resident reviewed for incontinent care. (Resident #47) LVN B failed to properly wash or sanitize their hands when moving from a soiled area to a clean area of Resident #47 while providing incontinent care. This deficient practice placed all residents identified as incontinent of bladder and/or bowel at risk for cross contamination, spread of infection and urinary tract infections. Findings include: Review of resident #47's face sheet reflected resident #47 was a [AGE] year-old male admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set ((MDS) dated [DATE] reflected resident #47 had a Brief Interview for Mental Status (BIMS) score of 11 indicating Resident #47 had moderately impaired cognition. The MDS assessment for bowel and Bladder reflected Resident #47 was always incontinent of bowel and bladder. Review of the care plan initiated 11/10/2013 with a goal date of 02/26/2020 reflected Resident #47 was susceptible to urinary tract infections. He had an activity of daily living self-care deficit, he was totally dependent on staff for toilet use. During an observation on 01/07/2020 at 03:45 PM LVN B provided incontinent care to resident # 47 with assistance from CNA [NAME] LVN B used hand sanitizer then donned gloves. While resident # 47 was supine LVN B unfastened the wet brief and folded it back and away from resident #47 toward his legs, LVN B then used disposable wipes to clean the resident's groin and pubic area. With assistance from CNA A he rolled Resident #47 onto their left side, LVN B then removed the wet brief, placing the wet brief at the end of the resident's bed near his feet. LVN B used disposable wipes to clean the resident's buttocks and rectal area. LVN B failed to remove gloves and sanitize hands prior to applying barrier cream to the resident's buttocks. LVN B unfolded a clean disposable brief placing it under the resident's buttocks, then with assistance from CNA A rolled Resident #47 onto the brief, LVN B then pulled the clean brief up between the residents' legs and fastened the tape. LVN B placed the wet brief into a trash bag provided by CNA A, LVN B pulled the blankets up over the resident, removed gloves placing the soiled gloves into the trash bag, and tied the bag closed. LVN B then pulled back the privacy curtain and took the trash to the soiled linen/trash closet in the hallway. LVN B came back to the resident's room and washed hands. LVN B did not sanitize his hands or change gloves when moving from a dirty area to a clean area while performing incontinent care to Resident #47, LVN B placed a wet disposable brief onto Resident #47's bedding during incontinent care. During an interview on 01/07/2020 at 3:55 PM LVN B and CNA A stated they usually wash hands or use hand sanitizer and change gloves when moving from a dirty area to a clean area while performing incontinent care but were nervous when being observed by a state surveyor. During an interview on 01/07/2020 at 4:00 PM the DON stated it was her expectation nursing staff would perform hand hygiene when moving from a dirty area to a clean area, including removing gloves, use of hand sanitizer or washing hands with soap and water and donning clean gloves. Review of a document provided by the DON, titled Perineal Care of Male dated (MONTH) 14, 2007 revealed the following: [NAME] wash hands and put on clean gloves for perineal care. H. Gently wash perineal area, wiping from clean urethral area toward dirty' rectal area. e. Change gloves. H. pat dry the urethral and perineal area, working in the same direction until dry. [NAME] Change gloves. I. Cleaning the rectal and buttocks area. a. Assist resident to turn onto side. b. Gently wash the rectal and buttocks area c. Change gloves. d. If using a no-rinse perineal cleaner, pat dry the rectal and buttocks area. f. Change gloves g. Apply moisture barrier h. remove gloves. [NAME] Closing steps a. Clean and store reusable items and discard disposables per facility policy. b. If gloved, remove and discard gloves. Wash hands. Review of the facility infection control policy titled Fundamentals of Infection Control Precautions dated (YEAR) revealed the following: Gloving, Wearing Gloves does not replace the need for hand washing because gloves may have small inapparent defects or be torn during use, and hands can become contaminated during removal of gloves.

Based on interview and record review the facility failed to implement their written policy to ensure that all alleged violations involving abuse, neglect, or mistreatment are reported immediately to the administrator of the facility for one of six residents reviewed for neglect (Resident #3). LVN E failed to immediately inform the facility's Abuse Coordinator when Resident #3 informed her that Resident #1 had touched her breast without her permission while she slept in her wheelchair. This failure to immediately notify the Abuse Coordinator affected Resident #3 by causing her increased anxiety and psychological distress. Findings Included: Review of the policy Abuse/Neglect dated 01/08/03 reflected; It is each individual's responsibility to recognize, report and promptly follow up abuse or neglect allegations, suspicion of abuse or neglect, and situations that may constitute abuse or neglect to any resident in the facility. When a suspected abused, neglected or exploited adult comes to the attention of any employee, that employee will make an immediate verbal report to the Abuse Coordinator. Review of Resident #1's Face Sheet reflected [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set ((MDS) dated [DATE] reflected a Brief Interview of Mental Status (BIMS) score of four (4) which indicated he was severely cognitively impaired. He was assessed as requiring extensive assistance of one to two staff for his activities of daily living except locomotion which was limited assistance. He was assessed as being on an antipsychotic medication daily. Resident #1 was not assessed as having behaviors. Review of Resident #1's Care Plan dated 09/20/2016 reflected he had impaired cognitive function and impaired short term memory with interventions of reduce distractions, use simple directive sentences and keep a consistent routine. Review of Resident #3's Face Sheet reflected a [AGE] year old female admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The resident was listed as her own Responsible Party (RP). Review of Resident #3's Quarterly MDS dated [DATE] reflected a BIMS score of nine (9) which indicated moderate cognitive impairment. Resident #3 was not assessed as having behaviors. Resident #3 was assessed as having received an antipsychotic, antianxiety and antidepressant medication daily during the observation period. She was assessed as requiring supervision to limited assistance for activities of daily living. Review of Resident #3's Care Plan dated 12/19/2016 reflected an intervention for staff to monitor and report signs of depression including hopelessness, anxiety, sadness, verbalizing negative statements, anxious complaints or tearfulness. In an interview on 05/24/2017 at 1:30 PM Resident #3 stated late at night on Friday 04/28/2017 around 12:30 AM to 2:00 AM she was on the patio with her male friend, Resident #1, whom she had asked to join her on the patio. Resident #3 stated she had a sleep disorder that caused her to go into a deep sleep while on the patio with Resident #1. Resident #3 stated she slightly wakened to become aware that Resident #1 was fondling her breast. Resident #3 stated she said, Stop then went back to sleep but not quite so deep. Resident #3 stated she woke up to an alert state just shortly after and asked Resident #1 if he played with her breast while she was asleep. Resident #1 told her, Yes. Resident #3 asked him why he did that and he told her he didn't know. Resident #3 stated she was very disturbed that Resident #1 would do that to her without her consent. Resident #3 stated at 6:00 PM on Saturday, 04/29/2017, she told LVN E exactly what happened during the previous night with Resident #1. Resident #3 stated LVN E's response was that she would need to call State and do a lot of paperwork. Resident #3 stated she begged LVN E not to tell anyone about it but that she just needed to get it off her chest. Resident #3 stated she felt like she had caused a burden on the facility by telling them of the event. Resident #3 stated her nipple was very sore on Saturday 04/29/2017 and the staff had found a scratch on the side of the same breast when they examined her on Sunday 04/30/2017. In an interview on 05/24/2014 at 2:06 PM Resident #1 was asked if he had touched Resident #3's breast without permission while she was asleep on the patio. Resident #1 nodded his head indicating yes. In an interview on 05/25/2017 at 9:30 AM LVN E stated on Saturday 04/29/2017 at approximately 6:00 PM Resident #3 told LVN E about Resident #1 touching her breast. LVN E stated she told Resident #3 they would need to call the State and get the paper work going for the event. Resident #3 started crying and exclaimed for LVN E not to tell anyone and that she just needed to get it off her chest. LVN E stated she asked Resident #3 if she would like LVN E to keep Resident #1 away from her and Resident #3 told her yes she would like that. LVN E stated she did not notify the Abuse Coordinator, she re-directed between Resident #1 and #3 and went back to work. LVN E stated the next morning, Sunday 04/30/2017. Resident #3 told her she just couldn't handle it anymore and she wanted to report the event. LVN E stated she got on the phone to the Administrator. LVN E stated she assisted in assessing Resident #3 and found a fresh scratch on Resident #3's breast that was four centimeters long and there was no other injury. LVN E stated in hind sight she should have phoned the Administrator as soon as Resident #3 told her Resident #1 had touched her breast without her permission. Review of the Event Nurse Note Skin Tear/Abrasion for Resident #3 dated 04/30/2017 at 9:01 PM reflected; Resident reported scratch to her right breast, four (4) centimeters, slightly scabbed. Occurred outside. Resident stated she did not have a scratch Friday evening but noticed it today during skin assessment. Cognition: Oriented/no problem. Conclusion: Resident stated that she was sleeping in her wheelchair in courtyard and woke up and Resident #1 was pinching/fondling her breast. Interventions: immediate separation of Residents and Resident #1 was moved to a different unit and 1 to 1 and every 15 minute checks. In an interview on 05/24/2017 at 5:23 PM the DON stated LVN E should have called the Administrator as soon as Resident #3 told her. In an interview on 05/24/2017 at 5:45 PM the Administrator stated they in-serviced on Abuse/Neglect reporting every month and LVN E should have told her immediately about Resident #3's report. Review of LVN E's employee file reflected she had signed in orientation to immediately report Abuse/Neglect allegations. In an interview on 05/24/17 at 5:23 PM the DON stated Resident #1 was the only male resident in the building that developed close relationships with other residents.

Based on observation, interview and record review the facility failed to develop and implement written policies and procedures to prevent neglect for one (1) of five (5) residents reviewed for neglect (Resident #1). Resident #1 was [AGE] years old with a history of [MEDICAL CONDITION], a [MEDICAL CONDITION], and a recent [DIAGNOSES REDACTED].#1 to the hospital for complaints of shortness of breath and not feeling well for approximately 50 minutes; despite her repeated requests. Resident #1 was transported to a local hospital in respiratory distress where she expired in less than three hours after arrival due to [MEDICAL CONDITION]. This deficient practice could affect a facility census of four residents receiving physician ordered respiratory treatments, and five residents receiving antibiotic therapy by placing them at risk for delayed physician treatments and interventions resulting in worsening of medical conditions, hospitalization s, and death. The Findings Include: Review of the facility's Abuse/Neglect policy dated 08 ,[DATE] reflected the following: Neglect: Definition failure to provide care and services to a person who is unable to care for themselves, or intentionally not providing services which can potentially result in harm. Review of a Face Sheet for Resident #1 reflected she was [AGE] years old, with an original admission date of [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED].), Dysphagia, Neuromuscular Dysfunction of the bladder, Pneumonia, Reflux, [MEDICAL CONDITION], Abdominal wall abscess, and Convulsions. Resident #1 was her own responsible party. Review of a MDS dated [DATE] for Resident #1 reflected she required extensive assistance of two staff for transfers, and bed mobility. Resident #1 had an [MEDICAL CONDITION] (a surgical procedure in which the small intestine is attached to the abdominal wall to bypass the large intestine; digestive wastes then exits the body through an artificial opening called a stoma), a [MEDICAL CONDITION] (a surgical opening in the neck through the trachea to provide an airway), an indwelling urinary catheter, and received oxygen via nasal cannula at 2 liters per minute. Resident #1 had a BIMS score of 8 indicating moderate cognitive impairment. There were no behaviors noted on the MDS. Review of a care plan for Resident #1 dated [DATE] reflected the following: -Full code CPR order is in place -Resident has oxygen therapy related to [MEDICAL CONDITION]. Resident has a trach. Goal: Resident will have no signs and symptoms of poor oxygen absorption. Intervention/Tasks: Monitor for signs and symptoms of respiratory distress and report to physician as needed- respirations, pulse oximetry (to monitor blood oxygen saturation levels), increased heart rate, restlessness, sweating, headache, confusion, pleuritic pain, and skin color. -Resident has cognitive impairment related to short term memory loss. Goal: Resident will be able to communicate basic needs. Interventions: monitor/document/report to physician any changes in cognitive function specifically changes in decision making ability, memory recall and general awareness. -Resident requires [MEDICAL CONDITION] medications for [DIAGNOSES REDACTED].>Review of physician orders [REDACTED]. Get CBC (complete blood count), urinalysis and culture with sensitivity if indicated; culture drainage from PERC drain (Percutaneous Abdominal Drain). Review of a mobile x-ray report for Resident #1 dated [DATE] time 1:00 PM reflected the following: The [MEDICAL CONDITION] is at T-3 ([MEDICATION NAME] vertebrae). There is hazy left lower lung infiltrate Review of a facility communication form to the physician dated [DATE] reflected the following: X-ray this morning shows hazy left lower lobe infiltrate. Resident complaining of weakness and shortness of breath. Continuous oxygen at 2 liters a minute. Shows 99% oxygen saturate rate. Vital signs within normal limits. 8:00 PM telephoned nurse practitioner and received new orders for [MEDICATION NAME] 750 mg. once daily for 7 days and [MEDICATION NAME] 40 mg. daily for 7 days. 8:30 PM initial dose of [MEDICATION NAME] given. In an interview on [DATE] at 11:45 PM during initial tour, LVN Z stated when she came on duty at 10:00 PM on [DATE] she was told in report that Resident #1 had been diagnosed with [REDACTED]. LVN Z stated she made rounds to observe all of the 42 residents on the halls she was assigned. LVN Z state she didn't check on Resident #1 until about 10:15 PM and took her vital signs which were normal. LVN Z went on to say she wasn't aware Resident #1 wanted to go the hospital until the police department came to the facility to check on her at approximately 11:15 PM on [DATE], because emergency medical services reported the resident called for transport. LVN Z stated she had not been informed by the CNAs on duty that Resident #1 wanted to go to the hospital. LVN Z stated that CNA C refused to inform her anytime a resident needs something. He will tell another CNA to inform the charge nurse, but he will not talk to her directly. In an interview on [DATE] at 12:15 AM, CNA C stated when he came on duty on Resident #1 was on her call light, as usual. CNA C went on to say that he was busy passing water to residents and checking on them so another aide answered the call. CNA C stated a few minutes later Resident #1's call light was on again and she (Resident #1) stated she just needed someone to hold her hand. CNA C stated he held Resident #1's hand for about 20 minutes and during that time she asked him to help her find her personal cell phone and that she wanted to go to the hospital. CNA C stated he couldn't find the phone, but Resident #1 found it herself and he left the room. CNA C stated he couldn't remember if he told the charge nurse, LVN Z, if Resident #1 had stated she wanted to go to the hospital. CNA C added Resident #1 was always on her call light and had requested to go to the hospital in the past as well. Review of a written statement of CNA C dated [DATE] reflected he answered Resident #1's call light at around 10:40 PM; and that he had just finished passing ice/water on the halls. CNA C stated Resident #1 wanted someone to hold her hand and not let go, but he was very busy and told her he would return. CNA C stated he managed to return to Resident #1's room approximately 20 minutes later and held her hand. CNA C wrote I tried to assure her everything was going to be alright, but she insisted on using the phone (cell phone). I looked for her cell phone but could not find it. She (Resident #1) then looked and found it herself. I asked her if she needed anything else more and she stated no: so I left the room. She (Resident #2) then must have used her cell phone to dial 911. At round 11:10 PM the police arrived to check on her. The nurse told the police officer all of the resident's (Resident #1) vital signs were good, but she insisted on going to the hospital. The ambulance was called and she was transported to the emergency room . In a follow up interview with CNA C on [DATE] at 12:30 AM, CNA C was asked to review his written statement and questioned by what he meant by assuring Resident #1 everything was going to be Ok. CNA C stated he now denied telling Resident #1 everything was going to be ok, and would not comment if he told LVN Z Resident #1 wanted to go to the hospital. CNA C did state he knew it was his responsibility to report to the charge nurse if a resident needs something or wants to go to the hospital. Review of a facility physician communication document for Resident #1 dated [DATE] and [DATE] completed by LVN Z reflected the following: 2200 (10:00 PM) Resident in bed no symptoms of pain or discomfort 2215 (10:15 PM) Blood pressure ,[DATE], pulse 77, respirations 20, temperature 97.0 degrees, oxygen saturation level 99 %, oxygen on at 2 liters per minute, No pain or respiratory distress noted. 2315 (11:15 PM) Sheriff's department arrived asking for room [ROOM NUMBER]. Stated that they had received two phone calls from resident. Went into resident's room with Sheriff and Resident complained of shortness of breath. There were no previous complaints of shortness of breath prior to this time. Oxygen saturation 99 %. 2340 (11:40 PM) Notified DON of situation going on 0030 (12:30 AM [DATE]) Resident still complaining of shortness of breath and demanding to go to the hospital. 0040 (12:40 AM [DATE]) Ambulance called per resident request 0100 (1:00 AM [DATE]) resident left facility. Review of a local police officer's statement dated [DATE] reflected the following: Received dispatch call for a welfare check at . (facility's address) initiated from the Sheriff's Department. Sheriff's department received several calls from a resident in room [ROOM NUMBER] requesting to be transported to the hospital for shortness of breath. Sheriff's Department called several times to the nursing home and no one answered the phone, so a welfare check was requested. A male nurse and another nurse stated the resident was fine and did not need to go to the hospital. The resident did inform the officer she wanted to go to the hospital, but it was explained police officers are not medical personnel and cannot make the decision. Arrival time 11:15 PM [DATE] and departure time 11:28 PM. Review of the local emergency medical services records for Resident #1 dated [DATE] reflected the following: Call received at 00:44 En route-00:45 On scene: 00:48 At Patient 00:49 Arrived on scene met nurse states that patient has difficulty breathing and patient demanded to be seen at the emergency room . The nurse gave us this report at the front door of the nursing home. Walked in patient's room finds patient in severe respiratory distress. Very cyanotic {blue in color indicating poor oxygenation} in fingertips and lips. Patient did wake up when spoken to and stated she does not feel good; at this time a NRB (non-rebreather mask) was placed over patient's trach, oxygen given at 15 liters per minute. Patient placed in the ambulance and started helping with breathing and her color improved greatly. At this time Air EVAC on standby and transported the patient to the flight crew base. Flight crew came onboard and informed us that patient would not fit in the aircraft for emergent transportation. Patient was given [MEDICATION NAME] intravenously for possible drug overdose and improved greatly and started opening her eyes and trying to talk. Air EVAC crew decided patient should be transported to local hospital. Arrived on scene at hospital at 01:36 AM and transferred care to hospital staff. {[MEDICATION NAME] is a medication used to treat respiratory distress and/or failure in patients with overdosing of opiate medications.) Review of hospital emergency room records for Resident #1 reflected: Exam: 02:00 AM-Patient is [AGE] year old female with complaints of respiratory distress. Appears alert, awake, obese and in distress, mildly distressed. Afebrile, cyanotic. Lung sounds- bilateral lower lobes with decreased breath sound that are moderate, and more so on the left side. 02:41 AM. blood pressure ,[DATE] (normal ,[DATE]) pulse 63, respirations 41 (normal 12 to 16), oxygen saturation on room air 81%. 03:09 AM. [MEDICAL CONDITION] removed and replaced with endotracheal tube. 03:12 AM response to endotracheal tube patient's symptoms have mildly improved. 03:45 AM. Patient became [MEDICAL CONDITION] (low heart rate), low blood pressure and went into [MEDICAL CONDITION]. Chest compressions started and intravenous [MEDICATION NAME] given. Pulseless, no spontaneous breathing. Patient pronounced dead at 03:45 AM. In an interview on [DATE] at 2:13 AM, the DON stated she was not contacted by any facility staff regarding Resident #1's requests to go to the hospital until after the police left the facility. The DON stated she told LVN Z to send Resident #1 to the hospital if she really wanted to go. The DON stated Resident #1 had behaviors of attention seeking and requesting to go to the hospital; but she also had a new [DIAGNOSES REDACTED]. The DON stated she had started in-servicing licensed staff on delay in care and honoring residents' requests for transport to the hospital. The DON stated she thought Resident #1 had been sent out right away after she spoke with LVN Z, and the next time she heard anything about the resident was when LVN Z telephoned her at about 4:00 AM and reported Resident #1's death. In a follow up telephone interview on [DATE] at 2:17 PM, LVN Z stated she knows to send a resident out if they are requesting to go, but she didn't feel Resident #1 should go because her vital signs were stable and her oxygen saturation rates were around 98%. LVN Z denied ever seeing Resident #1 with blue fingertips or lips. LVN Z stated at one point in time during the shift Resident #1 requested to have her oxygen increased, so she increased it from 2 liters per minute to 2.5 liters per minute. LVN Z stated the only time she notified Resident #1's physician was by fax after she left the facility via emergency medical services. LVN Z stated she had been a nurse for about a year and had taken care of resident's with [MEDICAL CONDITION] with tracheostomies as well. LVN Z added it was possible a resident could have something going on medically that they feels like shortness of breath, but could be something else. In a telephone interview on [DATE] at 10:09 AM, the hospital emergency physician that cared for Resident #1 stated emergency medical services reported to him that the patient (Resident #1) was cyanotic and in acute respiratory distress when they arrived on the scene. The physician went on to say Resident #1 was never stable in the emergency room and her blood gasses indicated she had been in respiratory distress for a while. When asked to qualify a while the physician would not say other than it didn't just happen. The physician stated patients with tracheostomies can become distressed quickly and some can say when they are feeling respiratory distress. The physician stated Resident #1 was chronically ill and he could not say if getting her to the hospital when she first asked to come would have changed the outcome. The physician added local emergency services wanted her sent to the hospital via a local helicopter flight crew, but her obesity prohibited the transfer. In an interview on [DATE] at 4:15 PM, Resident #1's physician stated he wasn't notified Resident #1 was requesting to go to the hospital. The physician stated he received a phone call after she went out and later was notified of her death. The physician stated he would have sent Resident #1 out when she first requested to go to the hospital because she is a very difficult resident to care for. The physician stated he could not say if earlier intervention would have prevented Resident #1's death because she was so medically complicated; but it is the expectation staff notifies him when a resident wants to be transported to the hospital so he can give them guidance. Review of a facility in-service dated [DATE] and [DATE] reflected the following: Facility staff nurses and CNAs on reporting any resident concerns/complaints to charge nurses i.e. wanting to call 911 or sheriff; change of condition; and respiratory distress. Staff nurses- any condition that requires immediate notification will be done no matter what time of day it is and must be by telephone, or in person if the physician is in the facility. The DON reported a facility census of five residents receiving antibiotic therapy and four residents receiving physician ordered respiratory therapies.

Based on observation, interview and record review the facility failed to provide the necessary care and services to attain or maintain the highest practice physical, mental, and psychosocial well-being, consistent with resident's comprehensive assessment and plan of care. for one (1) of five (5) residents reviewed for neglect (Resident #1). Resident #1 was [AGE] years old with a history of [MEDICAL CONDITION], a [MEDICAL CONDITION], and a recent [DIAGNOSES REDACTED].#1 to the hospital for complaints of shortness of breath and not feeling well for approximately 50 minutes; despite her repeated requests. Resident #1 was transported to a local hospital in respiratory distress where she expired in less than three hours after arrival due to [MEDICAL CONDITION]. This deficient practice could affect a facility census of four residents receiving physician ordered respiratory treatments, and five residents receiving antibiotic therapy by placing them at risk for delayed physician treatments and interventions resulting in worsening of medical conditions, hospitalization s, and death. The Findings Include: Review of a Face Sheet for Resident #1 reflected she was [AGE] years old, with an original admission date of [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED].), Dysphagia, Neuromuscular Dysfunction of the bladder, Pneumonia, Reflux, [MEDICAL CONDITION], Abdominal wall abscess, and Convulsions. Resident #1 was her own responsible party. Review of a MDS dated [DATE] for Resident #1 reflected she required extensive assistance of two staff for transfers, and bed mobility. Resident #1 had an [MEDICAL CONDITION] (a surgical procedure in which the small intestine is attached to the abdominal wall to bypass the large intestine; digestive wastes then exits the body through an artificial opening called a stoma), a [MEDICAL CONDITION] (a surgical opening in the neck through the trachea to provide an airway), an indwelling urinary catheter, and received oxygen via nasal cannula at 2 liters per minute. Resident #1 had a BIMS score of 8 indicating moderate cognitive impairment. There were no behaviors noted on the MDS. Review of a care plan for Resident #1 dated [DATE] reflected the following: -Full code CPR order is in place -Resident has oxygen therapy related to [MEDICAL CONDITION]. Resident has a trach. Goal: Resident will have no signs and symptoms of poor oxygen absorption. Intervention/Tasks: Monitor for signs and symptoms of respiratory distress and report to physician as needed- respirations, pulse oximetry (to monitor blood oxygen saturation levels), increased heart rate, restlessness, sweating, headache, confusion, pleuritic pain, and skin color. -Resident has cognitive impairment related to short term memory loss. Goal: Resident will be able to communicate basic needs. Interventions: monitor/document/report to physician any changes in cognitive function specifically changes in decision making ability, memory recall and general awareness. -Resident requires [MEDICAL CONDITION] medications for [DIAGNOSES REDACTED].>Review of physician orders [REDACTED]. Get CBC (complete blood count), urinalysis and culture with sensitivity if indicated; culture drainage from PERC drain (Percutaneous Abdominal Drain). Review of a mobile x-ray report for Resident #1 dated [DATE] time 1:00 PM reflected the following: The [MEDICAL CONDITION] is at T-3 ([MEDICATION NAME] vertebrae). There is hazy left lower lung infiltrate Review of a facility communication form to the physician dated [DATE] reflected the following: X-ray this morning shows hazy left lower lobe infiltrate. Resident complaining of weakness and shortness of breath. Continuous oxygen at 2 liters a minute. Shows 99% oxygen saturate rate. Vital signs within normal limits. 8:00 PM telephoned nurse practitioner and received new orders for [MEDICATION NAME] 750 mg. once daily for 7 days and [MEDICATION NAME] 40 mg. daily for 7 days. 8:30 PM initial dose of [MEDICATION NAME] given. In an interview on [DATE] at 11:45 PM during initial tour, LVN Z stated when she came on duty at 10:00 PM on [DATE] she was told in report that Resident #1 had been diagnosed with [REDACTED]. LVN Z stated she made rounds to observe all of the 42 residents on the halls she was assigned. LVN Z state she didn't check on Resident #1 until about 10:15 PM and took her vital signs which were normal. LVN Z went on to say she wasn't aware Resident #1 wanted to go the hospital until the police department came to the facility to check on her at approximately 11:15 PM on [DATE], because emergency medical services reported the resident called for transport. LVN Z stated she had not been informed by the CNAs on duty that Resident #1 wanted to go to the hospital. LVN Z stated that CNA C refused to inform her anytime a resident needs something. He will tell another CNA to inform the charge nurse, but he will not talk to her directly. In an interview on [DATE] at 12:15 AM, CNA C stated when he came on duty on Resident #1 was on her call light, as usual. CNA C went on to say that he was busy passing water to residents and checking on them so another aide answered the call. CNA C stated a few minutes later Resident #1's call light was on again and she (Resident #1) stated she just needed someone to hold her hand. CNA C stated he held Resident #1's hand for about 20 minutes and during that time she asked him to help her find her personal cell phone and that she wanted to go to the hospital. CNA C stated he couldn't find the phone, but Resident #1 found it herself and he left the room. CNA C stated he couldn't remember if he told the charge nurse, LVN Z, if Resident #1 had stated she wanted to go to the hospital. CNA C added Resident #1 was always on her call light and had requested to go to the hospital in the past as well. Review of a written statement of CNA C dated [DATE] reflected he answered Resident #1's call light at around 10:40 PM; and that he had just finished passing ice/water on the halls. CNA C stated Resident #1 wanted someone to hold her hand and not let go, but he was very busy and told her he would return. CNA C stated he managed to return to Resident #1's room approximately 20 minutes later and held her hand. CNA C wrote I tried to assure her everything was going to be alright, but she insisted on using the phone (cell phone). I looked for her cell phone but could not find it. She (Resident #1) then looked and found it herself. I asked her if she needed anything else more and she stated no: so I left the room. She (Resident #2) then must have used her cell phone to dial 911. At round 11:10 PM the police arrived to check on her. The nurse told the police officer all of the resident's (Resident #1) vital signs were good, but she insisted on going to the hospital. The ambulance was called and she was transported to the emergency room . In a follow up interview with CNA C on [DATE] at 12:30 AM, CNA C was asked to review his written statement and questioned by what he meant by assuring Resident #1 everything was going to be Ok. CNA C stated he now denied telling Resident #1 everything was going to be ok, and would not comment if her told LVN Z Resident #1 wanted to go to the hospital. CNA C did state he knew it was his responsibility to report to the charge nurse if a resident needs something or wants to go to the hospital. Review of a facility physician communication document for Resident #1 dated [DATE] and [DATE] completed by LVN Z reflected the following: 2200 (10:00 PM) Resident in bed no symptoms of pain or discomfort 2215 (10:15 PM) Blood pressure ,[DATE], pulse 77, respirations 20, temperature 97.0 degrees, oxygen saturation level 99 %, oxygen on at 2 liters per minute, No pain or respiratory distress noted. 2315 (11:15 PM) Sheriff's department arrived asking for room [ROOM NUMBER]. Stated that they had received two phone calls from resident. Went into resident's room with Sheriff and Resident complained of shortness of breath. There were no previous complaints of shortness of breath prior to this time. Oxygen saturation 99 %. 2340 (11:40 PM) Notified DON of situation going on 0030 (12:30 AM [DATE]) Resident still complaining of shortness of breath and demanding to go to the hospital. 0040 (12:40 AM [DATE]) Ambulance called per resident request 0100 (1:00 AM [DATE]) resident left facility. Review of a local police officer's statement dated [DATE] reflected the following: Received dispatch call for a welfare check at .facility's address) initiated from the Sheriff's Department. Sheriff's department received several calls from a resident in room [ROOM NUMBER] requesting to be transported to the hospital for shortness of breath. Sheriff's Department called several times to the nursing home and no one answered the phone, so a welfare check was requested. A male nurse and another nurse stated the resident was fine and did not need to go to the hospital. The resident did inform the officer she wanted to go to the hospital, but it was explained police officers are not medical personnel and cannot make the decision. Arrival time 11:15 PM [DATE] and departure time 11:28 PM. Review of the local emergency medical services records for Resident #1 dated [DATE] reflected the following: Call received at 00:44 En route-00:45 On scene: 00:48 At Patient 00:49 Arrived on scene met nurse states that patient has difficulty breathing and patient demanded to be seen at the emergency room . The nurse gave us this report at the front door of the nursing home. Walked in patient's room finds patient in severe respiratory distress. Very cyanotic {blue in color indicating poor oxygenation} in fingertips and lips. Patient did wake up when spoken to and stated she does not feel good; at this time a NRB (non-rebreather mask) was placed over patient's trach, oxygen given at 15 liters per minute. Patient placed in the ambulance and started helping with breathing and her color improved greatly. At this time Air EVAC on standby and transported the patient to the flight crew base. Flight crew came onboard and informed us that patient would not fit in the aircraft for emergent transportation. Patient was given [MEDICATION NAME] intravenously for possible drug overdose and improved greatly and started opening her eyes and trying to talk. Air EVAC crew decided patient should be transported to local hospital. Arrived on scene at hospital at 01:36 AM and transferred care to hospital staff. {[MEDICATION NAME] is a medication used to treat respiratory distress and/or failure in patients with overdosing of opiate medications.) Review of hospital emergency room records for Resident #1 reflected: Exam: 02:00 AM-Patient is [AGE] year old female with complaints of respiratory distress. Appears alert, awake, obese and in distress, mildly distressed. Afebrile, cyanotic. Lung sounds- bilateral lower lobes with decreased breath sound that are moderate, and more so on the left side. 02:41 AM. blood pressure ,[DATE] (normal ,[DATE]) pulse 63, respirations 41 (normal 12 to 16), oxygen saturation on room air 81%. 03:09 AM. [MEDICAL CONDITION] removed and replaced with endotracheal tube. 03:12 AM response to endotracheal tube patient's symptoms have mildly improved. 03:45 AM. Patient became [MEDICAL CONDITION] (low heart rate), low blood pressure and went into [MEDICAL CONDITION]. Chest compressions started and intravenous [MEDICATION NAME] given. Pulseless, no spontaneous breathing. Patient pronounced dead at 03:45 AM. In an interview on [DATE] at 2:13 AM, the DON stated she was not contacted by any facility staff regarding Resident #1's requests to go to the hospital until after the police left the facility. The DON stated she told LVN Z to send Resident #1 to the hospital if she really wanted to go. The DON stated Resident #1 had behaviors of attention seeking and requesting to go to the hospital; but she also had a new [DIAGNOSES REDACTED]. The DON stated she had started in-servicing licensed staff on delay in care and honoring residents' requests for transport to the hospital. The DON stated she thought Resident #1 had been sent out right away after she spoke with LVN Z, and the next time she heard anything about the resident was when LVN Z telephoned her at about 4:00 AM and reported Resident #1's death. In a follow up telephone interview on [DATE] at 2:17 PM, LVN Z stated she knows to send a resident out if they are requesting to go, but she didn't feel Resident #1 should go because her vital signs were stable and her oxygen saturation rates were around 98%. LVN Z denied ever seeing Resident #1 with blue fingertips or lips. LVN Z stated at one point in time during the shift Resident #1 requested to have her oxygen increased, so she increased it from 2 liters per minute to 2.5 liters per minute. LVN Z stated the only time she notified Resident #1's physician was by fax after she left the facility via emergency medical services. LVN Z stated she had been a nurse for about a year and had taken care of resident's with [MEDICAL CONDITION] with tracheostomies as well. LVN Z added it was possible a resident could have something going on medically that they feels like shortness of breath, but could be something else. In a telephone interview on [DATE] at 10:09 AM, the hospital emergency physician that cared for Resident #1 stated emergency medical services reported to him that the patient (Resident #1) was cyanotic and in acute respiratory distress when they arrived on the scene. The physician went on to say Resident #1 was never stable in the emergency room and her blood gasses indicated she had been in respiratory distress for a while. When asked to qualify a while the physician would not say other than it didn't just happen. The physician stated patients with tracheostomies can become distressed quickly and some can say when they are feeling respiratory distress. The physician stated Resident #1 was chronically ill and he could not say if getting her to the hospital when she first asked to come would have changed the outcome. The physician added local emergency services wanted her sent to the hospital via a local helicopter flight crew, but her obesity prohibited the transfer. In an interview on [DATE] at 4:15 PM, Resident #1's physician stated he wasn't notified Resident #1 was requesting to go to the hospital. The physician stated he received a phone call after she went out and later was notified of her death. The physician stated he would have sent Resident #1 out when she first requested to go to the hospital because she is a very difficult resident to care for. The physician stated he could not say if earlier intervention would have prevented Resident #1's death because she was so medically complicated; but it is the expectation staff notifies him when a resident wants to be transported to the hospital so he can give them guidance. Review of the facility's Abuse/Neglect policy dated 08 ,[DATE] reflected the following:Review of the facility's Abuse/Neglect policy dated 08 ,[DATE] reflected the following: Review of a facility in-service dated [DATE] and [DATE] reflected the following: Neglect: Definition failure to provide care and services to a person who is unable to care for themselves, or intentionally not providing services which can potentially result in harm. Review of the facility's Change of Condition Policy dated 2003 reflected the following: Notifying the Physician of a Change in Condition: The nurse should not hesitate to contact the physician at any time when an assessment and their professional opinion deem it necessary for immediate medical attention. #7. The nurse will document all attempts to contact a physician, all attempts to notify the family and/or legal representative, the physician's response, the physician's orders [REDACTED]. Facility staff nurses and CNAs on reporting any resident concerns/complaints to charge nurses i.e. wanting to call 911 or sheriff; change of condition; and respiratory distress. Staff nurses- any condition that requires immediate notification will be done no matter what time of day it is and must be by telephone, or in person if the physician is in the facility. The DON reported a facility census of five residents receiving antibiotic therapy and four residents receiving physician ordered respiratory therapies.

Based on observation, interview and record review the facility failed to consult with the resident's physician when there was a significant change in the resident's physical status for one (1) of five (5) residents reviewed for change in condition (Resident #1). Resident #1 was [AGE] years old with a history of [MEDICAL CONDITION], a [MEDICAL CONDITION], and a recent [DIAGNOSES REDACTED].#1 to the hospital for complaints of shortness of breath and not feeling well for approximately 50 minutes; despite her repeated requests. Resident #1 was transported to a local hospital in respiratory distress, where she expired in less than three hours after arrival due to [MEDICAL CONDITION]. This deficient practice could affect a facility census of four residents receiving physician ordered respiratory treatments, and five residents receiving antibiotic therapy by placing them at risk for delayed physician treatments and interventions resulting in worsening of medical conditions, hospitalization s, and death. The Findings Include: Review of a Face Sheet for Resident #1 reflected she was [AGE] years old, with an original admission date of [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED].), Dysphagia, Neuromuscular Dysfunction of the bladder, Pneumonia, Reflux, [MEDICAL CONDITION], Abdominal wall abscess, and Convulsions. Resident #1 was her own responsible party. Review of a MDS dated [DATE] for Resident #1, reflected she required extensive assistance of two staff for transfers, and bed mobility. Resident #1 had an [MEDICAL CONDITION] (a surgical procedure in which the small intestine is attached to the abdominal wall to bypass the large intestine; digestive wastes then exits the body through an artificial opening called a stoma), a [MEDICAL CONDITION] (a surgical opening in the neck through the trachea to provide an airway), an indwelling urinary catheter, and received oxygen via nasal cannula at 2 liters per minute. Resident #1 had a BIMS score of 8 indicating moderate cognitive impairment. There were no behaviors noted on the MDS. Review of a care plan for Resident #1 dated [DATE], reflected the following: -Full code CPR order was in place -Resident has oxygen therapy related to [MEDICAL CONDITION]. Resident has a trach. Goal: Resident will have no signs and symptoms of poor oxygen absorption. Intervention/Tasks: Monitor for signs and symptoms of respiratory distress and report to physician as needed- respirations, pulse oximetry (to monitor blood oxygen saturation levels), increased heart rate, restlessness, sweating, headache, confusion, pleuritic pain, and skin color. -Resident has cognitive impairment related to short term memory loss. Goal: Resident will be able to communicate basic needs. Interventions: monitor/document/report to physician any changes in cognitive function specifically changes in decision making ability, memory recall and general awareness. -Resident requires [MEDICAL CONDITION] medications for [DIAGNOSES REDACTED].>Review of physician orders [REDACTED]. Get CBC (complete blood count), urinalysis and culture with sensitivity if indicated; culture drainage from PERC drain (Percutaneous Abdominal Drain). Review of a mobile x-ray report for Resident #1 dated [DATE] time 1:00 PM, reflected the following: The [MEDICAL CONDITION] is at T-3 ([MEDICATION NAME] vertebrae). There is hazy left lower lung infiltrate. Review of a facility communication form to the physician dated [DATE], reflected the following: X-ray this morning shows hazy left lower lobe infiltrate. Resident complaining of weakness and shortness of breath. Continuous oxygen at 2 liters a minute. Shows 99% oxygen saturate rate. Vital signs within normal limits. 8:00 PM telephoned nurse practitioner and received new orders for [MEDICATION NAME] 750 mg. once daily for 7 days and [MEDICATION NAME] 40 mg. daily for 7 days. 8:30 PM initial dose of [MEDICATION NAME] given. In an interview on [DATE] at 11:45 PM during initial tour, LVN Z stated that when she came on duty at 10:00 PM on [DATE], she was told in report that Resident #1 had been diagnosed with [REDACTED]. LVN Z stated she made rounds to observe all of the 42 residents on the halls she was assigned. LVN Z state she didn't check on Resident #1 until about 10:15 PM and took her vital signs, which were normal. LVN Z went on to say she wasn't aware Resident #1 wanted to go the hospital until the police department came to the facility to check on her at approximately 11:15 PM on [DATE]; because emergency medical services reported the resident called for transport. LVN Z stated she had not been informed by the CNAs on duty that Resident #1 wanted to go to the hospital. LVN Z stated that CNA C refused to inform her anytime a resident needs something. He will tell another CNA to inform the charge nurse, but he will not talk to her directly. In an interview on [DATE] at 12:15 AM, CNA C stated when he came on duty, Resident #1 was on her call light, as usual. CNA C went on to say that he was busy passing water to residents and checking on them so another aide answered the call. CNA C stated a few minutes later Resident #1's call light was on again and she (Resident #1) stated she just needed someone to hold her hand. CNA C stated he held Resident #1's hand for about 20 minutes and during that time she asked him to help her find her personal cell phone and that she wanted to go to the hospital. CNA C stated he couldn't find the phone, but Resident #1 found it herself and he left the room. CNA C stated he couldn't remember if he told the charge nurse, LVN Z, if Resident #1 had stated she wanted to go to the hospital. CNA C added Resident #1 was always on her call light and had requested to go to the hospital in the past as well. Review of a written statement of CNA C dated [DATE], reflected he answered Resident #1's call light at around 10:40 PM; and that he had just finished passing ice/water on the halls. CNA C stated Resident #1 wanted someone to hold her hand and not let go; but he was very busy and told her he would return. CNA C stated he managed to return to Resident #1's room approximately 20 minutes later and held her hand. CNA C wrote I tried to assure her everything was going to be alright, but she insisted on using the phone (cell phone). I looked for her cell phone but could not find it. She (Resident #1) then looked and found it herself. I asked her if she needed anything else more and she stated no: so I left the room. She (Resident #1) then must have used her cell phone to dial 911. At round 11:10 PM the police arrived to check on her. The nurse told the police officer all of the resident's (Resident #1) vital signs were good, but she insisted on going to the hospital. The ambulance was called and she was transported to the emergency room . In a follow up interview with CNA C on [DATE] at 12:30 AM, CNA C was asked to review his written statement and questioned by what he meant by assuring Resident #1 everything was going to be Ok. CNA C stated he now denied telling Resident #1 everything was going to be Ok, and would not comment if he told LVN Z Resident #1 wanted to go to the hospital. CNA C did state he knew it was his responsibility to report to the charge nurse if a resident needs something or wants to go to the hospital. Review of a facility physician communication document for Resident #1 dated [DATE] and [DATE], completed by LVN Z, reflected the following: 2200 (10:00 PM) Resident in bed no symptoms of pain or discomfort 2215 (10:15 PM) Blood pressure ,[DATE], pulse 77, respirations 20, temperature 97.0 degrees, oxygen saturation level 99 %, oxygen on at 2 liters per minute, No pain or respiratory distress noted. 2315 (11:15 PM) Sheriff's department arrived asking for room [ROOM NUMBER]. Stated that they had received two phone calls from resident. Went into resident's room with Sheriff and Resident complained of shortness of breath. There were no previous complaints of shortness of breath prior to this time. Oxygen saturation 99 %. 2340 (11:40 PM) Notified DON of situation going on 0030 (12:30 AM [DATE]) Resident still complaining of shortness of breath and demanding to go to the hospital. 0040 (12:40 AM [DATE]) Ambulance called per resident request 0100 (1:00 AM [DATE]) resident left facility. Review of a local police officer's statement dated [DATE], reflected the following: Received dispatch call for a welfare check at .(facility address) initiated from the Sheriff's Department. Sheriff's department received several calls from a resident in room [ROOM NUMBER] requesting to be transported to the hospital for shortness of breath. Sheriff's Department called several times to the nursing home and no one answered the phone, so a welfare check was requested. A male nurse and another nurse stated the resident was fine and did not need to go to the hospital. The resident did inform the officer she wanted to go to the hospital, but it was explained police officers are not medical personnel and cannot make the decision. Arrival time 11:15 PM [DATE] and departure time 11:28 PM. Review of the local emergency medical services records for Resident #1 dated [DATE], reflected the following: Call received at 00:44 En route-00:45 On scene: 00:48 At Patient 00:49 Arrived on scene met nurse states that patient has difficulty breathing and patient demanded to be seen at the emergency room . The nurse gave us this report at the front door of the nursing home. Walked in patient's room finds patient in severe respiratory distress. Very cyanotic {blue in color indicating poor oxygenation} in fingertips and lips. Patient did wake up when spoken to and stated she does not feel good; at this time a NRB (non-rebreather mask) was placed over patient's trach, oxygen given at 15 liters per minute. Patient placed in the ambulance and started helping with breathing and her color improved greatly. At this time Air EVAC on standby and transported the patient to the flight crew base. Flight crew came onboard and informed us that patient would not fit in the aircraft for emergent transportation. Patient was given [MEDICATION NAME] intravenously for possible drug overdose and improved greatly and started opening her eyes and trying to talk. Air EVAC crew decided patient should be transported to local hospital. Arrived on scene at hospital at 01:36 AM and transferred care to hospital staff. {[MEDICATION NAME] is a medication used to treat respiratory distress and/or failure in patients with overdosing of opiate medications.) Review of hospital emergency room records for Resident #1 reflected: Exam: 02:00 AM-Patient is [AGE] year old female with complaints of respiratory distress. Appears alert, awake, obese and in distress, mildly distressed. Afebrile, cyanotic. Lung sounds- bilateral lower lobes with decreased breath sound that are moderate, and more so on the left side. 02:41 AM. blood pressure ,[DATE] (normal ,[DATE]) pulse 63, respirations 41 (normal 12 to 16), oxygen saturation on room air 81%. 03:09 AM. [MEDICAL CONDITION] removed and replaced with endotracheal tube. 03:12 AM response to endotracheal tube patient's symptoms have mildly improved. 03:45 AM. Patient became [MEDICAL CONDITION] (low heart rate), low blood pressure and went into [MEDICAL CONDITION]. Chest compressions started and intravenous [MEDICATION NAME] given. Pulseless, no spontaneous breathing. Patient pronounced dead at 03:45 AM. In an interview on [DATE] at 2:13 AM, the DON stated she was not contacted by any facility staff regarding Resident #1's requests to go to the hospital, until after the police left the facility. The DON stated she told LVN Z to send Resident #1 to the hospital if she really wanted to go. The DON stated Resident #1 had behaviors of attention seeking and requesting to go to the hospital; but she also had a new [DIAGNOSES REDACTED]. The DON stated she had started in-servicing licensed staff on delay in care and honoring residents' requests for transport to the hospital. The DON stated she thought Resident #1 had been sent out right away after she spoke with LVN Z, and the next time she heard anything about the resident was when LVN Z telephoned her at about 4:00 AM and reported Resident #1's death. In a follow up telephone interview on [DATE] at 2:17 PM, LVN Z stated she knows to send a resident out if they are requesting to go, but she didn't feel Resident #1 should go because her vital signs were stable and her oxygen saturation rates were around 98%. LVN Z denied ever seeing Resident #1 with blue fingertips or lips. LVN Z stated at one point in time during the shift Resident #1 requested to have her oxygen increased, so she increased it from 2 liters per minute to 2.5 liters per minute. LVN Z stated the only time she notified Resident #1's physician was by fax after she left the facility via emergency medical services. LVN Z stated she had been a nurse for about a year and had taken care of resident's with [MEDICAL CONDITION] with tracheostomies as well. LVN Z added it was possible a resident could have something going on medically that they feels like shortness of breath, but could be something else. In a telephone interview on [DATE] at 10:09 AM, the hospital emergency physician that cared for Resident #1 stated emergency medical services reported to him that the patient (Resident #1) was cyanotic and in acute respiratory distress when they arrived on the scene. The physician went on to say Resident #1 was never stable in the emergency room and her blood gasses indicated she had been in respiratory distress for a while. When asked to qualify a while the physician would not say other than it didn't just happen. The physician stated patients with tracheostomies can become distressed quickly and some can say when they are feeling respiratory distress. The physician stated Resident #1 was chronically ill and he could not say if getting her to the hospital when she first asked to come would have changed the outcome. The physician added local emergency services wanted her sent to the hospital via a local helicopter flight crew, but her obesity prohibited the transfer. In an interview on [DATE] at 4:15 PM, Resident #1's physician stated he wasn't notified Resident #1 was requesting to go to the hospital. The physician stated he received a phone call after she went out and later was notified of her death. The physician stated he would have sent Resident #1 out when she first requested to go to the hospital because she is a very difficult resident to care for. The physician stated he could not say if earlier intervention would have prevented Resident #1's death because she was so medically complicated; but it is the expectation staff notifies him when a resident wants to be transported to the hospital so he can give them guidance. Review of the facility's Abuse/Neglect policy dated [DATE] reflected the following: Neglect: Definition failure to provide care and services to a person who is unable to care for themselves, or intentionally not providing services which can potentially result in harm. Review of a facility in-service dated [DATE] and [DATE], reflected the following: Facility staff nurses and CNAs on reporting any resident concerns/complaints to charge nurses, i.e. wanting to call 911 or sheriff; change of condition; and respiratory distress. Staff nurses- any condition that requires immediate notification will be done no matter what time of day it is and must be by telephone, or in person if the physician is in the facility. The DON reported a facility census of five residents receiving antibiotic therapy and four residents receiving physician ordered respiratory therapies.

Based on observation, interview and record review the facility failed to implement written policies and procedures to prevent neglect for one (1) of five (5) residents reviewed for neglect (Resident #1). Resident #1 was [AGE] years old with a history of [MEDICAL CONDITION], a [MEDICAL CONDITION], and a recent [DIAGNOSES REDACTED].#1 to the hospital for complaints of shortness of breath and not feeling well for approximately 50 minutes; despite her repeated requests. Resident #1 was transported to a local hospital in respiratory distress where she expired in less than three hours after arrival due to [MEDICAL CONDITION]. This deficient practice could affect a facility census of four residents receiving physician ordered respiratory treatments, and five residents receiving antibiotic therapy by placing them at risk for delayed physician treatments and interventions resulting in worsening of medical conditions, hospitalization s, and death. The Findings Include: Review of a Face Sheet for Resident #1 reflected she was [AGE] years old, with an original admission date of [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED].), Dysphagia, Neuromuscular Dysfunction of the bladder, Pneumonia, Reflux, [MEDICAL CONDITION], Abdominal wall abscess, and Convulsions. Resident #1 was her own responsible party. Review of a MDS dated [DATE] for Resident #1 reflected she required extensive assistance of two staff for transfers, and bed mobility. Resident #1 had an [MEDICAL CONDITION] (a surgical procedure in which the small intestine is attached to the abdominal wall to bypass the large intestine; digestive wastes then exits the body through an artificial opening called a stoma), a [MEDICAL CONDITION] (a surgical opening in the neck through the trachea to provide an airway), an indwelling urinary catheter, and received oxygen via nasal cannula at 2 liters per minute. Resident #1 had a BIMS score of 8 indicating moderate cognitive impairment. There were no behaviors noted on the MDS. Review of a care plan for Resident #1 dated [DATE] reflected the following: -Full code CPR order is in place -Resident has oxygen therapy related to [MEDICAL CONDITION]. Resident has a trach. Goal: Resident will have no signs and symptoms of poor oxygen absorption. Intervention/Tasks: Monitor for signs and symptoms of respiratory distress and report to physician as needed- respirations, pulse oximetry (to monitor blood oxygen saturation levels), increased heart rate, restlessness, sweating, headache, confusion, pleuritic pain, and skin color. -Resident has cognitive impairment related to short term memory loss. Goal: Resident will be able to communicate basic needs. Interventions: monitor/document/report to physician any changes in cognitive function specifically changes in decision making ability, memory recall and general awareness. -Resident requires [MEDICAL CONDITION] medications for [DIAGNOSES REDACTED].>Review of physician orders [REDACTED]. Get CBC (complete blood count), urinalysis and culture with sensitivity if indicated; culture drainage from PERC drain (Percutaneous Abdominal Drain). Review of a mobile x-ray report for Resident #1 dated [DATE] time 1:00 PM reflected the following: The [MEDICAL CONDITION] is at T-3 ([MEDICATION NAME] vertebrae). There is hazy left lower lung infiltrate Review of a facility communication form to the physician dated [DATE] reflected the following: X-ray this morning shows hazy left lower lobe infiltrate. Resident complaining of weakness and shortness of breath. Continuous oxygen at 2 liters a minute. Shows 99% oxygen saturate rate. Vital signs within normal limits. 8:00 PM telephoned nurse practitioner and received new orders for [MEDICATION NAME] 750 mg. once daily for 7 days and [MEDICATION NAME] 40 mg. daily for 7 days. 8:30 PM initial dose of [MEDICATION NAME] given. In an interview on [DATE] at 11:45 PM during initial tour, LVN Z stated when she came on duty at 10:00 PM on [DATE] she was told in report that Resident #1 had been diagnosed with [REDACTED]. LVN Z stated she made rounds to observe all of the 42 residents on the halls she was assigned. LVN Z state she didn't check on Resident #1 until about 10:15 PM and took her vital signs which were normal. LVN Z went on to say she wasn't aware Resident #1 wanted to go the hospital until the police department came to the facility to check on her at approximately 11:15 PM on [DATE], because emergency medical services reported the resident called for transport. LVN Z stated she had not been informed by the CNAs on duty that Resident #1 wanted to go to the hospital. LVN Z stated that CNA C refused to inform her anytime a resident needs something. He will tell another CNA to inform the charge nurse, but he will not talk to her directly. In an interview on [DATE] at 12:15 AM, CNA C stated when he came on duty on Resident #1 was on her call light, as usual. CNA C went on to say that he was busy passing water to residents and checking on them so another aide answered the call. CNA C stated a few minutes later Resident #1's call light was on again and she (Resident #1) stated she just needed someone to hold her hand. CNA C stated he held Resident #1's hand for about 20 minutes and during that time she asked him to help her find her personal cell phone and that she wanted to go to the hospital. CNA C stated he couldn't find the phone, but Resident #1 found it herself and he left the room. CNA C stated he couldn't remember if he told the charge nurse, LVN Z, if Resident #1 had stated she wanted to go to the hospital. CNA C added Resident #1 was always on her call light and had requested to go to the hospital in the past as well. Review of a written statement of CNA C dated [DATE] reflected he answered Resident #1's call light at around 10:40 PM; and that he had just finished passing ice/water on the halls. CNA C stated Resident #1 wanted someone to hold her hand and not let go, but he was very busy and told her he would return. CNA C stated he managed to return to Resident #1's room approximately 20 minutes later and held her hand. CNA C wrote I tried to assure her everything was going to be alright, but she insisted on using the phone (cell phone). I looked for her cell phone but could not find it. She (Resident #1) then looked and found it herself. I asked her if she needed anything else more and she stated no: so I left the room. She (Resident #2) then must have used her cell phone to dial 911. At round 11:10 PM the police arrived to check on her. The nurse told the police officer all of the resident's (Resident #1) vital signs were good, but she insisted on going to the hospital. The ambulance was called and she was transported to the emergency room . In a follow up interview with CNA C on [DATE] at 12:30 AM, CNA C was asked to review his written statement and questioned by what he meant by assuring Resident #1 everything was going to be Ok. CNA C stated he now denied telling Resident #1 everything was going to be ok, and would not comment if he told LVN Z Resident #1 wanted to go to the hospital. CNA C did state he knew it was his responsibility to report to the charge nurse if a resident needs something or wants to go to the hospital. Review of a facility physician communication document for Resident #1 dated [DATE] and [DATE] completed by LVN Z reflected the following: 2200 (10:00 PM) Resident in bed no symptoms of pain or discomfort 2215 (10:15 PM) Blood pressure ,[DATE], pulse 77, respirations 20, temperature 97.0 degrees, oxygen saturation level 99 %, oxygen on at 2 liters per minute, No pain or respiratory distress noted. 2315 (11:15 PM) Sheriff's department arrived asking for room [ROOM NUMBER]. Stated that they had received two phone calls from resident. Went into resident's room with Sheriff and Resident complained of shortness of breath. There were no previous complaints of shortness of breath prior to this time. Oxygen saturation 99 %. 2340 (11:40 PM) Notified DON of situation going on 0030 (12:30 AM [DATE]) Resident still complaining of shortness of breath and demanding to go to the hospital. 0040 (12:40 AM [DATE]) Ambulance called per resident request 0100 (1:00 AM [DATE]) resident left facility. Review of a local police officer's statement dated [DATE] reflected the following: Received dispatch call for a welfare check at . (facility address) initiated from the Sheriff's Department. Sheriff's department received several calls from a resident in room [ROOM NUMBER] requesting to be transported to the hospital for shortness of breath. Sheriff's Department called several times to the nursing home and no one answered the phone, so a welfare check was requested. A male nurse and another nurse stated the resident was fine and did not need to go to the hospital. The resident did inform the officer she wanted to go to the hospital, but it was explained police officers are not medical personnel and cannot make the decision. Arrival time 11:15 PM [DATE] and departure time 11:28 PM. Review of the local emergency medical services records for Resident #1 dated [DATE] reflected the following: Call received at 00:44 En route-00:45 On scene: 00:48 At Patient 00:49 Arrived on scene met nurse states that patient has difficulty breathing and patient demanded to be seen at the emergency room . The nurse gave us this report at the front door of the nursing home. Walked in patient's room finds patient in severe respiratory distress. Very cyanotic {blue in color indicating poor oxygenation} in fingertips and lips. Patient did wake up when spoken to and stated she does not feel good; at this time a NRB (non-rebreather mask) was placed over patient's trach, oxygen given at 15 liters per minute. Patient placed in the ambulance and started helping with breathing and her color improved greatly. At this time Air EVAC on standby and transported the patient to the flight crew base. Flight crew came onboard and informed us that patient would not fit in the aircraft for emergent transportation. Patient was given [MEDICATION NAME] intravenously for possible drug overdose and improved greatly and started opening her eyes and trying to talk. Air EVAC crew decided patient should be transported to local hospital. Arrived on scene at hospital at 01:36 AM and transferred care to hospital staff. {[MEDICATION NAME] is a medication used to treat respiratory distress and/or failure in patients with overdosing of opiate medications.) Review of hospital emergency records for Resident #1 dated [DATE] reflected: Exam: 02:00 AM-Patient is [AGE] year old female with complaints of respiratory distress. Appears alert, awake, obese and in distress, mildly distressed. Afebrile, cyanotic. Lung sounds- bilateral lower lobes with decreased breath sound that are moderate, and more so on the left side. 02:41 AM. blood pressure ,[DATE] (normal ,[DATE]) pulse 63, respirations 41 (normal 12 to 16), oxygen saturation on room air 81%. 03:09 AM. [MEDICAL CONDITION] removed and replaced with endotracheal tube. 03:12 AM response to endotracheal tube patient's symptoms have mildly improved. 03:45 AM. Patient became [MEDICAL CONDITION] (low heart rate), low blood pressure and went into [MEDICAL CONDITION]. Chest compressions started and intravenous [MEDICATION NAME] given. Pulseless, no spontaneous breathing. Patient pronounced dead at 03:45 AM. In an interview on [DATE] at 2:13 AM, the DON stated she was not contacted by any facility staff regarding Resident #1's requests to go to the hospital until after the police left the facility. The DON stated she told LVN Z to send Resident #1 to the hospital if she really wanted to go. The DON stated Resident #1 had behaviors of attention seeking and requesting to go to the hospital; but she also had a new [DIAGNOSES REDACTED]. The DON stated she had started in-servicing licensed staff on delay in care and honoring residents' requests for transport to the hospital. The DON stated she thought Resident #1 had been sent out right away after she spoke with LVN Z, and the next time she heard anything about the resident was when LVN Z telephoned her at about 4:00 AM and reported Resident #1's death. In a follow up telephone interview on [DATE] at 2:17 PM, LVN Z stated she knows to send a resident out if they are requesting to go, but she didn't feel Resident #1 should go because her vital signs were stable and her oxygen saturation rates were around 98%. LVN Z denied ever seeing Resident #1 with blue fingertips or lips. LVN Z stated at one point in time during the shift Resident #1 requested to have her oxygen increased, so she increased it from 2 liters per minute to 2.5 liters per minute. LVN Z stated the only time she notified Resident #1's physician was by fax after she left the facility via emergency medical services. LVN Z stated she had been a nurse for about a year and had taken care of resident's with [MEDICAL CONDITION] with tracheostomies as well. LVN Z added it was possible a resident could have something going on medically that they feels like shortness of breath, but could be something else. In a telephone interview on [DATE] at 10:09 AM, the hospital emergency physician that cared for Resident #1 stated emergency medical services reported to him that the patient (Resident #1) was cyanotic and in acute respiratory distress when they arrived on the scene. The physician went on to say Resident #1 was never stable in the emergency room and her blood gasses indicated she had been in respiratory distress for a while. When asked to qualify a while the physician would not say other than it didn't just happen. The physician stated patients with tracheostomies can become distressed quickly and some can say when they are feeling respiratory distress. The physician stated Resident #1 was chronically ill and he could not say if getting her to the hospital when she first asked to come would have changed the outcome. The physician added local emergency services wanted her sent to the hospital via a local helicopter flight crew, but her obesity prohibited the transfer. In an interview on [DATE] at 4:15 PM, Resident #1's physician stated he wasn't notified Resident #1 was requesting to go to the hospital. The physician stated he received a phone call after she went out and later was notified of her death. The physician stated he would have sent Resident #1 out when she first requested to go to the hospital because she is a very difficult resident to care for. The physician stated he could not say if earlier intervention would have prevented Resident #1's death because she was so medically complicated; but it is the expectation staff notifies him when a resident wants to be transported to the hospital so he can give them guidance. Review of the facility's Abuse/Neglect policy dated 08 ,[DATE] reflected the following: Neglect: Definition failure to provide care and services to a person who is unable to care for themselves, or intentionally not providing services which can potentially result in harm. Review of a facility in-service dated [DATE] and [DATE] reflected the following: Facility staff nurses and CNAs on reporting any resident concerns/complaints to charge nurses i.e. wanting to call 911 or sheriff; change of condition; and respiratory distress. Staff nurses- any condition that requires immediate notification will be done no matter what time of day it is and must be by telephone, or in person if the physician is in the facility. The DON reported a facility census of five residents receiving antibiotic therapy and four residents receiving physician ordered respiratory therapies.

Based on interview and record review the facility failed to implement policies and procedures that prohibit neglect for one (1) of nine (9) residents (Resident #1) reviewed for neglect. On [DATE] Resident #1 developed [MEDICAL CONDITION] to the left posterior middle toe approximately 1.5 cm. x 2.0 cm. The facility failed to: A) Administer one of two (2) ordered oral medications for four (4) days due to the medication not being in the building and failed to notify Resident # 1's physician of the delay in a prescribed medication. B) Ensure Resident #1 got to his ordered podiatry appointment. The original appointment scheduled for [DATE] was cancelled and rescheduled for [DATE]. The resident died five days prior to the scheduled appointment. The facility further failed to notify the physician of the delayed physician ordered podiatrist appointment. C) LVN A, LVN G and Treatment Nurse B failed to accurately reassess the infection on [DATE] through [DATE] and notify the physician the infection was not healing. Resident #1 subsequently went to the hospital on [DATE], was diagnosed with [REDACTED]. Resident #1 died on [DATE]. An Immediate Jeopardy (IJ) was identified to have existed from [DATE] through [DATE]. While the IJ was removed, the facility remained out of compliance at a severity of actual harm with a scope identified as pattern. This deficient practice affected Resident # 1 and placed five (5) additional residents who had wounds or infections at risk for delayed care that could result in pain, suffering,[MEDICAL CONDITION], gangrene, and death. Findings Included: Review of Resident #1's Face Sheet reflected an [AGE] year old male admitted to the facility on [DATE] and readmitted [DATE]. Diagnoses' included End Stage [MEDICAL CONDITIONS], Hypertension, [MEDICAL CONDITIONS] and [MEDICAL CONDITION]. Review of Resident #1's Admission Minimum Data Set (MDS) assessment dated [DATE] reflected a Brief Interview for Mental Status (BIMS) score of nine (9) indicating moderate cognitive impairment. The MDS further reflected no indicators of wounds or wound infections. Pneumonia was reflected. Review of Resident #1's Care Plan dated [DATE] and revised [DATE] reflected The resident has [MEDICAL CONDITION]. ([MEDICAL CONDITION]) Interventions included Monitor/document/report to MD (Medical Doctor) PRN (as needed) any signs or symptoms of complications of extremities: coldness of extremity, pallor, cyanosis, and pain. Monitor/document/report to MD PRN any signs or symptoms of skin problems related to [MEDICAL CONDITION]: Redness [MEDICAL CONDITION], Blistering, Itching, Burning, Bruises, Cuts, other [MEDICAL CONDITION]. Review of Resident #1's Care Plan dated [DATE] reflected Resident has current skin concerns: Right toe and 3rd toe left foot. Interventions included Monitor areas for increased breakdown, s/s (signs and symptoms) of infection report to MD Keep MD and RP (Responsible Party) informed of Resident's progress. Review of Resident #1's Quarterly MDS dated [DATE] reflected a BIMS score of six (6) indicating severe cognitive impairment. The MDS further reflected no indicators of wounds or wound infections. Review of Resident #1's Progress Note dated [DATE] at 8:00 PM reflected Resident noted with increase confusion. (sic) 02 sat (Blood Oxygen Saturation) decreased to 73%. HR (Heart Rate) 133. Family at bedside. Swelling noted to left foot. Redness noted. Cool to touch. Necrosis (The death of living cells or tissues) noted to left great toe and 2nd/3rd toes. Sent to (local emergency room ) to evaluate and treat as indicated. Review of Resident #1's local hospital emergency room notes dated [DATE] reflected N/H (Nursing Home) resident was sent here for Dyspnea, Hypoxemia, Confusion, Left foot ulcer, Swelling. The notes further reflected Left foot swollen tender dry ulcer tip of great toe 3rd toe with dry gangrene, Doppler No Pulses left foot. Review of Resident #1's laboratory report dated [DATE] at 9:00 PM reflected a WBC (White Blood Cell Count) of 14.2 indicating the presence of an infection. The reference range for a WBC is maximum low of 5.0 and maximum high of 10.0. Review of Resident #1's Physician's Consultation Report dated [DATE] at 8:22 PM reflected the resident arrived at the local hospital with decreased level of consciousness. The patient arrived hypotensive (low blood pressure) in septic shock to the ER (emergency room ). Was evaluated by the emergency room (ER) physician and was felt to have a necrotic and ischemic left foot. The resident was treated with femoral artery and venous catheters which were placed on the same side of the concerned foot. Review of Resident #1's Discharge Summary from the local hospital dated [DATE] reflected a date of death of [DATE]. Cause of death was reflected as Septic Shock, Gangrene and Necrosis of the left lower extremity. [MEDICAL CONDITION], chronic, with an infection to the right upper arm [MEDICAL TREATMENT] graft and ischemic left lower extremity gram [MEDICAL CONDITION]. In an interview on [DATE] at 1:12 PM the Director of Nurses (DON) stated Resident #1's foot discoloration was first noted as a discolored area. soon after an incident occurred in which the resident had bumped his toes. The DON stated the resident's physician was notified and came to the facility to assess the foot on [DATE] when he wrote orders for oral and topical antibiotics. When asked, the DON stated she could not recall when the resident's toes were first noted to be discolored. The DON's response was I want to say he always had those discolored toes. Review of Resident #1's Physician's Progress Note dated [DATE] reflected a [DIAGNOSES REDACTED]. Left foot [MEDICAL CONDITION], DM (Diabetes Mellitus) foot. A) Review of Resident #1's physician's orders [REDACTED]. Bactoban Ointment (Topical Antibiotic) to foot BID after dressing. [MEDICATION NAME] (Oral Antibiotic) 150 mg (milligrams) one (1) tablet PO daily for seven (7) days. Podiatry Consult. Review of Resident #1's Medication Administration Record [REDACTED]. Review of Resident #1's physician orders [REDACTED]. Directly underneath the handwritten order is a handwritten statement reflecting Will start ABT (Antibiotic) when available. In an interview on [DATE] at 1:12 LVN A stated she had not administered [MEDICATION NAME] 150 mg PO on [DATE] as ordered by the Primary Care Physician (PCP) because the medication was not available. LVN A further stated she had checked the facility's emergency medication kit and the kit had none of the medication. LVN A stated she attempted to order the medication from the facility's contracted facility but was told the medication would not be available for three or four days. LVN A further stated she wrote a note under the PCP's order for [MEDICATION NAME] stating Will start antibiotic when available. LVN A stated she should have notified the DON of the issue but she could not recall if she had actually done so. In an interview on [DATE] at 12:55 PM the DON stated Resident #1's PCP order of [MEDICATION NAME] 150 mg once daily for seven (7) days was not started on [DATE] as ordered. The first administration of the medication was not administered until four (4) days later on [DATE]. The DON further stated she could not understand why the [MEDICATION NAME] had not been administered as ordered since a backup supply of the medication was kept in an emergency kit maintained in the facility's medication room. An observation of the facility's medication room on [DATE] at 1:10 PM (under the supervision of the DON) revealed the emergency medication kit to hold four (4) tablets of [MEDICATION NAME] 150 mg and 10 doses of [MEDICATION NAME] 50 mg. In an interview on [DATE] at 2:06 PM Resident #1's PCP stated the four (4) day delay in the administration of [MEDICATION NAME] could contribute to delay in infection recovery. Resident # 1's PCP stated he expected facility staff to notify him when delays occur in referrals and medication administration. In an interview on [DATE] at 2:18 PM the DON stated It (the medication) should have been started sooner. The DON went on to say it was best practice to notify the PCP of a medication or appointment delay. Yes, we failed the resident. The DON further stated she could not recall having been notified of a difficulty in obtaining [MEDICATION NAME]. The DON further stated LVN A should have notified her if the pharmacy stated there would be a delay in delivery of a medication. She would then, in turn, call that pharmacy and arrange for an alternate pharmacy to deliver in a timely manner. The DON stated if nursing staff was unable to obtain needed medication she would notify the PCP of the problem in order to allow him the opportunity to change his orders to an alternative medication or treatment. In an interview on [DATE] at 3:11 PM the Administrator stated Yes, the facility failed the resident when it did not give him his medications. The nurse should have notified the DON right away when the nurse felt a medication was not available. It (the [MEDICATION NAME]) should have been in the emergency kit. If not then she should have called the local pharmacy to try to get it. The Administrator stated Yes, the doctor should have been notified. when it was determined that ordered medications would not be available in a timely manner and when a timely referred appointment was not going to occur. B) Review of the facility's appointment calendar reflected Resident #1 had been scheduled for an appointment with a Podiatrist on [DATE] at 9:00 AM. The calendar entry was lined out. Review of the facility's appointment calendar reflected Resident #1 had been scheduled for an appointment with a Podiatrist on [DATE] at 1:15 PM. The calendar entry was lined out with an annotation reflecting Rescheduled to ,[DATE]. Review of the facility's appointment calendar reflected Resident #1 had been scheduled for an appointment with a Podiatrist on [DATE] at 9:00 AM. In an interview on [DATE] at 10:29 AM the DON stated missed appointments were not documented in the medical record but were documented in a calendar maintained by the facility's receptionist. The DON further stated she could not recall if Resident #1's podiatry appointment issues were reported to the resident's PCP. When asked of the possible medical consequences of a resident not getting his podiatry appointment as ordered, the DON would only state it's hard to say. In an interview on [DATE] at 11:31 AM the Receptionist stated she was responsible for scheduling and rescheduling medical appointments for the residents. The receptionist further stated she would be notified by nursing staff if an appointment was to be scheduled, rescheduled, or cancelled. The receptionist further stated she was not responsible for notifying staff of schedule changes. The receptionist further stated Resident #1's podiatry appointment was originally scheduled for [DATE] but she was told by a charge nurse (name unknown) that the resident had missed a [MEDICAL TREATMENT] appointment on the previous Tuesday ([DATE]) so the podiatry appointment was rescheduled for [DATE] instead and the resident went to the [MEDICAL TREATMENT] center instead on [DATE]. In an interview on [DATE] at 3:11 PM the Administrator stated the facility failed the resident and the physician should have been notified when a timely referred appointment was not going to occur. In an interview on [DATE] at 3:50 PM Resident #1's PCP stated he had not been contacted by the facility's staff regarding Resident #1's podiatrist appointments. Resident # 1's PCP stated he would have wanted to be notified of this issue. C) Review of Resident # 1's Skin Care Report dated [DATE] and conducted by LVN A reflected the resident's left great toe and middle toe to be tender to the affected area. There was no redness or drainage noted. Review of the Resident # 1's Skin Care Report dated [DATE] and conducted by LVN F reflected the resident's left great toe and middle toe to be tender, had reness redness and drainage to the affected area. The drainage was characterized as Serosanguineous Review of the website http://www.advancedtissue.com/type-drainage/ reflected Sanguineous drainage should not be common in wounds after a few hours or days, and this type of drainage later on may be indicative of trauma to the wound site. Review of website https://www.nlm.nih.gov/medlineplus/ency/article/ 6.htm reflected Serosanguineous means containing or relating to both blood and the liquid part of blood (serum). It usually refers to fluids collected from or leaving the body. For example, fluid leaving a wound that is serosanguineous is yellowish with small amounts of blood. In an interview on [DATE] at 2:10 PM Treatment Nurse B stated the resident had bumped his toes but could not recall the date. The resident's PCP ordered topical antibiotic ointment (TAO) and oral antibiotics.The Treatment Nurse further stated she did not observe gangrene or necrosis. The Treatment Nurse B stated she last saw Resident # 1's foot on [DATE] when it had tenderness, redness and drainage but had not considered the foot to be infected. The Treatment Nurse stated she did not notify the physician on [DATE] of the change in the resident's wound status. In an interview on [DATE] at 3:32 PM LVN G stated he had last assessed Resident #1's foot on [DATE] two (2) days prior to Resident# 1's change of condition and transportation to the local hospital. LVN G further stated that Resident #1's foot still looked infected when he treated the resident on that date. LVN G further stated the foot was red and swollen. LVN G further stated he did not notify the PCP. In an interview on [DATE] at 1:30 PM LVN A stated Resident #1's great toe was black. LVN A stated she reported the change to her charge nurse and the DON but could not recall when she made the observation or notification. LVN A further stated she last saw Resident #1's wound on [DATE]. The LVN further stated she could not recall the condition of the wound on that date but did record the status of the wound on the daily skin report for the resident. LVN A further stated she would recognize signs and symptoms of infection as color change, a different appearance on the skin, a change in the size of the wound, redness, warmness, tenderness, and swelling. Review of Resident #1's Skin Care Report dated [DATE] at 4:00 PM revealed the assessor to be LVN G. The report reflected an observation of tenderness and redness to the left foot. The resident's pain was assessed as a three (3) on a scale of one (1) to six (6) and described as dull and intermittent. Review of Resident #1's Skin Care Report dated [DATE] at 7:08 AM revealed the assessor to be LVN A. The report reflected an observation of tenderness to the left foot. The report did not reflect observations of swelling, redness, drainage, or warmth. No pain was indicated. In an interview on [DATE] at 3:51 PM Resident #1's PCP was asked if Resident #1's infected toes and foot could have been the cause of the resident's death. Resident # 1's PCP stated I am sure it would have played a role. The PCP further stated he had not been contacted by staff regarding concerns that the resident may be declining or not improving appropriately during the course of the antibiotic regimen the PCP had established. The PCP further stated the signs and symptoms he would expect nursing staff to identify as possible infection were redness, swelling, and puss on the wound. In an interview on [DATE] at 10:45 AM the DON stated nurses receive training on infection control on a regular basis through computer and in-person in-services. Signs and symptoms the staff are trained to note as indicative of infections were drainage, redness, tenderness, increased temperature, pain, and swelling. Review of the facility's Abuse and Neglect Policy (undated) reflected: The failure to provide goods or services, including medical services that are necessary to avoid physical or emotional harm, pain, or mental illness. The facility Administrator and DON were notified on [DATE] at 4:20 PM that an IJ situation had been identified due to the above failures. The following Plan of Removal was submitted by the Administrator on [DATE] at 9:00 AM. Interventions to prevent reoccurrence · 60% of med carts were audited to determine that all prescribed medications are available in-house as of 8:30pm [DATE]. As of the 60 % audit no errors have been identified. By [DATE] at 9am 100% of all med carts will have been audited. In the future, if any ordered medication is not available the following protocol will be followed: · The charge nurse will notify the pharmacy in attempt to get the medication · If unsuccessful, within 4 hours the charge nurse will notify the DON who will then contact the pharmacy in an attempt to rectify the issue · If the DON cannot obtain the medication from the primary pharmacy or a secondary pharmacy, the DON will contact the physician regarding the unavailability of the medication. · Any new orders will be followed as directed by the physician. · All residents identified as having wounds or infections will be assessed by the DON by 11 pm on [DATE] to ensure assessments are correct. · 20% of all residents will be assessed by an RN to ensure there are no identifiable infections on [DATE]. 100 % of all residents will be assessed by 12 pm [DATE] · The following in-services were begun on [DATE] by the Director of Nurses. Staff not in-serviced today will not be allowed to assume their duties until they have received the in-service. 54% of staff will be in-serviced by 12 am [DATE]. 76% of staff will be in-serviced by 8 am [DATE]. 78% of staff will be in-serviced by 3 pm [DATE]. 100% of staff will be in-serviced by [DATE]. · Licensed Nurses · If a medication is not available, the following protocol will be followed: o The charge nurse will notify the pharmacy in attempt to get the medication o If unsuccessful, within 4 hours the charge nurse will notify the DON who will then contact the pharmacy in an attempt to rectify the issue o If the DON cannot obtain the medication from the primary pharmacy or a secondary pharmacy, the DON will contact the physician regarding the unavailability of the medication. o Any new orders will be followed as directed by the physician. · Notification of the physician if a resident is unable to make it to a scheduled medical related appointment. · Signs and symptoms of wound infection · Notifying the physician timely for resident change of condition · Neglect · Certified Nurse Aides · Notifying the charge nurses of changes in a resident ' s condition · Neglect Any new staff hired after [DATE] in the above positions will receive training as stated above prior to assuming care of residents. · The medical director of the facility was notified at 7:15 pm by the DON on [DATE] regarding the immediate jeopardy · The medical director will be contacted by the DON for any unresolved issues with medication unavailability or residents missing a scheduled medical appointment. Monitoring · The DON and or designee will inquire daily during start up from charge nurse on their respective hall if they have any medications that are unavailable. · The DON and/or ADON will complete a med availability review on 15 residents per week for 4 weeks by comparing the MAR indicated [REDACTED] · The DON will view all resident wounds at least 2 times per week for 2 weeks, then 1 time per week for 2 weeks, to ensure correct documentation of status is correct. · The DON and or designee will review all residents with infections in the weekly standards of care meeting to ensure that physician notification is occurring if there is a decline. · The DON and/or designee will ask 10 staff members per week for 4 weeks, a situational question related to neglect. · Findings will be reviewed by the QA committee and changes made to the plan as needed. · All of the above monitoring will be documented on a facility formulated monitoring form. The investigator monitored the current plan of removal from [DATE] 10:00 AM until 12:30 PM as follows: Observations of facility directed staff in-services were conducted for nursing staff on the subjects of Notification of physicians and families of changes of condition, issues in obtaining ordered medications or treatments, the correct manner in which to handle a medication issue to include notification of the DON in order to allow her to intervene as appropriate. How to identify signs and symptoms of a new infection or a worsening of an infection already identified. An in-service on abuse and neglect was also conducted for all staff. Nurse aides were trained in Abuse and neglect, identification of changes in condition to include signs and symptoms of infection. Notification of a nurse of any observed change of condition. Review of the MARS (Medication Administration Records) for all residents identified as requiring wound care as well as all residents identified as being treated for [REDACTED]. Observations of all medication carts to confirm the actual presence of medications that have been ordered for all sampled residents to include all residents identified as requiring wound and infection care. Observations of all Residents receiving wound care (Resident #6 and Resident #9) to ensure current monitoring by staff for signs and symptoms of infection. Interviews of five (5) staff members (LVN I, Kitchen Aide J, CNA K, LVN L, and CNA M) to verify their attendance at the in-services as well as to verify their comprehension of the subject matter. On [DATE] at 12:30 PM the facility Administrator and DON were informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope of pattern due to the facility requiring time to train all staff and monitor their Plan of Removal. The DON provided a list two (2) residents currently receiving wound care and three (3) residents currently receiving care for infections.

Based on observation, interview and record review the facility failed to administer in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practible physical, mental, and psychosocial well-being for one (1) of nine (9) residents reviewed for Quality of Care. (Resident #1). On [DATE] Resident #1 developed [MEDICAL CONDITION] to the left posterior middle toe approximately 1.5 cm. x 2.0 cm. The facility failed to: A) Administer one of two (2) ordered oral medications for four (4) days due to the medication not being in the building and failed to notify Resident # 1's physician of the delay in a prescribed medication. B) Ensure Resident #1 got to his ordered podiatry appointment. The original appointment scheduled for [DATE] was cancelled and rescheduled for [DATE]. The resident died five days prior to the scheduled appointment. The facility further failed to notify the physician of the delayed physician ordered podiatrist appointment. C) LVN A, LVN G and Treatment Nurse B failed to accurately reassess the infection on [DATE] through [DATE] and notify the physician the infection was not healing. Resident #1 subsequently went to the hospital on [DATE], was diagnosed with [REDACTED]. Resident #1 died on [DATE]. An Immediate Jeopardy (IJ) was identified to have existed from [DATE] through [DATE]. While the IJ was removed, the facility remained out of compliance at a severity of actual harm with a scope identified as pattern. This deficient practice affected Resident # 1 and placed five (5) additional residents who had wounds or infections at risk for delayed care that could result in pain, suffering,[MEDICAL CONDITION], gangrene, and death. Findings Included: Review of Resident #1's Face Sheet reflected an [AGE] year old male admitted to the facility on [DATE] and readmitted [DATE]. Diagnoses' included End Stage [MEDICAL CONDITIONS], Hypertension, [MEDICAL CONDITIONS] and [MEDICAL CONDITION]. Review of Resident #1's Admission Minimum Data Set (MDS) assessment dated [DATE] reflected a Brief Interview for Mental Status (BIMS) score of nine (9) indicating moderate cognitive impairment. The MDS further reflected no indicators of wounds or wound infections. Pneumonia was reflected. Review of Resident #1's Care Plan dated [DATE] and revised [DATE] reflected The resident has [MEDICAL CONDITION]. ([MEDICAL CONDITION]) Interventions included Monitor/document/report to MD (Medical Doctor) PRN (as needed) any signs or symptoms of complications of extremities: coldness of extremity, pallor, cyanosis, and pain. Monitor/document/report to MD PRN any signs or symptoms of skin problems related to [MEDICAL CONDITION]: Redness [MEDICAL CONDITION], Blistering, Itching, Burning, Bruises, Cuts, other [MEDICAL CONDITION]. Review of Resident #1's Quarterly MDS dated [DATE] reflected a BIMS score of six (6) indicating severe cognitive impairment. The MDS further reflected no indicators of wounds or wound infections. Review of Resident #1's Progress Note dated [DATE] at 8:00 PM reflected Resident noted with increase confusion. (sic) 02 sat (Blood Oxygen Saturation) decreased to 73%. HR (Heart Rate) 133. Family at bedside. Swelling noted to left foot. Redness noted. Cool to touch. Necrosis (The death of living cells or tissues) noted to left great toe and 2nd/3rd toes. Sent to (local emergency room ) to evaluate and treat as indicated. Review of Resident #1's local hospital emergency room notes dated [DATE] reflected N/H (Nursing Home) resident was sent here for Dyspnea, Hypoxemia, Confusion, Left foot ulcer, Swelling. The notes further reflected Left foot swollen tender dry ulcer tip of great toe 3rd toe with dry gangrene, Doppler No Pulses left foot. Review of Resident #1's laboratory report dated [DATE] at 9:00 PM reflected a WBC (White Blood Cell Count) of 14.2 indicating the presence of an infection. The reference range for a WBC is maximum low of 5.0 and maximum high of 10.0. Review of Resident #1's Physician's Consultation Report dated [DATE] at 8:22 PM reflected the resident arrived at the local hospital with decreased level of consciousness. The patient arrived hypotensive (low blood pressure) in septic shock to the ER (emergency room ). Was evaluated by the emergency room (ER) physician and was felt to have a necrotic and ischemic left foot. The resident was treated with femoral artery and venous catheters which were placed on the same side of the concerned foot. Review of Resident #1's Discharge Summary from the local hospital dated [DATE] reflected a date of death of [DATE]. Cause of death was reflected as Septic Shock, Gangrene and Necrosis of the left lower extremity. [MEDICAL CONDITION], chronic, with an infection to the right upper arm [MEDICAL TREATMENT] graft and ischemic left lower extremity gram [MEDICAL CONDITION]. In an interview on [DATE] at 1:12 PM the Director of Nurses (DON) stated Resident #1's foot discoloration was first noted as a discolored area. soon after an incident occurred in which the resident had bumped his toes. The DON stated the resident's physician was notified and came to the facility to assess the foot on [DATE] when he wrote orders for oral and topical antibiotics. When asked, the DON stated she could not recall when the resident's toes were first noted to be discolored. The DON's response was I want to say he always had those discolored toes. Review of Resident #1's Physician's Progress Note dated [DATE] reflected a [DIAGNOSES REDACTED]. Left foot [MEDICAL CONDITION], DM (Diabetes Mellitus) foot. Review of Resident #1's Care Plan dated [DATE] reflected Resident has current skin concerns: Right toe and 3rd toe left foot. Interventions included Monitor areas for increased breakdown, s/s (signs and symptoms) of infection report to MD Keep MD and RP (Responsible Party) informed of Resident's progress. A) Review of Resident #1's physician's orders [REDACTED]. Bactoban Ointment (Topical Antibiotic) to foot BID after dressing. [MEDICATION NAME] (Oral Antibiotic) 150 mg (milligrams) one (1) tablet PO daily for seven (7) days. Podiatry Consult. Review of Resident #1's Medication Administration Record [REDACTED]. Review of Resident #1's physician orders [REDACTED]. Directly underneath the handwritten order is a handwritten statement reflecting Will start ABT (Antibiotic) when available. In an interview on [DATE] at 1:12 LVN A stated she had not administered [MEDICATION NAME] 150 mg PO on [DATE] as ordered by the Primary Care Physician (PCP) because the medication was not available. LVN A further stated she had checked the facility's emergency medication kit and the kit had none of the medication. LVN A stated she attempted to order the medication from the facility's contracted facility but was told the medication would not be available for three or four days. LVN A further stated she wrote a note under the PCP's order for [MEDICATION NAME] stating Will start antibiotic when available. LVN A stated she should have notified the DON of the issue but she could not recall if she had actually done so. In an interview on [DATE] at 12:55 PM the DON stated Resident #1's PCP order of [MEDICATION NAME] 150 mg once daily for seven (7) days was not started on [DATE] as ordered. The first administration of the medication was not administered until four (4) days later on [DATE]. The DON further stated she could not understand why the [MEDICATION NAME] had not been administered as ordered since a backup supply of the medication was kept in an emergency kit maintained in the facility's medication room. An observation of the facility's medication room on [DATE] at 1:10 PM (under the supervision of the DON) revealed the emergency medication kit to hold four (4) tablets of [MEDICATION NAME] 150 mg and 10 doses of [MEDICATION NAME] 50 mg. In an interview on [DATE] at 2:06 PM Resident #1's PCP stated the four (4) day delay in the administration of [MEDICATION NAME] could contribute to delay in infection recovery. Resident # 1's PCP stated he expected facility staff to notify him when delays occur in referrals and medication administration. In an interview on [DATE] at 2:18 PM the DON stated It (the medication) should have been started sooner. The DON went on to say it was best practice to notify the PCP of a medication or appointment delay. Yes, we failed the resident. The DON further stated she could not recall having been notified of a difficulty in obtaining [MEDICATION NAME]. The DON further stated LVN A should have notified her if the pharmacy stated there would be a delay in delivery of a medication. She would then, in turn, call that pharmacy and arrange for an alternate pharmacy to deliver in a timely manner. The DON stated if nursing staff was unable to obtain needed medication she would notify the PCP of the problem in order to allow him the opportunity to change his orders to an alternative medication or treatment. In an interview on [DATE] at 3:11 PM the Administrator stated Yes, the facility failed the resident when it did not give him his medications. The nurse should have notified the DON right away when the nurse felt a medication was not available. It (the [MEDICATION NAME]) should have been in the emergency kit. If not then she should have called the local pharmacy to try to get it. The Administrator stated Yes, the doctor should have been notified. when it was determined that ordered medications would not be available in a timely manner and when a timely referred appointment was not going to occur. B) Review of the facility's appointment calendar reflected Resident #1 had been scheduled for an appointment with a Podiatrist on [DATE] at 9:00 AM. The calendar entry was lined out. Review of the facility's appointment calendar reflected Resident #1 had been scheduled for an appointment with a Podiatrist on [DATE] at 1:15 PM. The calendar entry was lined out with an annotation reflecting Rescheduled to ,[DATE]. Review of the facility's appointment calendar reflected Resident #1 had been scheduled for an appointment with a Podiatrist on [DATE] at 9:00 AM. In an interview on [DATE] at 10:29 AM the DON stated missed appointments were not documented in the medical record but were documented in a calendar maintained by the facility's receptionist. The DON further stated she could not recall if Resident #1's podiatry appointment issues were reported to the resident's PCP. When asked of the possible medical consequences of a resident not getting his podiatry appointment as ordered, the DON would only state it's hard to say. In an interview on [DATE] at 11:31 AM the Receptionist stated she was responsible for scheduling and rescheduling medical appointments for the residents. The receptionist further stated she would be notified by nursing staff if an appointment was to be scheduled, rescheduled, or cancelled. The receptionist further stated she was not responsible for notifying staff of schedule changes. The receptionist further stated Resident #1's podiatry appointment was originally scheduled for [DATE] but she was told by a charge nurse (name unknown) that the resident had missed a [MEDICAL TREATMENT] appointment on the previous Tuesday ([DATE]) so the podiatry appointment was rescheduled for [DATE] instead and the resident went to the [MEDICAL TREATMENT] center instead on [DATE]. In an interview on [DATE] at 3:11 PM the Administrator stated the facility failed the resident and the physician should have been notified when a timely referred appointment was not going to occur. In an interview on [DATE] at 3:50 PM Resident #1's PCP stated he had not been contacted by the facility's staff regarding Resident #1's podiatrist appointments. Resident # 1's PCP stated he would have wanted to be notified of this issue. C) Review of Resident # 1's Skin Care Report dated [DATE] and conducted by LVN A reflected the resident's left great toe and middle toe to be tender to the affected area. There was no redness or drainage noted. Review of the Resident # 1's Skin Care Report dated [DATE] and conducted by LVN F reflected the resident's left great toe and middle toe to be tender, had reness redness and drainage to the affected area. The drainage was characterized as Serosanguineous Review of the website http://www.advancedtissue.com/type-drainage/ reflected Sanguineous drainage should not be common in wounds after a few hours or days, and this type of drainage later on may be indicative of trauma to the wound site. Review of website https://www.nlm.nih.gov/medlineplus/ency/article/ 6.htm reflected Serosanguineous means containing or relating to both blood and the liquid part of blood (serum). It usually refers to fluids collected from or leaving the body. For example, fluid leaving a wound that is serosanguineous is yellowish with small amounts of blood. In an interview on [DATE] at 2:10 PM Treatment Nurse B stated the resident had bumped his toes but could not recall the date. The resident's PCP ordered topical antibiotic ointment (TAO) and oral antibiotics.The Treatment Nurse further stated she did not observe gangrene or necrosis. The Treatment Nurse B stated she last saw Resident # 1's foot on [DATE] when it had tenderness, redness and drainage but had not considered the foot to be infected. The Treatment Nurse stated she did not notify the physician on [DATE] of the change in the resident's wound status. In an interview on [DATE] at 3:32 PM LVN G stated he had last assessed Resident #1's foot on [DATE] two (2) days prior to Resident# 1's change of condition and transportation to the local hospital. LVN G further stated that Resident #1's foot still looked infected when he treated the resident on that date. LVN G further stated the foot was red and swollen. LVN G further stated he did not notify the PCP. In an interview on [DATE] at 1:30 PM LVN A stated Resident #1's great toe was black. LVN A stated she reported the change to her charge nurse and the DON but could not recall when she made the observation or notification. LVN A further stated she last saw Resident #1's wound on [DATE]. The LVN further stated she could not recall the condition of the wound on that date but did record the status of the wound on the daily skin report for the resident. LVN A further stated she would recognize signs and symptoms of infection as color change, a different appearance on the skin, a change in the size of the wound, redness, warmness, tenderness, and swelling. Review of Resident #1's Skin Care Report dated [DATE] at 4:00 PM revealed the assessor to be LVN G. The report reflected an observation of tenderness and redness to the left foot. The resident's pain was assessed as a three (3) on a scale of one (1) to six (6) and described as dull and intermittent. Review of Resident #1's Skin Care Report dated [DATE] at 7:08 AM revealed the assessor to be LVN A. The report reflected an observation of tenderness to the left foot. The report did not reflect observations of swelling, redness, drainage, or warmth. No pain was indicated. In an interview on [DATE] at 3:51 PM Resident #1's PCP was asked if Resident #1's infected toes and foot could have been the cause of the resident's death. Resident # 1's PCP stated I am sure it would have played a role. The PCP further stated he had not been contacted by staff regarding concerns that the resident may be declining or not improving appropriately during the course of the antibiotic regimen the PCP had established. The PCP further stated the signs and symptoms he would expect nursing staff to identify as possible infection were redness, swelling, and puss on the wound. In an interview on [DATE] at 10:45 AM the DON stated nurses receive training on infection control on a regular basis through computer and in-person in-services. Signs and symptoms the staff are trained to note as indicative of infections were drainage, redness, tenderness, increased temperature, pain, and swelling. The facility Administrator and DON were notified on [DATE] at 4:20 PM that an IJ situation had been identified due to the above failures. The following Plan of Removal was submitted by the Administrator on [DATE] at 9:00 AM. Interventions to prevent reoccurrence · 60% of med carts were audited to determine that all prescribed medications are available in-house as of 8:30pm [DATE]. As of the 60 % audit no errors have been identified. By [DATE] at 9am 100% of all med carts will have been audited. In the future, if any ordered medication is not available the following protocol will be followed: · The charge nurse will notify the pharmacy in attempt to get the medication · If unsuccessful, within 4 hours the charge nurse will notify the DON who will then contact the pharmacy in an attempt to rectify the issue · If the DON cannot obtain the medication from the primary pharmacy or a secondary pharmacy, the DON will contact the physician regarding the unavailability of the medication. · Any new orders will be followed as directed by the physician. · All residents identified as having wounds or infections will be assessed by the DON by 11 pm on [DATE] to ensure assessments are correct. · 20% of all residents will be assessed by an RN to ensure there are no identifiable infections on [DATE]. 100 % of all residents will be assessed by 12 pm [DATE] · The following in-services were begun on [DATE] by the Director of Nurses. Staff not in-serviced today will not be allowed to assume their duties until they have received the in-service. 54% of staff will be in-serviced by 12 am [DATE]. 76% of staff will be in-serviced by 8 am [DATE]. 78% of staff will be in-serviced by 3 pm [DATE]. 100% of staff will be in-serviced by [DATE]. · Licensed Nurses · If a medication is not available, the following protocol will be followed: o The charge nurse will notify the pharmacy in attempt to get the medication o If unsuccessful, within 4 hours the charge nurse will notify the DON who will then contact the pharmacy in an attempt to rectify the issue o If the DON cannot obtain the medication from the primary pharmacy or a secondary pharmacy, the DON will contact the physician regarding the unavailability of the medication. o Any new orders will be followed as directed by the physician. · Notification of the physician if a resident is unable to make it to a scheduled medical related appointment. · Signs and symptoms of wound infection · Notifying the physician timely for resident change of condition · Neglect · Certified Nurse Aides · Notifying the charge nurses of changes in a resident ' s condition · Neglect Any new staff hired after [DATE] in the above positions will receive training as stated above prior to assuming care of residents. · The medical director of the facility was notified at 7:15 pm by the DON on [DATE] regarding the immediate jeopardy · The medical director will be contacted by the DON for any unresolved issues with medication unavailability or residents missing a scheduled medical appointment. Monitoring · The DON and or designee will inquire daily during start up from charge nurse on their respective hall if they have any medications that are unavailable. · The DON and/or ADON will complete a med availability review on 15 residents per week for 4 weeks by comparing the MAR indicated [REDACTED] · The DON will view all resident wounds at least 2 times per week for 2 weeks, then 1 time per week for 2 weeks, to ensure correct documentation of status is correct. · The DON and or designee will review all residents with infections in the weekly standards of care meeting to ensure that physician notification is occurring if there is a decline. · The DON and/or designee will ask 10 staff members per week for 4 weeks, a situational question related to neglect. · Findings will be reviewed by the QA committee and changes made to the plan as needed. · All of the above monitoring will be documented on a facility formulated monitoring form. The investigator monitored the current plan of removal from [DATE] 10:00 AM until 12:30 PM as follows: Observations of facility directed staff in-services were conducted for nursing staff on the subjects of Notification of physicians and families of changes of condition, issues in obtaining ordered medications or treatments, the correct manner in which to handle a medication issue to include notification of the DON in order to allow her to intervene as appropriate. How to identify signs and symptoms of a new infection or a worsening of an infection already identified. An in-service on abuse and neglect was also conducted for all staff. Nurse aides were trained in Abuse and neglect, identification of changes in condition to include signs and symptoms of infection. Notification of a nurse of any observed change of condition. Review of the MARS (Medication Administration Records) for all residents identified as requiring wound care as well as all residents identified as being treated for [REDACTED]. Observations of all medication carts to confirm the actual presence of medications that have been ordered for all sampled residents to include all residents identified as requiring wound and infection care. Observations of all Residents receiving wound care (Resident #6 and Resident #9) to ensure current monitoring by staff for signs and symptoms of infection. Interviews of five (5) staff members (LVN I, Kitchen Aide J, CNA K, LVN L, and CNA M) to verify their attendance at the in-services as well as to verify their comprehension of the subject matter. On [DATE] at 12:30 PM the facility Administrator and DON were informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope of pattern due to the facility requiring time to train all staff and monitor their Plan of Removal. The DON provided a list two (2) residents currently receiving wound care and three (3) residents currently receiving care for infections.

Based on interview and record review the facility failed to implement policies and procedures that prohibit neglect for one (1) of nine (9) residents (Resident #1) reviewed for neglect. On [DATE] Resident #1 developed [MEDICAL CONDITION] to the left posterior middle toe approximately 1.5 cm. x 2.0 cm. The facility failed to: A) Administer one of two (2) ordered oral medications for four (4) days due to the medication not being in the building and failed to notify Resident # 1's physician of the delay in a prescribed medication. B) Ensure Resident #1 got to his ordered podiatry appointment. The original appointment scheduled for [DATE] was cancelled and rescheduled for [DATE]. The resident died five days prior to the scheduled appointment. The facility further failed to notify the physician of the delayed physician ordered podiatrist appointment. C) LVN A, LVN G and Treatment Nurse B failed to accurately reassess the infection on [DATE] through [DATE] and notify the physician the infection was not healing. Resident #1 subsequently went to the hospital on [DATE], was diagnosed with [REDACTED]. Resident #1 died on [DATE]. An Immediate Jeopardy (IJ) was identified to have existed from [DATE] through [DATE]. While the IJ was removed, the facility remained out of compliance at a severity of actual harm with a scope identified as pattern. This deficient practice affected Resident # 1 and placed five (5) additional residents who had wounds or infections at risk for delayed care that could result in pain, suffering,[MEDICAL CONDITION], gangrene, and death. Findings Included: Review of the facility's Abuse and Neglect Policy (undated) reflected: The failure to provide goods or services, including medical services that are necessary to avoid physical or emotional harm, pain, or mental illness. Review of Resident #1's Face Sheet reflected an [AGE] year old male admitted to the facility on [DATE] and readmitted [DATE]. Diagnoses' included End Stage [MEDICAL CONDITIONS], Hypertension, [MEDICAL CONDITIONS] and [MEDICAL CONDITION]. Review of Resident #1's Admission Minimum Data Set (MDS) assessment dated [DATE] reflected a Brief Interview for Mental Status (BIMS) score of nine (9) indicating moderate cognitive impairment. The MDS further reflected no indicators of wounds or wound infections. Pneumonia was reflected. Review of Resident #1's Care Plan dated [DATE] and revised [DATE] reflected The resident has [MEDICAL CONDITION]. ([MEDICAL CONDITION]) Interventions included Monitor/document/report to MD (Medical Doctor) PRN (as needed) any signs or symptoms of complications of extremities: coldness of extremity, pallor, cyanosis, and pain. Monitor/document/report to MD PRN any signs or symptoms of skin problems related to [MEDICAL CONDITION]: Redness [MEDICAL CONDITION], Blistering, Itching, Burning, Bruises, Cuts, other [MEDICAL CONDITION]. Review of Resident #1's Care Plan dated [DATE] reflected Resident has current skin concerns: Right toe and 3rd toe left foot. Interventions included Monitor areas for increased breakdown, s/s (signs and symptoms) of infection report to MD Keep MD and RP (Responsible Party) informed of Resident's progress. Review of Resident #1's Quarterly MDS dated [DATE] reflected a BIMS score of six (6) indicating severe cognitive impairment. The MDS further reflected no indicators of wounds or wound infections. Review of Resident #1's Progress Note dated [DATE] at 8:00 PM reflected Resident noted with increase confusion. (sic) 02 sat (Blood Oxygen Saturation) decreased to 73%. HR (Heart Rate) 133. Family at bedside. Swelling noted to left foot. Redness noted. Cool to touch. Necrosis (The death of living cells or tissues) noted to left great toe and 2nd/3rd toes. Sent to (local emergency room ) to evaluate and treat as indicated. Review of Resident #1's local hospital emergency room notes dated [DATE] reflected N/H (Nursing Home) resident was sent here for Dyspnea, Hypoxemia, Confusion, Left foot ulcer, Swelling. The notes further reflected Left foot swollen tender dry ulcer tip of great toe 3rd toe with dry gangrene, Doppler No Pulses left foot. Review of Resident #1's laboratory report dated [DATE] at 9:00 PM reflected a WBC (White Blood Cell Count) of 14.2 indicating the presence of an infection. The reference range for a WBC is maximum low of 5.0 and maximum high of 10.0. Review of Resident #1's Physician's Consultation Report dated [DATE] at 8:22 PM reflected the resident arrived at the local hospital with decreased level of consciousness. The patient arrived hypotensive (low blood pressure) in septic shock to the ER (emergency room ). Was evaluated by the emergency room (ER) physician and was felt to have a necrotic and ischemic left foot. The resident was treated with femoral artery and venous catheters which were placed on the same side of the concerned foot. Review of Resident #1's Discharge Summary from the local hospital dated [DATE] reflected a date of death of [DATE]. Cause of death was reflected as Septic Shock, Gangrene and Necrosis of the left lower extremity. [MEDICAL CONDITION], chronic, with an infection to the right upper arm [MEDICAL TREATMENT] graft and ischemic left lower extremity gram [MEDICAL CONDITION]. In an interview on [DATE] at 1:12 PM the Director of Nurses (DON) stated Resident #1's foot discoloration was first noted as a discolored area. soon after an incident occurred in which the resident had bumped his toes. The DON stated the resident's physician was notified and came to the facility to assess the foot on [DATE] when he wrote orders for oral and topical antibiotics. When asked, the DON stated she could not recall when the resident's toes were first noted to be discolored. The DON's response was I want to say he always had those discolored toes. Review of Resident #1's Physician's Progress Note dated [DATE] reflected a [DIAGNOSES REDACTED]. Left foot [MEDICAL CONDITION], DM (Diabetes Mellitus) foot. A) Review of Resident #1's physician's orders [REDACTED]. Bactoban Ointment (Topical Antibiotic) to foot BID after dressing. [MEDICATION NAME] (Oral Antibiotic) 150 mg (milligrams) one (1) tablet PO daily for seven (7) days. Podiatry Consult. Review of Resident #1's Medication Administration Record [REDACTED]. Review of Resident #1's physician orders [REDACTED]. Directly underneath the handwritten order is a handwritten statement reflecting Will start ABT (Antibiotic) when available. In an interview on [DATE] at 1:12 LVN A stated she had not administered [MEDICATION NAME] 150 mg PO on [DATE] as ordered by the Primary Care Physician (PCP) because the medication was not available. LVN A further stated she had checked the facility's emergency medication kit and the kit had none of the medication. LVN A stated she attempted to order the medication from the facility's contracted facility but was told the medication would not be available for three or four days. LVN A further stated she wrote a note under the PCP's order for [MEDICATION NAME] stating Will start antibiotic when available. LVN A stated she should have notified the DON of the issue but she could not recall if she had actually done so. In an interview on [DATE] at 12:55 PM the DON stated Resident #1's PCP order of [MEDICATION NAME] 150 mg once daily for seven (7) days was not started on [DATE] as ordered. The first administration of the medication was not administered until four (4) days later on [DATE]. The DON further stated she could not understand why the [MEDICATION NAME] had not been administered as ordered since a backup supply of the medication was kept in an emergency kit maintained in the facility's medication room. An observation of the facility's medication room on [DATE] at 1:10 PM (under the supervision of the DON) revealed the emergency medication kit to hold four (4) tablets of [MEDICATION NAME] 150 mg and 10 doses of [MEDICATION NAME] 50 mg. In an interview on [DATE] at 2:06 PM Resident #1's PCP stated the four (4) day delay in the administration of [MEDICATION NAME] could contribute to delay in infection recovery. Resident # 1's PCP stated he expected facility staff to notify him when delays occur in referrals and medication administration. In an interview on [DATE] at 2:18 PM the DON stated It (the medication) should have been started sooner. The DON went on to say it was best practice to notify the PCP of a medication or appointment delay. Yes, we failed the resident. The DON further stated she could not recall having been notified of a difficulty in obtaining [MEDICATION NAME]. The DON further stated LVN A should have notified her if the pharmacy stated there would be a delay in delivery of a medication. She would then, in turn, call that pharmacy and arrange for an alternate pharmacy to deliver in a timely manner. The DON stated if nursing staff was unable to obtain needed medication she would notify the PCP of the problem in order to allow him the opportunity to change his orders to an alternative medication or treatment. In an interview on [DATE] at 3:11 PM the Administrator stated Yes, the facility failed the resident when it did not give him his medications. The nurse should have notified the DON right away when the nurse felt a medication was not available. It (the [MEDICATION NAME]) should have been in the emergency kit. If not then she should have called the local pharmacy to try to get it. The Administrator stated Yes, the doctor should have been notified. when it was determined that ordered medications would not be available in a timely manner and when a timely referred appointment was not going to occur. B) Review of the facility's appointment calendar reflected Resident #1 had been scheduled for an appointment with a Podiatrist on [DATE] at 9:00 AM. The calendar entry was lined out. Review of the facility's appointment calendar reflected Resident #1 had been scheduled for an appointment with a Podiatrist on [DATE] at 1:15 PM. The calendar entry was lined out with an annotation reflecting Rescheduled to ,[DATE]. Review of the facility's appointment calendar reflected Resident #1 had been scheduled for an appointment with a Podiatrist on [DATE] at 9:00 AM. In an interview on [DATE] at 10:29 AM the DON stated missed appointments were not documented in the medical record but were documented in a calendar maintained by the facility's receptionist. The DON further stated she could not recall if Resident #1's podiatry appointment issues were reported to the resident's PCP. When asked of the possible medical consequences of a resident not getting his podiatry appointment as ordered, the DON would only state it's hard to say. In an interview on [DATE] at 11:31 AM the Receptionist stated she was responsible for scheduling and rescheduling medical appointments for the residents. The receptionist further stated she would be notified by nursing staff if an appointment was to be scheduled, rescheduled, or cancelled. The receptionist further stated she was not responsible for notifying staff of schedule changes. The receptionist further stated Resident #1's podiatry appointment was originally scheduled for [DATE] but she was told by a charge nurse (name unknown) that the resident had missed a [MEDICAL TREATMENT] appointment on the previous Tuesday ([DATE]) so the podiatry appointment was rescheduled for [DATE] instead and the resident went to the [MEDICAL TREATMENT] center instead on [DATE]. In an interview on [DATE] at 3:11 PM the Administrator stated the facility failed the resident and the physician should have been notified when a timely referred appointment was not going to occur. In an interview on [DATE] at 3:50 PM Resident #1's PCP stated he had not been contacted by the facility's staff regarding Resident #1's podiatrist appointments. Resident # 1's PCP stated he would have wanted to be notified of this issue. C) Review of Resident # 1's Skin Care Report dated [DATE] and conducted by LVN A reflected the resident's left great toe and middle toe to be tender to the affected area. There was no redness or drainage noted. Review of the Resident # 1's Skin Care Report dated [DATE] and conducted by LVN F reflected the resident's left great toe and middle toe to be tender, had reness redness and drainage to the affected area. The drainage was characterized as Serosanguineous Review of the website http://www.advancedtissue.com/type-drainage/ reflected Sanguineous drainage should not be common in wounds after a few hours or days, and this type of drainage later on may be indicative of trauma to the wound site. Review of website https://www.nlm.nih.gov/medlineplus/ency/article/ 6.htm reflected Serosanguineous means containing or relating to both blood and the liquid part of blood (serum). It usually refers to fluids collected from or leaving the body. For example, fluid leaving a wound that is serosanguineous is yellowish with small amounts of blood. In an interview on [DATE] at 2:10 PM Treatment Nurse B stated the resident had bumped his toes but could not recall the date. The resident's PCP ordered topical antibiotic ointment (TAO) and oral antibiotics.The Treatment Nurse further stated she did not observe gangrene or necrosis. The Treatment Nurse B stated she last saw Resident # 1's foot on [DATE] when it had tenderness, redness and drainage but had not considered the foot to be infected. The Treatment Nurse stated she did not notify the physician on [DATE] of the change in the resident's wound status. In an interview on [DATE] at 3:32 PM LVN G stated he had last assessed Resident #1's foot on [DATE] two (2) days prior to Resident# 1's change of condition and transportation to the local hospital. LVN G further stated that Resident #1's foot still looked infected when he treated the resident on that date. LVN G further stated the foot was red and swollen. LVN G further stated he did not notify the PCP. In an interview on [DATE] at 1:30 PM LVN A stated Resident #1's great toe was black. LVN A stated she reported the change to her charge nurse and the DON but could not recall when she made the observation or notification. LVN A further stated she last saw Resident #1's wound on [DATE]. The LVN further stated she could not recall the condition of the wound on that date but did record the status of the wound on the daily skin report for the resident. LVN A further stated she would recognize signs and symptoms of infection as color change, a different appearance on the skin, a change in the size of the wound, redness, warmness, tenderness, and swelling. Review of Resident #1's Skin Care Report dated [DATE] at 4:00 PM revealed the assessor to be LVN G. The report reflected an observation of tenderness and redness to the left foot. The resident's pain was assessed as a three (3) on a scale of one (1) to six (6) and described as dull and intermittent. Review of Resident #1's Skin Care Report dated [DATE] at 7:08 AM revealed the assessor to be LVN A. The report reflected an observation of tenderness to the left foot. The report did not reflect observations of swelling, redness, drainage, or warmth. No pain was indicated. In an interview on [DATE] at 3:51 PM Resident #1's PCP was asked if Resident #1's infected toes and foot could have been the cause of the resident's death. Resident # 1's PCP stated I am sure it would have played a role. The PCP further stated he had not been contacted by staff regarding concerns that the resident may be declining or not improving appropriately during the course of the antibiotic regimen the PCP had established. The PCP further stated the signs and symptoms he would expect nursing staff to identify as possible infection were redness, swelling, and puss on the wound. In an interview on [DATE] at 10:45 AM the DON stated nurses receive training on infection control on a regular basis through computer and in-person in-services. Signs and symptoms the staff are trained to note as indicative of infections were drainage, redness, tenderness, increased temperature, pain, and swelling. The facility Administrator and DON were notified on [DATE] at 4:20 PM that an IJ situation had been identified due to the above failures. The following Plan of Removal was submitted by the Administrator on [DATE] at 9:00 AM. Interventions to prevent reoccurrence · 60% of med carts were audited to determine that all prescribed medications are available in-house as of 8:30pm [DATE]. As of the 60 % audit no errors have been identified. By [DATE] at 9am 100% of all med carts will have been audited. In the future, if any ordered medication is not available the following protocol will be followed: · The charge nurse will notify the pharmacy in attempt to get the medication · If unsuccessful, within 4 hours the charge nurse will notify the DON who will then contact the pharmacy in an attempt to rectify the issue · If the DON cannot obtain the medication from the primary pharmacy or a secondary pharmacy, the DON will contact the physician regarding the unavailability of the medication. · Any new orders will be followed as directed by the physician. · All residents identified as having wounds or infections will be assessed by the DON by 11 pm on [DATE] to ensure assessments are correct. · 20% of all residents will be assessed by an RN to ensure there are no identifiable infections on [DATE]. 100 % of all residents will be assessed by 12 pm [DATE] · The following in-services were begun on [DATE] by the Director of Nurses. Staff not in-serviced today will not be allowed to assume their duties until they have received the in-service. 54% of staff will be in-serviced by 12 am [DATE]. 76% of staff will be in-serviced by 8 am [DATE]. 78% of staff will be in-serviced by 3 pm [DATE]. 100% of staff will be in-serviced by [DATE]. · Licensed Nurses · If a medication is not available, the following protocol will be followed: o The charge nurse will notify the pharmacy in attempt to get the medication o If unsuccessful, within 4 hours the charge nurse will notify the DON who will then contact the pharmacy in an attempt to rectify the issue o If the DON cannot obtain the medication from the primary pharmacy or a secondary pharmacy, the DON will contact the physician regarding the unavailability of the medication. o Any new orders will be followed as directed by the physician. · Notification of the physician if a resident is unable to make it to a scheduled medical related appointment. · Signs and symptoms of wound infection · Notifying the physician timely for resident change of condition · Neglect · Certified Nurse Aides · Notifying the charge nurses of changes in a resident ' s condition · Neglect Any new staff hired after [DATE] in the above positions will receive training as stated above prior to assuming care of residents. · The medical director of the facility was notified at 7:15 pm by the DON on [DATE] regarding the immediate jeopardy · The medical director will be contacted by the DON for any unresolved issues with medication unavailability or residents missing a scheduled medical appointment. Monitoring · The DON and or designee will inquire daily during start up from charge nurse on their respective hall if they have any medications that are unavailable. · The DON and/or ADON will complete a med availability review on 15 residents per week for 4 weeks by comparing the MAR indicated [REDACTED] · The DON will view all resident wounds at least 2 times per week for 2 weeks, then 1 time per week for 2 weeks, to ensure correct documentation of status is correct. · The DON and or designee will review all residents with infections in the weekly standards of care meeting to ensure that physician notification is occurring if there is a decline. · The DON and/or designee will ask 10 staff members per week for 4 weeks, a situational question related to neglect. · Findings will be reviewed by the QA committee and changes made to the plan as needed. · All of the above monitoring will be documented on a facility formulated monitoring form. The investigator monitored the current plan of removal from [DATE] 10:00 AM until 12:30 PM as follows: Observations of facility directed staff in-services were conducted for nursing staff on the subjects of Notification of physicians and families of changes of condition, issues in obtaining ordered medications or treatments, the correct manner in which to handle a medication issue to include notification of the DON in order to allow her to intervene as appropriate. How to identify signs and symptoms of a new infection or a worsening of an infection already identified. An in-service on abuse and neglect was also conducted for all staff. Nurse aides were trained in Abuse and neglect, identification of changes in condition to include signs and symptoms of infection. Notification of a nurse of any observed change of condition. Review of the MARS (Medication Administration Records) for all residents identified as requiring wound care as well as all residents identified as being treated for [REDACTED]. Observations of all medication carts to confirm the actual presence of medications that have been ordered for all sampled residents to include all residents identified as requiring wound and infection care. Observations of all Residents receiving wound care (Resident #6 and Resident #9) to ensure current monitoring by staff for signs and symptoms of infection. Interviews of five (5) staff members (LVN I, Kitchen Aide J, CNA K, LVN L, and CNA M) to verify their attendance at the in-services as well as to verify their comprehension of the subject matter. On [DATE] at 12:30 PM the facility Administrator and DON were informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope of pattern due to the facility requiring time to train all staff and monitor their Plan of Removal. The DON provided a list two (2) residents currently receiving wound care and three (3) residents currently receiving care for infections.

Based on interview and record review the facility failed to consult with a resident's Primary Care Physician (PCP) of a need to alter treatment significantly (a need to commence a new form of treatment) for one (1) of nine (9) residents reviewed for Notification of Changes. (Resident #1). On [DATE] Resident #1 developed [MEDICAL CONDITION] to the left posterior middle toe approximately 1.5 cm. x 2.0 cm. The facility failed to: A) Notify Resident # 1's physician of a delay in physician ordered treatment when they facility failed to implement one of the prescribed oral medications for four (4) days due to the medication not being in the building. B) Notify Resident # 1's physician when the physician ordered podiatrist appointment delayed and not conducted in a timely; and C) Notify Resident # 1's physician when the resident's infection worsened and had not cleared during and after antibiodic treatment. Resident #1 subsequently went to the hospital on [DATE], was diagnosed with [REDACTED]. Resident #1 died on [DATE]. An Immediate Jeopardy (IJ) was identified to have existed from [DATE] through [DATE]. While the IJ was removed, the facility remained out of compliance at a severity of actual harm with a scope identified as pattern. This deficient practice affected Resident # 1 and placed five (5) additional residents who had wounds or infections at risk for delayed care that could result in pain, suffering,[MEDICAL CONDITION], gangrene, and death. Findings Include: Review of Resident #1's Face Sheet reflected an [AGE] year old male admitted to the facility on [DATE] and readmitted [DATE]. Diagnoses' included End Stage [MEDICAL CONDITIONS], Hypertension, [MEDICAL CONDITIONS] and [MEDICAL CONDITION]. Review of Resident #1's Admission Minimum Data Set (MDS) assessment dated [DATE] reflected a Brief Interview for Mental Status (BIMS) score of nine (9) indicating moderate cognitive impairment. The MDS further reflected no indicators of wounds or wound infections. Pneumonia was reflected. Review of Resident #1's Care Plan dated [DATE] and revised [DATE] reflected The resident has [MEDICAL CONDITION]. ([MEDICAL CONDITION]) Interventions included Monitor/document/report to MD (Medical Doctor) PRN (as needed) any signs or symptoms of complications of extremities: coldness of extremity, pallor, cyanosis, and pain. Monitor/document/report to MD PRN any signs or symptoms of skin problems related to [MEDICAL CONDITION]: Redness [MEDICAL CONDITION], Blistering, Itching, Burning, Bruises, Cuts, other [MEDICAL CONDITION]. Review of Resident #1's Care Plan dated [DATE] reflected Resident has current skin concerns: Right toe and 3rd toe left foot. Interventions included Monitor areas for increased breakdown, s/s (signs and symptoms) of infection report to MD Keep MD and RP (Responsible Party) informed of Resident's progress. Review of Resident #1's Quarterly MDS dated [DATE] reflected a BIMS score of six (6) indicating severe cognitive impairment. The MDS further reflected no indicators of wounds or wound infections. Review of Resident #1's Progress Note dated [DATE] at 8:00 PM reflected Resident noted with increase confusion. (sic) 02 sat (Blood Oxygen Saturation) decreased to 73%. HR (Heart Rate) 133. Family at bedside. Swelling noted to left foot. Redness noted. Cool to touch. Necrosis (The death of living cells or tissues) noted to left great toe and 2nd/3rd toes. Sent to (local emergency room ) to evaluate and treat as indicated. Review of Resident #1's local hospital emergency room notes dated [DATE] reflected N/H (Nursing Home) resident was sent here for Dyspnea, Hypoxemia, Confusion, Left foot ulcer, Swelling. The notes further reflected Left foot swollen tender dry ulcer tip of great toe 3rd toe with dry gangrene, Doppler No Pulses left foot. Review of Resident #1's laboratory report dated [DATE] at 9:00 PM reflected a WBC (White Blood Cell Count) of 14.2 indicating the presence of an infection. The reference range for a WBC is maximum low of 5.0 and maximum high of 10.0. Review of Resident #1's Physician's Consultation Report dated [DATE] at 8:22 PM reflected the resident arrived at the local hospital with decreased level of consciousness. The patient arrived hypotensive (low blood pressure) in septic shock to the ER (emergency room ). Was evaluated by the emergency room (ER) physician and was felt to have a necrotic and ischemic left foot. The resident was treated with femoral artery and venous catheters which were placed on the same side of the concerned foot. Review of Resident #1's Discharge Summary from the local hospital dated [DATE] reflected a date of death of [DATE]. Cause of death was reflected as Septic Shock, Gangrene and Necrosis of the left lower extremity. [MEDICAL CONDITION], chronic, with an infection to the right upper arm [MEDICAL TREATMENT] graft and ischemic left lower extremity gram [MEDICAL CONDITION]. In an interview on [DATE] at 1:12 PM the Director of Nurses (DON) stated Resident #1's foot discoloration was first noted as a discolored area. soon after an incident occurred in which the resident had bumped his toes. The DON stated the resident's physician was notified and came to the facility to assess the foot on [DATE] when he wrote orders for oral and topical antibiotics. When asked, the DON stated she could not recall when the resident's toes were first noted to be discolored. The DON's response was I want to say he always had those discolored toes. Review of Resident #1's Physician's Progress Note dated [DATE] reflected a [DIAGNOSES REDACTED]. Left foot [MEDICAL CONDITION], DM (Diabetes Mellitus) foot. A) Review of Resident #1's physician's orders [REDACTED]. Bactoban Ointment (Topical Antibiotic) to foot BID after dressing. [MEDICATION NAME] (Oral Antibiotic) 150 mg (milligrams) one (1) tablet PO daily for seven (7) days. Podiatry Consult. Review of Resident #1's Medication Administration Record [REDACTED]. Review of Resident #1's physician orders [REDACTED]. Directly underneath the handwritten order is a handwritten statement reflecting Will start ABT (Antibiotic) when available. In an interview on [DATE] at 1:12 LVN A stated she had not administered [MEDICATION NAME] 150 mg PO on [DATE] as ordered by the Primary Care Physician (PCP) because the medication was not available. LVN A further stated she had checked the facility's emergency medication kit and the kit had none of the medication. LVN A stated she attempted to order the medication from the facility's contracted facility but was told the medication would not be available for three or four days. LVN A further stated she wrote a note under the PCP's order for [MEDICATION NAME] stating Will start antibiotic when available. LVN A stated she should have notified the DON of the issue but she could not recall if she had actually done so. In an interview on [DATE] at 12:55 PM the DON stated Resident #1's PCP order of [MEDICATION NAME] 150 mg (antibiotic) once daily for seven (7) days was not started on [DATE] as ordered. The first administration of the medication was not administered until four (4) days later on [DATE]. The DON further stated she could not understand why the [MEDICATION NAME] had not been administered as ordered since a backup supply of the medication was kept in an emergency kit maintained in the facility's medication room. An observation of the facility's medication room on [DATE] at 1:10 PM (under the supervision of the DON) revealed the emergency medication kit to hold four (4) tablets of [MEDICATION NAME] 150 mg and 10 doses of [MEDICATION NAME] 50 mg. In an interview on [DATE] at 2:06 PM Resident #1's PCP stated the four (4) day delay in the administration of [MEDICATION NAME] could contribute to delay in infection recovery. Resident # 1's PCP stated he expected facility staff to notify him when delays occur in referrals and medication administration. In an interview on [DATE] at 2:18 PM the DON stated It (the medication) should have been started sooner. The DON went on to say it was best practice to notify the PCP of a medication or appointment delay. Yes, we failed the resident. The DON further stated she could not recall having been notified of a difficulty in obtaining [MEDICATION NAME]. The DON further stated LVN A should have notified her if the pharmacy stated there would be a delay in delivery of a medication. She would then, in turn, call that pharmacy and arrange for an alternate pharmacy to deliver in a timely manner. The DON stated if nursing staff was unable to obtain needed medication she would notify the PCP of the problem in order to allow him the opportunity to change his orders to an alternative medication or treatment. In an interview on [DATE] at 3:11 PM the Administrator stated Yes, the facility failed the resident when it did not give him his medications. The nurse should have notified the DON right away when the nurse felt a medication was not available. It (the [MEDICATION NAME]) should have been in the emergency kit. If not then she should have called the local pharmacy to try to get it. The Administrator stated Yes, the doctor should have been notified. when it was determined that ordered medications would not be available in a timely manner and when a timely referred appointment was not going to occur. B) Review of the facility's appointment calendar reflected Resident #1 had been scheduled for an appointment with a Podiatrist on [DATE] at 9:00 AM. The calendar entry was lined out. Review of the facility's appointment calendar reflected Resident #1 had been scheduled for an appointment with a Podiatrist on [DATE] at 1:15 PM. The calendar entry was lined out with an annotation reflecting Rescheduled to ,[DATE]. Review of the facility's appointment calendar reflected Resident #1 had been scheduled for an appointment with a Podiatrist on [DATE] at 9:00 AM. In an interview on [DATE] at 10:29 AM the DON stated missed appointments were not documented in the medical record but were documented in a calendar maintained by the facility's receptionist. The DON further stated she could not recall if Resident #1's podiatry appointment issues were reported to the resident's PCP. When asked of the possible medical consequences of a resident not getting his podiatry appointment as ordered, the DON would only state it's hard to say. In an interview on [DATE] at 11:31 AM the Receptionist stated she was responsible for scheduling and rescheduling medical appointments for the residents. The receptionist further stated she would be notified by nursing staff if an appointment was to be scheduled, rescheduled, or cancelled. The receptionist further stated she was not responsible for notifying staff of schedule changes. The receptionist further stated Resident #1's podiatry appointment was originally scheduled for [DATE] but she was told by a charge nurse (name unknown) that the resident had missed a [MEDICAL TREATMENT] appointment on the previous Tuesday ([DATE]) so the podiatry appointment was rescheduled for [DATE] instead and the resident went to the [MEDICAL TREATMENT] center instead on [DATE]. In an interview on [DATE] at 3:11 PM the Administrator stated the facility failed the resident and the physician should have been notified when a timely referred appointment was not going to occur. In an interview on [DATE] at 3:50 PM Resident #1's PCP stated he had not been contacted by the facility's staff regarding Resident #1's podiatrist appointments. Resident # 1's PCP stated he would have wanted to be notified of this issue. C) Review of Resident # 1's Skin Care Report dated [DATE] and conducted by LVN A reflected the resident's left great toe and middle toe to be tender to the affected area. There was no redness or drainage noted. Review of the Resident # 1's Skin Care Report dated [DATE] and conducted by LVN F reflected the resident's left great toe and middle toe to be tender, had reness redness and drainage to the affected area. The drainage was characterized as Serosanguineous Review of the website http://www.advancedtissue.com/type-drainage/ reflected Sanguineous drainage should not be common in wounds after a few hours or days, and this type of drainage later on may be indicative of trauma to the wound site. Review of website https://www.nlm.nih.gov/medlineplus/ency/article/ 6.htm reflected Serosanguineous means containing or relating to both blood and the liquid part of blood (serum). It usually refers to fluids collected from or leaving the body. For example, fluid leaving a wound that is serosanguineous is yellowish with small amounts of blood. In an interview on [DATE] at 2:10 PM Treatment Nurse B stated the resident had bumped his toes but could not recall the date. The resident's PCP ordered topical antibiotic ointment (TAO) and oral antibiotics.The Treatment Nurse further stated she did not observe gangrene or necrosis. The Treatment Nurse B stated she last saw Resident # 1's foot on [DATE] when it had tenderness, redness and drainage but had not considered the foot to be infected. The Treatment Nurse stated she did not notify the physician on [DATE] of the change in the resident's wound status. In an interview on [DATE] at 3:32 PM LVN G stated he had last assessed Resident #1's foot on [DATE] two (2) days prior to Resident# 1's change of condition and transportation to the local hospital. LVN G further stated that Resident #1's foot still looked infected when he treated the resident on that date. LVN G further stated the foot was red and swollen. LVN G further stated he did not notify the PCP. In an interview on [DATE] at 1:30 PM LVN A stated Resident #1's great toe was black. LVN A stated she reported the change to her charge nurse and the DON but could not recall when she made the observation or notification. LVN A further stated she last saw Resident #1's wound on [DATE]. The LVN further stated she could not recall the condition of the wound on that date but did record the status of the wound on the daily skin report for the resident. LVN A further stated she would recognize signs and symptoms of infection as color change, a different appearance on the skin, a change in the size of the wound, redness, warmness, tenderness, and swelling. Review of Resident #1's Skin Care Report dated [DATE] at 4:00 PM revealed the assessor to be LVN G. The report reflected an observation of tenderness and redness to the left foot. The resident's pain was assessed as a three (3) on a scale of one (1) to six (6) and described as dull and intermittent. Review of Resident #1's Skin Care Report dated [DATE] at 7:08 AM revealed the assessor to be LVN A. The report reflected an observation of tenderness to the left foot. The report did not reflect observations of swelling, redness, drainage, or warmth. No pain was indicated. In an interview on [DATE] at 3:51 PM Resident #1's PCP was asked if Resident #1's infected toes and foot could have been the cause of the resident's death. Resident # 1's PCP stated I am sure it would have played a role. The PCP further stated he had not been contacted by staff regarding concerns that the resident may be declining or not improving appropriately during the course of the antibiotic regimen the PCP had established. The PCP further stated the signs and symptoms he would expect nursing staff to identify as possible infection were redness, swelling, and puss on the wound. In an interview on [DATE] at 10:45 AM the DON stated nurses receive training on infection control on a regular basis through computer and in-person in-services. Signs and symptoms the staff are trained to note as indicative of infections were drainage, redness, tenderness, increased temperature, pain, and swelling. The facility Administrator and DON were notified on [DATE] at 4:20 PM that an IJ situation had been identified due to the above failures. The following Plan of Removal was submitted by the Administrator on [DATE] at 9:00 AM. Interventions to prevent reoccurrence · 60% of med carts were audited to determine that all prescribed medications are available in-house as of 8:30pm [DATE]. As of the 60 % audit no errors have been identified. By [DATE] at 9am 100% of all med carts will have been audited. In the future, if any ordered medication is not available the following protocol will be followed: · The charge nurse will notify the pharmacy in attempt to get the medication · If unsuccessful, within 4 hours the charge nurse will notify the DON who will then contact the pharmacy in an attempt to rectify the issue · If the DON cannot obtain the medication from the primary pharmacy or a secondary pharmacy, the DON will contact the physician regarding the unavailability of the medication. · Any new orders will be followed as directed by the physician. · All residents identified as having wounds or infections will be assessed by the DON by 11 pm on [DATE] to ensure assessments are correct. · 20% of all residents will be assessed by an RN to ensure there are no identifiable infections on [DATE]. 100 % of all residents will be assessed by 12 pm [DATE] · The following in-services were begun on [DATE] by the Director of Nurses. Staff not in-serviced today will not be allowed to assume their duties until they have received the in-service. 54% of staff will be in-serviced by 12 am [DATE]. 76% of staff will be in-serviced by 8 am [DATE]. 78% of staff will be in-serviced by 3 pm [DATE]. 100% of staff will be in-serviced by [DATE]. · Licensed Nurses · If a medication is not available, the following protocol will be followed: o The charge nurse will notify the pharmacy in attempt to get the medication o If unsuccessful, within 4 hours the charge nurse will notify the DON who will then contact the pharmacy in an attempt to rectify the issue o If the DON cannot obtain the medication from the primary pharmacy or a secondary pharmacy, the DON will contact the physician regarding the unavailability of the medication. o Any new orders will be followed as directed by the physician. · Notification of the physician if a resident is unable to make it to a scheduled medical related appointment. · Signs and symptoms of wound infection · Notifying the physician timely for resident change of condition · Neglect · Certified Nurse Aides · Notifying the charge nurses of changes in a resident ' s condition · Neglect Any new staff hired after [DATE] in the above positions will receive training as stated above prior to assuming care of residents. · The medical director of the facility was notified at 7:15 pm by the DON on [DATE] regarding the immediate jeopardy · The medical director will be contacted by the DON for any unresolved issues with medication unavailability or residents missing a scheduled medical appointment. Monitoring · The DON and or designee will inquire daily during start up from charge nurse on their respective hall if they have any medications that are unavailable. · The DON and/or ADON will complete a med availability review on 15 residents per week for 4 weeks by comparing the MAR indicated [REDACTED] · The DON will view all resident wounds at least 2 times per week for 2 weeks, then 1 time per week for 2 weeks, to ensure correct documentation of status is correct. · The DON and or designee will review all residents with infections in the weekly standards of care meeting to ensure that physician notification is occurring if there is a decline. · The DON and/or designee will ask 10 staff members per week for 4 weeks, a situational question related to neglect. · Findings will be reviewed by the QA committee and changes made to the plan as needed. · All of the above monitoring will be documented on a facility formulated monitoring form. The investigator monitored the current plan of removal from [DATE] 10:00 AM until 12:30 PM as follows: Observations of facility directed staff in-services were conducted for nursing staff on the subjects of Notification of physicians and families of changes of condition, issues in obtaining ordered medications or treatments, the correct manner in which to handle a medication issue to include notification of the DON in order to allow her to intervene as appropriate. How to identify signs and symptoms of a new infection or a worsening of an infection already identified. An in-service on abuse and neglect was also conducted for all staff. Nurse aides were trained in Abuse and neglect, identification of changes in condition to include signs and symptoms of infection. Notification of a nurse of any observed change of condition. Review of the MARS (Medication Administration Records) for all residents identified as requiring wound care as well as all residents identified as being treated for [REDACTED]. Observations of all medication carts to confirm the actual presence of medications that have been ordered for all sampled residents to include all residents identified as requiring wound and infection care. Observations of all Residents receiving wound care (Resident #6 and Resident #9) to ensure current monitoring by staff for signs and symptoms of infection. Interviews of five (5) staff members (LVN I, Kitchen Aide J, CNA K, LVN L, and CNA M) to verify their attendance at the in-services as well as to verify their comprehension of the subject matter. On [DATE] at 12:30 PM the facility Administrator and DON were informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope of pattern due to the facility requiring time to train all staff and monitor their Plan of Removal. The DON provided a list two (2) residents currently receiving wound care and three (3) residents currently receiving care for infections.

Based on observation, interview and record review, the facility failed to promote care for residents in a manner that maintained or enhanced each resident's dignity and respect for two of nine residents reviewed for smoking (Residents #1 and # 2). Resident #1 and #2, who were smokers, were "patted down" by the administrator in search for cigarettes and felt degraded as a result. Resident ID #1 had episodes of crying and compared living in the nursing home to living in a prison due to being "patted down." This failure could place 8 residents, who were smokers at the facility, at risk of loss of self-esteem, self-worth and diminished quality of life. The findings included: Review of Resident #1's of the face sheet dated 7/3/09 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a mini mental examination completed on 10-10-12 revealed Resident #1 scored a 27 out of 30. The maximum score for the test was 30 points. According to the test she was oriented to time, person, place, able to immediate recall, able to read and write and follow 3 stage commands. Record Review of the Care Plan dated 3/17/14 revealed that Resident #1 was a smoker. The care plan had been updated on 3/31/14 and also on 7/2/14. The goals were for the resident to comply with smoking policy through the review date. The approaches were to inform the resident on smoking and ignition source policy, the resident will smoke in designated areas only, monitor for the resident's complying with the facility policy, and notify the MD/Family of any changes. Observation on 7/21/14 at 4:58 PM revealed Resident #1 was sitting out in the courtyard with 6 other smokers and one staff member. The resident was well groomed and agreed to talk privately with the surveyor. Interview with Resident #1 on 7/21/14 at 4:58 PM revealed she was not ready to go in the building so she ambulated to the other side of the courtyard for the interview. The surveyor asked the resident at that time if she ever had been verbally or physically abused by anyone at the facility. The resident stated she had been at the facility about 3 years and she has had a problem lately with staff coming in her room and taking her things without asking. She stated she had been keeping cigarettes in her room but not anymore. She stated "the new administrator makes me spread out my arms and spread my legs like I am a criminal as she looks for cigarettes, I don't think that is right." The resident stated she felt interrogated by the administrator. Interview with the administrator on 7/22/14 at 11:20 AM revealed that Resident #1 was noncompliant with the smoking policy and that the policy had not been enforced until she became hired. The administrator denied "patting anyone down" and stated that an investigation had been conducted for 3 days with the corporate office and they did not find this to be true. This surveyor asked for a copy of the investigation but it was not available at the time and they could not present it to the surveyor during the investigation. Review of the smoking policy dated 1/9/14 revealed that smoking, tobacco, matches lighters or other smoking paraphernalia are not permitted to be kept or stored in a resident's room or in their possession without supervision. Smoking by residents on the premises is only permitted only when supervised by staff of the facility or visitors. Smoking is prohibited in any room, ward, or compartment where flammable liquids, combustible gas, or oxygen are used or stored and in any other hazard locations. Confidential interview with staff member A revealed she witnessed the administrator a while back "pat down" Resident #1 in the hallway. The staff member stated she heard the administrator tell Resident #1 to empty her pockets and the resident did empty them all but the left pants pocket and the administrator did not ask her to empty that one as well, she just took her hand and reached in the pocket without permission and pulled out a lighter. The staff member stated the old administrator used to let them keep the lighters and cigarettes on them but this administrator is enforcing the smoke policy but not going about it the right way. The surveyor asked this staff member if the corporate office interviewed them during their investigation and the staff member stated no and they did not even ask for a witness statement. Confidential interview with staff member B revealed she was witness to the administrator going through Resident #1's pockets and she told the staff member to go down to the room with her because she did not want to go alone. The staff member stated she felt uncomfortable and it did make Resident #1 cry and" I think it made her feel embarrassed." The staff member stated the administrator did make her raise her arms and spread her legs. The surveyor asked this staff member if corporate office talked with her during their 3 day investigation and she stated they did not talk to her and did not get a statement. Confidential interview with staff member C revealed that this staff member and another staff member were up at the nurses' station and they saw Resident #1 coming toward them crying and very upset. The staff members asked what was wrong and Resident #1 replied "they are sending me to the psych ward to get on medicine so I won't hide my cigarettes." The resident was also upset because they were searching her room and taking away paintings and colored pictures telling her they were safety hazards. The staff members stated that the old administrator use to let them carry the cigarettes on them but the new one does not allow it. The staff member stated she has never known of Resident #1 smoking in her room and she understood the smoking policy but it was a matter of how you went about it and that Resident #1 was becoming highly upset about being "patted down." The surveyor asked this staff member if she talked with corporate office during their investigation and she stated that she was asked to "write a statement but not sign it and they would type it up later." Confidential interview with staff member D revealed this staff member witnessed Resident #1 coming out of her room one morning as the administrator was also walking down the hall. The staff member stated the administrator proceeded to ask Resident #1 if she had any cigarettes on her. Resident #1 had told her no but the staff member stated that the administrator without asking started patting her down and even looked in her purse without her permission. The staff member stated that the resident continued to tell her to stop patting her down and that she was not crazy. Resident #1 voiced to the staff member that the administrator continues to "pick on her due to her color." (note resident is a black female). The staff member felt that the administrator was picking on her because Resident #1's room was "decluttered" and another resident had a more cluttered room and it went untouched. The surveyor asked if corporate office had talked with her or asked for a written statement and she stated no. Interview with Resident #1's Psychologist (Psychologist E) on 7/22/14 at 2:30 PM revealed that Resident #1 had been unhappy to the point she was isolating herself in her room and not eating in the dining room. Resident #1 stated to him that " I live in a nursing home but it feels like being in a prison being patted down." He stated he agreed that she should not be patted down and threatened with being discharged , and that he did talk with the administrator. He stated he also talked with two staff members who were highly upset and felt like the administrator was harassing her. Resident #2 (discharged resident) Review of the face sheet dated 4/3/14 revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2 had a care plan dated 5/19/14 that the resident was a smoker. It stated that the resident would comply with the facility smoking policy. Interview with the Director of Nursing (DON) on 7/22/14 at 10:10 AM revealed that Resident #2 was discharged from the facility and that there was an issue that came up with Resident #2. The DON stated she received a call one Sunday Morning from the weekend RN. The weekend RN stated that the Administrator came up to the facility and "pat searched" Resident #2. She stated the weekend RN was very upset and called stating she was sending the complaint to the corporate hotline at that time. Confidential interview with a staff member revealed the staff member did not actually see Resident #2 being patted down but that the resident told her that and he was very upset about the way the administrator treated him. She stated that was the reason the family discharged him from the facility. Interview with the Responsible Party on 7/23/14 at 12:30 PM revealed that she was upset with the administrator after that Sunday Morning and that was the reason they discharged Resident #2. The surveyor asked the Responsible Party if Resident #2 was interviewable and if so, would he speak with the surveyor. Resident #2 at that time, came to the phone and went over the events of that Sunday Morning. Resident #2 stated that " the administrator yelled at me (him) and that she was searching me (him) for cigarettes. She did pat me down and did not find anything but she was not a nice person and it made me pretty mad." Interview with the Administrator at 2:20 PM on 7/22/14 revealed that corporate office did come to the facility and did a 3 day investigation but the human resource person had the investigation at her house 4 hours away and could not produce the investigation to the surveyor. The facility provided a list indicating there were 8 smokers who reside at the facility.