Every finding on record at Falcon Point Post Acute

Based on observation, interview, and record review the facility failed to have ceiling suspended curtains, which extend around the bed to provide total visual privacy in combination with adjacent walls and curtains for 1 of 5 residents (Resident #1) observed for wound care. The Wound care nurse and CNA A did not provide Resident #1 privacy during wound dressing change on 08/18/26. This failure could place residents at risk for emotional distress, loss of personal dignity, anxiety, and depression. Record review of Resident # 1's face sheet dated 08/18/26 revealed a [AGE] year-old female admitted to the facility on [DATE] and again on 08/08/26. Resident diagnoses included dementia (memory loss, problem-solving, and other thinking skills that interfere with daily life), cognitive communication deficit, pressure ulcer of the sacral (the large, triangular bone at the base of the spine) region, and major depression. Record review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS score of 6 indicating that resident cognition was severely impaired. Section M-Skin Condition revealed one unhealed pressure ulcer. Record review of Resident #1's Comprehensive Care Plan dated 05/18/26 revealed that resident was care planned for ADL self-care performance deficit r/t limited mobility requiring staff participation. Observation of wound care on 08/18/26 at 11:05AM for Resident #1 by the wound care nurse with CNA C/staffing coordinator assisting. CNA C/staffing coordinator washed her hands and placed on PPE that consisted of gowns, gloves, and a mask. The wound care nurse disinfected her workspace (bedside table) with germicidal disposable wipes. The wound care nurse washed her hands, placed parchment paper on table, and then placed wound care supplies on top of the parchment paper. The wound care nurse then washed her hands and placed on her PPE (gown, gloves, and mask). Both staff proceeded to go into Resident #1's room to do wound dressing [NAME] to resident sacrum. Resident #1 was resting in bed on an air mattress with call light in reach. The staff closed the door and began to administer care to Resident #1. At this time, it was observed that Resident #1 did not have a privacy curtain. The wound care nurse and CNA C/staffing coordinator repositioned Resident #1 to her left side with resident buttocks facing the door that was closed. Resident had a dressing to her sacrum and resident skin to the buttocks area was redden and somewhat excoriated (scrape off the surface of the skin). The wound care nurse removed the old dressing, sanitized her hands, placed on a new set of gloves, and began to clean the sacral wound with normal saline, patted the wound dry with new dry gauzes. The wound care nurse removed gloves, sanitized hands, and placed on a clean set of gloves. The wound care nurse applied collagen powder to the wound bed and covered the wound bed with a silicone border dressing. Interview on 08/18/28 at 11:37AM, the Wound Care Nurse said the resident should have a privacy curtain in her room. The Wound Care Nurse said although resident door was closed, someone could have opened the door and walked in while providing wound care for Resident #1. The Wound Care Nurse said by resident not having a privacy curtain it could placed the resident at risk of her body being exposed. The Wound Care Nurse said she was not aware that resident did not have a privacy curtain in her room. The Wound Care Nurse said she would let the maintenance department know so that they could put a privacy curtain up for Resident #1. Interview on 08/18/26 at 11:40AM with the Assistant Maintenance Director said he had been working at the facility for 3 years. The Assistant Maintenance Director said the maintenance department was responsible for making sure each resident had a privacy curtain in their room to provide them with privacy when needed. The Assistant Maintenance Director said he did not know who removed the privacy curtain in Resident #1's room but would make sure he would install a privacy curtain for Resident #1. An attempted interview on 08/18/26 at 11:45AM with Resident #1 was unsuccessful. Resident was not oriented. Interview on 08/18/26 at 1:54PM, the DON said whoever is providing care for the resident was responsible in making sure a privacy curtain was present and pulled when providing care for a resident. The DON said the nursing staff needed to communicate with the maintenance department if the privacy curtain was not present in a resident room. The DON said if a resident does not have a privacy curtain present in their room it placed the resident at risk of not having their privacy or dignity violated. The. The DON was asked for policy on dignity. The DON only provided a policy on Resident Rights. Interview on 08/18/26 at 3:44PM, the Maintenance Director said he took Resident #1's privacy curtain down because it was dirty. The Maintenance Director said he was going to replace the privacy curtain but then realized he had the wrong size. The Maintenance Director said he had informed the Assistant Maintenance Director what had taken place, but his assistant did not get around to installing the right size. Record review of the facility policy on Resident Rights and Responsibilities revised April 2025 reflected in part: .It is the policy of this facility to inform the resident both orally and in writing of their rights as a resident.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and transmission of communicable diseases and infection for 1 of 5 residents (Resident #2) reviewed for infection control. CNA C left Resident #2's room without washing his hands after providing care for Resident #2 on 08/18/26.RN B and CNA C failed to don (to put on an item) in full PPE when providing incontinent care for Resident #2 on 08/18/26.The facility failed to have infection control/EBP signage on Resident #2's door who was on EBP on 08/18/26.CNA C failed to clean Resident #2's buttocks one wipe at a time away from the vaginal area on 08/18/26. These failures placed residents at risk for cross contamination and infections. Record review of Resident #2's face sheet dated 08/18/26 revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident #2 diagnoses included the following: weakness, need for assistance with perineal care, difficulty walking, cognitive communication deficit, Alzheimer's Disease (brain disorder that gradually destroys memory, thinking skills, and the ability to carry out simple daily tasks). Record review of Resident #2's quarterly MDS dated [DATE] reflected a BIMS score of 3 indicating that resident cognition was severely impaired. Section GG-Functional Abilities revealed that resident required partial to moderate assistance with personal hygiene. Section H-Bladder and Bowel revealed that resident was occasionally incontinent of urine and bowel. Record review of Resident #2's Comprehensive Care Plan dated 06/25/26 and revised 07/15/26 revealed that resident was being care planned for ADL self-care performance r/t impaired mobility with personal hygiene/oral care requiring staff participation to use toilet, hygiene, and oral care. Further review revealed that resident was being care planned for a urinary tract infection dated 06/25/26 and revised 07/01/26 with the following interventions: maintain standard precautions when providing resident care and monitor/document report the MD s/sx of delirium.restlessness and agitation. Record review of Resident #2's Physician Order Summary Report for June 2026 reflected the following order: -Dated 06/26/26 hydroxyzine 25mg by mouth every 8 hours as needed for anxiety-Dated 06/26/26 Cefdinir (antibiotic used to treat bacterial infections) oral capsule 300mg give 1 capsule by mouth two times a day related to urinary tract infection for 10 days. Record review of Resident #2's Physician Order Summary Report for the month of August 2026 reflected the following order: -Dated 08/12/26 Central line/midline (a device whose tip rests in the upper arm vein near the axilla [armpit]) care change dressing 3 days if not visible for assessment and PRN if wet, saturated, or loose every 4 days. Further review of Physician Orders did not reveal an order for EBP. Record review of Resident #2's MAR and TAR for the months of June and July 2026 reflected the medication cefdinir 300mg oral capsules and hydroxyzine were being administered as order. Observation on 08/18/26 at 12:00PM of Resident #2 resting on a low bed appearing very restless, moving about in bed and breathing fasting. Resident had an IV to her upper right arm. RN B was called to resident room. RN B said Resident #2 was being treated for pneumonia and sometimes would become anxious. RN B said resident had a midline to her upper right arm. The surveyor asked RN B if she could check resident oxygen saturation which was at 94% on room air and resident heart rate was 88. RN B said she had given Resident #2 medication hydroxyzine for anxiety earlier that morning. RN B began to reposition resident in bed talking to resident trying to calm resident. While RN B was positioning Resident #2 in bed, it was observed underneath the resident's the fitted sheet there was a large wet circled and the outer edges of the circle were yellow in color. Observation on 08/18/26 at 12:05PM of incontinent care for Resident #2 by CNA C with the assistance of RN B. Both staff entered resident room without placing on full PPE that included a gown. The staff washed their hands and placed on gloves. Resident #2 did not have an infection control/EBP signage on door or in room. Resident brief was heavily soiled in urine including the draw sheet. The resident's skin was intact. As CNA C was providing incontinent care, he discovered that he needed a fitted sheet because the fitted sheet was soiled with urine. At 12:16PM CNA C removed his soiled gloves and left the room without washing his hands. CNA C returned to the room at 12:19PM with extra linen, washed his hands and placed on a new set of gloves and proceeded with incontinent care for Resident #2. When the staff positioned resident to her left side, CNA C began to clean resident buttocks with disposable wipes cloth back and forward instead one wipe at time away from the vaginal area. 08/18/26 at 12:30PM attempted an interview with Resident #2 but resident was not inter-viewable. Interview on 08/16/26 at 12:33PM, RN B said if the resident was not provided incontinent care in a timely manner, it would place the resident at risk for infections, one being a urinary tract infection, sepsis, skin irritations, and bed sores. RN B said the resident was receiving IV antibiotic for pneumonia. RN B said when providing incontinent care, one is supposed to clean the resident from clean to dirty to prevent infections and contamination. RN B said residents that had intravenous lines, wounds, indwelling Foley catheters, colostomies, needed to be on Enhanced Barrier Precautions (EBP) and that the staff needed to wear gown, gloves, and mask for infection control. RN B said it was the Infection Control Nurse that was responsible for placing the EBP signs on resident doors that met these criteria. RN B said she had been in-serviced on infection control and EBP. Interview on 08/16/26 at 12:46PM, CNA C said he was supposed to check residents for incontinent care every hour and if not done, it placed the resident at risk for infections and skin breakdown. CNA C said if a resident has IV (a means to deliver fluids, medicine, or nutrients directly into the vein) , G-tubes (medical device placed through the skin of the belly directly into the stomach to deliver food, flids, and medications), colostomies (surgical procedure that brings a portion of the large intestine out through an opening in the belly wall to redirect waste out of the body) he was supposed to wear gown and gloves. CNA C said he was not aware that Resident #2 had an IV. CNA C said he had been in-serviced on infection control and EBP. CNA C said hand washing was practiced before providing care, and before leaving the resident room for infection control. CNA C said when cleaning the resident skin during incontinent care, he was supposed to clean from front to back one wipe at time. CNA C said when cleaning the buttocks should not clean the buttocks back and forward to prevent cross contamination. Observation on 08/16/26 at 1:00PM of RN B placing EBP signage on Resident #2's door. RN B then placed a 5-drawer plastic bind on the inside of resident room near the front entrance of resident room. Inside of the drawers were disposable gowns and gloves. Interview on 08/16/26 at 1:54PM, the DON said he was the Infection Control Preventionist. The DON said incontinent care should be provided to the residents at least every two hours and as needed. The DON said if incontinent care was not provided to the resident every 2 hours or as needed, it placed the resident at risk for skin breakdown. The DON said it was the nurse who was responsible in making sure the residents were being provided incontinent care in a timely manner. The DON said it was also himself and the ADON to ensure this was happening. The DON said when incontinent care was being provided, the staff should be cleaning the resident buttocks up and away from the perineal area to avoid cross-contamination. The DON said the staff should be washing their hands before administering care to the residents, during care if hands are visible soiled, and before leaving the resident room. The DON said EBP was practiced with residents that had intravenous line, Foley catheters, wounds, etc. and that the staff should don in the following PPE: disposable gowns, mask, and gloves to prevent infections. Record review of the facility policy on Infection Prevention and Control Program revised April 2025 reflected in part: .The Infection Prevention and Control Program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program.It is the policy of this facility to provide the necessary supplies, education, and oversight to ensure healthcare workers perform hand hygiene based on accepted standard.Enhanced Barrier Protection (EBP): used in conjunction with standard precautions and expand the use of PPE through the use of gown and gloves during high contact resident care activities that provide opportunities for indirect transfer of MDRO to staff hands and clothing then indirect transferred to resident's or from resident-to-resident. (eg., resident with wounds.indwelling medical devices) .

Based on observation, interview, and record review the facility failed to provide the necessary services for residents who were unable to carry out activities of daily living receive the necessary services to maintain good nutrition, grooming, and personal hygiene for 1 of 5 residents (Resident #2) The facility failed to ensure CNA C provided incontinent care for Resident #2 every 2 hours. Resident #2's brief and linens on bed was heavily soiled in urine on 08/16/26. This failure placed Resident # 2 at risk for unwanted skin breakdown. Record review of Resident #2's face sheet dated 08/18/26 revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident #2 diagnoses included the following: weakness, need for assistance with perineal care, difficulty walking, cognitive communication deficit, Alzheimer's Disease (brain disorder that gradually destroys memory, thinking skills, and the ability to carry out simple daily tasks). Record review of Resident #2's quarterly MDS dated [DATE] reflected a BIMS score of 3 indicating that resident cognition was severely impaired. Section GG-Functional Abilities revealed that resident required partial to moderate assistance with personal hygiene. Section H-Bladder and Bowel revealed that resident was occasionally incontinent of urine and bowel. Record review of Resident #2's Comprehensive Care Plan dated 06/25/26 and revised 07/15/26 revealed that resident was being care planned for ADL self-care performance r/t impaired mobility with personal hygiene/oral care requiring staff participation to use toilet, hygiene, and oral care. Observation on 08/18/26 at 12:00PM of Resident #2 resting on a low bed appearing very restless, moving about in bed and breathing fasting. RN B was called to resident room. RN B said Resident #2 was being treated for pneumonia and sometimes would become anxious. The surveyor asked RN B if she could check resident oxygen saturation which was at 94% on room air and resident heart rate was 88. RN B said she had given Resident #2 medication for anxiety earlier that morning. RN B began to reposition resident in bed talking to resident trying to calm her. While RN B was positioning Resident #2 in bed, it was observed underneath resident the fitted sheet had a large wet circled and the outer edges of the circle were yellow in color. Observation 08/18/26 at 12:05PM of incontinent care for Resident #2 by CNA C with the assistance of RN B. Resident #2's brief was heavily soiled in urine including the draw sheet. Resident skin was intact. As CNA C was providing incontinent care for Resident #2, he discovered that he needed a fitted sheet and left the room to get a clean fitted sheet and extra linen. After providing care for Resident #2, RN B covered resident with extra linen and put a sweater on resident commenting that resident was cold natured. When RN B and CNA C completed providing incontinent for Resident #2, resident breathing had slowed and resident appeared less anxious, breathing had slowed and resident was not moving around in bed. The surveyor attempted an interview with Resident #2 on 08/18/26 at 12:30PM. Resident #2 was unsuccessful. Interview on 08/16/26 at 12:33PM, RN B said she had been working at the facility since May of 2026. RN B said when she observed Resident #2 during incontinent care Resident #2's brief and sheets were heavily soiled in urine. RN B said the last time she had checked on Resident #2 was around 8:30AM. RN B said at this time, she observed that resident brief was soiled with urine but not on the resident's linen. RN B said she told CNA C to change Resident #2's brief but could not remember CNA C response when she told him to change the resident's brief. RN B said the CNAs were supposed to check the residents every 2 hours and as needed for assistance with incontinent care. RN B said if the resident was not provided with incontinent care in a timely manner, it could place the resident at risk for skin irritations and bed sores. Interview on 08/16/26 at 12:46PM, CNA C said he had been working at the facility since March 2026 from 7AM-7PM full time. CNA C said when he arrived on duty to work Resident #2 did not require incontinent care. CNA C said RN B told him after breakfast that she and him needed to go to Resident #2's room and provide incontinent care around 9:00AM. CNA C said he and RN B never went to the resident's room to provide incontinent care because they got busy and therefore did not provide incontinent care for Resident #2 until he was asked to be observe providing incontinent care for Resident #2. CNA C said he was supposed to check the residents for incontinence every hour and if not done, it placed the residents at risk for skin breakdown. Interview on 08/16/26 at 1:54PM, the DON said incontinent care should be provided to the resident at least every two hours and as needed. The DON said if incontinent care was not provided to the resident every 2 hours or as needed, it placed the resident at risk for skin breakdown. The DON said it was the nurses on the units who were responsible in making sure that the residents were being provided incontinent care in a timely manner. The DON said it was also himself and the ADON to ensure this was happening. Record review of the facility policy on ADL, Services to carry out revised January 2020 reflected in part: .It is the policy of this facility that residents are given the appropriate treatment and services to maintain or improve his/her abilities.Residents who are unable to carry out activities of daily living (ADL) will receive: good nutrition, grooming, personal hygiene, and oral hygiene. Record review of the facility policy on Incontinent Care dated March 2017 reflected in part: It is the policy of this facility to provide incontinence care for those dependent residents requiring assistance with bladder and/or bowel incontinence.

Based on observation, interview and record review the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program 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, psychosocial well-being of each resident, encouraging both independences and interaction in the community for 1 of 3 (Resident #29) residents and 1 of 3 (Unit A) units reviewed for activities .1. The facility failed to ensure residents in Unit A had activities provided that followed the facility schedule on 03/24/2026 at 10:30 AM and 03/27/2026 at 10:30 AM and 2:00 PM. 2. The facility failed to ensure Resident #29 participated in activities that followed her care plan during 03/24/2026 and 03/27/2026 . These failures could place residents at risk of a decline in their mental and psychosocial well-being . Record review of Resident #29's face sheet, dated 03/24/2026, reflected a [AGE] year-old female who was originally admitted to the facility on [DATE] and last re-admitted [DATE]. Her diagnoses included senile degeneration of brain (this encompasses a range of neurological disorders characterized by a progressive decline in cognitive function, impacting memory, reasoning, and the ability to perform everyday activities), dementia (declining brain function related to thinking and judgement that is severe enough to impact daily life) and major depressive disorder (prolonged periods of sadness and hopelessness). She was on the secured unit.Record review of Resident #29's care plan meeting, dated 01/16/2026 , she enjoyed walking and would need non-dairy accommodation for activities. Record review of Resident #29's quarterly MDS, dated [DATE], reflected Resident #29 had a BIMS score of 04, which indicated severe cognitive impairment related to memory and thinking. She required moderate assistance with ADLs which included toileting, showering, dressing and footwear.Record review of Resident #29's care plan, last captured 03/27/2026, reflected she had actual falls (last revised 01/19/2026) with interventions which included day staff providing redirection to engaging activities like ball tossing to minimize daytime napping and support adequate nighttime sleep. Resident #29 was also care-planned for being dependent on staff for meeting emotional, intellectual, physical and social needs and would sit outside and come to music and pastry socials (dated 03/25/2026), with interventions which included inviting her to scheduled activities.In confidential interviews conducted on an undisclosed date and undisclosed time revealed 3 out of 15 residents in Unit A, which was the secured unit, complained about not having enough activities provided to suit their preferences such as playing cards, pencils, paper and notebooks for their personal use and going on walks around the facility.In an observation and interview of Unit A on 03/24/2026 at 2:00 PM, revealed residents were sitting in front of the television conversing or watching TV . Other residents were sitting by the nurse's station. Resident #29 was sitting in front of the television. She said she was okay and did not have any concerns. There were no activities such as ball toss, coloring, or music observed . There was a calendar for March 2026 hanging in the main lobby to the secured unit. Activities for 03/24/2026 were pastries and jokes at 10:30am, sit outside/music at 11:00a.m., BINGO at 2:00p.m., word search at 3:30pm, and evening news at 6:00p.m. Activities for 03/27/2026 were balloon toss/music at 10:30a.m., craft at 11:00p.m., read a poem at 1:00p.m., BINGO for 2:00p.m., and evening news at 6:00p.m.In an observation of activities provided on 03/24/2026 and 03/26/2026 at 11:30 AM, revealed residents were observed outside sitting and talking with the Activities Director .In an observation of and interview in Unit A on 03/27/2026 at 10:30 AM, residents were observed sitting in front of the television conversing or watching TV. Two residents appeared to be asleep with their heads on their folded arms while sitting at the dining tables. Resident #29 was sitting in front of the television. Residents stated they were doing fine and had no concerns. In another observation on Unit A on 03/27/2026 at 2:00 PM, revealed Resident #29 was sitting in the common area watching TV along with 10 residents. CNA M said activities in Unit A included providing water, snacks, music and dance. Most residents refused to do activities outside of the unit and preferred to watch TV. CNA M put on music after dinner on 03/23/2026. CNA M showed the supply closet with coloring books, coloring pencils and puzzles. In a later observation on 03/27/2026 at 2:27 PM, there were 10 residents in the common area coloring and listening to music on the TV. Five residents were sitting in the common area or dining room not participating, and two residents were in the common area sitting with residents but not coloring. RN G was observed assisting residents to the common area for activities. RN G said the Activities Director came to get residents for BINGO. RN G said activities in Unit A included church and therapy, where someone from the therapy department would come and get about 10 residents to exercise. RN G said staff came to play balloons with residents the morning of 03/27/2026 but could not specify any timeframe . In an interview with the Director of Rehab on 03/27/2026 at 2:39 PM, she said her staff conducted individual and group therapy about one to two times per week in Unit A. Groups consisted of 2 to 4 residents if they were scheduled for therapy or if they were willing to participate. Some residents were able to come down to the main gym, but most residents were not able to come off the unit. In an interview with the Activities Director on 03/27/2026 at 3:37 PM, she said she had a consistent group of 8 residents for BINGO and around 5 residents would play cards outside . There were two residents who were able to participate in activities outside of Unit A. The Activities Director said she hosted snack or ice cream socials or balloon toss for the other 22 residents in Unit A directly after she hosted socials for the outside unit but did not know what activities were going on the same time she had BINGO. She said there was no activities calendar for Unit A that was geared towards suitable activities for those who wanted to stay in the unit . When asked why there was no balloon toss as scheduled for 03/27/2026 at 10:30 AM, the Activities Director said she went in there at 7:00 AM and had residents play balloon toss until 8:30 AM but agreed she did not follow the day's timeline. The Activities Director said she would go into Unit A and reinforce activities with the staff there more often .In an interview with the DON on 03/27/2026 at 4:14 PM, he said it was difficult to take residents off Unit A because they needed a nurse and a nurse aide for supervision and care. He said the Activities Director provided activities and input advice for activities when she was not in Unit A for unit staff to provide. He said his nursing staff would be able to provide diversional activities. He was not aware of an alternate activity scheduled tailored for residents in Unit A. When asked if the activities in Unit A met residents' needs, he said he would talk to the Activities Director and look into it. Record review of the facility's policy on activities, copyrighted 2026, it read in part, It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. 2. Activities will be designed with the intent to:a. Enhance the resident's sense of well-being, belonging, and usefulness.b. Create opportunities for each resident to have a meaningful life.c. Promote or enhance physical activity.d. Promote or enhance cognition.e. Promote or enhance emotional health.f. Promote self-esteem, dignity, pleasure, comfort, education, creativity, success and independence.g. Reflect resident's interests and age.h. Reflect cultural and religious interests of the residents.i. Reflect choices of the residents.4. Activities may be conducted in different ways:a. One-to-One Programs.b. Person Appropriate - activities relevant to the specific needs, interests, culture, background, etc. for the resident they are developed for.c. Program of Activities - to include a combination of large and small groups, one-to-one, and self-directed as the resident desires to attend.9. Special considerations will be made for developing meaningful activities for residents with dementia and/or special needs. These include, but are not limited to, considerations for:a. Residents who exhibit unusual amounts of energy or walking without purpose.

Based on observation, interview and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 20% based on 9 errors out of 45 opportunities of medication observation, which involved 2 of 5 residents (Resident #81, Resident #78 and Resident #34) and 1 of 7 staff (RN F) observed during medication administration reviewed for medication errors. 1. RN F failed to administer Lacosamide Oral Tablet 150 MG (Lacosamide) (to treat partial-onset seizures), to Resident #81 on 3/24/26.2. RN F failed to administer MiraLAX Oral Powder 17 GM(grams)/SCOOP(Used to treat occasional constipation) to Resident #81 on 3/24/26.3. RN F failed to administer Prednisone Oral Tablet (used to treat a number of different conditions, such as inflammation and marrow patient [swelling], severe allergies, adrenal problems arthritis, asthma blood or bone marrow problems. [Prednisone]), to Resident #81 on 3/24/26.4. RN F failed to administer Ascorbic Acid Tablet 500 MG to Resident #34 on 3/24/26.5. RN F failed to administer Ferrous Sulfate Tablet 325 (65 Ferrous) to Resident #34, on 3/24/26.6. RN F failed to administer Tramadol HCl Oral Tablet 50 MG (Tramadol HCl) to Resident #78 on 3/24/26.7. RN F failed to administer Brimonidine Tartrate (used to lower pressure inside the eye that is caused by open- angle glaucoma or ocular[eye] hypertension) Solution to Resident #78 on 3/24/26.8. RN F failed to administer Dorzolamide HCl-Timolol (use to treat elevated intraocular pressure in patients with ocular hypertension or open -angle glaucoma) and Mal Ophthalmic Solution 2-0.5 % (Dorzolamide HCl-Timolol Maleate) to Resident #78 on 3/24/26.9. RN F failed to administer Artificial Tears (used to lubricate dry eyes and help keep moisture on the surface of the eyes) and Ophthalmic Solution 1 % (Carboxymethylcellulose Sodium (Ophth [for the eyes]) to Resident #78 on 3/24/26.These failures could place residents at risk for increased negative side effects, and a decline in health. Findings include:1. Record review of Resident #81's face sheet, dated 3/25/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #81 had diagnoses which included gastrostomy (a small opening into the abdomen and inserted a tube directly into the stomach allowing for food and liquids to be delivered directly into the stomach), gastro-esophageal reflux (Gastric reflux) disease without esophagitis, aphasia (not able to talk) following unspecified cerebrovascular disease (stroke), hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (medical condition involving paralysis of one side limbs (one arm and one legs), convulsions (when muscles contract and relax quickly and cause uncontrolled shaking of the body essential (primary) hypertension, (high blood pressure) and cognitive communication deficit, other lack of coordination. Record review of Resident #81's quarterly MDS, dated [DATE], reflected the BIMS score was 0 out of 15, which indicated the resident had severe cognitive impairment. The resident was totally dependent on staff for bed repositioning and personal hygiene. Resident #81 was incontinent of bladder and bowel. Record review of Resident #81's care plan, dated 1/24/26, reflected Resident #81 had an ADL self-care performance deficit and the goal was the resident would improve the current level of function. Record review of Resident #81's Physician's Orders, dated 2/17/26, reflected the following orders: Had NPO (nothing per oral/nothing by mouth) check gastric tube placement by auscultation (using stethoscope to listen to bowel sound) prior to meds, formula, and water flushes every shift. Check for residual every shift if > 60ccs, stop feeding and notify MD every shift. Feeding of Isosource 1.5 Cal 45 cc/hr. via pump, Flush GT with 30 ml water before and after administration of medication, flush with 10 cc between each medication every shift. Record review of Resident #81's Physician order, reflected in part:Lacosamide Oral Tablet 150 MG (Lacosamide) (to treat partial-onset seizures) *Controlled Drug*Give 1 tablet via PEG-Tube every 12 hours for nausea- order date 4/28/23MiraLAX Oral Powder 17 GM/SCOOP (Used to treat occasional constipation) (Polyethylene Glycol 3350), Give 1 scoop via G-Tube one time a day for Constipation mix with 4-8 OZ OF water or juice (hold for LBM, report and document)-order date 3/6/24Prednisone Oral Tablet (used to treat a number of different conditions, such as inflammation marrow patient (swelling), severe allergies, adrenal problems arthritis, asthma blood or bone marrow problems. (Prednisone) Give 40 mg via PEG-Tube one time a day for diffuse urticaria (an inflammatory skin condition characterized by the sudden appearance of numerous itchy, raised, red or skin-colored welts ( wheals) spread across large areas of the body ) for 5 Days- order date 3/19/26. During an observation of medication administration on 3/24/26 at 8:26 a.m. for Resident #81, revealed RN F was observed checking Resident #81's blood pressure (BP144/87, Pulse-71), RN F opened the medication cart, then punched three other medications, crushed it individually and then diluted with 10cc of water. RN F then went back to the resident's room, checked G-Tube for residual, and administered the medications through Resident #81's G-Tube. RN F placed the blood cuff in the medication cart without cleaning the blood pressure cuff. 2. Record review of Resident #34's face sheet, dated 03/24/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #34 had diagnoses which included: iron deficiency anemias (not having enough healthy red blood cells to carry oxygen to the body's tissues), anxiety disorder (a mental health condition characterized by persistent, excessive, and uncontrollable worry or fear that interferes with daily life, unlike normal, temporary stress), hypertension (blood vessels is too high), and heart failure (heart does not pump enough blood for the body's needs), hyperlipidemia (abnormally high fat and lipids) and type 2 diabetes mellitus without complication, (a chronic condition where the body cannot effectively use (insulin resistance) or produce enough of it, leading to high blood sugar levels hyperglycemia).Record review of Resident #34's quarterly MDS, dated [DATE], reflected the BIMS score was 10 out of 15, which indicated the resident had moderate cognitive impairment. The resident was totally dependent on staff for bed repositioning and personal hygiene. Resident #34 was incontinent of bladder and bowel. Record review of Resident #34's care plan, dated 1/24/26, reflected Resident #34 had an ADL self-care performance deficit and the goal was the resident would improve the current level of function.Record review of Resident #34's Physician order, reflected in part:Ascorbic Acid Tablet 500 MG Give 1 tablet by mouth one time a day to enhance iron absorption in iron deficiency anemia related to iron deficiency anemia, -Start Date 02/23/20Ferrous Sulfate Tablet 325 (65 Fe) MG Give 1 tablet by mouth one time a day for Treatment of iron deficiency anemia related to iron deficiency anemia, -Start Date02/23/2026Tramadol HCl Oral Tablet 50 MG (Tramadol HCl) Give 1 tablet by mouth every 12 hours for severe pain -Start Date07/21/2025During observation with RN F on 3/24/26 at 9:00 AM, she checked Resident #34's blood pressure (114/83 P71) before administering medication to Resident #34. RN F administered medication to Resident #34's medications by mouth. RN said, that was all medications for now. RN F did not administer Ascorbic Acid Tablet 500 MG Give 1 tablet by mouth one time a day, Ferrous Sulfate Tablet 325 (65 Fe) MG Give 1 tablet by mouth one time a day and Tramadol HCl Oral Tablet 50 MG (Tramadol HCl) Give 1 tablet by mouth every 12 hours. All medication were initialed as given at 9:00 AM.Interview with Resident #34 on 3/25/26 at 12:30 PM revealed Resident #34 stated regarding her pain medication, she said she did not know what medication she was taking and she was not in pain.3. Record review of Resident #78's ----- reflected an [AGE] year-old male who was admitted to the facility on 4/2/24 and re-admitted [DATE]. Resident #78 had diagnoses which included muscle weakness, difficulty in walking, not elsewhere classified, unspecified glaucoma (is a group of eye disease that damage the optic nerve- the cable connecting the eye to the brain-usually caused by too much fluid pressure building up inside the eye), benign prostatic hyperplasia (non-cancerous condition in older men where the prostate gland enlarges, pressing on the urethra and bladder) with lower urinary tract infection, anemia (lower than normal amount of healthy red blood cells or hemoglobin in your blood) in other chronic diseases classified elsewhere, personal history of urinary (tract) infections, unsteadiness on feet, other lack of coordination and Alzheimer's disease ( a progressive incurable brain disorder the slowly destroys memory, thinking skills and eventually the ability to perform simple tasks).Record review of Resident #78's annual MDS, dated [DATE], reflected the BIMS score was 7 out of 15, which indicated the resident had moderate cognitive impairment. The resident was totally dependent on staff for bed repositioning and personal hygiene. The MDS indicated Resident #78 was incontinent of bladder and bowel. Record review of Resident #78's care plan, dated 2/15/26, reflected Resident #78 had an ADL self-care performance deficit and the goal was the resident would improve the current level of function.Record review of Resident #78's physician order, reflected in part:1. Brimonidine Tartrate Solution 0.1 % Instill 1 drop in right eye three times a day for IOP(intra ocular pressure) right eye -Start Date 01/21/2026 2. dorzolamide HCl-Timolol Mal Ophthalmic Solution 2-0.5 % (Dorzolamide HCl-Timolol Maleate) Instill 1 drop in both eyes two times a day related to glaucoma, wait at least 5 minutes between different eye drop.3. Artificial Tears Ophthalmic Solution 1 % (Carboxymethylcellulose Sodium (Ophth) Instill 1 drop in both eyes four times a day for dry eyes.During observation with MA S on 3/24/26 at 10:06 AM, revealed she administered 2 medications by mouth to Resident #78. MA S said the nurses did eye drops. RN F did not administer Brimonidine Tartrate Solution 0.1 % Instill 1 drop in right the eye three times a day. Dorzolamide HCl-Timolol Mal Ophthalmic Solution 2-0.5 % (Dorzolamide HCl-Timolol Maleate) Instill 1 drop in both eyes two times a day. Artificial Tears Ophthalmic Solution 1 % (Carboxymethylcellulose Sodium [Ophth]) Instill 1 drop in both eyes four times a day . All medication was initialed as given at 9:00 AM to Resident #78.Interview with Resident#78 on 3/25/26 at 5:00 PM, he said he did not get his eyes medication and that was why his eyes were itchy.Interview with RN F on 3/26/26 at 4:30 PM, she said she went back to Resident #78 eyedrops when she went back. She can't remember the eyedrops she had to give Resident #78, he had artificial drops and the other one that started with B. She knew when medications were not given in a timely manner it would be effective and she did have in-services before started working with the facility.Interview with RN F on 3/26/26 at 4:30 PM revealed she worked 7a-7p. When asked why Residents #34, #78 and #81 medications were not given as ordered by the doctor, RN F said she went back and found out that she had to get 3 more medication, she had iron, vitamins, she didn't remember the time she did it but it was right after, not many hours. What she remembered was she passed meds at another side and went back after and she was not there. She went back to Resident #34, and they didn't have Tramadol. She had to get it from Pixis (a machine where residents could get a one-time dose of a medication with a code from the pharmacy). RN F stated the number of pills were given to Resident #34 during medication pass on 3/24/26. She did not give Tramadol at that time at 9:00 am. She thought she was finished and done with medication. In an interview with the DON on 3/26/26 at 5:38 PM, the DON said his expectation for medication administration was for nurses to administer medication as ordered by the physician. The DON said the facility had morning medication pass times for 9:00 a.m., medications given twice daily were for 9:00 a.m. and 5:00 p.m., medication for 3 times daily were given at 9:00 a.m., 1:00 p.m. and 5:00p.m. and medication for every 12 hours were for 9:00 a.m. and 9:00 p.m. if the state surveyor did not observe the medications given 3/24/2026 in the morning, he could not defend but the medications were initialed as given at 9:00 a.m The DON said he always monitored the staff periodically and the pharmacist also monitored the staff. The last time the pharmacist monitored staff was in January 2026. The DON said if RN F gave the medication, she should have informed the state surveyor During an interview on 3/26/26 at 5:40 p.m., the Administrator said he expected nursing staff to give medications timely, correctly, according to the physician orders and follow the facility time schedule for medication. Record review of the facility's Administering Medications policy, dated 3/2019, revealed in part, Policy Statement Medications Compliance Guidelines:Resident medications are administered in an accurate, safe, timely, and sanitary manner. 6. Administer medications as ordered by the physician. Routine medications shall be administered according to the established medication administration schedule for the community.The Director of Nursing Services will supervise and direct all nursing personnel who administer medications and/or have related functions. Medications must be administered in accordance with the orders, including any required time frame.

Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement.1. The facility failed to ensure leftover food consisting of sliced American cheese and shredded cheese past their use by dates were discarded. 2. The facility failed to ensure scrambled eggs, pureed sausage, pureed beef, brown gravy left outside on pans which were to be used later with temperatures in the danger zone were discarded. 3. The facility failed to ensure frozen pork chops were thawed properly.4. The facility failed to ensure equipment/serving utensils were washed and sanitized. These failures could place residents who ate food from the kitchen at risk of foodborne illness and disease. Observation of the facility's kitchen on 03-24-26 at 8:45 AM revealed the following. 1. Thawing frozen pork chops with a temperature of 66.2 degrees Fahrenheit in the kitchen sink immersed in water 75 degrees Fahrenheit. 2. A pan of brown gravy with a temperature of 116 degrees Fahrenheit on a food cart stationed on the kitchen hallway by the walk-in fridge. 3. A pan of pureed beef with a temperature of 61 degrees Fahrenheit on a food cart stationed on the kitchen hallway by the walk-in fridge.4. A pan of pureed sausage with a temperature of 58 degrees Fahrenheit on a food cart stationed on the kitchen hallway by the walk-in fridge.5. A pan of Scrambled Eggs with a temperature of 86 degrees Fahrenheit on a food cart stationed on the kitchen hallway by the walk-in fridge.6. A package of sliced American cheese with no used by date,7. Shredded cheese with no used by date. 8. Can opener blade was dirty with food debris. An interview with the Dietary Food Service Manager on 3-26-26 at 8:45 AM, revealed that the sliced American cheese and shredded cheese stored in the refrigerator should be discarded prior to the use by date. She stated the leftover foods observed in pans within the danger zone (a range between 40 degrees Fahrenheit to 140 degrees Fahrenheit where bacteria could grow rapidly) should have been discarded. She further stated that it was her responsibility that the department meets requirements. She said she will in-service dietary staff on proper handling, storing, dating leftover food for compliance.Record review of the facility's policies and procedures for Food Safety dated 3-30-23 read in part .potentially hazardous leftover foods are properly covered, labeled, dated, and refrigerated immediately. They are discarded on the used by date unless otherwise indicated. A policy on thawing frozen food properly was requested from the Food Service Manager and the Administrator on 03/26/2026 at 4:18pm, the Administrator stated that the facility did not have one.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 10 residents (Residents #34, Resident #66 and Resident #81) and 1 of 3 staff (RN F). The facility failed to ensure that personal wash basins, emesis basins and toothbrushes were labeled with resident's names to prevent infection.RN F failed to sanitize the blood pressure cuff between Resident #81 and Resident #34 on 3/24/26.RN F failed to wear PPE when administering Resident #81's G-Tube medications, who was on EBP, on 3/24/26.Resident #66 was observed with his catheter bag on the floor on 03/24/2026. These failures could place residents at risk for spread of infection, cross contamination, and decrease in quality of life. 1.Observation on 3/24/2026 at 9:00am revealed the following:-In room [ROOM NUMBER] there was basin directly on the bathroom floor, not in a plastic bag and it had no name. -In room [ROOM NUMBER] there was a basin directly on the bathroom floor not in a plastic bag with no name. -In room [ROOM NUMBER] there was a basin on the floor and an emesis basin in the bathroom, not in a plastic bag with no names. Two residents reside in the room.-In room [ROOM NUMBER] there was a basin directly on the floor, not in a plastic bag and it had no name on it. -In room [ROOM NUMBER] there was a basin on the floor not in a plastic bag with no name. Two residents reside in the room.-In room [ROOM NUMBER] there was a denture cup on the sink with no name. Two residents reside in the room.-In room [ROOM NUMBER] there was an emesis basin, wash basins with no name on them and they were not in plastic bags. Toothbrushes were on the sink and a razor with no names. Two residents reside in the room. In an interview with CNA J on 3/25/2026 at 10:00 am she said the basins and toothbrushes should be labeled with residents' names. She said if basins and toothbrushes were not labeled with residents' names it would cause cross contamination and possible infection. 2 and 3.Record review of Resident #81's face sheet, dated 3/25/26, revealed a [AGE] year-old female was admitted on [DATE] and re-admitted on [DATE]. Resident #81 had a diagnoses of gastrostomy (a small opening into the abdomen and inserted a tube directly into the stomach allowing for food and liquids to be delivered directly into the stomach), gastro-esophageal reflux ( Gastric reflux) disease without esophagitis, aphasia (not able to talk) following unspecified cerebrovascular disease (stroke), hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (medical condition involving paralysis of one side limbs (one arm and one legs), convulsions (when muscles contract and relax quickly and cause uncontrolled shaking of the body), essential (primary) hypertension, (high blood pressure) and cognitive communication deficit, other lack of coordination. Record review of Resident #81's quarterly MDS, dated [DATE], reflected the BIMS score was 0 out of 15, which indicated the resident had severe cognitive impairment. Further record review of the MDS revealed the resident was totally dependent on staff for bed repositioning and personal hygiene. Further record review of the MDS indicated Resident #81 was incontinent of bladder and bowel. Record review of Resident #81's care plan, dated 1/24/26, reflected Resident #81 had an ADL self-care performance deficit and the goal was the resident would improve current level of function. Observation of medication administration on 3/24/26 at 8:26AM by RN F revealed Resident #81's door had EPB posted. RN F did not wear a gown. RN F checked Resident #81's blood pressure and pulse oximeter and administered 3 medications via resident G-Tube. Interview on 3/24/26 at 9:12AM with RN F she said for not using EBP while administering medication to Resident #81, she was very sorry. Record review of Resident #34's face sheet, dated 03/24/26, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #34 had diagnoses which included: iron deficiency anemias (not having enough healthy red blood cells to carry oxygen to the body's tissues), anxiety disorder (a mental health condition characterized by persistent, excessive, and uncontrollable worry or fear that interferes with daily life, unlike normal, temporary stress), hypertension (blood vessels is too high), heart failure (heart does not pump enough blood for the body's needs), hyperlipidemia (abnormally high fat and lipids) and type 2 diabetes mellitus without complication,( a chronic condition where the body cannot effectively use (insulin resistance) or produce enough of it, leading to high blood sugar levels hyperglycemia). Record review of Resident #34's quarterly MDS, dated [DATE], reflected the BIMS score was 10 out of 15, which indicated the resident had moderate cognitive impairment. Further record review of the MDS revealed the resident was totally dependent on staff for bed repositioning and personal hygiene. Further record review of the MDS indicated Resident #34 was incontinent of bladder and bowel. Record review of Resident #34's care plan, dated 1/24/26, reflected Resident #34 had an ADL self-care performance deficit and the goal was the resident would improve current level of function. During an observation on 03/24/2026 at 8:26 a.m. RN F performed blood pressure checks. RN F did not sanitize the blood pressure cuff in-between uses after checking Resident #81's and Resident #34's blood pressure. RN F did not wear a gown before checking Resident #81's blood pressure, pulse oximeter, and before administering 3 medications via G-Tube. During an interview on 03/24/2026 at 9:12 a.m. with RN F she said she forgot to sanitize the blood pressure cuff between residents, she knew better because it was for infection control and the DON had given them a lot of in-services on sanitizing BP cuff in-between residents. RN F said she forgot to wear PPE while assisting with transferring Resident #81. She said she did have in-service about PPE usage to prevent infection every month at least bi-weekly. Interview with ADM on 3/26/26 at 5:00 PM, regarding expectation for Resident #81 on EBP during care. ADM said his expectation was for all residents with EBP signs should be posted on their door, the staffs were supposed to don PPE before entering their room to perform any care, to prevent infection. 4. Record review of Resident #66's face sheet last captured on 03/27/2026, revealed he was a [AGE] year-old male originally admitted on [DATE]. His medical diagnoses type 2 diabetes mellitus (high blood sugar), weakness, and neuromuscular dysfunction of bladder. Record review of Resident #66's care plan last captured 03/26/2026, he had a focus area of occasionally refusing care including ADLs and treatments dated 08/28/2025 with interventions including allowing the resident to make decisions about treatment regime and educating the resident of the possible outcomes of not complying with treatment of care. Resident #66 had a focus area of behavior problem of removing the privacy bag of his foley and taking the foley catheter bag off the hanger from the bed and placing it on the floor and emptied his own foley catheter bag dated 03/24/2026 with interventions including caregivers providing opportunity for positive interaction and educating the resident, family and caregivers on successful coping and interaction strategies. Record review of Resident #66's progress notes, there was no documentation on educating residents on the behavior of removing catheter bag off the bed and placing it on the floor before 03/24/2026. Observation of Resident #66 on 03/24/2026 around 10:20am, Resident #66 was sitting in bed and his catheter bag was on the floor. Resident #66 said that for his convenience he liked to move it around and did not like it to attach to the bed off the floor. Resident #66 said it was not the staff's fault and that it was his preferences, and he knew it should have been attached to the bed off the floor. Interview with RN O on 03/26/2026 at 2:33pm, he said Resident #66's catheter bag was not supposed to be on the floor. Resident #66 would keep removing it from the attachment. Resident #66 said he wanted to keep it that way for his own convenience. Staff attempted to redirect him but Resident #66 was independent with bladder care. RN O said a risk to residents could be the tubing connecting the catheter to the resident could become tangled and pop out or burst. It could result in an infection control issue. Interview with the DON and Administrator on 03/26/2026 at 4:02pm, the DON said Resident #66 knew what he was doing and preferred emptying his own catheter bag and was independent with urinary incontinent care. Resident #66 was known to remove his privacy covering and had done whatever he wanted with his foley. Resident #66 said he did not like it; he did not give any reason why he did not like to secure the tubing. This behavior was ongoing since admission. If Resident #66 was steady and in bed this behavior would not affect him, but since he was independent and moved around on his own Resident #66 could trip on his catheter tube. Interview with MDS K and MDS L on 03/27/2026 at 11:08am, MDS K said that he was not aware Resident #66 had a behavior of unhooking his catheter bag and letting it touch the floor. MDS K did not see it until recently. MDS K said not documenting this behavior could cause residents harm down the road if the behavior kept recurring, it could cause trauma which would require the facility to intervene, including informing the physician. Record review of the facility's policy on Infection Control, undated, read in part, . 5. Gowns and protective apparel 1. Gowns and protective apparel are worn to provide barrier protection and reduce the opportunity for transmission of microorganisms in the LTCF. Gowns are worn to prevent contamination of clothing and to protect the skin of personnel from blood and body fluid exposures.2. Gowns are also worn by personnel during the care of patients infected with epidemiologically important microorganisms to reduce the opportunity for transmission of pathogens from residents or items in their environment to other residents or environment. 6. Resident care equipment and articles.3. Non-invasive resident care equipment is cleaned daily or as need between use by the nursing assistant. 7. Although soiled linen may be contaminated with pathogenic microorganisms, the risk of disease transmission is negligible if it is handled, transported, and laundered in a manner that avoids transfer of microorganisms. Hygienic and common-sense storage and processing of clean and soiled linen is recommended. Record review of the facility Policy and Procedures title Infection Prevention and Control policy dated December 2023 read in part.Policy Statement:The facility adopted infection prevention and control policies and procedures are intended to help maintain a safe, sanitary and comfortable environment and to prevent and manage transmission of disease and infection.Policy Interpretation and Implementation:Infection prevention and control policies and procedures apply to all personnel, consultation, contractors, resident, visitors and volunteers. The objectives of the infection prevention and control policies and procedures are to:A. Monitor, detect, investigate and control infections in the facility.B. Maintain a safe, sanitary and comfortable environment for resident, personnel, visitors and the general public.C. Provide evidence-based guidelines for infection prevention and control based on current practices.

Based on observation, interview, and record review the facility failed to ensure that residents are were free of any significant medication errors for 2 of 18 residents (Resident #68 and Resident #81) reviewed for medications.The facility failed to ensure that Resident #68's blood pressure medications hydralazine and telmisartan were held within the parameter the physician ordered. 2. RN F failed to administer Lacosamide Oral Tablet 150 MG (Lacosamide) (to treat partial-onset seizures), give 1 tablet via PEG-Tube every 12 hours for nausea, initialed as given to Resident #81, when it was not given on 3/24/26.These failures could place residents with high or low blood pressure at risk of fainting or a stroke due to not getting their blood pressure medication as ordered by their physician. 1.Record review of Resident #68's admission face sheet dated 3/27/2026 revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included hypertension (high blood pressure), hypothyroidism (, dementia (memory problem), depression (, urinary tract infection, Alzheimer's disease and cognitive communication. Record review of Resident #68 quarterly MDS dated [DATE] Section C:500 revealed a BIMS score of 06 indicating the resident was cognitively severely impaired Record review of Resident #68's physician's order dated 11/02/2025 revealed an order for hydralazine HCl oral tablet 25 ml give 1 tablet by mouth three times a day for hypertension. Hold if SBP<130 or pulse >85.Record review of Resident #68 order dated 11/03/2025 for Telmisartan oral tablet 40mg by mouth one time a day for hypertension, Hold for SBP < 130 or pulse < than 60. Record review of Resident #68's MARs for February and March of 2026 revealed the following. February 2026 on the following dates Hydralazine 25 mg to be given three times a day for hypertension. Hold if SBP<130 or pulse >85. The Hydralazine was not documented as held on 2/2/2026 when SBP was 128/68 at 3:00pm and 126/58 at 9:00pm, 2/3/2026 when SBP was 112/62 at 9:00am and 127/67 at 3:00pm, 125/69 at 9:00pm, 2/4/2026: SBP was 122/75 at 9:00am, 124/74 at 3:00pm and 118/70 at 9:00pm, 2/5/2026 SBP was 126/77 at 3:00pm and 126/71 at 9:00pm, 2/6/2026 SBP was 128/70 at 9:00pm, 2/7/2026 SBP was 128/73 at 3:00pm and 126/74 at 9:00pm, 2/8/2026 SBP was 128/76 at 3:00pm and 127/75 at 9:00pm, 2/10/2026 SBP was 125/77 at 9:00am, 116/76 at 3:00pm and 127/74 at 9:00pm, 2/11/2026 SBP was 126/73 at 9:00am, 127/74 at 9:00pm, 2/12/2026 SBP was 124/70 at 9:00am, 127/68 9:00pm, 2/13/2026 SBP was 120/60 at 3:00pm, 2/14/2026 SBP was 128/74 at 3:00pm, 2/17/26: SBP was 120/69 at 9:00am, 124/70 at 9:00pm, 3/18/2026 SBP was 121/73 at 3:00pm, 2/19/2026 SPB was 124/76 at 3:00pm, 2/20/2026 SBP was 124/67 at 3:00pm and 124/76 at 9:00pm, 2/21/2026 SBP was 124/76 at 9:00pm, 2/22/2026 SBP was 127/67 at 9:00pm, 2/23/2026 when SBP was 124/70 at 3:00pm, 2/25/2026 SBP was 123/74 at 9:00am and on 2/26/2026 SBP was 124/74 at 9:00pm. The pulse on 2/4/2026 was 97 at 3:00pm, 2/5/2026 it was 87 at 9:00am, and on 2/21/2026 the pulse was 98 at 9:00am and 87 at 3:00pm. February 2026 on the following dates Telmisartan 40 mg to be given three times a day at 9:00am, to be held if SBP < 130 or pulse < than 60 was not documented as held on 2/3/2026 when SBP was 112/62 9:00 am, 2/4/2026: SBP was 122/75 9:00am, 2/10/2026 SBP was 125/77 9:00 am, 2/11/2026 SBP was 126/73 9:00am, 2/11/26: SBP was 12o/69 at 9:00am, 2/12/2026 SBP was 124/70 9:00am, 2/17/2025 120/69 9:00am and 2/25/2026 SBP was 123/74 at 9:00am The pulse at 9:00am on 2/7/2026 was 55, on 2/11/2026 it was 58, 2/12/2026 it was 55, 2/17/2026 it was 51, 2/20/2026 it was 50, 2/25/2026 it was 58 and on 2/27/2026 it was 52. Record review of the nurses' notes revealed no reasons why the medication was not held. March 2026 on the following dates Hydralazine 25 mg to be given three times a day for hypertension. Hold if SBP<130 or pulse >85 was not documented as held on 3/3/2026 when SBP was 122/69 at 3:00pm, and SBP was 129/77 at 9:00pm, 3/4/2026 SBP was 128/77 at 3:00pm, 3/7/2026 when SBP was 119/62 at 9:00am, and 127/76 at 9:00pm, 3/8/2026: SBP was 127/76 at 3:00pm and 124/77 at 9:00pm, 3/13/2026 SBP was 128/99 at 3:00pm, 3/16/2026 SBP was 126/68 at 9:00am, 3/26/2026 SBP was 118/68 and on 3/25/2026 the pulse was 90. March 2026 on the following dates Telmisartan 40 mg to be given once a day. Hold if SBP < 130 or pulse < than 60 was not documented as held on 3/7/2026 at 9:00am when SBP was 119/62, 3/16/2026: SBP was 126/68. The pulse on 3/1/2026 at 9:00am was 54, at 9:00am on 3/1/2026, 3/3/2026 it was 56, 3/6/2026, 3/7/2026, 3/8/2026, 3/11/26, 3/12/2026, 3/16/2026, 3/17/2026, 3/20/2026, 03/22/2026 and 3/25/2026 the pulse was 50 and, on 3/10/2026 it was 51, 3/13/2026 it was 57, 3/23/2026 it was 56 and 3/24/2026 it was 58. Record review of Resident #68 clinical record for February and March 2026 revealed no documentation that the doctor was notified of the result of the blood pressure and pulse reading when they were consistently in the parameter they should be held. Further review of the nurse's notes for February and March revealed no documented reason why the medications were not held as ordered by the physician. In an interview on 3/27/2026 at 1:05 pm with LVN W, she said if there was an order for blood pressure medication to be held with a certain parameter and it was not held the blood pressure could get higher or lower and it could cause the resident to get sicker. She said in the case of Resident #68 if the blood pressure was low and Telmisartan or hydralazine was given the blood pressure could drop lower, and the resident could faint and if the pulse gets higher it could cause fainting, dizziness or stroke. She said in the case of Resident #68 not holding the medication had no adverse effect on him because his blood reading was always < than 130 and < than 60. She said holding the medication for Resident #68 based on his blood pressure reading he would get bradycardia. She said she notified the doctor and no instructions were given to make any change. She said she did not document the conversation in nurse's notes, she said in nursing if it's not documented it was not done. At that point she said she should have documented the nurse's notes, and she takes full responsibility for not documenting. In an interview on 3/27/2026 at 1:18pm the DON, regarding medications that were not held for Resident #68, revealed that he was going to call the provider to ask if he could review the parameters for the blood pressure or change the medication. He said if blood pressure medications were not followed, the blood pressure could go higher or lower. He said if the nurse did not observe any change in the resident's condition, it'll be up to the provider to review the medications and make the change. He said the facility also reviewed medications. He said medication review for LTC was only done if there's a change in conditions for residents such as falls. In that case they would go through the interventions and see if medication was causing orthostatic change in blood pressure. He said the nurse should look at the parameters before they give blood pressure medication. If blood pressure was out of parameters and the nurse still gave medication, it could cause the blood pressure to be higher or lower. He said they have quarterly medication administration in- services. He said the nurses should reach out to the physician if the blood pressure was always out of the parameter that it was ordered to be held so they could review the medications and make the needed changes. He said moving forward, if there's a pattern or there was no effect on the residents even within the parameters the physician asked for the medications to be held, they should notify the physician and let them decide what intervention needed to be done and document in the resident's record. 2.Record review of Resident #81's face sheet, dated 3/25/26, revealed a [AGE] year-old female was admitted on [DATE] and re-admitted on [DATE]. Resident #81 had a diagnoses of gastrostomy (a small opening into the abdomen and inserted a tube directly into the stomach allowing for food and liquids to be delivered directly into the stomach), gastro-esophageal reflux( Gastric reflux) disease without esophagitis, aphasia (not able to talk) following unspecified cerebrovascular disease (stroke), hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (medical condition involving paralysis of one side of limbs (one arm and one leg), convulsions (when muscles contract and relax quickly and cause uncontrolled shaking of the body), essential (primary) hypertension, ( high blood pressure), and cognitive communication deficit, other lack of coordination. Record review of Resident #81's quarterly MDS, dated [DATE], reflected the BIMS score was 0 out of 15, which indicated the resident had severe cognitive impairment. Further record review of the MDS revealed the resident was totally dependent on staff for bed repositioning and personal hygiene. Further record review of the MDS indicated Resident #81 was incontinent of bladder and bowel. Record review of Resident #81's care plan, dated 1/24/26, reflected Resident #81 had an ADL self-care performance deficit and the goal was the resident would improve current level of function. Record review of Resident #81's Physician's Orders, dated 2/17/26, reflected the following orders: Had NPO (nothing per oral/nothing by mouth) check gastric tube placement by auscultation (using stethoscope to listen to bowel sound) prior to meds, formula, and H2O flushes every shift. Check for residual every shift if > 60ccs, stop feeding and notify MD every shift. Feeding of Isosource 1.5 Cal 45 cc/hr. via pump, Flush GT with 30 ml water before and after administration of meds, flush with 10 cc between each medication every shift. Record review of Resident #81's Physician order, reflected in part:Lacosamide Oral Tablet 150 MG (Lacosamide) (to treat partial-onset seizures)*Controlled Drug*Give 1 tablet via PEG-Tube every 12 hours for nausea- order date 4/28/23. During an observation of medication administration on 3/24/26 at 8:26 a.m., for Resident #81, RN F was observed checking Resident 81's blood pressure (BP144/87, P71), RN F open the medication cart, then punched three other medications, crushed them individually and then diluted with 10cc of water, then went back to the resident's room, checked G-Tube for residual, and administered the medication through Resident #81's G-Tube. Interview with RN F on 3/26/26 at 4:30 pm she said works 7a-7p. She started working in August 2025 as needed. When asked why Resident #34, #78 and #81 medications were not given as ordered by the doctor. RN F said she went back and found out that she had to get 3 more medications, she had iron, vitamin, she didn't remember the time she gave it t but it was right after, not many hours. What she remembers was she passed meds at another side and went back after and the surveyor was not there. In an interview with the DON on 3/26/26 at 5:38 PM, the DON said his expectation for medication administration was for nurses to administer medication as ordered by the physician. The DON said the facility had morning medication pass times for 9:00 a.m., medications given twice daily was for 9:00 a.m. and 5:00pm, medication for 3 times daily were to given 9:00 am, 1:00pm and 5:00pm and medication for every 12 hours was for 9:00 am and 9:00 pm if the state surveyor did not observe medications given 3/24/2026 in the morning, he could not defend it but the medications were initialed as given at 9:00 a.m The DON said he always monitored the staff periodically and the pharmacist also monitored the staff. The last time the pharmacist monitored staff was in January 2026. The DON said if RN F gave the medication, she should have informed the nurse surveyor During an interview on 3/26/26 at 5:40 p.m., the Administrator said he expected nursing staff to give medications timely, correctly, and according to the physician orders. Record review of the facility's policies and procedure title Administering Medication dated April 2019 read in part. Policy StatementMedications are administered in a safe and timely manner and as prescribed.Policy Interpretation and Implementation1. Only persons licensed or permitted by the state to prepare, administer, and document administration of medications may do so.4. Medications are administered in accordance with the prescriber's order, including any required time frame. 5. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include:a. Enhancing optimal therapeutic effect of the medicationb. Preventing potential medication or food interaction and c. Honoring resident choices and preferences consistent with his6. Medication errors are documented, reported and reviewed by QAPI committee to inform process changes.7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders)8. If a dosage is believed to be inappropriate or excessive for a resident, or the medication has been identified as having potential adverse consequences for a resident or suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident attending physician or facility medical director to discuss the concern. 22. The individual administering the medication initials the resident MAR or appropriate line after giving each medication before administering the next medication.

Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 3 (Resident #66) reviewed for care plans .-The facility failed to ensure Resident #66's behavior of placing his catheter bag on the floor was documented in the care plan. This failure could place residents at risk of staff not being aware of how to provide care tailored to individual residents' needs . Record review of Resident #66's face sheet, last captured on 03/27/2026, reflected a [AGE] year-old male who was originally admitted to the facility on [DATE]. His medical diagnoses included type 2 diabetes mellitus (high blood sugar), weakness, and neuromuscular dysfunction of bladder (nerve damage disrupts communication between the brain, spinal cord and bladder, leading to impaired bladder control).Record review of Resident #66's care plan, last captured 03/26/2026, reflected he had a focus area of occasionally refusing care which included ADLs and treatments, dated 08/28/2025, with interventions which included allowing the resident to make decisions about treatment regime and educating the resident of the possible outcomes of not complying with treatment of care. Resident #66 had a focus area of behavior problem of removing the privacy bag of his foley and taking the foley catheter bag off the hanger from the bed and placing it on the floor and emptied his own foley catheter bag, dated 03/24/2026, with interventions which included caregivers providing opportunity for positive interaction and educating the resident, family and caregivers on successful coping and interaction strategies. Record review of Resident #66's progress notes, reflected there was no documentation on educating the residents on the behavior of removing the catheter bag off the bed and placing it on the floor before 03/24/2026. The care plan was updated on 03/24/2026 to reflect Resident #66's behavior after surveyor intervention.Observation on 03/24/2026 around 10:20 AM, revealed Resident #66 was sitting in bed and his catheter bag was on the floor. Resident #66 said for his convenience he liked to move it around and did not like it to attach to the bed off the floor. Resident #66 said it was not the staff's fault and that it was his preferences, and he knew it should have been attached to the bed off the floor. Interview with RN O on 03/26/2026 at 2:33 PM, he said Resident #66's catheter bag was not supposed to be on the floor. Resident #66 would keep removing it from the attachment. Resident #66 said he wanted to keep it that way for his own convenience. Staff attempted to redirect him but Resident #66 was independent with bladder care. RN O said a risk to residents could be the tubing connecting the catheter to the resident could become tangled and pop out or burst. It could result in an infection control issue. RN O did not know whether or not this was documented in Resident #66's care plan. Interview with the DON and Administrator on 03/26/2026 at 4:02 PM, the DON said Resident #66 knew what he was doing and preferred emptying his own catheter bag and was independent with urinary incontinent care. Resident #66 was known to remove his privacy covering and had done whatever he wanted with his foley. Resident #66 said he did not like it, he did not give any reason why he did not like to secure the tubing. This behavior was ongoing since admission. It was not care-planned until recently . The DON said staff like the MDS team, or the IDT team should have been care-planning it. Without it being documented, other staff members would not be aware of it. If Resident #66 was steady and in bed this behavior would not affect him, but since he was independent and moved around on his own Resident #66 could trip on his catheter tube. Interview with MDS K and MDS L on 03/27/2026 at 11:08 AM, MDS K said he was not aware Resident #66 had a behavior of unhooking his catheter bag and letting it touch the floor. MDS K did not see it until recently. Resident behaviors would be discussed in morning meetings and documented in the medical records and care plan. MDS K said it was the MDS team's responsibility to add it in the care plan, but he was not informed of this behavior. MDS K said not documenting this behavior could cause residents harm down the road if the behavior kept recurring, it could cause trauma which would require the facility to intervene, which included informing the physician.A policy on comprehensive care plans was requested on 04/27/2026 at 11:44 AM by email to the Administrator and DON and was not provided as of exit.

Based on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible for 1 of 4 residents (Resident #1) reviewed for accident hazards. LVN W failed to properly dispose of lancets, used to prick Resident #1's finger to obtain blood for the glucose checks, and threw it in the regular trash can rather than the sharps container attached to the side her medication cart. This failure could place residents at risk of harming themselves or others with unsecured equipment.Findings include:Record review of Resident #1's face sheet, dated 03/24/2026, reflected a 53year-old female who was admitted to the facility on [DATE] and readmitted [DATE]. Her medical diagnoses included down syndrome (a genetic condition present at birth where a person has an extra chromosome, specifically chromosome 21), cognitive communication deficit, need for assistance with personal care, other abnormalities of gait and mobility, muscle weakness (generalized), type 2 diabetes mellitus (body cannot effectively use insulin ( insulin resistance) or produce enough of it, leading to high blood sugar level) with unspecified complications (high blood pressure).Record review of Resident #1's quarterly MDS assessment, dated 11/30/25, reflected a BIMS score of 3 out of 15, which indicated severe cognition impairment. She required assistance from staff with ADL care. Record review of Resident #1's care plan, dated 11/27/2025, reflected Resident #1 had a focus area for impaired cognitive function, cognitive loss and impaired decision-making abilities with interventions which included monitoring, documenting and report as needed any changes in cognitive functions and changes in memory, general awareness and decision-making ability. Observation during blood glucose check on 3/24/26 at 11:09 AM revealed Resident #1 sitting in a high back wheelchair in her room. LVN W got a glucose check machine, one lancet sharp, glucose strips and alcohol pad from the medication cart packed in front of Resident#1's door, wore PPE(Personal Protective Equipment) and clean gloves, explained the procedure to the resident. LVN W wiped Resident #1's finger with the alcohol pad, she then pricked Resident #1's finger and was unable to obtain blood drops. LVN W then took off the gloves and disposed the lancet in the trash in the resident's room. LVN W went to the parked medication cart and picked up another lancet, pricked Resident #1's finger and obtained blood, the glucose was 200mg/dl (milligrams per deciliter), LVN W then disposed the lancet and strip in the trash can in the room. During an observation/interview on 3/24/2026 at 11:30 a.m., LVN W stated the importance of ensuring sharps were properly disposed was to ensure no residents and staff could hurt themselves and expose themselves to an infection or disease. LVN W said she should have placed the lancet in the sharp box.During an interview on 3/25/2026 at 5:00 p.m. with the DON, revealed the policy on sharps disposal was requested. The ADM and DON both stated they were not aware of the improper disposal of the sharps. They both stated all sharps were to be properly disposed of to maintain infection control and to ensure the safety of residents who could hurt themselves and contract an infection or disease. During an interview on 3/25/2026 at 5:02 p.m. with the Administrator the policy on sharps disposal was requested. The ADM and DON both stated they were not aware of the improper disposal of the sharps. They both stated all sharps were to be properly disposed of to maintain infection control and to ensure the safety of residents who could hurt themselves and contract an infection or disease.Record review of the facility's policy on Regulated (Biohazard) Medical Waste, copyrighted July 2025, read in part, Policy:It is the policy of this facility to ensure that regulated medical waste is managed, handled, stored, and transported as per Federal, State and local guidance and regulations. (Include any specific state or local guidance and regulations.).10.Contaminated sharps will be placed in appropriate sharps containers located at the point of use. Items to be considered into placement within sharps containers include discarded laboratory tubes with small amounts of blood, scalpel blades, needles and syringes, and unused sterile sharps. 11.Sharps containers must be the following:a. Closable;b. Puncture resistant;c. Leak proof on sides and bottom;d. Labeled with the appropriate biohazard labels as per OSHA( Occupational Safety And Health Administration) standards.12. Sharps containers must be maintained upright throughout use and replaced routinely. Do not overfill the container.13.Sharps containers will be closed immediately prior to removal or replacement to prevent spillage or protrusion of contents during handling, storage, or transport.

Based on observation, interview and record review the facility failed to ensure all drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 4 medication carts (Nurses Cart P) reviewed for medication storage. -Nurse Cart P medication cart had medications that were opened and undated. This failure could place residents at risk of receiving expired medication and improperly stored medications which could result in delayed healing. Findings During an observation on [DATE] at 2:35pm of Nurse Cart P revealed the following opened medications were not dated when they were opened: The following eye drops and nasal drops were open with no date:1. Loteprednol Etabonate Ophthalmic2. Bacitracin Zinc and Polymyxin B Ophthalmic3. Fluticasone Propionate Nasal Spray USP 50mcg Interview with LVN GG on [DATE] at 4:44 PM revealed she was not aware of the following eye drops Loteprednol Etabonate Ophthalmic and Bacitracin Zinc and Polymyxin B Ophthalmic that were opened and not dated. She stated Loteprednol Etabonate Ophthalmic and Bacitracin Zinc and Polymyxin B Ophthalmic medication was good for 30 days for effectiveness. LVN GG said she checked her medication cart whenever she administered her medications. During an interview on [DATE] at 4:38 p.m., the Director of Nurse (DON) said eye drops opened should have an open date. The DON said the medicines would not be effective for the treatment after 30 days. The nurses were responsible for dating eye drops and nasal drops whenever it was opened. Record review of the facility's policy, not dated, Storage of Medication Purpose: Ensure that medications are stored in a safe, secure and orderly manner. Procedure: 11. multi-dose vials that have been opened or accessed should be dated and discarded within 28 days of opening /initial access unless the manufacturer specifies a shorter or longer date.

Based on observation, interview and record review the facility failed to dispose of garbage and refuse properly for 1 of 2 dumpsters (dumpster A) reviewed for sanitary conditions. The facility failed to ensure dumpster A's lids and doors were secured. The failure could place residents at risk of infection from improperly disposed garbage . Observation on 3-24-26 at 8:45 AM revealed the facility dumpster area had 2 commercial sized dumpsters. Dumpster A was 3/4 full of garbage and the doors were open and the surrounding area had an accumulation of debris. In an interview with the food service manager on 3/24/26 at 8:45 AM she stated that the dumpster doors must always be closed to keep vermin, pests, and insects out of the dumpster and from entering the facility. She further stated that housekeeping and nursing also discard their waste and garbage in the dumpster. It was the responsibility of staff from dietary, nursing and housekeeping for ensuring the food waste will properly be removed and disposed of from the community. Record review of facility's policies and procedures on disposal of garbage and refuse not dated revealed that .7. Refuse containers and dumpster kept outside the facility shall be designed and constructed to have tightly fitting lids, doors or covers. Containers and dumpsters shall be kept clean so that accumulation of debris and insect/rodent attractions are minimized.

Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement.-The facility failed to ensure residents' lunch was served at a safe temperature on 3/6/2026.These failures could place residents who ate food from the kitchen at risk of foodborne illness and disease.Observation of food temperature and interview on 3/6/2026 at 12:39pm, the DM delivered a regular lunch test tray which included fish tenders, hushpuppies, potato wedges and coleslaw. She left immediately to get a thermometer, alcohol wipes and a glass of ice water and came back at 12:45pm. The DM placed the thermometer in the ice water, and the temperature reading was 32.9F. The DM left and came back at 12:50pm with a new thermometer and then took it out and placed the thermometer in the ice water with a reading of 32.5F. The DM then measured each food item, placing the thermometer end in ice water and waiting until the reading went down to 32.5F and wiping before measuring the next food item. The fish tenders read 113.5F, the potatoes were 100.5F, the hushpuppies were 98.5F, and the coleslaw was 56.1F. The DM said the fish tenders should have been 135F especially off the steam table, the potatoes should be the same at 135F, the hushpuppies should be 130F and the coleslaw should have been 40F. The DM said the thermometer should have read 32F from the ice water, and that kitchen staff check food temperatures on the steam table before they go out. The first cart leaves the kitchen within 10 minutes, when the kitchen staff deliver trays on metal racks to hallways and then aides will deliver food to residents. The DM said the facility did not have hot plates, but they had metal tray racks to deliver food. If food was not the right temperature, then residents could get sick. Interview with Dietary Aide A on 03/06/2026 at 3:28pm, she said that residents did not complain about food. Dietary Aide A said it could take 10 to 15 minutes to get trays from the kitchen to the hallway.Interview with the Administrator on 3/6/2026 at 4:30pm, he said he had not heard of complaints of cold food. He said warming plates were not used at the facility. If residents were served food in the temperature danger zone, it could cause residents to fall ill.Record review of the policy on food temperatures, undated, it read, Purpose: Ensure food is served at a safe temperature to prevent food-borne illness. Procedure: 1. Hot foods should be maintained at a minimum of 135 degrees F. 2. Cold foods should be maintained at a maximum of 41 degrees F.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 1 of 6 residents (Resident #5) and 2 of 2 staffs (CNA KK, CNA HH) reviewed for infection control. -The facility failed to ensure CNA FF donned PPE before transferring Resident #5 via mechanical lift from her bed to her wheelchair on 3/6/26. -The facility failed to ensure CNA HH donned PPE before transferring Resident #5 via mechanical lift from her bed to her wheelchair on 3/6/26. This failure could place residents at risk for spread of infection and cross contamination to residents causing resident illness and/or distress. Record review of Resident #5's face sheet dated 03/6/2026 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted [DATE]. Her medical diagnoses included down syndrome, unspecified, cognitive communication deficit, need for assistance with personal care, other abnormalities of gait and mobility, muscle weakness (generalized), type 2 diabetes mellitus with unspecified complications Record review of Resident #5's quarterly MDS assessment, dated 11/30/25, reflected a BIMS score of 3 out of 15, which indicated severe cognition impairment. She required assistance from staff with ADL care. Record review of Resident #5's care plan, dated 11/27/25, reflected, . The resident had an ADL self-care deficit .Interventions .Personal hygiene and Toilet use- Resident is totally dependent with two person transfers from bed to wheelchair and from wheelchair to bed. During observation on 3/6/26 at 11:55 AM, Resident #5 had an Enhanced Barrier Precaution sign posted on her door. Resident #5 was lying in bed, CNA FF did not don (put on) PPE before entering Resident #5's room with the mechanical lift, CNA HH entered room to assist with Resident #5's transfer, she donned clean gloves without donning other PPE (gloves and gown), t [NAME] transferred resident to her wheelchair. In an interview with CNA FF on 3/06/26 at 2:16 p.m., she said she forgot to wear PPE while transferring Resident #5. She said she wore PPE earlier while performing incontinent care to Resident #5. She said she did have in-services about using PPE to prevent infection to her and the resident.In an interview with CNA HH on 3/06/26 at 2:31 p.m., she said she forgot to wear PPE while assisting with transferring Resident #5, She said she did have in-services about using PPE to prevent infection every month at least bi-weekly.Interview with the Administrator on 3/6/26 at 5:00 PM, regarding expectations for Resident #5 on EBP during care. The Administrator said his expectation was for all residents with EBP signs posted on their door, the staff were supposed to don PPE before entering their room to perform any care, to prevent infection.Review of the facility's policy titled Enhanced barrier precautions not dated: .Policy.Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug-resistant organisms (MDROs) to residents. Policy Interpretation and Implementation 1. Enhanced barrier precautions (EBPs) refer to infection prevention and control interventions designed to reduce the transmission of multi-drug-resistant organisms (MDROs) during high contact resident care activities. 2. Enhanced barrier precautions apply when: a. A resident is infected or colonized with a CDC-targeted MDRO, but does not have a wound or indwelling medical device, and does not have secretions or excretions that cannot be covered or contained; b. A resident is NOT known to be infected or colonized with any MDRO, has a wound or indwelling medical devices, and does not have secretions or excretions that are unable to be covered or contained; and c. Contact precautions do not otherwise apply. 3. Contact precautions apply when: a. A resident is infected or colonized with any MDRO and has secretions or excretions that cannot be covered or contained; and b. A resident is NOT known to be infected or colonized with any MDRO, has a wound or indwelling medical device, and has secretions or excretions that cannot be covered or contained; or c. A resident is infected or colonized with any MDRO and there is a current investigation of a suspected or confirmed MDRO outbreak. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). b. Personal protective equipment (PPE) is changed before caring for another resident. c. Face protection may be used if there is also a risk of splash or spray. 8. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing; b. bathing/showering; c. providing hygiene or grooming; d. changing briefs or assisting with toileting; e. transferring; f. providing bed mobility;

Based on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 6 residents (Resident #22) reviewed for incontinent care. -The facility failed to ensure CNA FF changed gloves and cleaned Resident #22's scrotum and buttocks before putting on a clean brief during incontinent care on 3/6/26. This failure could place residents at risk for pain, infection, injury, and hospitalization. Record review of Resident #22's face sheet dated 03/06/2026 revealed he was an [AGE] year-old male who was admitted to the facility on [DATE]. His medical diagnoses included reduced mobility , mild protein-calorie malnutrition, other sequelae of cerebral infarction (consequences of stroke), secondary hypertension (blood pressure), hyperlipidemia (high fat in the blood) unspecified hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (paralysis or partial paralysis following stroke affecting left non-dominant side), other lack of coordination, cognitive communication deficit, dependence on supplemental oxygen, need for assistance with personal care, muscle weakness (generalized), other abnormalities of gait and mobility.Record review of Resident #22's admission MDS assessment, dated 12/25/25, reflected a BIMS score of 15 out of 15, which indicated intact cognition. He required assistance from staff with ADL care. Record review of Resident #22 's care plan, dated 10/04/25, reflected, . The resident had an ADL self-care deficit .Interventions.Personal Hygiene and Toilet use- Resident is totally dependent . Resident #22 was also care-planned for incontinent care, with interventions including changing brief in a timely manner preventing skin break down. Observation of incontinent Care on 3/6/26 at 10:40AM, performed by CNA FF, she washed hands then donned clean gloves. Resident #22 was lying on his back with wife at his bedside. CNA FF picked up a clean and wet wipes, unfasten the soiled brief, using wet wipes cleaned the groin but did not clean the penis or the scrotum. Resident #22 was repositioned on his left side. Resident #22 was soiled of urine and feces., CNA FF cleaned in between the buttocks several times using the wet wipes. She did not clean around the buttocks without changing gloves, opened a jar of zinc oxide ointment and applied it to resident around buttocks and the groin, she then placed a clean brief on and then took off the soiled gloves and washed hands.Interview on 3/6/26 at 11:50AM with CNA FF, regarding incontinent care, she said she did a good job, she was asked why she used the same gloves throughout incontinent care, she said Oh, I forgot, I was confused because (Resident #22's) wife handed ointment of zinc oxide to me, that threw me off and I did not change the gloves. CNA FF said she had in-services on incontinent care, and she knew not changing gloves, cleaning the buttocks, scrotum could cause more skin break, odors and urinary tract infection.Interview with the Administrator on 3/6/26 at 5:00 PM, regarding expectation for incontinent care and handing, he said his expectation was for incontinent care to be done in a manner to prevent urinary tract infection. Review of the facility's policy titled Subject: Perineal Care Revision date February 2018: Purpose The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition.MALEFor a male resident: a. Wet washcloth and apply soap or skin cleansing agent. b. Wash perineal area starting with urethra and working outward. e. Wash and rinse urethral area using a circular motion. f. Continue to wash the perineal area including the penis, scrotum and inner thighs. g. Thoroughly rinse perineal area in same order, using fresh water and clean washcloth. h. If the resident has an indwelling catheter, hold the tubing to one side and support the tubing against the leg to avoid traction or unnecessary movement of the catheter. i. Gently dry perineum following same sequence. j. Reposition foreskin of uncircumcised male. k. Ask the resident to turn on his side with his upper leg slightly bent, if able. l. Rinse washcloths and apply soap or skin cleansing agent. m. Wash and rinse the rectal area thoroughly, including the area under the scrotum, the anus, and the buttocks. n. Dry area thoroughly.

Based on observation, interview and record review the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (Resident #13) reviewed for accident hazards.The facility failed to ensure Resident #13's electrical bed remote did not have exposed wiring, with the inner blue, green and red wires separated from the white outer sheath.This failure could place residents at risk of injury from using damaged electrical equipment. Record review of Resident #13's face sheet dated 3/6/2026, revealed she was an [AGE] year-old female originally admitted on [DATE] and last re-admitted on [DATE] . Her medical diagnoses included type 2 diabetes mellitus (high blood sugar), morbid obesity due to excess calories, unsteadiness on feet, cellulitis (inflammation of the skin), presence of a cardiac pacemaker (electrical device that helps regulate the heart's rhythm by sending electrical impulses to the heart muscle to ensure a normal heart rate), and spinal stenosis lumbar region (narrowing of spinal canal, putting pressure on the spine and nerves).Record review of Resident #13's Quarterly MDS dated [DATE], revealed she scored an 8 out of 15 on the BIMS (short interview gauging thinking and memory), indicating moderate cognitive impairment. Resident #13 was totally dependent on staff for ADLs including showering, toileting, putting on and taking off footwear, and oral and personal hygiene.Record review of Resident #13's care plan last captured 03/06/2026 revealed she was care-planned for congestive heart failure with interventions to monitor for signs and symptoms of heart failure including shortness of breath upon exertion, weakness and increased heart rate. Resident #13 also had a pacemaker with interventions including monitoring vital signs and symptoms of altered cardiac output or pacemaker malfunction including dizziness, pulse rate lower than programmed rate and difficulty breathing.Observation and interview with Resident #13 on 3/6/2026 at 10:08am, Resident #13's bed remote was connected to a grey cord which connected to an outlet on the left side of the bed. Resident #13 was sitting in her wheelchair at the right side of her bed and took the remote in her hand and showed the exposed wiring. There was black electrical tape wrapped around half of the cord. There were exposed inner wires of red, green and blue underneath the grey sheath at the remote end and at the outlet end. There was a cut around the middle of the grey sheath with the same exposed red, green and blue wiring underneath. She said the inner wires connecting her electrical bed to the operating remote cord had been exposed from its outer sheath since she received this bed until the night of 03/05/2026 when the remote was taped up with black electrical tape. Resident #13 was unaware of when she received the bed. She said that the Maintenance Director said the remote for her electrical bed was on backorder. Observation and interview with the Maintenance Director on 3/6/2026 at 11:50am, he answered that the bed was low voltage when asked if exposed wires were okay. The Maintenance Director said the sheath was still on the individual wires of the remote cord. When asked if the manufacturer would consider that okay, he said he did not think they would. When asked if the bed was a safety hazard due to the exposed inner wires, the Maintenance Director said the bed had low voltage. He received the report about Resident #13's exposed wire on 03/03/2026 and he said he wrapped it up with electrical tape the same day.Observation and interview with LVN M on 3/6/2026 at 11:55am, LVN M looked at the wires under the bed and exposed sheath near the remote and along the wire. She said that Resident #13's bed remote's wires should not have been exposed like that .Interview with LVN G on 3/6/2026 at 12:06pm, LVN G said they told the Maintenance Director two weeks ago about the bed remote's exposed wiring. LVN G said that after Resident #13's family complained about it, LVN G told the Maintenance Director again on 03/05/2026 and someone came to wrap the exposed wiring with scotch tape that night . Record review of the facility's policy on maintenance services, undated, it read in part, The day-to-day maintenance operation is under the supervision of the Maintenance Director . The policy did not specify how resident equipment should be maintained.

Based on observation, interview and record review, the facility failed to incorporate the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care for 1 (Resident #5) of 1 resident reviewed for PASARR.-The facility failed to submit a complete and accurate request for nursing facility specialized services for Resident #5 in the LTC Online Portal within 20 business days.This failure could place residents at risk of not receiving necessary services to help them achieve their highest possible mental and physical well-being. Record review of Resident #5's face sheet dated 03/06/2026, revealed she was a [AGE] year-old female originally admitted on [DATE] and last re-admitted on [DATE]. Her medical diagnoses included Down Syndrome (a genetic condition that causes mild-to-moderate intellectual disability, developmental delays, and distinct physical features), Type 2 Diabetes Mellitus (high blood sugar), cognitive communication deficit, Disorganized Schizophrenia (a severe, chronic subtype of schizophrenia characterized by highly disorganized thinking, speech, and behavior, rather than prominent hallucinations or delusions), Bipolar Disorder (mental illness characterized by extreme mood swings between mania and depression) and unspecified lack of expected normal physiological development in childhood.Record review of Resident #5's care plan last captured 03/06/2026, she had a focus area initiated on 06/17/2025 of being identified as having PASRR positive status related to ID/DD , with interventions including facility holding annual and quarterly meetings. She had focus areas related to Down Syndrome initiated 01/23/2025 related to having communication problems related to Down Syndrome and rarely or never being understood or understanding, with interventions including anticipating and meeting needs and referring her to speech therapy for evaluation and treatment as ordered.Record review of Resident #5's Quarterly MDS dated [DATE], she was coded as rarely or never understood and did not complete the BIMS (a brief interview to gauge memory and thinking skills). She was totally dependent on staff for all ADLs including toileting, showering, dressing, eating and personal and oral hygiene. Record review of Resident #5's hospital records dated 01/16/2025, she was initially admitted to the hospital on [DATE] with a history of developmental delay and seizures and was transferred to the facility on [DATE].Record review of Resident #5's PASARR Level l dated 01/16/2025, she scored a 0, indicating a negative Level l screener , meaning she was not suspected as having a serious mental illness, intellectual disability or developmental disability at the time.Record review of Resident #5's baseline care plan dated 01/15/2025, Resident #5 was coded as understanding staff and not able to easily communicate with staff. Resident #5 was coded for physical, occupational and speech therapy to improve functional status.Record review of Resident #5's medical records, there were no Level II PASARR uploaded to her documents. Record review of Resident #5's record for IDT Meeting and NFSS Request by the state, Resident #5 had an IDT meeting on 3/24/2025 for a support mattress, physical therapy, speech therapy, wheelchair service, occupational therapy, and a positioning wedge. The state received Resident #5's NFSS request on 04/25/2025 for physical, occupational and speech assessment and service. The record also indicated Resident #5 was approved for a positioning wedge on 3/25/25 and the NFSS request was not submitted. Record review of Resident #5's NFSS (a form submitted by facilities to request and receive specialized therapy and/or equipment for residents such as those who are PASARR positive) for Therapy titled NFSS Therapist, Referring Physician and NF Administration CMWC (Customized Mechanical Wheelchair)/DME Signature Page, Resident #5's therapist signed on 6/26/2025, her physician signed on 7/8/2025 and the Administrator signed the document on 7/21/25. Resident #5 had an NFSS form for her mattress that was signed by a therapist on 8/29/25, her physician on 8/29/25 and the Administrator on 8/29/25 . Observation and interview with Resident #5 on 3/6/2026 at 4:06pm, she was in her wheelchair in the hallway. She appeared well-groomed, in a pleasant mood. Resident #6 said hello and that she was fine and did not respond to other questions. Resident #5 had a purple wedge on her dresser, leg braces and a low air mattress close to the ground. Interview with the Director of Rehabilitation on 3/6/2026 at 4:06pm, she said she was informed that Resident #5 was on PASARR services by the MDS Department but did not remember who exactly. Resident #5 began services on 08/29/2025, which included physical, occupational and speech therapy. Resident #5 was also approved for a low air mattress and wheelchair at the time. Attempted interview by phone with MDS A on 3/6/2026 at 4:12pm, voicemail was left with no returned communication as of exit. Interview by phone with MDS B on 3/6/2026 at 4:16pm, MDS B said she had been at the facility since December 2025. MDS B said that once the facility received approval for PASARR services, the facility had 14 days to apply for services . MDS B said that the MDS Department worked on obtaining services and scheduling meetings with the local mental health authorities.Interview with the Administrator on 3/6/2026 at 5:38pm, he said he was not aware that Resident #5's NFSS documents were not submitted in a timely manner. He said that MDS A would know more about this situation.Record review of the facility's policy titled, Post admission Notification of Significant Change in Individual with Mental Disorder/Intellectual Disability, un dated, it read in part, This facility must notify the state mental health authority or state intellectual disability authority, as applicable, promptly after a significant change in the mental or physical condition of a resident who has a mental illness or intellectual disability for resident review. The policy did not address the submission deadlines.Requested Resident #5's Level II assessment from the Administrator by email on 3/6/2026 at 4:38pm, no documents were submitted as of exit.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, and comfortable environment for residents, staff, and the public for 1 (CR #1) of 10 residents reviewed for sanitary conditions. CR#1 was transferred from room A to room B on 12/30/25. Room B had scuff marks along the walls and baseboards, scuff marks that exposed the dry wall along the walls, and clothing and a wheelchair that belonged to previous residents. These failures could place residents at risk of illness, contamination, and infection.Findings included:Record review of CR#1's facesheet revealed a [AGE] year-old woman was initially admitted on [DATE], and the most current admission date was on 12/20/25. Her admitting diagnoses was COPD (ongoing lung condition caused by damage to the lungs), dementia (loss of cognitive functioning that interferes with daily life and activities) with mild behavior disturbance, macular degeneration (eye disease that affects central vision), difficulty in walking, respiratory failure, and cognitive communication deficit (refers to difficulties in communication that arise from impairments in cognitive processes, affecting an individual's ability to express and understand messages effectively). Record review of CR#1's care plan last updated 12/28/25 revealed that she had impaired visual function and severe visual impairment related to macular degeneration. CR#1 also had a history of falls. In December 2025, it was documented that CR#1 had an unwitnessed fall without injury on 12/21/25, witnessed falls without injury on 12/28/25 and 12/29/25, and an unwitnessed fall with injury on 12/31/25. Record review of CR#1's MDS dated [DATE], under Section C- Cognitive patterns revealed a BIMS score of 15 (normal cognition). Under section E for behaviors and frequency of behaviors, 2 was documented signifying that CR#1 had exhibited behavioral symptoms not directed towards of others in the past 4-6 days. Under section GG- Functional Abilities, CR#1 was independent with rolling from left and right, lying to sitting on the side of the bed, and sitting to lying. She required supervision or touch assistance with sitting to stand, transferring, and walking 10-150 feet. Record review of an updated BIMS assessment for CR#1, completed 12/27/25, revealed a score of 6 (severe cognitive impairment). Record review of CR#1's progress notes dated 12/30/25 at 1:05 p.m., social services documented that they informed CR#1'sRP that she was moved from Room A to Room B and the RP agreed with the move. In an interview on 1/6/26 at 10:17 a.m. with the RP, she stated that after CR#1 was discharged to the hospital post fall, she went back to the facility on 1/3/26 to grab the rest of CR#1's belongings. Inside the room, she found a bloody pillow that was sitting inside of CR#1's wheelchair, clothing items inside of the drawers of the resident who lived there previously, and fecal matter on the bottom of the other bed. RP stated that Room B was not cleaned prior to CR#1's room change and stated it looked like the room had been used as storage. RP stated that she would submit photos with time stamps into evidence. In an observation on 1/6/26 at 12:20 p.m., Room B had 2 beds inside the room and the dresser was tucked in a corner near the front door. In the far-left corner of the room near the window was a large electric wheelchair used for a geriatric patient that had the foot holders sitting on top of the chair with other wheelchair parts. The walls were a pale-yellow color and they were scuffed with black and grey marks all around the room and the base boards. The walls also had deep scuffs that exposed the white dry wall underneath the paint and next to Bed A, there were droplets of a liquid that had dried on the wall wet. An oxygen machine with the date 12-29-25, was seen on the nightstand of Bed B. Inside of the closet was a trash bag full of clothes. On the collar of one of the shirts inside the room, it had the previous resident's name and room number. Hung on the rack inside the closet was a jacket, 2 sweaters, 2 shirts, and there were two pairs of sweatpants. A few feet next to the closet, there was a dark reddish/purple circle the size of a fist on the carpet near the front of the room. The origin of the spot was unknown. Record review of the photographic evidence submitted by RP on behalf of CR#1 at 1/7/26 at 10:26 p.m. revealed the following:1. Thursday 1/1/26 at 3:19 p.m., There was a white pillowcase on a pillow sitting across the handlebars of the wheelchair. There was bright red blood on the right side of the pillowcase and there was blood on the pillow. An oxygen machine can be seen in the background. Caption documented that the pillow was inside of Room B and she knew it was CR#1's because it was inside of the wheelchair she used. In an interview on 1/8/26 at 11:17 a.m., LVN A stated that she was PRN and she came into work once a week. She stated that she was informed on 12/30/25 by the DPON that CR#1 was moving into Room B on the skilled hallway, and Resident #2 who resided in that room, would be moving to a room on the long-term care side of the facility. She stated that prior to CR#1's move in, the room should have been deep cleaned by housekeeping. LVNA explained a deep clean consisted of using disinfectant and alcohol wipes to wipe everything down, changing linens, and removing all items out of the room from previous residents. Prior to moving in, the nurse on duty would verify that was done before another resident moved in. On the day of the move, herself and other staff (names not disclosed) were transferring CR#1's personal belongings to her room and moving Resident #2's items out. She did not know why the motorized wheelchair from a resident who was discharged on 11/6/25 was still inside Room B and restated that she only worked once a week PRN. In an interview on 1/8/26 at 11:33 a.m., the Maintenance Director stated that he was informed of new admissions or room transfers through a room readiness group text. He stated that he was currently over housekeeping and the maintenance department and once he was informed on which room, he would have a member of housekeeping deep clean the room by disinfecting the mattress and disinfecting any hard services, lights, or door handles. When the room was complete, he would verify that the room was ready to go. When he was asked about why there were so many scuffs on the walls of Room B when it was supposed to have been ready for move-in, he stated that the marks on the while were created by the resident wheelchairs. He was informed that Room B had only been occupied for 1 day before CR#1 was sent to the hospital. He stated that maintenance would fix any cosmetic issues and they were usually completed once a resident moved out so that the room would be ready for the next admission. When communicated that the appearance of Room B did not promote a comfortable and homelike environment, the Maintenance Director said he understood and he called in housekeeping to begin a deep clean of Room B and asked the Floor tech to shampoo the carpet. In an interview with HK B on 1/8/25 at 11:51 a.m., she stated that she went on vacation from 12/21/25- 1/5/26. She explained that a deep clean consisted of cleaning the television, remote, disinfecting the mattress, and everything overall. She stated that before she left, there was another resident in Room B and CR#1 had not been moved. She stated that no one came behind her to check the rooms after she completed cleaning them and she was only responsible for cleaning, and she did not touch any resident belongings or transfer them outside of the rooms. In an interview on 1/8/26 at 12:00 p.m., the Floor Tech stated he was responsible for cleaning floors around the facility. He was supposed to clean the floor inside of Room B (he could not recall when) but he was pulled onto other halls and was told he could finish out the hall where Room B was located at a different time. In an interview on 1/8/26 at 12:30 p.m., ADON C stated that she managed the long-term care halls and ADON D managed the short-term care halls where Room B was located. She stated that housekeeping was supposed to clean the room after every resident leaves. She was informed that clothing items from the previous resident were left inside of the closet in Room B. She stated the items left behind were expensive and she was sure his wife would be looking for those articles of clothing. In an interview on 1/8/26 at 1:03 p.m., ADON D stated that she was familiar with CR#1 but she could not remember when she was moved from long term care to short term care. She recalled that CR#1 was removed from her previous room because she was not compatible with her previous roommate. When staff initiated a room change, housekeeping was advised to clean the room if it was not already done. Staff (nurses and aids) checked the room, the bed, call lights, and made sure everything was in place. The nurse on duty would double check the room and verify where the resident would be going, then the room transfer would be done. For the transfer with CR#1, ADON D stated that when she walked by to check the room, the CNA was still preparing it and prior to that, the Maintenance Director had checked the call light and restroom. When asked why the geriatric wheelchair was still inside the room, left behind by a resident that was discharged in 11/2025, she responded she would have to find out that information. ADON D was asked why Resident #2's clothing was still inside of the closet in Room B, she stated these items should have been moved. When asked if the scuff marks and exposed dry wall should have been addressed, she stated she could not speak to that, and it would probably be better addressed by maintenance. A call attempt to HK C was made on 1/8/26 at 2:22 p.m. but she did not answer. Voicemail was left requesting a call back. In an interview on 1/8/26 at 2:30 p.m., the DON stated CR#1 had a buildup of different behaviors that escalated and changed daily. These behaviors did not make her a good fit at the facility and she was accepted to another facility for care. To accommodate her behaviors, he moved Resident #2 from Room B to the long-term care hall and CR#1 to Room B from the long-term care hall. He explained that the reason the geriatric electric wheelchair was still inside of Room B was because the battery was drained and it would take at least 3 people to move it out. He confirmed that the wheelchair belonged to a previous resident of Room B, and the facility was waiting on a friend of that resident to come and grab it. Resident #2's clothing items were left inside of the room because it was a temporary move, and they were anticipating CR#1 to be admitted to another facility. The DON stated that when there was a resident discharge, all department heads were made aware and responsible for their roles. Housekeeping would go in and prepare the room while nursing would move a lot of things out of the room. When asked if the scuffs on the walls and baseboards were the standard for rooms, he stated that it was not and they (DON and the Administrator) would have to get with maintenance to figure out what happened. Record review of the facility's policy titled: Physical Environment (not dated) stated that the purpose was to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public.

Based on observation, interview, and record review the facility failed to maintain an infection and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections for 1 (CR#1) of 10 residents reviewed for infection control. The facility failed to clean and disinfect blood from the wall and carpet in Room B, after CR#1 had a fall on 12/31/25 the resulted in a head injury. These failures could place residents at risk of sickness, infection, and a diminished quality of life. Findings included:Record review of CR#1's facesheet revealed a [AGE] year-old woman was initially admitted on [DATE], and the most current admission date was on 12/20/25. Her admitting diagnoses were COPD (ongoing lung condition caused by damage to the lungs), dementia (loss of cognitive functioning that interferes with daily life and activities) with mild behavior disturbance, macular degeneration (eye disease that affects central vision), difficulty in walking, respiratory failure, and cognitive communication deficit (refers to difficulties in communication that arise from impairments in cognitive processes, affecting an individual's ability to express and understand messages effectively). Record review of CR#1's care plan last updated 12/28/25 revealed that she had impaired visual function and severe visual impairment related to macular degeneration. CR#1 also had a history of falls. In December 2025, it was documented that CR#1 had an unwitnessed fall without injury on 12/21/25, witnessed falls without injury on 12/28/25 and 12/29/25, and an unwitnessed fall with injury on 12/31/25. Record review of CR#1's MDS dated [DATE], under Section C- Cognitive patterns revealed a BIMS score of 15 (normal cognition). Record review of an updated BIMS assessment for CR#1, completed 12/27/25, revealed a score of 6 (severe cognitive impairment). Record review of CR#1's progress notes dated 12/30/25 at 1:05 p.m., social services documented that he contacted CR#1's RP and informed her that CR#1 was moved from Room A to Room B and the RP agreed with the move. Record review of CR#1's progress notes dated 12/31/25 at 12:53 p.m., LVN A documented a CIC (change in condition) due to a fall. Her BP was 120/70, P- 61, and temp- 97.8 degrees. CR#1 experienced increased confusion and memory loss. Record review of CR#1's progress notes dated 12/31/25 at 2:03 p.m., LVN A documented that she found CR#1 on the floor in Room B after an unwitnessed fall. Noted with bruising and active bleeding to forehead. Pressure was applied, vital signs obtained, NP, and family notified. CR#1 was transferred to the hospital for further evaluation and left the unit in stable condition. Record review of CR#1's progress notes dated 1/2/26 at 4:10 p.m., the DON documented that he communicated with the RP and CR#1 was accepted to a different nursing home and she would be admitted after her hospital discharge. In an interview on 1/6/26 at 10:17 a.m., the RP stated after CR#1 was discharged to the hospital post fall, she went back to the facility on 1/3/26 to grab the rest of CR#1's belongings. Inside the room, she found a bloody pillow that was sitting inside of CR#1's wheelchair, clothing items inside of the drawers of the resident who lived there previously, and fecal matter on the bottom of the other bed. The RP stated that Room B was not cleaned prior to CR#1's room change and stated it looked like the room had been used as storage. The RP stated that she would submit photos with time stamps into evidence. In an observation on 1/6/26 at 12:20 p.m., Room B was vacant with 2 beds inside the room and the dresser was tucked in a corner near the front door. A few feet next to the closet, there was a dark reddish/purple circle the size of a fist on the carpet near the front of the room. The origin of the spot was unknown. Record review of the photographic evidence submitted by the RP on behalf of CR#1 on 1/7/26 at 10:26 p.m. revealed the following:Thursday 1/1/26 at 3:19 p.m., indicated there was a white pillowcase on a pillow sitting across the handlebars of the wheelchair. There was bright red blood on the right side of the pillowcase and there was blood on the pillow. An oxygen machine can be seen in the background. Caption documented that the pillow was inside of Room B and she knew it was CR#1's because it was inside of the wheelchair she used. In an interview on 1/8/26 at 11:17 a.m., LVN A stated that she was PRN and she came into work once a week. She stated that she was informed on 12/30/25 that CR#1 was moving into Room B on the skilled hallway, and Resident #2 who resided in that room, would be moving to a room on the long-term care side of the facility. She stated that prior to CR#1's move in, the room should have been deep cleaned. LVN A explained a deep clean consisted of using disinfectant and alcohol wipes to wipe everything down, changing linens, and removing all items out of the room from previous residents. Prior to moving in, the nurse on duty would verify that was done before another resident moved in. LVN A stated that she was the nurse who found CR#1 on 12/31/25 post fall. She stated when she found her, her head was bleeding and she sat in the middle of the floor. Her oxygen tank was next to her and she hypothesized (educated guess) that CR#1 could have hit her head on the floor or the wall. In an observation on 1/8/26 at 11:27 a.m., LVN A joined the surveyor back inside of Room B to explain how she found CR#1 post fall. In the area where LVN A stated that she fell, there was a very dark colored spot near the wall of the room. HK B was in the hallway and the surveyor asked if she could put on gloves and grab a light-colored cloth and spray the dark spot so that they could see the color of the spot. HK B rubbed the spot with the cloth and stated that it felt hard like it was glue. She then sprayed the spot with the substance inside of the spray bottle and rubbed it with her cloth. On the cloth, there was a reddish-brown tint. HK B looked at the cloth and stated it could be blood. She sprayed the spot and wiped it a second time and stated yea, I think it is blood. Upon further observation, the edge of the wall near the spot, there was a smudge of a dark red substance that appeared to be 3x2 inches in diameter. In an interview on 1/8/26 at 11:33 a.m., the Maintenance Director stated that he was informed of new admissions or room transfers through a room readiness group text. He stated that he was currently over housekeeping and the maintenance department and once he was informed on which room, he would have a member of housekeeping deep clean the room by disinfecting the mattress and disinfecting any hard services, lights, or door handles. When the room was complete, he would verify that the room was ready to go. Maintenance would fix any cosmetic issues and they were usually completed once a resident moved out so that the room would be ready for the next admission. He was asked to step into Room B and he was shown the spot and informed of the findings from HK B. He explained that Room B was on the schedule to have the carpet cleaned and HK B was the usual housekeeper on that hall, however HK B had been on vacation for a while. In HK B's absence, Room B was assigned to HK C. Maintenance director reviewed the spot on the carpet and the spot on the wall and stated that it was an issue with infection control and the room should have been reviewed for cleanliness. He called Floor tech and informed him that carpet inside of Room B needed to be cleaned and asked HK B to deep clean the room after. In an interview with HK B on 1/8/25 at 11:51 a.m., she stated that she went on vacation from 12/21/25- 1/5/26. She explained that a deep clean consisted of cleaning the television, remote, disinfecting the mattress, and everything overall. She stated that before she left, there was another resident in Room B and CR#1 had not been moved. She stated that no one came behind her to check the rooms after she completed cleaning them. In an interview on 1/8/26 at 12:00 p.m. with Floor Tech, he stated that he was responsible for cleaning floors around the facility. He was supposed to clean the floor inside of Room B (he could not recall when) but he was pulled into other halls and was told he could finish out the hall where Room B was located at a different time. In an interview on 1/8/26 at 12:30 p.m. with ADON C, she stated that she managed the long-term care halls and ADON D managed the short-term care halls where Room B was located. She was shown the image of the dark spot on the carpet and the red smudge on the wall in Room B. She stated that CR#1 probably hit her head on the wall. She explained that leaving bodily fluids like blood exposed was an issue with infection control and housekeeping should have cleaned it up with blood cleaner. From the photo where there were blood stains on the pillow, ADON C stated that the blood looked fresh and said that it was a big problem. She stated that housekeeping was supposed to clean the room after every resident leaves. ADON C was asked to confirm what the substance was on the pillow and the floor from looking at the photos. She stated that it was blood and there was no way around it. In an interview on 1/8/26 at 1:03 p.m. with ADON D, she stated that she was familiar with CR#1 but she could not remember when she was moved from long term care to short term care. She recalled that CR#1 was removed from her previous room because she was not compatible with her previous roommate. When staff initiated a room change, housekeeping was advised to clean the room if it was not already done. Staff (nurses and aids) checked the room, the bed, call lights, and made sure everything was in place. The nurse on duty would double check the room and verify where the resident would be going, then the room transfer would be done. For the transfer with CR#1, ADON D stated that when she walked by to check the room, the CNA was still preparing it and prior to that, the Maintenance Director had checked the call light and restroom. When CR#1 fell on [DATE], she said that she was busy doing the paperwork for EMS and she did not enter the room. ADON D explained that any blood left behind from the fall should have been cleaned and disinfected and the pillow with blood on it should have been disposed. The harm in leaving blood exposed could potentially get someone sick. A call attempt to HK C was made on 1/8/26 at 2:22 p.m. but she did not answer. Voicemail was left requesting a call back. In an interview on 1/8/26 at 2:30 p.m., the DON stated CR#1 had a buildup of different behaviors that escalated and changed daily. These behaviors did not make her a good fit at the facility, and she was accepted to another facility for care. To accommodate her behaviors, he moved Resident #2 from Room B to the long-term care hall and CR#1 to Room B from the long-term care hall. The DON stated that when there was a resident discharge, all department heads were made aware and responsible for their roles. Housekeeping would go in and prepare the room while nursing would move a lot of things out of the room. When the DON was informed about the blood left behind on the floor and the wall from CR#1's fall on 12/31/25, he stated that housekeeping should have gone in the room, and it should have been thoroughly cleaned. He stated that leaving blood stained pillows exposed was not the standard and the harm in leaving hazardous bodily fluids exposed could be someone getting sick or infection. Record review of the facility's Policy and Practices titled: Infection Control, revised October 2018, documented that: This facilities infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment, and to help prevent and manage transmission of diseases and infections. The objectives of the infection control policy and practices were to:Prevent, detect, investigate, and control infections in the facility.Maintain a safe sanitary and comfortable environment for personnel, residents, visitors, and the general public.Establish guidelines for implementing isolation precautions, including standard transmission-based precautions.Establish guidelines for the availability and accessibility of supplies and equipment necessary for standard and transmission-based precautions.Maintain records of incidents and corrective actions related to infections.Provide guidelines for the safe cleaning and processing of reusable resident care equipment.

Based on interview and record review, the facility failed to coordinate assessments with the resident review (PASARR) program under Medicaid in subpart C for 1 (Resident #1) of 2 residents reviewed for PASRR services.The facility failed to submit a complete and accurate request for NFSS in the LTC online portal within 20 days after the initial IDT meeting held on 6/14/24.This failure could place residents who were PASRR positive at risk of not getting the PASRR services for a better quality of life and could lead to a decline in health.Findings included:Record review of Resident #1's face sheet dated 12/16/25 revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: encephalitis (inflammation of the brain) and encephalomyelitis (inflammation of the brain and spinal cord), demyelinating disease (affects the protective cover around nerve cells) of central nervous system, manic episode (a period of abnormally elevated extreme changes in mood, behavior, activity, and energy level) without psychotic symptoms, bipolar disorder (a mental health condition that causes extreme mood swings), functional quadriplegia (a complete inability to move due to severe disability or frailty), and major depressive disorder.Record review of Resident #1's most recent quarterly MDS annual assessment dated [DATE] indicated a BIMS score of 15 meaning intact cognitive response.Record review of Resident #1's care plan dated revision dated 1/7/25 indicated Resident #1 has been identified as having PASRR positive DD and has refused all services. Interventions were: if Resident #1 changes his mind regarding services, staff to contact county with any changes. Will conduct annual meetings. Record review of Resident #1's PCSP dated 6/14/24 revealed the initial IDT meeting was held on 6/14/24. Attendees included Resident #1, LIDDA- Habilitation Coordinator, DON, DOR, MDS Coordinator A, MDS Coordinator B, and Resident #1's RP. The following NFSS were identified and confirmed: Customized Manual Wheelchair, Specialized Assessment OT, Specialized Assessment PT, Specialized Assessment ST, Specialized OT, Specialized PT and Specialized ST - all services were coded 2 indicated new.During an interview on 12/16/25 at 4:24 pm, with MDS Coordinator A and the DOR, MDS Coordinator A said the initial IDT meeting was held on 6/14/24. The DOR said Resident #1 was approved for PT, OT, and ST and Resident #1 refused all the evaluations. MDS Coordinator A said this was the first time they ran into a situation where the resident refused services, and she was not sure what to do with this situation. MDS Coordinator A said she contacted the PASRR representative from the Local Authority for guidance when the resident refused. MDS Coordinator A said initially Resident #1, and his RP were ok with the services offered but then Resident #1 refused. MDS Coordinator A said they had an annual meeting with Resident #1 recently and he refused again.During an interview on 12/17/25 at 9:15 am, with Resident #1, he said he refused services because he was going to get steroids to help him walk.During an interview on 12/30/25 at 9:04 am with Resident #1's RP, the RP said Resident #1 needed to see a psychiatrist because he had mental issues. The RP said she had trouble with Medicaid insurance because Resident #1's physician no longer takes his insurance.During an interview on 12/30/25 at 10:37 am with MDS Coordinator A she said the DOR is normally responsible for submitting the NFSS form in the LTC portal. MDS Coordinator A said they discussed the NFSS form as a team and checked the portal daily to see if the NFSS form was approved. MDS Coordinator A said Resident #1 was able to make his own decisions. She said Resident #1 would probably benefit from the services, but they cannot force him to do anything.During an interview on 12/30/25 at 11:15 am with the Administrator, he said the MDS Coordinator, and the DOR were responsible for submitting the NFSS form. He said he thought the hiccup was when Resident #1 initially said yes to the services and then refused. The Administrator said there was no risk to Resident #1 because he had refused all services.Record review of the facility's PASRR policy not dated read in part . Ensure each resident in a nursing facility is screened for a mental disorder (MD) or intellectual disability (ID) prior to admission and that individuals identified with MD or ID are evaluated and receive care and services in the most integrated setting appropriate to their needs .

Based on interview and record review, the facility failed to obtain timely laboratory services to meet the needs of residents for 1 of 7 residents (CR #1) reviewed for laboratory services. LVN A did not have Resident CR #1's STAT CBC and CMP lab test obtained as ordered by the physician resulting to CR #1's [MEDICAL TREATMENT] being held for 5 days. CR #1 had a change in condition of altered mental status, vomiting and was transferred to the hospital where he had critical lab levels, [MEDICAL CONDITION] (brain damage), responded to only painful stimulus, and required a NG tube and [MEDICAL TREATMENT] treatment. This failure could place residents at risk of medical emergencies, delay in treatment, and hospitalization . Findings included: Record review of CR #1's facesheet revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. His [DIAGNOSES REDACTED]. Record review of CR #1's care plan last reviewed on 12/30/20 revealed he had end - stage [MEDICAL CONDITION] requiring hemo-[MEDICAL TREATMENT]. Potential for infection, fluid volume overload, [MEDICAL CONDITION], electrolyte imbalance. His interventions included: monitor on an ongoing basis for possible changes in fluid volume levels, monitored for dyspepsia, sudden weight gain, increased blood pressure and pulse rate, neck vein distension, abnormal breath sounds, monitor laboratory values as ordered by physician, weigh before and after [MEDICAL TREATMENT] procedure according to protocol and as needed, post [MEDICAL TREATMENT] treatment monitoring per protocol. Observe for possible adverse reactions to treatment and assist as indicated. Nephrologist referral and follow up evaluation as needed, staff will take resident to and from [MEDICAL TREATMENT], [MEDICATION NAME] as ordered. Record review of CR #1's physician order [REDACTED]. Record review of CR #1's physician order [REDACTED]. Record review of CR #1's progress notes dated 12/7/20 at 2:04PM revealed CR #1 tested positive for COVID - 19. Record review of CR #1's CMP lab results collected 12/8/20 revealed he had a critical potassium level of 2.1 mmol/L (reference range 3.6 - 5.2mmol/L). Lab results revealed the results were verified and called in and read to LVN A on 12/8/20 at 2:55PM. Interview on 2/26/21 at 1:15PM, NP #1 said she could not recall the specifics from 12/8/20 when CR #1 received his lab results but said she recalled they ordered Potassium supplement because of his lab results for low potassium and said they drew the lab as a routine lab because he had tested positive for COVID-19. The NP said she does not recall ordering a follow-up lab after he received the critical lab result. The NP stated there may have been some confusion because they thought the [MEDICAL TREATMENT] center would complete a follow-up lab. Interview on 2/26/21 at 4:40PM, LVN A said the lab called and reported the critical Potassium level for CR #1 on 12/8/20. LVN A said she called the NP and she ordered Potassium supplement for four days. She said she went to tell [MEDICAL TREATMENT] about CR #1's critical lab results and the [MEDICAL TREATMENT] nurse was already in his room with [MEDICAL TREATMENT] started. She said she told the [MEDICAL TREATMENT] nurse about the results and she said she would inform the nephrologist. LVN A said the NP did not order any follow up labs at that time. Record review of CR #1's physician telephone orders dated 12/9/20 revealed, New order Kcl 40meq BID X 4 days. Record review of CR #1's December 2020 MAR indicated [REDACTED]. Record review of CR #1's nurses notes dated 12/8/20 - 12/9/20 revealed no mention of critical lab results received and notification to [MEDICAL TREATMENT] nurse. Record review of CR #1's [MEDICAL TREATMENT] notes dated 12/8/20 - 12/9/20 revealed he received [MEDICAL TREATMENT] and there was no mention of critical lab results. Record review of CR #1's nurse notes dated 12/10/20 at 6:47PM written by LVN A revealed in part, .no [MEDICAL TREATMENT] today due to low potassium results . Record review of CR #1's [MEDICAL TREATMENT] notes dated 12/10/20 at 11:00AM revealed, HD held as ordered due to critically low K level from SNF to start patient on KCL 40meq BID for 4 days. Record review of CR #1's nurses notes dated 12/11/20 at 5:01PM revealed in part, .Resident continues on Potassium 40meq 2 tabs BID for 4 days for low Potassium. [MEDICAL TREATMENT] held today . Record review of CR #1's [MEDICAL TREATMENT] notes dated 12/11/20 at 10:40AM revealed, Spoke with doctor today, lab results received, per MD, will consider changing HD orders to M-W-F since [MEDICAL TREATMENT] cannot be adjusted to 3.0K. HD to resume on Monday (12/14/20) and will redraw K level. Interview on 2/26/21 at 2:32PM, the [MEDICAL TREATMENT] DON said the [MEDICAL TREATMENT] nurse who worked back in December with CR #1 no longer worked for them. The [MEDICAL TREATMENT] DON said per the documentation, they were informed of the critical labs on 12/10/20 because the resident received [MEDICAL TREATMENT] on 12/7/20, 12/8/20, and 12/9/20. The [MEDICAL TREATMENT] DON said the Nephrologist reviewed CR #1's labs on 12/10/20 and ordered for the labs to be redrawn so the resident could resume [MEDICAL TREATMENT] on Monday. The [MEDICAL TREATMENT] DON said she was not able to locate documentation of the order from the Nephrologist but said in this case they would have needed a STAT lab and the [MEDICAL TREATMENT] center lab company did not do STAT labs and said it took several days for them to retrieve lab results. She said in a situation where they need a STAT lab the facility would complete the lab since they are able to do STAT labs. Record review of CR #1's physician orders [REDACTED]. Record review of CR #1's nurses notes dated 12/12/20 - 12/13/20 revealed no evidence of K level laboratory tests being redrawn. Record review of CR #1's [MEDICAL TREATMENT] notes dated 12/14/20 at 11:00AM revealed subject line of No recent K level. Awaiting blood draw. Further review of the note revealed, Latest K level was 2.1 from last Thursday result. SNF able to obtain a STAT K level order today and was drawn at 11AM. Doctor made aware and agreed to hold HD until K level obtained. Record review of CR #1's physician telephone orders dated 12/14/20 revealed an order for [REDACTED].>Record review of CR #1's NP #1 progress note dated 12/14/20 revealed resident had persistent nausea every morning following breakfast and was recently started on anti-nausea medication that required evaluation. Also noted follow - up [MEDICAL CONDITION] on [MEDICAL TREATMENT] and had recent low potassium and had not had [MEDICAL TREATMENT] that required evaluation. The NP assessment and plan revealed in part, [DIAGNOSES REDACTED] - KCl supplementation 40mEq twice daily x 4 days, end stage [MEDICAL CONDITION] - [MEDICAL TREATMENT] M - F, on hold due to [DIAGNOSES REDACTED], STAT labs ordered today . Record review of CR #1's nurses notes dated 12/14/20 at 1:23PM by LVN A revealed, 7a-7p lab tech in facility draw resident labs. Record review of CR #1's nurses notes dated 12/14/20 at 7:00PM by LVN A revealed, NP aware [MEDICAL TREATMENT] held for today. Interview on 2/26/21 at 4:42PM, LVN A said she was approached by the [MEDICAL TREATMENT] nurse the morning of 12/14/20 around 8AM asking for updated lab results for CR #1 so he could continue his [MEDICAL TREATMENT]. LVN A said there were no new labs drawn for CR #1 since 12/8/20 so she called the NP and got a STAT order for CBC and CMP. LVN A said she filled out the invoice for the labs on the computer and the lab tech was coming onto the unit as she finished the invoice, so she handed it to him in person. LVN A said they would usually call the lab company after they put in the invoice and let them know they have a STAT order but since the tech was already in the building she just handed it to him. She said she saw the lab tech go down the hall because he was doing labs for another resident as well and left afterwards. LVN A said this was sometime in the morning when the lab tech came in. LVN A said she continued to check for the lab results on the computer for the rest of her shift (7a - 7p) and the results never came in. LVN A said she never called the lab company to check for results and said she just checked the computer. LVN A said she told the oncoming nurse to continue checking for the lab results. Record review of CR #1's nurses notes dated 12/15/20 at 4:53AM by LVN B revealed, Resident removed his O2 mask several times at this point Pulse OX 93% on room air. Respirations even and unlabored CNP notified awaiting call back. This nurse called lab company to obtain lab results however the tech states the lab results were from 12/8/20. This nurse asks to reorder the CBC, CMP STAT tech places order. Resident bed is changed, and he is clean at this time. Record review of CR #1's nurses notes dated 12/15/20 at 6:00AM by LVN B revealed, upon checking on the resident it is noted resident had another larger emesis burnt orange in color resident is still staring at ceiling able to respond to his name and can move eyes to look at this nurse. Resident also has removed his O2 mask several times at this point Pulse Ox 94% on room air, temp 97.8, BP 132/66 respirations even and unlabored CNP notified awaiting call back. Record review of CR #1's nurses notes dated 12/15/20 at 6:15AM by LVN B revealed, CNP responds to obtain status and request resident be sent to hospital via transportation service. Record review of CR #1's nurses notes dated 12/15/20 at 6:30AM by LVN B revealed, Transportation services called to transport resident to the hospital for evaluation and treatment. RP and NP notified. Record review of CR #1's [MEDICAL TREATMENT] notes dated 12/15/20 at 9:00AM revealed a subject line of, Patient change in level of consciousness. Further review of the note revealed, According to patients primary nurse, patient is obtunded. Vital signs remain stable but very slow response to stimulation, doesn't follow commands. SNF obtained order for patient transfer to hospital. Awaiting ambulance pick-up. Doctor notified of patients change of condition. Record review of CR #1's CMP lab test results dated 12/15/20 at 8:56AM revealed the results were verified and called into a facility nurse on 12/15/20 at 12:57PM. Further review of the results revealed CR #1 had a critical potassium level of 6.6 mmol/L (reference range 3.6 - 5.2 mmol/L). Resident also had a critical creatinine level of 5.6mg/dL (reference range .70 - 1.30 mg/dL). Interview on 2/26/21 at 3:00PM, LVN B said she works the 7PM - 7AM shift. She said on 12/14/20 the previous shift nurse (LVN A) told her CR #1 had some pending labs to check for. LVN B said CR #1 was doing okay when she first started her shift and had a change in condition around 4AM on 12/15/20. She said the resident was nauseous and vomited which was not unusual for him but what alarmed her was his altered mental state. She said CR #1 was usually very talkative, but he was very quiet and was looking straight ahead staring at the wall. She said he would respond and acknowledge her when she spoke to him, but his alertness was a change. LVN B said she called the lab company to check on the lab results from the previous day because they still had not showed in the computer and the lab company reported they did not have any labs for CR #1 since 12/8/20 and did not have an order for [REDACTED]. She said while waiting for the NP to call back CR #1 had a second episode of emesis. She said the NP did call back around 6AM and said to send CR #1 to the hospital. She said the NP told her to call the transportation company to see how long the transfer would take and call her back. LVN B said she called the transportation company and they said it would take an hour or two for them to get there. LVN B said she called the NP back and relayed what the transportation company said, and the NP told her to go ahead and transfer him using the transportation company. LVN B said the resident was stable and still at the facility up until the time she left which was around 7AM and continued to have the altered mental state. Interview on 2/26/21 at 1:20PM, NP #1 said she could not recall being contacted about CR #1's change in condition but said she usually get up around 5am and would typically respond around that time if contacted. She said she recalled the [MEDICAL TREATMENT] center wanted to hold CR #1's [MEDICAL TREATMENT] because of his lab results from 12/8/20 and they refused to restart his [MEDICAL TREATMENT] on 12/14/20 without retrieving his new Potassium level so either herself of NP #2 wrote an order for [REDACTED]. She said she also recalled CR #1 having a change in condition and they decided to transfer him to the hospital. She could not recall any specifics from him being sent out to the hospital but said they did eventually receive the lab results, but he was already transferred out to the hospital. She said the resident had an elevated ammonia level which she believed caused the altered mental state. Record review of CR #1's hospital records from emergency room (ER) dated 12/15/20 revealed he was seen in ER at 11:12AM. Chief complaint was he had an altered mental status since 3AM; he had not received [MEDICAL TREATMENT] in the last 5 days due to low potassium levels on 12/8/20. Resident was noted to only respond to painful stimuli by moaning and not following commands. Record review of CR #1's lab results from hospital dated 12/15/20 at 12:20PM revealed he had a critical potassium level of 6.7meq/L, high creatinine level of 5.83mg/dL, and a high ammonia level of 83.0uMol/L. Further review revealed the reexamination/reevaluation noted, labs notable for [MEDICAL CONDITION] 6+, elevated ammonia level. Given insulin, [MEDICATION NAME] and [MEDICATION NAME] for [MEDICAL CONDITION] and renal consulted for HD. Patient encephalopathic (damage or disease that affects the brain), plan NG tube given patient very altered and will give [MEDICATION NAME] . Plan admission for further evaluation, HD and monitoring. Record review of CR #1's hospital discharge summary dated 12/22/20 revealed in part, .he was sent from nursing home for altered mental status. He was found to have hepatic [MEDICAL CONDITION] (a decline in brain function that occurs as a result of severe liver disease),[MEDICAL CONDITION], UTI. He was treated for [REDACTED]. He received [MEDICAL TREATMENT] during his stay . Interview on 3/3/21 at 4:52PM, the DON said the facility had no proof or evidence LVN A ordered CR #1 lab on 12/14/20. The DON said she checked the computer where it shows the invoice for them entering lab orders and there was nothing there for 12/14/20 and she called the lab company and they reported they did not have an order for [REDACTED]. She said the facility had started a new practice since then where they will put in a progress note with the confirmation number once they put in lab/ x-ray orders. She also stated the nurses were in-serviced on how to order STAT lab and checking on STAT lab results. The DON felt LVN B followed procedure once CR #1 had his change of condition on 12/15/20 and said she did in-service the nurse over not waiting for the NP to respond if there's a concern and said she could contact her (the DON) or the Medical Director. She said she did not think the resident required emergency transport because he was stable and only had the AMS. Record review of in-services dated 12/15/20 and 12/19/20 revealed a topic of STAT labs with content of, All STAT labs must be called into lab. You still enter them into lab system and flag it as STAT, but you must also call the lab to notify them of STAT lab and get a confirmation number. Record review of one on one training with LVN A dated 12/22/20 revealed she was trained over STAT lab follow - up and ensuring lab is called into lab company and confirmation number is received. Record review of the facility Test Results policy (Revised April 2007) did not address ordering and following up on labs/STAT labs.

Based on interview and record review, the facility failed to ensure that residents who required [MEDICAL TREATMENT] received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals for one of seven residents (CR #1) reviewed for [MEDICAL TREATMENT]. The facility failed to timely complete CR #1's STAT laboratory physician orders [REDACTED]. CR #1 [MEDICAL TREATMENT] treatment was held for 5 days instead of 4 because the STAT lab was not timely completed, and he was transferred to the hospital for altered mental status and diagnosed with [REDACTED]. This failure placed residents at risk of not receiving proper coordination of [MEDICAL TREATMENT] services which could cause a decline in health. Findings include: Record review of CR #1's facesheet revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. His [DIAGNOSES REDACTED]. Record review of CR #1's care plan last reviewed on 12/30/20 revealed he had end - stage [MEDICAL CONDITION] requiring hemo-[MEDICAL TREATMENT]. Potential for infection, fluid volume overload, [MEDICAL CONDITION], electrolyte imbalance. His interventions included: monitor on an ongoing basis for possible changes in fluid volume levels, monitored for dyspepsia, sudden weight gain, increased blood pressure and pulse rate, neck vein distension, abnormal breath sounds, monitor laboratory values as ordered by physician, weigh before and after [MEDICAL TREATMENT] procedure according to protocol and as needed, post [MEDICAL TREATMENT] treatment monitoring per protocol. Observe for possible adverse reactions to treatment and assist as indicated. Nephrologist referral and follow up evaluation as needed, staff will take resident to and from [MEDICAL TREATMENT], [MEDICATION NAME] as ordered. Record review of CR #1's physician order [REDACTED]. Record review of CR #1's physician order [REDACTED]. Record review of CR #1's progress notes dated 12/7/20 at 2:04PM revealed CR #1 tested positive for COVID - 19. Record review of CR #1's CMP lab results collected 12/8/20 revealed he had a critical potassium level of 2.1 mmol/L (reference range 3.6 - 5.2mmol/L). Lab results revealed the results were verified and called in and read to LVN A on 12/8/20 at 2:55PM. Interview on 2/26/21 at 1:15PM, NP #1 said she could not recall the specifics from 12/8/20 when CR #1 received his lab results but said she recalled they ordered Potassium supplement because of his lab results for low potassium and said they drew the lab as a routine lab because he had tested positive for COVID-19. The NP said she does not recall ordering a follow-up lab after he received the critical lab result. The NP stated there may have been some confusion because they thought the [MEDICAL TREATMENT] center would complete a follow-up lab. Interview on 2/26/21 at 4:40PM, LVN A said the lab called and reported the critical Potassium level for CR #1 on 12/8/20. LVN A said she called the NP and she order Potassium supplement for four days. She said she went to tell [MEDICAL TREATMENT] about CR #1's critical lab results and the [MEDICAL TREATMENT] nurse was already in his room with [MEDICAL TREATMENT] started. She said she told the [MEDICAL TREATMENT] nurse about the results and she said she would inform the nephrologist. LVN A said the NP did not order any follow up labs at that time. Record review of CR #1's physician telephone orders dated 12/9/20 revealed, New order Kcl 40meq BID X 4 days. Record review of CR #1's December 2020 MAR indicated [REDACTED]. Record review of CR #1's nurses notes dated 12/8/20 - 12/9/20 revealed no mention of critical lab results received and notification to [MEDICAL TREATMENT] nurse. Record review of CR #1's [MEDICAL TREATMENT] notes dated 12/8/20 - 12/9/20 revealed he received [MEDICAL TREATMENT] and there was no mention of critical lab results. Record review of CR #1's nurse notes dated 12/10/20 at 6:47PM written by LVN A revealed in part, .no [MEDICAL TREATMENT] today due to low potassium results . Record review of CR #1's [MEDICAL TREATMENT] notes dated 12/10/20 at 11:00AM revealed, HD held as ordered due to critically low K level from SNF to start patient on KCL 40meq BID for 4 days. Record review of CR #1's nurses notes dated 12/11/20 at 5:01PM revealed in part, .Resident continues on Potassium 40meq 2 tabs BID for 4 days for low Potassium. [MEDICAL TREATMENT] held today . Record review of CR #1's [MEDICAL TREATMENT] notes dated 12/11/20 at 10:40AM revealed, Spoke with doctor today, lab results received, per MD, will consider changing HD orders to M-W-F since [MEDICAL TREATMENT] cannot be adjusted to 3.0K. HD to resume on Monday (12/14/20) and will redraw K level. Interview on 2/26/21 at 2:32PM, the [MEDICAL TREATMENT] DON said the [MEDICAL TREATMENT] nurse who worked back in December with CR #1 no longer worked for them. The [MEDICAL TREATMENT] DON said per the documentation, they were informed of the critical labs on 12/10/20 because the resident received [MEDICAL TREATMENT] on 12/7/20, 12/8/20, and 12/9/20. The [MEDICAL TREATMENT] DON said the Nephrologist reviewed CR #1's labs on 12/10/20 and ordered for the labs to be redrawn so the resident could resume [MEDICAL TREATMENT] on Monday. The [MEDICAL TREATMENT] DON said she was not able to locate documentation of the order from the Nephrologist but said in this case they would have needed a STAT lab and the [MEDICAL TREATMENT] center lab company did not do STAT labs and said it took several days for them to retrieve lab results. She said in a situation where they need a STAT lab the facility would complete the lab since they are able to do STAT labs. Record review of CR #1's physician orders [REDACTED]. Record review of CR #1's nurses notes dated 12/12/20 - 12/13/20 revealed no evidence of K level laboratory tests being redrawn. Record review of CR #1's [MEDICAL TREATMENT] notes dated 12/14/20 at 11:00AM revealed subject line of No recent K level. Awaiting blood draw. Further review of the note revealed, Latest K level was 2.1 from last Thursday result. SNF able to obtain a STAT K level order today and was drawn at 11AM. Doctor made aware and agreed to hold HD until K level obtained. Record review of CR #1's physician telephone orders dated 12/14/20 revealed an order for [REDACTED].>Record review of CR #1's NP #1 progress note dated 12/14/20 revealed resident had persistent nausea every morning following breakfast and was recently started on anti-nausea medication that required evaluation. Also noted follow - up [MEDICAL CONDITION] on [MEDICAL TREATMENT] and had recent low potassium and had not had [MEDICAL TREATMENT] that required evaluation. The NP assessment and plan revealed in part, [DIAGNOSES REDACTED] - KCl supplementation 40mEq twice daily x 4 days, end stage [MEDICAL CONDITION] - [MEDICAL TREATMENT] M - F, on hold due to [DIAGNOSES REDACTED], STAT labs ordered today . Record review of CR #1's nurses notes dated 12/14/20 at 1:23PM by LVN A revealed, 7a-7p lab tech in facility draw resident labs. Record review of CR #1's nurses notes dated 12/14/20 at 7:00PM by LVN A revealed, NP aware [MEDICAL TREATMENT] held for today. Interview on 2/26/21 at 4:42PM, LVN A said she was approached by the [MEDICAL TREATMENT] nurse the morning of 12/14/20 around 8AM asking for updated lab results for CR #1 so he could continue his [MEDICAL TREATMENT]. LVN A said there were no new labs drawn for CR #1 since 12/8/20 so she called the NP and got a STAT order for CBC and CMP. LVN A said she filled out the invoice for the labs on the computer and the lab tech was coming onto the unit as she finished the invoice, so she handed it to him in person. LVN A said they would usually call the lab company after they put in the invoice and let them know they have a STAT order but since the tech was already in the building she just handed it to him. She said she saw the lab tech go down the hall because he was doing labs for another resident as well and left afterwards. LVN A said this was sometime in the morning when the lab tech came in. LVN A said she continued to check for the lab results on the computer for the rest of her shift (7a - 7p) and the results never came in. LVN A said she never called the lab company to check for results and said she just checked the computer. LVN A said she told the oncoming nurse to continue checking for the lab results. Record review of CR #1's nurses notes dated 12/15/20 at 4:53AM by LVN B revealed, Resident removed his O2 mask several times at this point Pulse OX 93% on room air. Respirations even and unlabored CNP notified awaiting call back. This nurse called lab company to obtain lab results however the tech states the lab results were from 12/8/20. This nurse asks to reorder the CBC, CMP STAT tech places order. Resident bed is changed, and he is clean at this time. Record review of CR #1's nurses notes dated 12/15/20 at 6:00AM by LVN B revealed, upon checking on the resident it is noted resident had another larger emesis burnt orange in color resident is still staring at ceiling able to respond to his name and can move eyes to look at this nurse. Resident also has removed his O2 mask several times at this point Pulse Ox 94% on room air, temp 97.8, BP 132/66 respirations even and unlabored CNP notified awaiting call back. Record review of CR #1's nurses notes dated 12/15/20 at 6:15AM by LVN B revealed, CNP responds to obtain status and request resident be sent to hospital via transportation service. Record review of CR #1's nurses notes dated 12/15/20 at 6:30AM by LVN B revealed, Transportation services called to transport resident to the hospital for evaluation and treatment. RP and NP notified. Record review of CR #1's [MEDICAL TREATMENT] notes dated 12/15/20 at 9:00AM revealed a subject line of, Patient change in level of consciousness. Further review of the note revealed, According to patients primary nurse, patient is obtunded. Vital signs remain stable but very slow response to stimulation, doesn't follow commands. SNF obtained order for patient transfer to hospital. Awaiting ambulance pick-up. Doctor notified of patients change of condition. Record review of CR #1's CMP lab test results dated 12/15/20 at 8:56AM revealed the results were verified and called into a facility nurse on 12/15/20 at 12:57PM. Further review of the results revealed CR #1 had a critical potassium level of 6.6 mmol/L (reference range 3.6 - 5.2 mmol/L). Resident also had a critical creatinine level of 5.6mg/dL (reference range .70 - 1.30 mg/dL). Interview on 2/26/21 at 3:00PM, LVN B said she works the 7PM - 7AM shift. She said on 12/14/20 the previous shift nurse (LVN A) told her CR #1 had some pending labs to check for. LVN B said CR #1 was doing okay when she first started her shift and had a change in condition around 4AM on 12/15/20. She said the resident was nauseous and vomited which was not unusual for him but what alarmed her was his altered mental state. She said CR #1 was usually very talkative, but he was very quiet and was looking straight ahead staring at the wall. She said he would respond and acknowledge her when she spoke to him, but his alertness was a change. LVN B said she called the lab company to check on the lab results from the previous day because they still had not showed in the computer and the lab company reported they did not have any labs for CR #1 since 12/8/20 and did not have an order for [REDACTED]. She said while waiting for the NP to call back CR #1 had a second episode of emesis. She said the NP did call back around 6AM and said to send CR #1 to the hospital. She said the NP told her to call the transportation company to see how long the transfer would take and call her back. LVN B said she called the transportation company and they said it would take an hour or two for them to get there. LVN B said she called the NP back and relayed what the transportation company said, and the NP told her to go ahead and transfer him using the transportation company. LVN B said the resident was stable and still at the facility up until the time she left which was around 7AM and continued to have the altered mental state. Interview on 2/26/21 at 1:20PM, NP #1 said she could not recall being contacted about CR #1's change in condition but said she usually get up around 5am and would typically respond around that time if contacted. She said she recalled the [MEDICAL TREATMENT] center wanted to hold CR #1's [MEDICAL TREATMENT] because of his lab results from 12/8/20 and they refused to restart his [MEDICAL TREATMENT] on 12/14/20 without retrieving his new Potassium level so either herself of NP #2 wrote an order for [REDACTED]. She said she also recalled CR #1 having a change in condition and they decided to transfer him to the hospital. She could not recall any specifics from him being sent out to the hospital but said they did eventually receive the lab results, but he was already transferred out to the hospital. She said the resident had an elevated ammonia level which she believed caused the altered mental state. Record review of CR #1's hospital records from emergency room (ER) dated 12/15/20 revealed he was seen in ER at 11:12AM. Chief complaint was he had an altered mental status since 3AM; he had not received [MEDICAL TREATMENT] in the last 5 days due to low potassium levels on 12/8/20. Resident was noted to only respond to painful stimuli by moaning and not following commands. Record review of CR #1's lab results from hospital dated 12/15/20 at 12:20PM revealed he had a critical potassium level of 6.7meq/L, high creatinine level of 5.83mg/dL, and a high ammonia level of 83.0uMol/L. Further review revealed the reexamination/reevaluation noted, labs notable for [MEDICAL CONDITION] 6+, elevated ammonia level. Given insulin, [MEDICATION NAME] and [MEDICATION NAME] for [MEDICAL CONDITION] and renal consulted for HD. Patient encephalopathic (damage or disease that affects the brain), plan NG tube given patient very altered and will give [MEDICATION NAME] . Plan admission for further evaluation, HD and monitoring. Record review of CR #1's hospital discharge summary dated 12/22/20 revealed in part, .he was sent from nursing home for altered mental status. He was found to have hepatic [MEDICAL CONDITION] (a decline in brain function that occurs as a result of severe liver disease),[MEDICAL CONDITION], UTI. He was treated for [REDACTED]. He received [MEDICAL TREATMENT] during his stay . Interview on 3/3/21 at 4:52PM, the DON said the facility had no proof or evidence LVN A ordered CR #1 lab on 12/14/20. The DON said she checked the computer where it shows the invoice for them entering lab orders and there was nothing there for 12/14/20 and she called the lab company and they reported they did not have an order for [REDACTED]. She said the facility had started a new practice since then where they will put in a progress note with the confirmation number once they put in lab/ x-ray orders. She also stated the nurses were in-serviced on how to order STAT lab and checking on STAT lab results. The DON felt LVN B followed procedure once CR #1 had his change of condition on 12/15/20 and said she did in-service the nurse over not waiting for the NP to respond if there's a concern and said she could contact her (the DON) or the Medical Director. She said she did not think the resident required emergency transport because he was stable and only had the AMS. Record review of in-services dated 12/15/20 and 12/19/20 revealed a topic of STAT labs with content of, All STAT labs must be called into lab. You still enter them into lab system and flag it as STAT, but you must also call the lab to notify them of STAT lab and get a confirmation number. Record review of one on one training with LVN A dated 12/22/20 revealed she was trained over STAT lab follow - up and ensuring lab is called into lab company and confirmation number is received. Record review of End - Stage [MEDICAL CONDITION], Care of a resident with policy (revised September 2010) revealed in part, .Agreement between this facility and the contracted [MEDICAL CONDITION] facility include all aspects of how the residents care will be managed, including; a. How the care plan will be developed and implemented; b. How information will be exchanged between the facilities; and c. Responsibility for waste handling, sterilization and disinfection of equipment .

Based on interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one of 8 residents (CR #1) reviewed for quality of care, in that; The facility failed to ensure staff accurately assessed and identified a change in CR #1's condition, intervene and monitor the resident and notify the physician/ Nurse Practitioner of ongoing, rapid decline in the resident's condition. The facility failed to administer nebulizer treatments as ordered and failed to document assessments/monitoring as scheduled on the MAR. As a result, CR#1 declined and was unresponsive about 3 hours later and was pronounced DOA by 911 crew in the facility . An Immediate Jeopardy (IJ) was identified on 9/5/2020. While the IJ was lowered on 9/11/2020, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated because the facility continued to train staff and monitor the effectiveness of the Plan of Removal. These failures affected one former resident and placed all facility residents who may experience changes in their condition at risk of complications from delay in intervention . Findings include: CR #1 Record review of CR #1's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]., and [MEDICAL CONDITION]. Record review of CR #1's quarterly MDS dated [DATE] revealed the resident was severely impaired for cognition. She was totally dependent on staff for locomotion and eating, she required two staff physical assistance with activities of daily living. CR #1's special treatments, procedures and program included oxygen therapy. Record review of CR #1's comprehensive care plan, dated 04/03/20, reflected she had potential for shortness of breath related to acute and chronic [MEDICAL CONDITION] with [MEDICAL CONDITION], chronic diastolic(congestive) heart failure. The interventions included to monitor for changes in CR #1's symptoms that may indicate worsening respiratory status and report to physician, staff education on positioning, nebulizer treatments as ordered , oxygen continuous as ordered, CR #1 had potential for impaired thought processes, confusion related to [DIAGNOSES REDACTED]. Further review of CR#1's clinical records, comprehensive assessment and comprehensive care plan revealed no history of crackles breathing/lung sound. Record review of CR#1's progress notes dated 6/1/20 at 7:10 PM revealed CR #1 was noted with cough and congestion. NP notified, chest X-ray ordered and Duo-Neb ( [MEDICATION NAME]/[MEDICATION NAME]) every four hours for 7 days for congestion and cough, Oxygen saturation to room air 96%. At 7:17 PM her vital signs post [MEDICAL TREATMENT] T97.6, P60. BP 116/63, Chest X-ray done result still pending. There was no documentation regarding CR #1's assessment at that time. Record review of CR#1's Nurses progress notes dated 6/2/20 at 1:16 PM revealed CR #1 was noted by the Nurse to appeared drowsy and noticed gurgling and crackles on entering the room, CR#1 was suctioned. CR #1 although showing some weakness, showed some stimulation. Record review of WebMD website on abnormal breathing/lung sounds : Crackling (Rales) undated revealed This is a series of short, explosive sounds. They can also sound like bubbling, rattling, or clicking. You're more likely to have them when you breathe in, but they can happen when you breathe out, too. You can have fine crackles, which are shorter and higher in pitch, or coarse crackles, which are lower. Either can be a sign that there's fluid in your air sacs. Record review on CR#1's Nurse Administration Record dated 6/1/2020 revealed Duo-Neb congestion and cough was scheduled every 4 hours X 7 days. Record review on CR#1's MAR indicated [REDACTED]. There was no documentation on 6/2/20 of Duo- Neb being administered to CR #1 at 9:00 AM and 1:00 PM. Record review on CR#1's records revealed no documented ongoing assessments and monitoring of CR#1. Record review of CR#1's Nurses progress notes dated 6/2/20 at 4:05 pm revealed the resident's condition had continued to deteriorate with use of accessory muscles to breathe, staff could not obtain vital signs, and the resident was displaying Cheyne -strokes breathing ( abnormal pattern of breathing characterized by progressively deeper, and sometimes faster, breathing followed by a gradual decrease that results in a temporary stop in breathing called an apnea) and a discharge coming from her mouth. Her respiratory rate was 5 and 911 was called. The resident was dead by the time 911 arrived. Interview with DON on 9/2/20 at 4:34 PM she printed Chest X-ray and she confirmed there was no documentation the doctor/NP was notified about X-ray result. DON said it got mixed up in their system. and it should have been documented in the nurse's progress note and the doctor should have initialed it. Interview with DON on 9/3/20 at 12:30 p.m. regarding stat x-ray order, she said when resident had a stat X-ray, the Lab services would always fax the x-ray result and the nurses should follow-up by notifying the doctor or the NP and document. Record review on CR#1's Chest X-ray, single view notes: Impression: 1. Opacification of left hemidiaphragm with mild patchy density compatible with left basilar pneumonia or atelectasis. Small left pleural effusion. In clinical context of cough, fever, elevated WBC or other signs of lung infection , findings would be compatible with pneumonia, otherwise, atelectasis should be considered. Follow up CXR suggested as clinically warranted. 2. Mild cardiomegaly. 3. Mild degree of osteopenia 4. Mild degree of [MEDICAL CONDITION]. Interview with the NP on 9/3/20 at 1:13 PM revealed she has no documentation of being contacted on 6/2/19 earlier to report change in condition, NP said she was notified about change in condition after 911 was called. NP was not sure of the facility calling her for chest X-ray result because it would have been documented. Interview with LVN A on 9/2/20 at 2:19 PM who took care of CR #1 on 6/2/20, she said she did not know much about CR #1 who was moved to her unit. She did not get any report from any nurse. She noticed CR #1 was weak, drowsy, heard resident gurgling with crackles on entering the room and she suctioned her and was then aroused on stimulation. About 2 hours later, she went back to check on the resident and her breathing had changed. LVN A called LVN B for help because she could not get the vital signs, she then stepped out of the room to call 911 and then call the NP. Further interview with LVN A regarding notifying the doctor/NP about CR #1's change in condition, she said she was just thrown into taking care of CR #1 because the facility was short of staff and did not get any report and was not sure when the nebulizer treatment was given last. LVN A said she started working as a unit manager a week and a half ago before the incident happened. Interview with LVN B on 9/3/20 at 3:54pm, she said she took care of CR#1 on 6/2/2020 just before dinner, she remembered being called by LVN A to assist with CR #1's vital signs, resident pulse was very weak, with very shallow respiration and unable to obtain blood pressure. She checked the blood glucose and it was high. LVN B said LVN A stepped out to call 911 while she stayed in the room. LVN B was not aware of prior chest x-ray ordered on [DATE]. Further interview on 9/8/20 at 3:54 p.m. with LVN B, she said she knew when to assess residents with change of condition, notifying DON, ADON, doctor/NP . During an interview on 9/9/20 at 5:49 p.m. interim DON said he thought the immediate jeopardy was a result of not notifying the doctor/NP for change of CR #1's condition and poor documentation by the nurse. LVN A did not notify the charge nurse ( ADON RN) about the change in condition. He said they interviewed the nurses to see if they felt overwhelmed or if it was too much and no one said it was. The interim DON said there was just no communication. They didn't communicate with each other, not even on the 24-hour report. Nothing on the nurse to nurse. The interim DON said he started in-services. The DON said he ensured staff was educated by conducting in-services and skill checks In an interview on 09/09/20 at 3:22 pm, the Administrator said we did in-services. We did in-service that day or within 48 hours. The DON was not in the facility when CR #1 had change in condition and he did not know that the DON had to be a Registered Nurse. He acknowledged no notification to anyone at that time for CR #1. The Administrator said LVN A nurse was terminated for failure to follow the policy on an unrelated issue. She was informed there were two nurses who identified a change in condition, but no action was taken, and doctor/NP was not notified. Record review of facility's policy on physician notification revealed a physician can be notified by phone, fax, voicemail, e-mail, mail, pager, or a telephone message to another person acting as the physician's agent ( for example, office staff). Record review of the facility's change of condition policy revealed in part, .The nurse assigned to the resident or supervising the care of the resident is responsible for notification of and communication to the medical staff regarding significant changes or significant deterioration in the resident's condition and for assuring that there is physician response . Further review of the policy revealed in part, .A nurse should not assume that the practitioner knows the patient well or can remember relevant details such as previous lab abnormalities or the patient's current medication regimen. A brief review of the patients known medical history is vital . The practitioner needs a detailed description of the patient's condition to determine whether a symptom is problematic or simply a normal or expected variant . Immediate notification: Any symptom, sign or apparent discomfort that is: Acute or sudden in onset, and a marked change in relation to usual symptoms and signs, or unrelieved by measures already prescribed . The policy also revealed in part, .Notify Physicians in the following order unless otherwise indicated by physicians order, by routine service, or as indicated by the patient condition: a) attending physician b) Advanced Practice Registered Nurse or c) As necessary, notify the nursing supervisor and/or administrator on-call for administrative and/or clinical consultation and/or assistance d) In the event that there continues to be concern about the patient's condition, follow further nursing and medical staff chain of command. e) The nursing supervisor (in house) and nursing administrator (on call) will determine the need to initiate the following steps: a) Notification of the Medical Director . Record review of the facility's policy of Laboratory (Lab) and Diagnostic Test Results-Clinical Protocol (Revised September 2012) : Assessment and Recognition: 1. The physician will identify, and order diagnostic and lab testing based on diagnostic and monitoring needs. 2. The staff will process test requisitions and arrange for tests. 3. The laboratory, diagnostic radiology provider, or other testing source will report test results to the facility. Review by Nursing Staff: A nurse review all results: read in part a. If the staff who first receive or review lab and diagnostic test results cannot follow the remainder of this procedure for reporting and documenting the results and their implications, another nurse in the facility (supervisor, charge nurse,etc.) should follow or coordinate the procedure. 2. the person who is to communicate results to a physician will review and be prepared to discuss the following ( to the extent that such information is available): a. The individual's current condition and any recent changes in status, including vital signs and mental status . 3. Before contacting the physician, the nurse will gather and organize the information listed above and coordinate any telephone communications with others who may also need to speak with the physician. Identifying Situations that Warrant Immediate Notification: Nursing staff will consider the following factors to help identify situations requiring prompt physician notification concerning lab or diagnostic test result: 1. The physician has requested to be notified as soon as a result is received 2. The result is something that should be conveyed to a physician regardless of other circumstances ( that is, the abnormal result is problematic regardless of any other factors). Determining the Reason for Testing . a. If the resident has signs and symptoms of acute illness or condition change and he/she not stable or improving , or there are no previous results for comparison, then the nurse will notify the physician promptly to discuss the situation, including a description of relevant clinical findings as well as the test results. Options for Physician Notification 1. A physician can be notified by phone, fax, voicemail, e-mail, mail, pager, or a telephone message to another person acting as the physician's agent ( for example, office staff). a. Facility staff should document information about when, how, and to whom the information was provided and the response. This should be done in the progress notes section of the medical record and not on the lab results report, because test results should be correlated with other relevant information such as the individual's overall situation, current symptoms, advance directive prognosis, etc . The facility Administrator and DON were notified on 9/5/20 at 10:45 a.m. that an IJ was identified due to the above failures and a POR was requested. The POR was submitted by the Administrator on 09/07/20. After several revisions, the final plan of removal was accepted on 09/10/20 at 5:30 pm. The POR read in part: .was assessing all residents for change in condition. Licensed Nurse Management assessed current residents on 9/5/2020 - 9/7/2020 for any change in condition including, but not limited to; vital signs , body temperature, pulse rate, respiration rate, lung sounds, abnormal breathing, audible crackles heard with respirations, O2 stats, blood pressure, neurological status, current level of pain and any recent changes in pain level. Nurse management will document completed assessment on each resident and notify physician and/or physician extender, and resident representative of any identified changes. Immediate Action The DON .and charge nurses immediately on 9/6/20 began assessing all residents for change in condition, via walking rounds if any resident has a change in condition, Physician notification will be done based on the guidelines. This was completed on 9/10/20 Education Education was provided by the Interim DON to the Licensed Nurse Management on below highlighted policies and guidelines. Interim DON and/or Licensed Nurse Management in-serviced licensed nursing staff on the 6 below highlighted policies and guidelines beginning on 9/5/20. All licensed nursing staff will be in-serviced by 9/9/2020 and if not completed will not be allowed to return to work until required training is completed. 1. Acute Changes in Condition: The physician will help identify individuals with a significant risk for having acute changes of condition during their stay; for example, an individual with an indwelling urinary catheter who has had recurrent symptomatic urinary tract infections, or someone with unstable vital signs or recurrent pneumonia. In addition, the nurse shall assess and document/report the following baseline information: a. Vital signs; b. Neurological status; c. Lung Sounds (abnormal breathing, audible crackles with respirations) d. Level of consciousness; e. Cognitive and emotional status; f. Resident's age and sex; g. Onset, duration, severity; h. Recent labs; All active diagnoses; and i. All current medications. 2. Resident Examination and Assessment The purpose of this procedure is to examine and assess the resident for any abnormalities in health status, which provides a basis for the care plan. If nurses need assistance with resident examination or assessment nurses are to reach out to their unit manager, ADON, or Interim DON for further guidance. 3. Identifying Signs and Symptoms of Pneumonia The physician will help identify residents who have recently had pneumonia or [MEDICAL CONDITION] and those who are at risk for getting respiratory infections (for example, those with [MEDICAL CONDITION] or a history of [MEDICAL CONDITION]). The staff will identify residents with symptoms that suggest possible [MEDICAL CONDITION] or pneumonia (for example- dyspnea (at rest and/or on exertion), tachypnea, increased sputum production, fever, chest pain, cough, lung sounds including abnormal breathing, audible crackles with respirations, or hemoptysis). 4. Guideline for Physician Notification: These guidelines are to help ensure that all significant changes in residents' status are promptly identified and are communicated to the physician in a timely, efficient and effective manner . ongoing assessment and monitoring continued and documented in a resident's clinical record. The immediate (acute) and non-immediate (sub-acute) problems listed below are not meant to be all-inclusive. The charge nurse and/or with assistance of a supervisor should contact the attending physician at any time following clinical guidelines as well as professional nursing judgment a clinical situation requires immediate discussion and management. When contacting the physician, especially at night and on weekends (when physicians are not familiar with the residents may be on call), the nurse should have the following information available and share with the physician; Detailed description of current issue or problem, including a chronological story of symptoms and treatment to date, vital signs, and results of physical assessment. Active medical problems (problem list). Advance directives (if available) and orders for life-sustaining treatments (including Resuscitation (Code) status/any limitations on hospitalization ). All Licensed Nurses on duty will be provided education on Notification of Change in condition using the Competency Assessment Resident Examination and Assessment to include training on timely and thoroughness of assessing a resident. This education will be provided by DON and ADON RN. A posttest was provided beginning 9/6/20 ended 9/6/20. On 9/6/20 Nurse surveyor discovered the facility DON was not a Registered Nurse, DON was a GN ( Graduate Nurse) and has not taken her RN board exams and has been DON since 6/4/20. All Licensed Nurses on duty will be provided education on Notification of Change in condition using the Competency Assessment Resident Examination and Assessment to include training on timely and thoroughness of assessing a resident. This education will be provided by ADON RN ( now interim DON). A posttest was provided beginning 9/7/20 and will end 9/10/20. Any nurse that has not been trained will be removed from the schedule and will not work until this education has been provided. All nurses receive this education to demonstrate understanding of our process change and the policy and procedure on change of condition, Physician notification. All Licensed Nurses on duty will be provided education on Abuse and neglect. This education will be provided by interim DON. A posttest was provided beginning 9/6/20 and will end 09/10/20 Any nurse that has not had this training will be removed from the schedule and will not work until this education has been provided. All nurses receive this education to demonstrate understanding of our process change and the policy and procedure on abuse and neglect. Monitoring/Follow up. The staff will monitor and document the resident/patient's progress and responses to treatment, and the physician will adjust treatment accordingly. The physician will help the staff monitor a resident/patient with a recent acute change of condition until the problem or condition has resolved or stabilized. Staff will document in 24 hour report and give verbal report to oncoming nurse to ensure monitoring is followed through to the next shift. 5. Nursing Report and Communication The purpose of this in-service was to ensure licensed nursing staff are trained on communication within the facility to on-coming shifts or a transfer from one hall to another. Licensed nursing staff are to review the 24-hour report, lab tracking logs, and verbal report prior to taking charge of a hall. Licensed nursing staff were in-serviced on guidelines for notification of physician. This guideline was placed at each nurses' station on communication books for reference if needed. Licensed nursing staff also educated on communication with Unit manager, ADON, and Interim DON if they are unsure a change in condition needs to be reported to the physician. Follow Up Initiated 9/6/2020- Interim DON and/or designee will review 24hr reports, physician order [REDACTED]. Interim DON and/or Designee will monitor 15 resident assessments daily for 4 weeks and 5 resident assessments daily for the following 4 weeks. DON and/or Designee will notify administrator immediately of any non-compliance. Findings will be reviewed weekly by Interim DON and Administrator and reported in facilities QAPI Meeting at least quarterly. Clinical Stand Up (current meeting format with the following focuses added)- 24 hr reports will be reviewed every morning in the clinical stand up meeting for change of conditions and proper treatment and follow up (start effective immediately) Weekend Nurse Manager will review all 24hr reports for change of conditions and proper treatment and follow up. Any areas of concerned will be addressed immediately. Surveyors' Monitoring Interview with two RNs and 10 LVNs conducted between 9/8/20 and 9/10/20 revealed on Notification of acute Changes, Resident Rights, Guidelines for notifying physicians of clinical problems, charting and documentation, resident assessment revealed twelve licensed nurses ( DON, ADON, LVNs A, B, C, D, E, F, G, H,I, J and RN A, RN B) representing all two shifts, management, and weekend staff all had training on identifying a change of condition, who to notify of the change of condition as per the care plan, nurses will note the change of condition and promptly notify the family, physician and nursing leadership/DON. All staff interviewed demonstrate understanding of training. Interviews on 09/8/20 to 09/10/20 from 9:30 A.M. to 6:25 P.M. revealed twelve licensed nurses ( DON, ADON, LVNs A, B, C, D, E, F, G, H,I, J and RN A, RN B) representing all twelve shifts, management, and weekend staff all had training on identifying a change of condition, who to notify of the change of condition, nurses will note the change of condition and promptly notify the family, physician and nursing leadership/DON. Areas of notification include: a. Resident Rights; b. Notification of acute Changes c. Guidelines for notifying physicians of clinical problems d. A significant change in the resident's physical/emotional/mental condition; e. A need to alter the resident's medical treatment significantly; f. Refusal of treatment or medications (i.e. two (2) or more consecutive times); g. A need to transfer the resident to a hospital/treatment center; h. charting and documentation i. Instructions to notify the physician of changes in the resident's condition. Interviews conducted between 9/7/20 and 9/10/20 showed that five RN's and thirty-two LVN's had attended and understood the in-services conducted related to change in condition. Record review of the 9/07/20 In-Service Training Report completed by the facility documented 37 nurses signed they were in-serviced on 9/10/20 have some done over the weekend. Thirty-seven staff members signed the 9/10/20 In-service Training Report on Change of Condition/ Notification of Physician and Family which included the Policy on Changes of Condition . Record review of the Change of Condition Quiz documented 37 staffs were tested on their knowledge of change of condition, notification to physicians and documentation. Record review of the Report Sheets for all Halls documented all residents had a baseline vital signs completed. On 9/10/20 at 5:30 p.m. the Administrator was informed the IJ was lowered. The facility remained out of compliance at a severity level of harm with a scope of isolated due to the facility administration and staff requiring time to train all staff and monitor their plan of removal.

Based on interview and record review, the facility failed to immediately consult with residents physician when there was a significant change in the resident's physical, mental, or psychosocial status for 1 of 7 resident (CR #1) reviewed for notification of changes. The facility failed to notify CR#1's physician of her worsened change in condition noted on 6/2/20 . CR #1 was found unresponsive about 3 hours later and pronounced DOA in the facility. An Immediate Jeopardy (IJ) was identified on 9/5/2020. While the IJ was lowered on 9/10/2020, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated because the facility continued to train staff and monitor the effectiveness of the Plan of Removal. This failure affected one former resident and placed all facility residents who may experience changes in their condition at risk on delayed medical intervention. Findings include: CR #1 Record review of CR #1's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]., and [MEDICAL CONDITION]. Record review of CR #1's quarterly MDS dated [DATE] revealed the resident was severely impaired for cognition. She was total dependent on staff for locomotion and eating, she required two staff physical assistance with activities of daily living. CR #1's special treatments, procedures and program included oxygen therapy. Record review of CR #1's review comprehensive care plan, dated 07/03/20, reflected she had potential for shortness of breath related to Acute and Chronic [MEDICAL CONDITION] with [MEDICAL CONDITION], Chronic diastolic (congestive) heart failure. The interventions included to monitor for changes in CR #1's symptoms that may indicate worsening respiratory status and report to physician, staff education on positioning, nebulizer treatments as ordered , oxygen continuous as ordered, CR #1 had potential for impaired thought processes, confusion related to [DIAGNOSES REDACTED]. Further review of CR#1's clinical records, comprehensive assessment and comprehensive care plan revealed no history of crackles breathing/lung sound. Record review of CR#1's progress notes dated 6/1/20 at 7:10 PM revealed CR #1 was noted with cough and congestion. NP notified, chest X-ray ordered and Duo-Neb ( [MEDICATION NAME]/[MEDICATION NAME]) every four hours for 7 days for congestion and cough, Oxygen saturation to room air 96%. At 7:17 PM her vital signs post [MEDICAL TREATMENT] T97.6, P60. BP 116/63, Chest X-ray done result still pending. There was no documentation regarding CR #1's assessment at the time. Record review of CR#1's Nurses progress notes dated 6/2/20 at 1:16 PM revealed CR #1 was noted by the Nurse to appear drowsy and noticed gurgling and crackles on entering the room, CR#1 was suctioned. CR #1 although showing some weakness and showed some stimulation. Note did not indicate the NP was notified of the changes identified. Record review of WebMD website on abnormal breathing/lung sounds : Crackling (Rales) undated revealed This is a series of short, explosive sounds. They can also sound like bubbling, rattling, or clicking. You're more likely to have them when you breathe in, but they can happen when you breathe out, too. You can have fine crackles, which are shorter and higher in pitch, or coarse crackles, which are lower. Either can be a sign that there's fluid in your air sacs. Record review on CR#1's records revealed no documented ongoing assessments and monitoring of CR#1 or that Np notified. Record review of CR#1's Nurses progress notes dated 6/2/20 at 4:05 pm revealed the resident's condition had continued to deteriorate with use of accessory muscles to breathe, staff could not obtain vital signs, and the resident was displaying Cheyne -strokes breathing ( abnormal pattern of breathing characterized by progressively deeper, and sometimes faster, breathing followed by a gradual decrease that results in a temporary stop in breathing called an apnea) and a discharge coming from her mouth. Her respiratory rate was 5 and 911 was called. The resident was dead by the time 911 arrived. Interview with the NP on 9/3/20 at 1:13 PM revealed she has no documentation of being contacted on 6/2/19 earlier to report change in condition, NP said she was notified about change in condition after 911 was called. Record review on CR#1's Chest X-ray, single view notes: Impression: 1. Opacification of left hemidiaphragm with mild patchy density compatible with left basilar pneumonia or atelectasis. Small left pleural effusion. In clinical context of cough, fever, elevated WBC or other signs of lung infection , findings would be compatible with pneumonia, otherwise, atelectasis should be considered. Follow up CXR suggested as clinically warranted. 2. Mild cardiomegaly. 3. Mild degree of osteopenia 4. Mild degree of [MEDICAL CONDITION]. Interview with LVN A on 9/2/20 at 2:19 PM who took care of CR #1 on 6/2/20, she said she did not know much about CR #1 who was moved to her unit. She did not get any report from any nurse. She noticed CR #1 was weak, drowsy, heard resident gurgling with crackles on entering the room and she suctioned her and was then aroused on stimulation. About 2 hours she went back to check on Resident she her breathing had changed and called LVN B for help because she could not get the vital signs, she then stepped out of the room to call 911 and then call the NP. Further interview with LVN A regarding notifying the doctor/NP about CR #1's change in condition, she said she was just thrown into taking care of CR #1 because the facility was short of staff and did not get any report and was not sure when the nebulizer treatment was given last. LVN A said she started working as a unit manager 1 week and a half before the incident. Interview with LVN B on 9/3/20 at 3:54pm, she said she took care of CR#1 on 6/2/2020 just before dinner, she remembered being called by LVN A to assist with CR #1's vital signs, resident pulse was very weak, with very shallow respiration and unable to obtained blood pressure. She checked the blood glucose and it was high. LVN B said LVN A stepped out to call 911 while she stayed in the room. LVN B was not aware of prior chest x-ray ordered on [DATE]. Further interview on 9/8/20 at 3:54 p.m. with LVN B, she said she knew when to assess residents with change of condition, notifying DON, ADON, doctor/NP . During an interview on 9/9/20 at 5:49 p.m. interim DON said he thought the immediate jeopardy was a result of not notifying the doctor/NP for change of CR #1's condition and poor documentation by the nurse. LVN A did not notify the charge nurse ( ADON RN) about the change in condition. He said they interviewed the nurses to see if they felt overwhelmed or if it was too much and no one said it was. The interim DON said there was just no communication. They didn't communicate with each other, not even on the 24 hour report. Nothing on the nurse to nurse. The interim DON said he started in-services. The DON said he ensured staff was educated by conducting in-services and skill checks In an interview on 09/09/20 at 3:22 pm, the Administrator said we did in-services. We did in-service that day or within 48 hours. The DON was not in the facility when CR #1 had change in condition and he did not know that the DON had to be a Registered Nurse. He acknowledged no notification to anyone at that time for CR #1. The Administrator said LVN A nurse was terminated for failure to follow the policy on an unrelated issue. She was informed there were two nurses who identified a change in condition, but no action was taken, and doctor/NP was not notified. Record review of facility's policy on physician notification revealed a physician can be notified by phone, fax, voicemail, e-mail, mail, pager, or a telephone message to another person acting as the physician's agent ( for example, office staff). a. Facility staff should document information about when, how, and to whom the information was provided and the response. This should be done in the progress notes section of the medical record and not on the lab results report, because test results should be correlated with other relevant information such as the individual's overall situation, current symptoms, advance directive prognosis, etc . The facility Administrator and DON were notified on 9/5/20 at 10:45 am that an IJ was identified due to the above failures and a POR was requested. IJ templates were provided. The POR was submitted by the Administrator after several revisions, the final plan of removal was accepted on 09/07/2020 2:33 PM. The POR read in part: The DON and charge nurses immediately on 9/6/20 began assessing all residents for change in condition, via walking rounds if any resident has a change in condition, Physician notification will be done based on the guidelines. This was completed on 9/10/20 Education All Licensed Nurses on duty will be provided education on our Diagnostic Testing and communicating panic or critical lab values done by DON, ADON and unit manager. A posttest was provided beginning 09/06/20 and will end on 9/9/20. Any nurse that has not been trained will be removed from the schedule and will not work until this education has been provided. All nurses receive this education to demonstrate understanding of our process change and the policy and procedure as it relates to diagnostic testing. All Licensed Nurses on duty will be provided education on Notification of Change in condition using the Competency Assessment Resident Examination and Assessment to include training on timely and thoroughness of assessing a resident. This education will be provided by DON and ADON RN. A posttest was provided beginning 9/6/20 ended 9/6/20. On 9/6/20 at 3:10 p.m. Nurse surveyor discovered the facility DON was not a Registered Nurse, DON was a GN ( Graduate Nurse) and has not taken her RN board exams and has been DON since 6/4/20. All Licensed Nurses on duty will be provided education on Notification of Change in condition using the Competency Assessment Resident Examination and Assessment to include training on timely and thoroughness of assessing a resident. This education will be provided by ADON RN ( now interim DON). A posttest was provided beginning 9/7/20 and will end 9/10/20. Any nurse that has not been trained will be removed from the schedule and will not work until this education has been provided. All nurses receive this education to demonstrate understanding of our process change and the policy and procedure on change of condition, Physician notification. All Licensed Nurses on duty will be provided education on Abuse and neglect. This education will be provided by interim DON. A posttest was provided beginning 9/6/20 and will end 09/10/20 Any nurse that has not had this training will be removed from the schedule and will not work until this education has been provided. All nurses receive this education to demonstrate understanding of our process change and the policy and procedure on abuse and neglect. Monitoring Interim DON will review daily all resident with a change in condition to ensure timely notification of Physician The interim DON and Administration will Review lab tracking log daily to ensure labs results reported to Physician in a timely manner. A QA&A meeting will be conducted by Administrator on September 10, 2020 and daily to validate that the facility's Notification in change of condition is in place and of sustaining compliance. Surveyor's Monitoring Interview with two RNs and 10 LVNs conducted between 9/8/20 and 9/10/20 revealed of Notification of acute Changes, Resident Rights, Guidelines for notifying physicians of clinical problems, charting and documentation, resident assessment revealed twelve licensed nurses ( DON, ADON, LVNs A, B, C, D, E, F, G, H,I, J and RN A, RN B) representing all two shifts, management, and weekend staff all had training on identifying a change of condition, who to notify of the change of condition as per the care plan, nurses will note the change of condition and promptly notify the family, physician and nursing leadership/DON. Interviews on 09/8/20 to 09/10/20 from 9:30 A.M. to 6:25 P.M. revealed twelve licensed nurses ( DON, ADON, LVNs A, B, C, D, E, F, G, H,I, J and RN A, RN B) representing all twelve shifts, management, and weekend staff all had training on identifying a change of condition, who to notify of the change of condition, nurses will note the change of condition and promptly notify the family, physician and nursing leadership/DON. Areas of notification include: a. Resident Rights; b. Notification of acute Changes c. Guidelines for notifying physicians of clinical problems d. A significant change in the resident's physical/emotional/mental condition; e. A need to alter the resident's medical treatment significantly; f. Refusal of treatment or medications (i.e. two (2) or more consecutive times); g. A need to transfer the resident to a hospital/treatment center; h. charting and documentation i. Instructions to notify the physician of changes in the resident's condition. Record review of in-service training report dated 9/08/20 completed by the facility revealed 37 nurses signed in-serviced on Change of Condition/ Notification of Physician and Family which included the Policy on Changes of Condition . Record review of the Change of Condition Quiz revealed 37 staffs members were tested on their knowledge of notification to physicians of change in condition and documentation of changes in condition. Record review of the facility's 24 hour report sheets for all halls revealed all residents had baseline vital signs assessment completed 9/10/2020. On 9/10/20 at 5:30 p.m. the Administrator was informed the IJ was lowered. The facility remained out of compliance at a severity level of harm with a scope of isolated due to the facility administration and staff requiring time to train all staff and monitor their plan of removal.

Based on interview and record review, the facility failed to provide or obtain timely laboratory services to meet the needs of 1 of 7 residents (CR #1) reviewed for laboratory services. The facility failed to notify CR #1's physician/NP an abnormal result of STAT chest X-ray that NP ordered following a change in the resident's condition on 6/1/2020. CR #1's condition rapidly declined resulting in CR#1 being found unresponsive on 6/2/2020 and was pronounced DOA by 911 This deficient practice affected one former resident and placed all residents at risk for a delay in identifying or diagnosing a problem, adjusting medications, and ensuring treatment needs were identified and addressed. Findings include: CR #1 Record review of CR #1's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]., and [MEDICAL CONDITION]. Record review of CR #1's quarterly MDS dated [DATE] revealed the resident was severely impaired for cognition. She was total dependent on staff for locomotion and eating, she required two staff physical assistance with activities of daily living. CR #1's special treatments, procedures and program included oxygen therapy. Record review of CR #1's comprehensive care plan, dated 04/03/20, reflected she had potential for shortness of breath related to acute and chronic [MEDICAL CONDITION] with [MEDICAL CONDITION], chronic diastolic(congestive) heart failure. The interventions included to monitor for changes in CR #1's symptoms that may indicate worsening respiratory status and report to physician, staff education on positioning, nebulizer treatments as ordered , oxygen continuous as ordered, CR #1 had potential for impaired thought processes, confusion related to [DIAGNOSES REDACTED]. Record review of CR#1's progress notes dated 6/1/20 at 7:10 PM revealed CR #1 was noted with cough and congestion. NP notified, chest X-ray ordered and Duo-Neb ( [MEDICATION NAME]/[MEDICATION NAME]) every four hours for 7 days for congestion and cough, Oxygen saturation to room air 96%. At 7:17 PM her vital signs post [MEDICAL TREATMENT] T97.6, P60. BP 116/63, Chest X-ray done result still pending. There was no documentation regarding CR #1's assessment at that time. Record review of CR#1's closed record with the DON (GN) on 9/2/20 at 4:28 PM revealed no Chest X-ray result on file for CR#1 and none was scanned in the system. Interview with DON (GN) on 9/2/20 at 4:34 PM, she said she printed CR#1's Chest X-ray result from the lab company's data base and confirmed there was no documentation indicating CR#1's doctor/NP was notified of the X-ray result. The DON (GN) said it got mixed up in their system. The DON said if the X-ray was received and the doctor notified then it should be documented in the nurses' progress note and the doctor should have also initialed it the X-ray result indicating result was reviewed by the doctor /Np. Interview with DON ( GN) on 9/3/20 at 12:30 p.m. regarding stat x-ray order, she said when resident had a stat X-ray, the Lab services would always fax the x-ray result and the nurses should follow-up by notifying the doctor or the NP and document. Record review of CR #1's chest x-ray single view dated 06/01/20 revealed comparison view was none, and result was electronically signed by the doctor on 6/1/20 at 7:25 p.m. Chest X-ray, single view notes: Impression: 1. Opacification of left hemidiaphragm with mild patchy density compatible with left basilar pneumonia or atelectasis. Small left pleural effusion. In clinical context of cough, fever, elevated WBC or other signs of lung infection , findings would be compatible with pneumonia, otherwise, atelectasis should be considered. Follow up CXR suggested as clinically warranted. 2. Mild cardiomegaly. 3. Mild degree of osteopenia 4. Mild degree of [MEDICAL CONDITION]. Interview with the NP on 9/3/20 at 1:13 PM, NP said she has no documentation of being contacted on 6/2/19 earlier to report change in condition, NP said she was notified about change in condition after 911 was called. NP was not sure of the facility calling her for chest X-ray result because it would have been documented. Interview on 9/2/20 at 2:19 PM, LVN A said she took care of CR #1 on 6/2/20, she said she did not know much about CR #1 who was moved to her unit. She did not get any report from any nurse. She noticed CR #1 was weak, drowsy, heard resident gurgling with crackles on entering the room and she suctioned her and was then aroused on stimulation. About 2 hours later, she went back to check on resident, but the resident's breathing had changed. LVN A then called LVN B for help because she could get the vital signs, she then stepped out of the room to call 911 and then call the NP. LVN A was not aware of prior chest x-ray ordered on [DATE]. Interviews on 9/3/20 at 3:54 PM, LVN B said she took care of CR#1 on 6/2/2020 just before dinner, she remembered being called by LVN A to assist with CR #1's vital signs, resident pulse was very weak, with very shallow respiration and unable to obtain blood pressure. She checked the blood glucose and it was high. LVN B said LVN A stepped out to call 911 while she stayed in the room. LVN B was not aware of prior chest x-ray ordered on [DATE]. Further interview on 9/8/20 at 3:54 p.m. with LVN B, she knew when to assessed residents with changed of condition, notifying DON, ADON, doctor/NP and for stat x-ray, the lab services always faxed it and called the facility staff. LVN B said they would called the doctor or NP about the results and document. Record review on CR#1's Chest X-ray, single view notes: Impression: 1. Opacification of left hemidiaphragm with mild patchy density compatible with left basilar pneumonia or atelectasis. Small left pleural effusion. In clinical context of cough, fever, elevated WBC or other signs of lung infection , findings would be compatible with pneumonia, otherwise, atelectasis should be considered. Follow up CXR suggested as clinically warranted. 2. Mild cardiomegaly. 3. Mild degree of osteopenia 4. Mild degree of [MEDICAL CONDITION]. Record review of the facility's policy of Laboratory (Lab) and Diagnostic Test Results-Clinical Protocol (Revised September 2012) : Assessment and Recognition: 1. The physician will identify, and order diagnostic and lab testing based on diagnostic and monitoring needs. 2. The staff will process test requisitions and arrange for tests. 3. The laboratory, diagnostic radiology provider, or other testing source will report test results to the facility. Review by Nursing Staff: A nurse review all results: read in part . a. If the staff who first receive or review lab and diagnostic test results cannot follow the remainder of this procedure for reporting and documenting the results and their implications, another nurse in the facility (supervisor, charge nurse,etc.) should follow or coordinate the procedure. 2. the person who is to communicate results to a physician will review and be prepared to discuss the following ( to the extent that such information is available): . a. The individual's current condition and any recent changes in status, including vital signs and mental status . 3. Before contacting the physician, the nurse will gather and organize the information listed above and coordinate any telephone communications with others who may also need to speak with the physician. Identifying Situations that Warrant Immediate Notification: Nursing staff will consider the following factors to help identify situations requiring prompt physician notification concerning lab or diagnostic test result: 1. The physician has requested to be notified as soon as a result is received 2. The result is something that should be conveyed to a physician regardless of other circumstances ( that is, the abnormal result is problematic regardless of any other factors). Determining the Reason for Testing . a. If the resident has signs and symptoms of acute illness or condition change and he/she not stable or improving , or there are no previous results for comparison, then the nurse will notify the physician promptly to discuss the situation, including a description of relevant clinical findings as well as the test results. Options for Physician Notification 1. A physician can be notified by phone, fax, voicemail, e-mail, mail, pager, or a telephone message to another person acting as the physician's agent ( for example, office staff). a. Facility staff should document information about when, how, and to whom the information was provided and the response. This should be done in the progress notes section of the medical record and not on the lab results report, because test results should be correlated with other relevant information such as the individual's overall situation, current symptoms, advance directive prognosis, etc .

Based on observation, interview and record review; the facility failed to ensure nursing staff possess the competencies and skill sets necessary to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental and psychosocial well-being for 1 of 7 ( CR#1) residents reviewed for nursing services. LVN A failed to accurately assess and identify a change in CR #1's condition, intervene and monitor the resident and notify the physician/Nurse Practitioner of ongoing, rapid decline in the resident's condition. LVN A failed to administer nebulizer treatments as ordered and failed to document assessments/monitoring as scheduled on the MAR. As a result, CR#1 declined , was found unresponsive 3 hours later and was pronounced DOA by 911. These failures affected one former resident and placed all facility residents who may experience changes in their condition at risk of complications from delay in intervention . Findings include: CR #1 Record review of CR #1's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]., and [MEDICAL CONDITION]. Record review of CR #1's quarterly MDS dated [DATE] revealed the resident was severely impaired for cognition. She was total dependent on staff for locomotion and eating, she required two staff physical assistance with activities of daily living. CR #1's special treatments, procedures and program included oxygen therapy. Record review of CR #1's comprehensive care plan, dated 04/03/20, reflected she had potential for shortness of breath related to acute and chronic [MEDICAL CONDITION] with [MEDICAL CONDITION], chronic diastolic(congestive) heart failure. The interventions included to monitor for changes in CR #1's symptoms that may indicate worsening respiratory status and report to physician, staff education on positioning, nebulizer treatments as ordered , oxygen continuous as ordered, CR #1 had potential for impaired thought processes, confusion related to [DIAGNOSES REDACTED]. Record review of CR#1's progress notes dated 6/1/20 at 7:10 PM revealed CR #1 was noted with cough and congestion. NP notified, chest X-ray ordered and Duo-Neb ( [MEDICATION NAME]/[MEDICATION NAME]) every four hours for 7 days for congestion and cough, Oxygen saturation to room air 96%. At 7:17 PM her vital signs post [MEDICAL TREATMENT] T97.6, P60. BP 116/63, Chest X-ray done result still pending. There was no documentation regarding CR #1's assessment at that time. Interview with LVN A ( Unit Manager) on 9/2/20 at 2:19 PM involved and took care of CR #1 on 6/2/20, she said she did not know much about CR #1 who was moved to her unit. She did not get any report from any nurse. LVN A said she had just started working at the facility a week and half before the incident . She noticed CR #1 was weak, drowsy, heard resident gurgling with crackles on entering the room and she suctioned her and was then aroused on stimulation. About 2 hours she went back to check on the resident , noticed the resident's breathing had changed and she called LVN B for help because she could get the vital signs, she then stepped out of the room to call 911 and then call the NP. Further interview with LVN A regarding notifying the doctor/NP about CR #1's change in condition, she said she was just thrown out into taking care of CR #1 because the facility was short of staff and did not get any report and was not sure when the nebulizer treatment was given last. LVN A said she started working as a unit manager a week and a half before the incident. LVN A was not aware of chest X-ray ordered on [DATE]. Record review of LVN A personnel file revealed date of hired was 5/26/20 full time and she changed to PRN ( working as needed) on 7/10/20 due to unknown deployment. Further review revealed no competent checks on her file. Interview with DON (Graduate Nurse) on 9/3/20 at 4:30 p.m. regarding LVN A's competency check , she said she was not sure where it was because she was not the DON (GN) when LVN A was hired. DON (GN) said the Director of HR (Human Resources) does some new hire training. Interview with the Director of HR on 9/10/20 at 4:04 p.m., she said she does the computer training for new hires and the DON and ADON does the nursing hands-on in the unit. She did not have LVN A's check list. Record review of the facility policy statement revised August 2006: The Nursing Services department is under the direct supervision of a Registered Nurse: Policy Interpretation and Implementation: 1. The Nursing Services department is managed by the Director of Nursing Services. The Director is a Registered Nurse ( RN), licensed by this state, and has experience in nursing service administration, rehabilitative and geriatric nursing. 2. The Director is employed full-time (40-hours per week) and is responsible for, but is not necessarily limited to: a. Developing and periodically updating the nursing service objectives and statements of philosophy; b. Developing standards of nursing practice . h. Developing staff training programs for nursing service personnel J. Ensuring that all health services notes are informative and descriptive of the supervision and care rendered including the resident's response to his or her care.

Based on observation, interview, and record review, the facility failed to ensure a resident who entered the facility with pressure ulcers received care and treatment consistent with professional standards of practice to promote healing and prevent further development or worsen of pressure ulcers for 1 of 5 resident (Resident #1) reviewed for pressure ulcers. The facility did not provide adequate interventions to prevent Resident #1's left hip pressure ulcer from worsening The facility did not provide adequate interventions to prevent Resident #1's from developing three new pressure ulcers to his right hip, left upper back, and left lateral thigh within 6 weeks . The facility failed to document the development and assessment of Resident #1's pressure ulcer to right front hip for 6 days. These failures could affect facility residents who have pressure ulcers or are at risk of developing pressure ulcers by placing them at risk of developing new pressure ulcers and worsening of existing pressure ulcers. Findings included: Resident #1 Record review of the face sheet for Resident #1 revealed a [AGE] year-old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #1's annual MDS dated [DATE] revealed a staff assessment of mental status indicating the resident had short term and long-term memory problems. Further review of the MDS revealed he was totally dependent on staff for care and had impairment to both sides of his upper and lower extremities. MDS revealed Resident #1 was at risk for pressure ulcers and had one unhealed pressure ulcer at a stage 4 that he was admitted with. The MDS reflected he received skin treatments of pressure reducing device for chair and bed, pressure ulcer care, and applications of ointments/medications. Record review of Resident #1's quarterly MDS dated [DATE] revealed same information as his annual assessment on 1/1/20. Record review of Resident #1's care plan updated 4/2/20 revealed he had a skin tear to left upper back area. Interventions included: provide progress notes to resident/family on healing, staff will be aware of fragile skin, assess wound healing weekly, provide treatment as ordered by physician, assess skin daily with routine care, full skin evaluation with bath/shower, assess changes in skin status that indicate worsening of pressure ulcer and notify the physician, perform skin care with attention to keeping skin folds clean and dry, reassess treatment plan if no healing within 2-4 weeks. Record review of Resident #1's care plan updated 4/17/20 revealed he had developed a pressure ulcer: unstageable with (slough and/or eschar) to left lateral hip. His interventions included: mechanical lift to avoid skin friction/shearing, repositioning: two persons assist, refer to wound specialist/wound clinic for evaluation, refer to dietician for evaluation of current nutritional status, start Pro-stat 30 cc via gastric tube twice a day for protein malnutrition. Provide progress report to resident/family on healing status, provide pressure reducing surfaces on bed and chair, provide supplemental nutritional support, labs: [MEDICATION NAME] level to evaluate protein, perform wound care, assess wound healing weekly, float heels off the bed, elbow protectors on both elbow, full skin evaluation with bath/shower, maintain head of bed angle at less than 30 degrees, administer pain medication. Record review of Resident #1's care plan updated 4/25/19 revealed he was had potential for alteration in skin integrity: Risk for skin tears/bruising/ breakdown due to: thin and fragile skin; dependent for bed mobility, repositioning and transfers, bowel and bladder incontinence; [MEDICAL CONDITION], impaired sensory perception due to severely impaired cognition, compromised nutrition; NPO with dependence for pe[DEVICE]. Interventions included: 1/25/19 left hip pressure ulcer - present upon admission. Administer skin care treatment and monitoring as ordered by physician wound care specialist referral and follow up as needed. Monitor for signs/symptoms of infection. Notify family with progress and treatment changes as needed. Frequent skin checks with routine care every shift and as needed. Complete skin assessment weekly and review or changes indicating possible skin care needs. Provide preventative skin care management during all shifts. Utilize pressure relieving devices as indicated. Assist resident with turning and repositioning, cluster task for check and changing for incontinence. Notify physician and responsible party as indicated for skin changes identified along with further skin care needs and interventions needed. Utilize wedge cushions and pillows for positioning, air loss mattress, assist resident with application of bilateral hand splints as tolerated. Record review of Resident #1's March/April 2020 Physician orders [REDACTED]. Nutrition/Supplements Tube Feeding - Order started on 1/1/20 and discontinued 4/21/20 to start [MEDICATION NAME] 1.5 at 45ml/hour x 20 hours. Tube Feeding - Order started on 4/21/20 - current to start [MEDICATION NAME] 1.5 at 50ml/hour x 20 hours. Supplement - Order started on 4/15/20 and discontinued on 4/21/20 for Prostat 30cc via peg tube twice a day for protein malnutrition. Supplement - Order started on 4/28/20 - for Prostat 30cc via peg tube twice a day for protein malnutrition. Record review of Resident #1's physician order [REDACTED]. Left Hip Left Hip - Order started on 2/25/20 and discontinued 3/17/20 to cleanse left hip with normal saline, pat dry, apply collagen patch, [MEDICATION NAME], calcium alginate and cover with foam dressing daily. Left Hip - Order started on 3/17/20 and discontinued 3/24/20 to cleanse left hip normal saline, pat dry, apply collagen powder, collagen patch, skin prep to edges and cover dry dressing daily. Left Hip - Order started on 3/24/20 and discontinued 4/1/20 to cleanse left hip with normal saline, pat dry, apply [MEDICATION NAME], collagen powder, and calcium alginate and cover with dry dressing daily Left Hip - Order started on 4/1/20 - current to cleanse left hip wound with normal saline, pat dry, apply collagen powder, collagen patch and cover with dry dressing daily. Left Upper Back/ Flank area Left Upper Back - Order started on 3/11/20 and discontinued 3/17/20 to cleanse left upper back with normal saline, pat dry, apply collagen patch and cover with dry dressing daily. Left Upper Back - Order started on 3/17/20 and discontinued 4/7/20 to cleanse left upper back with normal saline, pat dry, apply collagen patch, calcium alginate and cover with dry dressing daily. Left Upper Back - Order started on 4/7/20 and discontinued 4/28/20 to cleanse left upper back with normal saline, pat dry, apply [MEDICATION NAME], collagen powder, calcium alginate and cover with dry dressing daily. Left Flank area - Order started on 4/28/20 - current to cleanse wound to left flank area with normal saline, pat dry, apply collagen powder and collagen gel then cover with foam dressing daily. Left Lateral Hip Left Lateral hip - order started on 4/15/20 - current to cleanse left lateral hip with normal saline, pat dry, apply [MEDICATION NAME], collagen, calcium alginate and dry dressing daily. Right Hip-Re-opened wound Order started on 4/11/19 for Nyamyc 100,000 units/GM powder, wash area above right hip with soap and water pat dry apply [MEDICATION NAME] 2 times daily. Right Hip - Order started on 4/24/20 and discontinued on 4/28/20 to cleanse right hip with normal saline, pat dry, apply [MEDICATION NAME] and calcium alginate and dry dressing daily Right Hip - Order started on 4/28/20 - current to cleanse right hip with normal saline, pat dry, apply collagen then cover with dry dressing daily. Surveyors record review of Resident #1's electronic record on 4/28/20 at 9:30AM revealed no mention of right hip wound in his progress notes or wound assessments. Records review of Resident #1's wound healing progress/weekly wound assessment report revealed: Pressure ulcer left hip Measurements on date of wound discovery/development (1/25/19) - 3.50 x 3.00 x 1.00 (stage 4) Measurements on 3/3/20 - 1.60 x 1.70 x .10 (stage 4) Measurements on 3/11/20 - 1.70 x 1.70 x .10 (stage 4) Measurements on 3/17/20 - 1.80 x 1.90 x .10 (stage 4) Measurements on 3/24/20 - 2.00 x 2.10 x .10 (stage 4) Measurements on 3/31/20 - 2.90 x 2.80 x .10 (stage 4) Measurements on 4/7/20 - 2.60 x 2.50 x .10 (stage 4) Measurements on 4/15/20 - 2.50 x 2.40 x .10 (stage 4) Measurements on 4/22/20 - 2.40 x 2.30 x .10 (stage 4) Other: shear left upper back Measurements on date of wound discovery/development (3/11/20) - 2.10 x 1.40 (not staged) Measurements on 3/17/20 - 2.00 x 1.30 Measurements on 3/24/20 - 1.40 x .90 Measurements on 3/31/20 - 1.70 x 1.10 Measurements on 4/7/20 - 1.80 x 1.30 Measurements on 4/15/20 - 1.70 x 1.50 Measurements on 4/22/20 - 1.60 x 1.80 Pressure ulcer left lateral thigh - front Measurements on date of wound discovery/development (4/15/20) - 3.10 x 2.50 x 0.0 (unstageable due to slough/eschar) Measurements on 4/22/20 - 3.50 x 2.40 x .20 (unstageable due to slough/eschar) Further review of Resident #1's wound assessments revealed no mention of any other current wounds (no wound to right hip). Record review of Resident #1's skin inspection reports revealed skin not intact - existing from 3/2/20 - 4/27/20. Interview with DON on 4/28/20 at 11:00AM revealed the skin inspection reports would not show if Resident #1 presented with a new wound. She said if he developed new skin concerns it would be captured on the wound assessments. Record review of Residents #1's progress notes dated 3/11/20 at 11:23AM revealed, Other//Left Upper Back .Wound doctor at bedside to assess wounds, shearing noted to left upper back with 100% granulated tissue with no drainage, new order to cleanse with normal saline, pat dry, apply collagen patch and cover with dry dressing daily. Wound to left hip unchanged with 10% slough and 90% granulated tissue with scant amount of serosanguineous (fluid composed of serum and blood) exudate. Current treatment continues. Air mattress in place. Voicemail left to family. Note was entered by wound care nurse. Record review of Resident #1's progress notes dated 3/17/20 at 12:45PM revealed, Pressure Ulcer//Left Hip// .Wound doctor at bedside to assess wounds, shearing to left upper back with 90% granulated tissue and 10% skin tissue with no drainage, current treatment continues. Wound to left hip unchanged with 100% granulated tissue with no drainage. New order for heavy collagen, collagen patch, skin prep to edges, and dry dressing. Air mattress in place. voicemail left to family. Note entered by wound care nurse. Record review of Resident #1's progress notes dated 3/24/20 at 12:22PM revealed, Pressure Ulcer//Left Hip// .Wound doctor at bedside to assess wounds, shearing to left upper back with 80% granulated tissue and 20% skin tissue with no drainage, current treatment continues. Wound to left hip with increased surface area with 80% granulated tissue and 20% slough with small amount of serosang exudate. New order for [MEDICATION NAME], calcium alginate, and collagen powder, and dry dressing. Air mattress in place. Family updated. Record review of Resident #1's progress notes dated 3/31/20 at 12:00PM revealed, Other//Left Upper Back// .Wound doctor at bedside to assess wounds, shearing to left upper back with 100% granulated tissue with scant amount of serosang exudate, current treatment continues. wound to left hip with increased surface area with 100% granulated tissue with small amount of serosang exudate. New order for collagen patch and collagen powder and dry dressing. Air mattress in place. Family updated. Note was entered by wound care nurse. Record review of Resident #1's progress notes dated 4/7/20 at 11:55AM revealed, Pressure Ulcer//Left Hip// .Wound doctor at bedside to assess wounds, shearing to left upper back with 50% granulated tissue and 50% slough with small amount of serosang exudate, current treatment continues. Wound to left hip improved with decreased surface area with 100% granulated tissue with scant amount of serosang exudate. Current treatment continues. Air mattress in place. voicemail left to family. Note was entered by wound care nurse. Record review of Resident #1's progress notes dated 4/15/20 at 2:31PM revealed, Pressure Ulcer//Left Lateral Thigh - Front// .Wound doctor at bedside to assess wounds, shearing to left upper back with 70% granulated tissue and 30% slough with small amount of serosang exudate, area debrided by wound doctor current treatment continues. Wound to left hip improved with decreased surface area with 100% granulated tissue with scant amount of serosang exudate, current treatment continues. Unstageable pressure ulcer noted with 20% slough, 60% eschar, and 20% granulated tissue with no drainage noted. New order to cleanse with normal saline, pat dry, apply [MEDICATION NAME], collagen powder, calcium alginate and dry dressing daily. Air mattress in place. Family updated. Record review of Resident #1's progress notes dated 4/22/20 at 1:46PM revealed, Pressure Ulcer//Left Hip// .Wound doctor at bedside to assess wounds, shearing to left upper back with 80% granulated tissue and 20% slough with small amount of serosang exudate, area debrided by wound doctor current treatment continues. Wound to left hip improved with decreased surface area with 100%granulated tissue with scant amount of serous exudate, current treatment continues. Unstageable pressure ulcer noted with 20% slough, 50% eschar, and 30% granulated tissue with small amount of serosang exudate. current treatment continues. Air mattress in place. Family updated. Note entered by wound care nurse. Record review of NP progress note for Resident #1 dated 4/22/20 revealed a chief complaint of new wound and an evaluation was required of wound healing and new wounds. Her review of skin revealed in part, .left hip wound, left flank shearing, left lateral hip wound, and right hip wound . left hip wound 2.4 x 2.3 x .1. 100% granulation. Scant serosanguineous drainage. Left flank shearing 1.6 x 1.8 x UTD (unable to determine). 20% slough, 80% granulation. Mild exudate. Debrided by wound care physician. Left lateral hip/thigh. 3.5 x 2.4 x UTD. 20% slough, 30% eschar, and 50% granulation. Right hip wound no measurements . Further review of the note revealed an assessment and plan noting, Right hip pressure ulcer - new problem - treatment nurse to evaluate and treat; consult wound care physician for new problem. Note indicated the plan of care was discussed with LVN #1, wound care nurse, and the DON. End of note revealed [DIAGNOSES REDACTED]. Record review of Resident #1's physician orders [REDACTED]. Record review of Resident #1's NP progress note dated 4/15/20 revealed in part, .Requested by nursing to evaluate the patient for new wound to left hip. Requesting protein supplements to be started for wound healing . protein calorie malnutrition, established problem - initiate protein supplement 30cc twice daily . Record review of Resident #1's progress noted dated 4/21/20 at 12:35PM revealed in part, .Monthly Nutrition Review - Wound/Tube feeding Re-Evaluation: Resident is [AGE] year-old male currently NPO. Tube feeding Order: [MEDICATION NAME] 1.5 @ 45 mL/hour x 20 . Resident has been gradually losing weight during the month. Weights for this month are as follows: 70.0, 68.6, and currently 66.0. Resident with improved existing wound with new additional wound recently identified . Resident has increased needs to promote weight gain and wound healing, therefore tube feeding rate was increased to meet those needs. Resident has noted weight loss during the month in addition to newly identified wound. Possible that resident needs are increasing due to progression of clinical conditions. Recommend increasing tube feeding to 50 mL/hour . Also recommend discontinuing liquid protein supplement as recommended tube feeding will provide 2.26grams protein/kilogram body weight. Will continue to monitor and will follow up as needed . Note was written by the Dietician. Interview on 4/28/20 at 9:45AM, Resident #1's RP said since 3/9/20 she had not been able to visit Resident #1 due to COVID restrictions. She said since then Resident #1 has developed two new wounds. The RP said she and other family members would visit the resident every day and make sure he was being cared for. She said she had concerns that since they are not able to come to the facility to see the resident, the facility may not have been as attentive to him as usual, causing him to develop new pressure ulcers. The RP said the resident has been having a wound to his left hip and now has an additional wound to his left hip area and another wound on his back. The RP said she did not know of any other wound development but wanted the matter looked into before he had further skin breakdown. She said the only rationale she was given for him now suddenly developing new wounds was because he was a complicated case given his malformations. Her main concern was that they were not repositioning the resident as they should and felt it was the only explanation why he would suddenly develop these new wounds now that families are not allowed in the building. She said she was notified of the development of the new wounds a week before 4/23/20. She said she requested to the see the wounds and was first told they could not send her pictures or video of the wound because of HIPAA. She said on 4/23/20 they finally allowed her to view the wounds via video call. She said she was shocked to see how large the wounds were and said they were very red. She said the residents old wound to his left hip looked like it had gotten worse. The RP said the family was very upset about him developing the wounds and was looking into moving the resident. Observation and interview on 4/28/20 at 10:05AM, Resident #1 was lying in bed unable to communicate. Resident had [MEDICAL CONDITION] attached. Residents body was noted to have deformities due to congenital disease. The upper body (chest and ribcage) were noted to be abnormally large compared to extremities. Also left upper chest and ribcage was larger than right chest/ribcage. Contractures were also noted to all four extremities. LVN #1 assisted surveyor with viewing Resident #1's wound areas. LVN #1 showed surveyor wound area to left mid upper back (ribcage area) that was covered with a dry dressing and the area to the residents left hip that was also covered by a dry dressing. LVN #1 was asked about the development of Resident #1's pressure ulcers and she stated, the pressure ulcer to the left hip was not new for it had re-opened in the last 4-6 weeks but the pressure ulcer to the mid-upper back was new. LVN #1 also stated there was two pressure ulcers to the left hip area covered by the one dressing and one of the pressure ulcers to the left hip was also new. Observation and interview on 4/28/20 at 10:12AM, LVN #1 was asked if Resident #1 had any other pressure ulcers in addition to the ones already observed in the left hip and left mid-upper back areas. LVN #1 said he had another pressure ulcer to the right hip area that had recently developed. LVN #1 then was asked to assist with the observation of the pressure ulcer to the right hip area. Observation revealed an ulcer to the right hip/close to the right inguinal area covered by small dry dressing. While assisting with the observation, LVN #1 said she was placing small area of resident's gown between right lower abdominal area and right inner hip/inguinal area to help relieve the pressure to that area. She also stated that she and other staff were using pillows to relieve pressure areas on Resident #1's body. Interview on 4/28/20 at 10:30PM, wound care physician said Resident #1 had developed new wounds within the last 6 - 8 weeks and his left hip wound that they had down to almost healed had also began to slowly reopen. The wound care physician said he was not sure why the resident was now developing these new pressure ulcers. He said the resident was very high risk for developing pressure ulcers given his severe deformities and said the resident was also nutritionally compromised. The wound care physician said today was his first day viewing the wound to the residents right hip and said the resident had previously had a wound to that area that had healed up a while ago. He could not recall how long ago the resident had the wound to right hip but said it had been healed for a long time. The physician suggested a reason for wound developing and not healing could be due to [MEDICAL CONDITION] with the resident not able to see his family who would visit him daily. He said the resident cannot communicate but he had noticed a change in the residents affect and said it was flat and the resident was not responding like he usually would. The physician said he was going to order some labs for the resident to see if there was something going on. Record review and interview on 4/28/20 at 11:00AM, the DON said Resident #1 had recently developed wound to his right hip within the past week and she was not sure of the exact date when it developed. She was asked where it would be documented because surveyor only saw mention of the wound in the physician orders [REDACTED]. The DON said the information should be in the wound assessments. The DON looked through the electronic record with surveyor where it was viewed there was no mention of the right hip wound under the wound assessments. The DON then instructed the surveyor to look under the progress notes and to click on the tab to view wound assessments. The last wound assessment note that appeared on screen was from 4/22/20 that did not have mention of the right hip wound. The DON said she would check with the wound care nurse of where her documentation was for the wound on the right hip and clarify when it was discovered. The DON said Resident #1 was at risk for developing pressure ulcers because of his severe deformities. She said the facility did have preventative interventions in place for him not to develop pressure ulcers since his admission. She said the resident has always had an air mattress and they would do frequent repositioning every 2 hours and as needed. She said the staff would make sure the resident stayed cleaned by providing incontinent care, baths, apply moisture barrier creams, and completing weekly skin assessments. She said the resident also saw a wound care specialist weekly for the care of his wounds and received daily wound care from the facility for his existing wound. The DON said the resident had a special formula for his [DEVICE] that he's always had to provide him with enough protein. The DON was asked after Resident #1 developed his first new pressure ulcer to left upper back on 3/17/20, were there any new or changed interventions to further prevent the development of pressure ulcers and she said they adjusted the way they were positioning the resident by using more pillows and rolled up towels versus the positioning wedge. She said as the resident continued to develop the two additional pressure ulcers they continued to try and change the way they were positioning the resident to relieve pressure off wounds but said it was very difficult to do without putting pressure on other pressure points on his body because of his deformities. The DON added the resident did have a specialized wheel chair, but the resident was not put into it lately because family only wanted him up in the wheel chair with them present. Family had been restricted from visiting due to COVID precautions since March. There were no other interventions mentioned specific to the resident deformities aside from repositioning. Interview and record review on 4/28/20 at 3:00PM, the DON was asked if she got clarification from the wound care nurse on when Resident #1's right hip wound was discovered and where the documentation was for it. The DON replied that the notes for the right hip wound was given to the surveyor with the copies of the residents record that were requested (records were brought to surveyor around 2:00PM). The paper records were reviewed with the DON and revealed a progress note dated 4/24/20 at 1:39PM that was entered by the wound care nurse. The note revealed, recurring ulcer noted to right hip with 100% granulation tissue and no drainage. New order to cleanse with normal saline, pat dry, apply [MEDICATION NAME] and calcium alginate and cover with dry dressing. Family notified, and NP notified. The DON was asked where the note was in the electronic record and she explained it was in the progress notes. The DON was reminded the progress notes were reviewed with the surveyor and there was not a wound assessment note on 4/24/20 that came up. The electronic record was reviewed again with DON and the note referenced above for 4/24/20 was then showing in the record. The DON said she did not recall reviewing the progress notes in the electronic record with the surveyor and said she only recalled looking through the weekly wound assessments. Surveyor requested to speak with the wound care nurse to discuss when the note from 4/24/20 was entered. Interview on 4/28/20 at 3:56PM, CNA #1 and CNA #2 said they both cared for Resident #1. They said the resident was always in bed and needed two people assist with everything. They said they were aware of Resident #1's wounds and the interventions they would use was to reposition him every 2 hours and as needed. They said they would try and keep him turned on his right side to keep him off his wounds on the left side. They said since the resident developed wound to his back they stopped using the positioning wedge and just used pillows to position him in bed. They said the ADON gives them instructions on how to care for Resident #1 and how they should position him in bed. The CNA's denied discovering Resident #1's new wounds and said the bandages were already there when they would come in to care for him. They said if they were to notice and new skin concerns they would notify the nurse. Interview and record review on 4/28/20 at 4:15PM, the DON said the wound care nurse had already left for the day. The wound care nurse phone number was requested. The DON was shown the NP progress note dated 4/22/20 reviewed above that indicated the right hip wound was discovered on 4/22/20 and not 4/24/20 as indicated by the wound care nurse progress report. The DON said the NP note read as if the NP had discovered the wound. She said the staff would have only been aware of the wound if the NP would have notified them and said the staff were not aware of the wound on 4/22/20. The DON said the NP's usually visit residents and assess them on their own and the facility staff are usually not present. The DON was shown the portion of the note that indicated the plan of care was discussed with herself, the wound care nurse, and LVN #1. The DON said she saw that's what the note said but denied being told about the right hip wound on 4/22/20 and suggested the NP may have forgot to mention the right hip wound to staff. The NP phone number was also requested from the DON. Interview on 4/28/20 at 4:20, the ADON said Resident had developed his last wound to the right hip sometime last week and said she thought the wound care nurse was the one who discovered the right hip wound. The ADON said the interventions they were using for to prevent and treat Resident #1's wounds were by frequent repositioning, offloading him, making sure nothings touching and they were doing so with the use of pillows. The ADON was asked her opinion on why Resident #1 had developed his new wounds and she suggested temperature change with it being warmer outside. She said they decreased the number of pillows being used so the resident would not get hot and sweaty and provided a fan in his room. She said the family liked to position the resident a certain way, but they had to explain to the family they could not use all those pillows because it could affect the effectiveness of his air mattress. She said the fan was just put into his room the past weekend (2-3 days ago). She said they had been using a positioning wedge in the past but stopped the use of the positioning wedge when he began developing new wounds. The ADON spoke about the difficulties of positioning the resident and offloading with the deformities he had. Observation on 4/28/20 at 4:30PM, Resident #1 pressure ulcers were as follows: pressure ulcer (approximately 1-2 cm in circumference, stage 2) to left mid- upper back (ribcage area), two pressure ulcers to left hip area (both ulcers adjacent to each other and with approximately 2-3 cm in circumference each), one pressure ulcer to the right hip/close to the right inguinal area (approximately 2 cm in diameter, possible stage 2 due to broken skin). Observation was made with ADON. Phone interview attempted on 4/28/20 at 4:54PM with the wound care nurse, there was no answer. A voicemail was left with no return phone call. Phone interview on 4/28/20 at 5:16PM, the NP said she had identified the wound to Resident #1's right hip during her visit with him on 4/22/20. She said she usually doesn't look at his wounds because he had a wound care doctor but given the concerns of him developing new wounds she wanted to assess them. She said her and a nurse from the facility were looking over the resident wounds when they noticed that he had also developed a wound to his right hip. She said the facility was made aware of the right hip wound that was discovered during her visit. She could not recall who the nurse was who was in the room with her. Record review of the facility's Pressure Ulcer/Skin Breakdown - Clinical protocol policy (revised April 2018) revealed in part, .1. the nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers; for example, immobility, recent weight loss, and a history of pressure ulcers. 2. In addition, the nurse shall describe and document/report the following: a. full assessment of pressure sore including location, stage, length, width, and depth, presence of exudates or necrotic tissues; b. pain assessment; c. residents mobility status; d. current treatments, including support surfaces; and e. all active [DIAGNOSES REDACTED]. 2. The physician will clarify the status of relevant medical issues . 1. The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents. 2. The Physician will help identify medical interventions related to wound management . 3. The physician will help staff characterize the likelihood of wound healing based on a review of pertinent factors . 4. As needed the physician will help identify medical and ethical issues influencing wound healing . Further review of the policy revealed in part, . 1. During the resident visit, the physician will evaluate and document the progress of wound healing - especially for those with complicated, extensive, or poorly - healing wounds. 2. The physician will guide the care plan as appropriate, especially when wounds are not heal (TRUNCATED)

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents, for one of 14 residents (Resident #1) reviewed for accidents, in that: Resident # 1's care plan for a two-person Hoyer lift transfer assistance was not implemented when CNA#2 transferred the resident alone. As a result, Resident #1 sustained a hematoma to the right rib cage, flank, chest and axillary area. This failure affected one resident and placed her at risk of injuries and pain . Findings included: Resident #1 Record review of Resident #1's face-sheet revealed a [AGE] year-old female, initially admitted to the facility on [DATE], and re-admitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #1's Annual MDS dated [DATE] revealed resident's cognitive skills for daily decision making was moderately impaired. Further review revealed Resident #1 was totally dependent on two staff for bed mobility and transfers. Record review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS score of 7, indicating severely impaired cognition. Further review revealed Resident #1 was totally dependent on two staff for bed mobility, transfers and toilet use. Record review of Resident #1's care plan (review date: 7/20/19) revealed in part .Care plan description: Resident #1 is dependent on staff assistance with ADLs due to decreased muscle strength, personal history of [MEDICAL CONDITION], has bilateral hand contracture, impaired balance and decreased physical and functional mobility, decreased safety awareness, and dementia. Intervention: Hoyer lift machine use for transfers with 2 persons assist at all times. Provide Resident #1 assistance with bath/showers and shampoo according to schedule and as needed. 2 persons assist at all times. Assist Resident #1 with dressing, grooming/ 2 person assist at all times. Observation and interview of Resident #1 on 6/26/19 at 11:28 AM revealed, Resident #1 was lying in bed, groomed and dressed appropriately. Further observation revealed Resident #1's bed was in a low position. Resident #1 stated Panky hit me when asked about the bruise to her right side. Resident expressed no pain. Resident looked away from the surveyor and did not answer any further questions. Record review of facility's investigation dated 6/25/19 revealed: Who made the allegation: Other: LVN #1. When: 6/20/19 at 4:00 PM. Injury: Yes. Description of injury: Bruising to right rib cage/flank, chest and axillary areas. Investigation summary: CNA reported small discolored area to right rib cage area during morning ADL care, CNA #1 to charge nurse. Resident was assessed for and denied pain and routine care was resumed by staff. Resident was transferred by two staff with the mechanical lift to the wheel-chair for morning meal. At approximately 4 pm, resident was re-assessed by nurse and discolored area was noted to have increased in size and spread from the right rib cage to flank, chest and axillary area. Assessment was completed by charge nurse and NP. Record review noted that resident has history of abnormal coagulation profile and is receiving anticoagulation therapy. [MEDICATION NAME] 8.5 mg PO daily. New order was obtained for INR at bedside, resulting in 3.5 ( therapeutic range : 2- 3.5). [MEDICATION NAME] was placed on hold. Orders for STAT lab, PT/INR, X-Ray of right shoulder 2V, new order for ultra sound of chest. Head to toe assessment by nurse, NP/RP notification, initiated in-service on abuse/neglect, and transfer training with return demonstration. Interviews with staff revealed that resident was transferred with mechanical lift on 6/19/19 with one assist. Employee (CNA #2) was suspended pending investigation and provided with one on one in-service with return demonstration with safe transfer techniques with a mechanical transfer. The investigation finding was inconclusive. The report was completed by the facility DON. Record review of Resident #1's X-Ray result revealed: Date of exam: 6/20/19. History: Hematoma, Bruising Right shoulder 2 V: Findings: 3 views of the right shoulder were obtained. The bone structures are intact, without evidence of fracture or dislocation. The soft tissues are within normal limits. Impression: No acute findings. Record review of Resident #1's X-Ray result revealed: Exam date: 6/21/19 Exam: Chest ultra sound Signs and symptoms: Localized swelling, mass and lump, trunk. Radiology report: Procedure: soft tissue ultrasound the right chest. History: Bruising and swelling involving the right chest post using a lift at assisted living facility. Comparison: none. Sonographic interrogation of the lateral right chest was performed. There is subcutaneous [MEDICAL CONDITION] and soft tissue swelling involving the lateral right chest. No defined hematoma formation or fluid collection was observed. Impression: Subcutaneous [MEDICAL CONDITION] and soft tissue swelling involving the lateral right chest. Record review of facility's in-Service Training Report dated 6/20/19 revealed Topic: Abuse and Neglect. Further review revealed 35 facility staff were in-serviced. Record review of facility's mechanical lift competency check list dated 6/21/19 revealed 22 facility staff completed the in-service. Record review of One-on-One Training Acknowledgement form dated 6/24/19 revealed: Associate name: CNA #2. Training objectives: Transfer training with mechanical lift. Summary of training: Training provided to employee regarding mechanical lift. When employee uses mechanical lift, she understands that all mechanical lift transfers must be done with two people at all times. Employee also viewed training video on mechanical lifts. Phone interview on 6/26/19 at 10:19 AM, CNA #2 stated she worked on the evening shift, and when she went to put the resident to bed, she transferred the resident by herself because she knew how to do it. She stated she watched a video on transfers and knew how to transfer residents. She then stated there was another CNA present( CNA #1) who also worked on the hall with her, and that CNA watched her as she transferred Resident #1. CNA stated nothing went wrong during the shift, and there were no problems. CNA also explained there were no red areas on Resident #1 when she put the resident in the bed, and that she did not know how it happened. CNA stated she was aware of the resident's care need, and the Resident required two persons for transfers. CNA #2 stated staff are able to look in the computers to see the type of care residents need, and exactly what to do with the resident. Interview with CNA #1 on 6/26/19 at 10:50 AM, CNA #1 stated on the day the discolored area was discovered, she went to Resident #1's room to give the resident a bed bath, as she proceeded to remove the resident's gown, she saw a blue/black area under the resident's arm. CNA # 1 stated she immediately called LVN #1 who came in and assessed the resident. CNA#1 stated she asked Resident #1 if she was hit or dropped, but the resident denied. CNA #1 stated resident also denied pain. CNA explained when she worked with Resident #1 two days prior, there were no discoloration to the resident's skin. Interview with LVN #1 on 6/26/19 at 11:42 AM, LVN #1 stated on the day of the incident, she was notified in the morning by the CNA #1 of the discolored area, she proceeded to assess the resident, called the NP and the RP. LVN #1 stated around 4 PM the same day, she noticed the bruised area got bigger and darker. LVN #1 stated Resident #1 did not complain of any pain and did not say she was hit by anyone. Interview with CNA #3 on 6/26/19 at 2:20 PM, CNA #3 stated she worked with CNA #2 on the day Resident #1 was transferred by one person. CNA #3 stated on that day, she was assigned to one side of the hall, and CNA #2 was assigned to the other side of the hall. CNA #3 stated she never went to Resident #1's room, and CNA #2 did not ask for her assistance with transfer. She did not observe CNA #2 during any transfers. CNA #3 further stated she did not know what happened to Resident #1. Interview with DON on 6/26/19 at 2:29 PM, the DON stated a one on one in-service was completed with CNA #2 because she knew Resident #1 was care-planned for a two person transfer but chose to do it by herself. The DON further stated the rest of the staff were in-serviced on transfers, abuse and neglect. When asked if any additional re0education was provided to facility staff to prevent reoccurrence of the incident, the DON said the rest of the staff were not re-educated on following care-plans because CNA #2 was the only staff who did not follow the care-plan.

Based on interview and record review, the facility failed to develop and implement policies and procedures that prohibit the mistreatment and neglect of residents for one of 36 residents (CR#1) reviewed for neglect. LVN #1 left CR #1 unattended, did not intervene when CR #1 was having difficulty breathing and had an oxygen saturation of 80% while on 5 litters of oxygen. CR #1 was later found with no pulse or respirations and was later pronounced dead. The facility failed to promptly assess and provide medical care when the resident experienced difficulty in breathing and swallowing, had garbled speech, gurgling when breathing and was lethargic. MA #2 failed to notify LVN #1 after she was unable to administer medications to CR #1 due to CR #1's inability to swallow. LVN #1 left CR #1 unattended, with no pulse and respirations and failed to promptly initiate CPR (Cardio [MEDICAL CONDITION] Resuscitation) to CR #1, who was identified as a full code. An immediate jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and severity level of actual harm that is not immediate jeopardy. This failure affected one resident who died in the facility and placed 45 residents on three of the nine halls (halls 500, 600, and 800) of the facility at risk of not receiving services necessary with a change in condition which could lead to a decline in their health or death. Findings include: Intake # 7 Record review of CR #1's face sheet revealed a [AGE] year old female admitted to the facility on [DATE], readmitted [DATE] and died in the facility on [DATE]. Further review of CR #1's face sheet revealed the following Diagnosis: [REDACTED]. Record review of CR #1's admission assessment MDS dated [DATE] revealed CR #1's cognitive score was 12 out of 15 indicating moderate cognitive impairment. CR#1's behavior was checked for [MEDICAL CONDITION]. The assessment went on to read the resident required extensive assistance for bed mobility, transfer, locomotion, toilet use and was independent with eating (set up help only). CR #1 also required limited assistance with personal hygiene. Record review of CR #1's clinical record revealed there was no care plan for the resident. Record review of CR#1's physician order [REDACTED]. Record review of CR#1's MAR indicated [REDACTED]. Further review of this MAR indicated [REDACTED]. [MEDICATION NAME] 20 mg was administered once on [DATE] (on night shift 7pm [DATE]- 7a.m. on [DATE]). Record review of CR#1's MAR indicated [REDACTED] [DATE] -,[DATE] [DATE]- ,[DATE] [DATE]- ,[DATE] [DATE]- ,[DATE] [DATE]- not legible [DATE] - ,[DATE] Record review of CR #1's progress notes dated [DATE] at 4:33 a.m., written by LVN #2, read Resident in bed, not asleep. Resident has yelled all this shift long when asked what was wrong, resident was not making any sense, re-directed as needed but unsuccessful, PRN medication ([MEDICATION NAME]) given per MAR, ineffective. Resident incontinent of bowel and bladder and requires assistance with ADLs. Call light in reach. Will continue to monitor for safety, vital signs: blood pressure -,[DATE], 85-heart rate, respiration -18 and 95%- oxygen saturation. Record review of CR #1's progress notes revealed no entries from 4:33 a.m. until the note below documented at 8:23 p.m. on [DATE]. Record review of CR #1's progress note dated [DATE] at 8:23 p.m., written by LVN #2 read report given this AM regards to patient was yelling just about all night long. This is usual behavior. Noted patient quiet at this time. After breakfast went in to give roommate [MEDICATION NAME] as ordered, noted a cough and congestion and gurgling. Medication aide stated she was not able to give morning medication. She noted some difficulty in swallowing. Informed that blood pressure was ,[DATE], heart rate was 55 and speech difficult to understand. Eyes open and able to focus. Responded to name. Cried out at times. Second set of vitals taken 96 temperature, heart rate 53, respiration ,[DATE], oxygen saturation 80% on 5 liters of oxygen via nasal cannula (no blood pressure was documented as being obtained at this time.) Call placed to physician at 10:45a.m., left message on service with vital signs. Went back to room to assist roommate, noted resident coughing, called RN to do assessment of patient, also informed unit supervisor (Unit Manager #1) that patient's condition has changed and going to call physician. Noted patient coughing more, second call placed to physician. Message left on service. Patient may need to go to the ER for evaluation. Awaiting a return call. Went to the clean utility room to get a suction machine at 11:09 a.m. took it back to patient's room and noted patient appeared not to be breathing. Called for assistance from RN and code blue was called. Staff arrived in force, two nurse practitioners with code team. Six (6) staff members in room. CPR was initiated at 11:16 a.m. Crash cart to room at 11:17 a.m. Ventilation started at 11:17 a.m. 911 called at 11:18 a.m., also patient's son was called at this time and was informed patient had a change of condition. He stated he was across town and would call family that was close. Also called daughter and informed of condition in change. After speaking to son, Daughter in law arrived at 11:30 a.m., and was informed patient had passed away. Son arrived at 11:55 a.m. Patient was pronounced by NP at 11:29 a.m. Call placed to physician and message left on service that patient had expired and pronounced 11:29 a.m. This progress note was written by LVN#1 at the end of her 12 hour shift on [DATE]. Interview on [DATE] at 11:05a.m., CNA #1 said she had cared for CR #1 on the morning of [DATE]. The aide said she brought CR #1 breakfast around 7:30 a.m. on [DATE] and the resident was in an upright position in bed sleeping with her oxygen tubing hanging on her forehead. The CNA said the resident spoke to her quietly, then would holler a little louder then go back to a low voice. CR #1 appeared to be sleepy which the CNA said she thought was because the resident did not sleep the night before. CNA #1 said she was told the resident was up all night. CNA #1 said CR #1 was usually ready to get up in the morning and would eat breakfast in the dining room but that day the resident said she did not feel like eating and told CNA #1 maybe later. CNA #1 said she removed the breakfast tray later that morning and it had not been touched by CR #1. Interview on [DATE] at 2:24 p.m., the DON, when asked if she had reviewed the incident regarding the death of CR #1 on [DATE], said she started reviewing the incident and had no concerns so far. When asked why CR #1 was not sent to the hospital when she stayed up all night yelling and screaming, with increased agitation and staff unable to re-direct her, the DON said on [DATE], she consulted the physician for a possible hospital transfer when CR #1's behavior worsened. She said they contacted the physician on [DATE] because the family member of CR #1's roommate was upset with the yelling but the physician said there was no need for a transfer because the resident was not a danger to herself or to anyone else. Interview on [DATE] at 9:25 a.m., Unit Manger #1 said she was not notified of CR #1's difficulty swallowing or taking medications on [DATE]. Unit Manager #1 said she poked her head in to see the resident about 8:45 a.m., on [DATE] and the resident appeared sleepy but responded to her name and said hi back to her. Unit Manager #1 said around 11:00 a.m., when she was going down the hall, LVN #1 told her she had just called CR #1's physician. Interview on [DATE] at 9:48 a.m., MA #2 said she went into CR #1's room on [DATE] to give the resident her morning medications around 9:23 a.m. MA #2 said CR #1 did not have her oxygen cannula in her nostrils. MA #2 said she placed the cannula into her nose and decided to give the resident time to get some oxygen before administering the medication. MA #2 said CR #1 was lying back in the bed in an upright position, asleep with her eyes closed. MA #2 stated she noticed the resident's chest wall was going up and down and she appeared to be gasping for air. MA #2 said she then went down the hall to give morning medications to other residents on the same hall. MA #2 said she finished passing medications on hall 600 around 9:30 a.m. then she went back to CR #1's room and tried to give her the morning medications. MA #2 said she started to offer the resident a sip of water but the resident could not swallow the water. She then documented on the resident's MAR indicated [REDACTED]#1) on the hallway. MA #2 notified her that CR #1 could not take her medications due to a swallowing problem. MA #2 said CR #1 did not have a swallowing problem before and was always able to swallow her medications. Record review of CR #1's MAR indicated [REDACTED]. Further review of the back of the MAR indicated [REDACTED]. Interview on [DATE] at 2:08p.m., LVN #2 said she took care of CR #1 during the night shift from 7:00 p.m. on [DATE] till 7:00 a.m. on [DATE]. LVN #2 said CR #1 did not have any changes during the night shift. LVN #2 said the resident's vital signs were checked around 12:00 a.m. but she didn't document the vitals on the resident's progress notes until around 4:33 a.m. LVN #2 further said the resident was very agitated, disruptive, screamed throughout the night and was so confused she could not hold a conversation. LVN #2 said CR #1 was talking to herself and saying things like put me in the bed when she was already in bed. She further stated the resident constantly yelled and screamed out loud since readmitting to her unit from the hospital. LVN #2 said CR #1's behavior got worse over the weekend, she was particularly restless all night on [DATE] and could not be re-directed. LVN #2 said all attempts to redirect CR #1 were not successful including administrating an as needed medication [MEDICATION NAME] that was ordered for agitation. Interview on [DATE] at 11:17 a.m., LVN #1 said she began her shift about 7:10 a.m., on [DATE]. She got report from the night nurse that CR #1 was crying out all night which was her usual behavior. She was given as needed medication for her behavior which did not help. The resident continued disturbing everybody and other residents were getting upset. LVN #1 said during shift change, CR #1 was in her room and quiet. After she did dining room duty for breakfast LVN #1 said she was giving CR #1's roommate (Resident #1) an [MEDICATION NAME] injection sometime after 10:00 a.m. and CR #1 was alert to her name, not oriented and coughed twice. CR #1 then fell asleep. LVN #1 said she finished with Resident #1 then went to check on CR #1. CR #1's vital signs were taken and they showed oxygen saturation was 80%, blood pressure was ,[DATE], heart rate 55 and respiration were between ,[DATE] beats per minute. LVN #1 then left to call the physician who did not answer so she left a message. She said she then went to the supply room to get suctioning supplies. LVN #1 said it took about 5 to 10 minutes for her to return to CR #1's room. Upon entering CR #1's room she found CR #1 not breathing and without a pulse. She then left the room to call the RN to assess the resident and call for help, confirm the code status and call 911. When same questions were asked of LVN #1 her recollection continued to remain clear that she left the room when she assessed CR #1 with no pulse or respirations to seek assistance of the RN. LVN#1 maintained she did not initiate CPR. Interview on [DATE] at 4:00 p.m., LVN #1 said CR #1 did not appear to be in any acute respiratory distress, and her breathing was not labored. When asked to demonstrate CR #1's breathing the last time she saw her breathing, LVN #1's demonstration indicated shallow breathing. LVN#1 said the resident's head of bed was elevated, her eyes were closed and she made sounds. She stated CR #1's respirations were faint and shallow. Interview on [DATE] at 9:45 a.m., a family member of Resident #1 said she and another family member were in Resident #1's room for a visit the morning of [DATE]. Resident #1 is CR #1's roommate. She described CR #1's breathing as gurgling in agony. She stated CR#1 was congested and yelled and screamed constantly. The family member said she left for work but the other relative stayed with Resident #1. She stated the relative texted her and said the roommate was drowning in her own phlegm. The family member said LVN #1 would not have given the [MEDICATION NAME] injection to CR #1's roommate any time before 10 a.m. She said it most certainly was after 10 a.m. She stated the relative that was there then texted her at 11:16 a.m., saying I think my (Resident #1's) roommate (CR #1) just took her last breath and died . The family member continued by saying she had informed staff on [DATE] that CR #1 was drowning in her own phlegm and no one would come to check on her. Interview on [DATE] at 11:51 a.m., the DON said she believed the facility was in an immediate jeopardy situation because LVN#1 did not respond timely to CR#1's change in condition and should not have left the resident when she was assessed with [REDACTED]. The DON said she expected LVN#1 to stay with the resident, call for help and initiate CPR. Interview on [DATE] at 12:56p.m., the Facility Administrator said she was aware CR #1 passed away on [DATE] but did not know any of the events leading to the incident. The Administrator said as of today ([DATE]), she had been made aware that MA #2 passed medications and noted that CR #1 had swallowing difficulty which she reported to LVN #1 who did not promptly respond to the resident's change in condition. The Administrator further said LVN #1 had been terminated from the facility. Record review of facility's abuse prevention policy, which was not dated, read in part neglect is failure to provide goods and services necessary to avoid physical harm, mental anguish and mental illness. Record review of facility's policy on change in condition or status, revised [DATE], read in part our facility shall promptly notify the resident's his or her attending physician and representative of change in the resident's medical/mental condition and or status. The nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician when there has been a significant change in the resident's condition. A significant change of condition is a decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease related intervention, impact more than one area of the resident's health status and requires interdisciplinary review or revision of care plan. On [DATE] at 4:35p.m., an IJ was identified and the facility Administrator and DON were notified. The IJ was removed on [DATE]. The facility submitted and implemented the following plan to remove the IJ on [DATE]: Plan to remove immediacy: On [DATE] the facility initiated an in-service on identifying change of condition, remaining with a resident when in distress and calling for help with all care staff. Staff involved in the care of the resident during the code have been interviewed and statements received. The 24 HR reports from both stations have been reviewed again on [DATE] for the last 7 days to ensure that all change of conditions were identified and addressed. On [DATE] & [DATE] the nurse managers went to each resident individually and did a visual observation to ensure that all residents were in stable condition and no additional changes of condition were identified. The medical director was notified on [DATE] and gave orders to draw magnesium levels, CMP, and do EKG's on all residents on antipsychotic medications and consent forms were updated. Labs were drawn on [DATE] and are pending results and EKG's are pending at this time. All families of residents on antipsychotics were called by nurse managers on [DATE] and given additional education on the risks of antipsychotic use in the elderly and consent forms have been updated accordingly. The MARS and TARS were reviewed by nurse managers on [DATE] for this month of May to observe any vital sign trends and any identified trends were given to the pharmacy consultant for medication review and physician notification with any recommendations. Pharmacy consultant is reviewing all residents on antipsychotic medications for appropriate diagnosis, necessity of medication, and gradual dose reduction will be completed by [DATE]. The charge nurse, LVN #1, who was assigned to the resident, was terminated for failure to respond timely and appropriately to identify change of condition on [DATE]. In-serviced all departments available that a resident's code status can be located on the first page of the chart by Red Page for DNR and Green page for full code, face sheet, physician orders, on the MARS/TARS, and/or behind the advanced directive tabs in the medical record. Nursing staff available were in-serviced on how to handle a code on [DATE]. Nursing staff will not be allowed to come to work until training has been received on how to handle a code. How to handle a code will be included in the New Hire Orientation Process effective immediately. 1. Personal protective equipment, including gloves, masks, gowns and eyewear. 2. Pocket face masks, Ambu bags (,[DATE] L capacity), and/or mouth shields. 3. The basic life support (BLS) sequence of events is referred to as C-A-B (chest compressions, airway, and breathing). This has been revised from the previous sequence of A-B-C (airway, breathing, chest compressions). Call for help, stay with resident and prepare them for initiation of CPR, someone announces code blue over intercom, calls 911 and notifies family and physician. 4. Begin CPR if the adult victim is unresponsive and not breathing normally (ignoring occasional gasps) without assessing the victim's pulse. 5. Following initial assessment, begin CPR with chest compressions rather than opening the airway and delivering rescue breathing. 6. Use AED. 7. All rescuers trained or not, should provide chest compressions to victims of [MEDICAL CONDITION]. 8. Delivering high-quality chest compressions is essential: 1. Push hard to a depth of at least 2 inches (5 cm) at a rate of at least 100 compressions per minute. 2. Allow full chest recoil after each compression. 3. Minimize interruptions in chest compressions. Follow up: IDT for unnecessary medication review and [MEDICAL CONDITION] medication: review will be done weekly starting [DATE] (attendees: Nurse Managers, MDS/PPS, DON, ED, Pharmacy Consultant) Nurse Managers and/or designee will follow up with recommendations from IDT. Next week IDT will review follow up notes from previous meeting. First meeting will be held on Friday [DATE] at 10:30 a.m. and weekly thereafter. New Admit/Re-admit: Chart Audit will be completed on all new admits and readmits to ensure accuracy of orders, required follow up, and medications Nurse Managers and DON were in-serviced on the process [DATE]. Clinical Stand Up (current meeting format with the following focuses added)- 24 hr reports will be reviewed every morning in the clinical stand up meeting for changes of condition and proper treatment and follow up (start effective immediately). Weekend Nurse Manager will review all 24hr reports for changes of condition and proper treatment and follow up. Any areas of concerned will be addressed immediately. All new doctor's orders for antipsychotic medications will be reviewed by DON or designee to ensure appropriate diagnoses, necessity of medication and consent forms have been completed. Initiated [DATE] All findings will be reported to the QAPI Committee for further insight and direction. Monitoring: The surveyor monitored the plan to remove the immediate jeopardy on [DATE] and [DATE] as follows: Monitoring began on [DATE]. LVNs, RNs and MAs were interviewed on two shifts on changes in condition identification, communication/report to charge nurse, physician notification, and proper assessment following changes in condition. Record review of the facility In-Services revealed: [DATE] - thirteen staff members were trained on proper assessment, monitoring of residents with a change in condition and staying with resident when unresponsive, initiation of CPR and prompt ways of identifying code status and to call 911. Staff were to notify the DON or designee of any identified changes in condition. [DATE] - more than 60% of the facility's nursing staff members had been trained on assessment and prompt intervention when notified of any changes in resident's condition. Interview on [DATE] at 9:00 a.m., ADON #1 stated she completed chart audits, evaluated all residents in the facility for changes in condition, and the pharmacy consultant had completed medication review of all residents on [MEDICAL CONDITION] medications. She found that staff were implementing the appropriate and current plan. All residents on [MEDICAL CONDITION] medication had drug reduction initiated and the responsible parties were contacted to discuss the potential affects as well any black box warnings. Record review of in-services dated [DATE], [DATE] and [DATE] revealed ADON and unit managers trained all staff scheduled to work [DATE], [DATE] and [DATE]. Interviews with 3 MAs, and 7 CNAs on [DATE] between 7:30a.m., and 9:00a.m., revealed they received training on how to notify their charge nurse of any change identified in a resident during care and to ensure another manger was made aware of the change too, when to notify a charge nurse of anything usual noted about any patient, and if the nurses did not respond immediately to call the DON designee or the administrator. Interview on [DATE] at 8:50 a.m., the facility corporate nurse stated the facility would be continuing to monitor the DON and staff to ensure the plan was implemented and effective. She further reported she would continue to monitor the facility approved plan of removal to ensure the safety of the residents. She said she was monitoring and evaluating all changes in conditions, as well as those with newly prescribed [MEDICAL CONDITION] medications to ensure staff were implementing the plan. She also stated the facility's medical director was involved with the plan. After monitoring the implementation of the plan, the IJ was removed. The Administrator was informed the IJ was removed on [DATE] at 10:43 a.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolation and a severity level of actual harm that is not immediate jeopardy. The facility was continuing to monitor their plans to ensure residents' physicians were promptly consulted following changes in condition, psychoactive drugs were being monitored and staff were being trained on procedures including assessing, reporting resident changes in condition, initiating CPR and drug interactions. Facility census dated [DATE] revealed 45 residents resided on halls 500, 600 and 800.

Based on interview and record review the facility failed to provide the necessary care and services to attain or maintain the highest practicable mental and physical well-being in accordance with the comprehensive assessment and plan of care for one of 36 residents (CR#1) reviewed for quality of care. LVN #1 left CR #1 unattended, did not intervene when CR #1 was having difficulty breathing and had an oxygen saturation of 80% while on 5 litters of oxygen. CR #1 was later found with no pulse or respirations and was later pronounced dead. The facility failed to promptly assess and provide medical care when CR #1 experienced difficulty in breathing and swallowing, had garbled speech, gurgling when breathing and was lethargic. MA #2 failed to notify LVN #1 after she was unable to administer medications to CR #1 due to CR #1's inability to swallow. LVN #1 left CR #1 unattended, with no pulse and respirations and failed to promptly initiate CPR (Cardio [MEDICAL CONDITION] Resuscitation) to CR #1, who was identified as a full code. These failures resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity of actual harm that is not an immediate jeopardy with a scope identified as isolated. These failures affected one resident who died in the facility on [DATE] and placed 45 other residents on three of the nine halls (halls 500, 600, and 800) of the facility at risk of not receiving prompt assessments and intervention concerning a change in condition, which would cause a delay in treatment, a decline in health or death. Findings include: Intake # 7 Record review of CR#1's face sheet revealed a [AGE] year old female admitted to the facility on [DATE], readmitted [DATE] and discharged [DATE]. Further review of CR#1's face sheet revealed the following Diagnosis: [REDACTED]. Record review of CR#1's admission assessment MDS dated [DATE] revealed CR#1's BIMS score was 12 out of 15, indicating moderate cognitive impairment. CR#1's behavior was checked for [MEDICAL CONDITION]. Further review of this assessment revealed CR #1 required extensive assistance for bed mobility, transfers, locomotion, and toilet use, but was independent with eating (set up help only). CR #1 also required limited assistance with personal hygiene. Record review of CR #1's clinical records revealed there was no care plan for the resident. Record review of CR#1's physician order [REDACTED].#1's Physician orders [REDACTED]. Record review of CR#1's MAR indicated [REDACTED]. Further review of this MAR indicated [REDACTED]. Record review of CR#1's MAR indicated [REDACTED] [DATE] -,[DATE] [DATE]- ,[DATE] [DATE]- ,[DATE] [DATE]- ,[DATE] [DATE]- not legible [DATE] - ,[DATE] Record review of CR #1's progress notes dated [DATE] at 4:33 a.m., revealed a note written by LVN #2 which read Resident in bed, not asleep. Resident has yelled all this shift long when asked what was wrong, resident was not making any sense, re-directed as needed but unsuccessful, PRN medication ([MEDICATION NAME]) given per MAR, ineffective. Resident incontinent of bowel and bladder and requires assistance with ADLs. Call light in reach. Will continue to monitor for safety, vital signs: blood pressure -,[DATE], 85-heart rate, respiration -18 and 95%- oxygen saturation. Record review of CR #1's progress notes revealed no entries from 4:33 a.m. on [DATE] until the note below documented at 8:23 p.m. on [DATE]. Record review of CR #1's progress note dated [DATE] at 8.23 p.m., revealed a note written by LVN#1 at the end of her 12 hour shift on [DATE] which read in part .report given this AM regards to patient was yelling just about all night long. This is usual behavior. Noted patient quiet at this time. After breakfast went in to give roommate [MEDICATION NAME] as ordered, noted a cough and congestion and gurgling. Medication aide stated she was not able to give morning medication. She noted some difficulty in swallowing. Informed that blood pressure was ,[DATE], heart rate was 55 and speech difficult to understand. Eyes open and able to focus. Responded to name. Cried out at times. Second set of vitals taken 96 temperature, heart rate 53, respiration ,[DATE], oxygen saturation 80% on 5 liters of oxygen via nasal cannula (no blood pressure was documented as being obtained at this time). Call placed to physician at 10:45a.m., left message on service with vital signs. Went back to room to assist roommate, noted resident coughing, called RN to do assessment of patient, also informed unit supervisor (Unit Manager #1) that patient's condition has changed and going to call physician. Noted patient coughing more, second call placed to physician. Message left on service. Patient may need to go to the ER for evaluation. Awaiting a return call. Went to the clean utility room to get a suction machine at 11:09 a.m. took it back to patient's room and noted patient appeared not to be breathing. Called for assistance from RN and code blue was called. Staff arrived in force, two nurse practitioners with code team. Six (6) staff members in room. CPR was initiated at 11:16 a.m. Crash cart to room at 11:17 a.m. Ventilation started at 11:17 a.m. 911 called at 11:18 a.m., also patient's son was called at this time and was informed patient had a change of condition. He stated he was across town and would call family that was close. Also called daughter and informed of condition change. After speaking to son, Daughter in law arrived at 11:30 a.m., and was informed patient had passed away. Son arrived at 11:55 a.m. Patient was pronounced by NP at 11:29 a.m. Call placed to physician and message left on service that patient had expired and pronounced 11:29 a.m. Interview on [DATE] at 11:05a.m., CNA #1 said she had cared for CR #1 the morning of [DATE]. The aide said when she brought CR #1 breakfast on [DATE] around 7:30 a.m., the resident was sleeping in an upright position in bed, with her nasal cannula hanging on her forehead instead of in her nostrils. The CNA said the resident spoke to her quietly, then would holler a little louder then go back to a low voice. She said CR #1 appeared to be sleepy, which the CNA said she thought was because the resident did not sleep the night before. CNA #1 said she was told the resident was up all night. CNA #1 said CR #1 was usually ready to get up in the morning and would eat breakfast in the dining room but that day the resident said she did not feel like eating and told CNA #1 maybe later. CNA #1 said she took the tray out later that morning and it had not been touched by CR #1. Interview on [DATE] at 2:24 p.m., the DON, when asked if she had reviewed the incident regarding the death of CR #1 on [DATE], said she started reviewing the incident and had no concerns so far. When asked why CR #1 was not sent to the hospital when she stayed up all night yelling and screaming, with increased agitation and staff were unable to re-direct her, the DON said she consulted the physician on [DATE] for a possible hospital transfer when CR #1's behavior worsened. She stated the family member of CR #1's roommate was upset with the yelling, so they consulted the physician on [DATE], but the physician said there was no need for a transfer because the resident was not a danger to herself or to anyone else. Interview on [DATE] at 9:25 a.m., Unit Manger #1 said she was not notified of CR#1's difficulty swallowing or taking medications on [DATE]. Unit Manager #1 said on [DATE] around 8:45 a.m. she poked her head into CR #1's room to check on the resident. She further said the resident appeared sleepy but responded to her name and said hi back to her. Unit Manager #1 said around 11:00 a.m., when she was going down the hall, LVN #1 told her that she had just called CR #1's physician. Interview on [DATE] at 9:48 a.m., MA #2 said she went into CR#1's room on [DATE] to give the resident her morning medications around 9:23 a.m. MA#2 said CR #1 did not have her oxygen cannula in her nostrils. MA #2 said she placed the cannula into CR #1's nose and decided to give the resident time to get some oxygen before administering the medication. MA #2 said CR #1 was lying back in bed, in an upright position with her eyes closed, asleep. She stated she could see CR #1's chest wall going up and down and the resident appeared to be gasping for air. MA #2 said she left CR #1 and went down the hall to give morning medications to other residents on the same hall. MA #2 said she finished passing medications to the other residents on hall 600 around 9:30 a.m. then she went back to CR #1's room and tried to give her the morning medications. MA #2 said she started to offer the resident a sip of water but the resident could not swallow the water. MA #2 said she documented on the resident's MAR indicated [REDACTED]. MA #2 further said upon exiting the resident's room she saw CR #1's charge nurse (LVN #1) on the hallway. MA #2 said she notified the charge nurse that CR #1 could not take her medications due to a swallowing problem. MA #2 said CR #1 did not have a swallowing problem before and was always able to swallow her medications. Record review of CR #1's MAR indicated [REDACTED]. Further review revealed a note for [DATE] on the back of the MAR indicated [REDACTED]. Interview on [DATE] at 2:08p.m., LVN #2 said she took care of CR #1 during the night shift from 7:00 p.m. on [DATE] till 7:00 a.m. on [DATE]. LVN #2 said CR #1 did not have any changes during the night shift. LVN #2 said the resident's vital signs were checked around 12:00 a.m. but she did not document the vitals on the resident's progress notes until around 4:33 a.m. LVN #2 further said the resident was very confused, agitated, disruptive, could not hold a conversation, and screamed throughout the night. LVN #2 said the CR #1 was talking to herself and saying things like put me in the bed when she was already bed. She further stated the resident constantly yelled and screamed out loud since readmitting to her unit from the hospital. LVN #2 said the resident's behavior got worse over the weekend. She was particularly restless all night on [DATE] and could not be re-directed. LVN #2 said all attempts to redirect CR #1 were unsuccessful, including administrating the as needed medication [MEDICATION NAME] that was ordered for agitation. Interview on [DATE] at 11:17 a.m., LVN #1 said she began work about 7:10 a.m., on [DATE]. She stated she received a report from the night nurse that CR#1 was crying out all night which was her usual behavior and was given the as needed medication for her behavior which did not help. LVN #1 said she was told CR #1 continued disturbing everybody and other residents were getting upset. LVN #1 said during shift change, CR #1 was in her room and quiet. LVN #1 said she had breakfast dining room duty on [DATE]. She stated after dining room duty she entered CR #1's room sometime after 10:00 a.m. to give CR #1's roommate (Resident #1) a [MEDICATION NAME] injection. She said when she entered the room CR#1 was alert to her name, not oriented, coughed twice and then fell asleep. LVN #1 said she finished giving Resident #1 then injection and then went to check on CR#1. CR#1's vital signs were taken and they showed an oxygen saturation of 80%, blood pressure of ,[DATE], heart rate 55 and respiration were between ,[DATE] beats per minute. LVN #1 said she left the room to call the physician, who did not answer, and she left a message. She said she then went to the supply room to get suctioning supplies, which took between 5 to 10 minutes. LVN #1 said when she returned to CR #1's room, she found CR #1 not breathing with no pulse. She said she left the room again to call the RN to assess the resident, call for help, confirm the code status and call 911. When LVN #1 was asked to retell the details again, LVN #1's recollections continued to remain the same, that she left the room when she assessed CR #1 with no pulse or respirations to seek assistance of the RN. LVN#1 maintained she did not initiate CPR. Interview on [DATE] at 4:00 p.m., LVN #1 said CR #1 did not appear to be in any acute respiratory distress, and her breathing was not labored. When asked to demonstrate CR #1's breathing the last time she saw her breathing, LVN #1's demonstration indicated shallow breathing. LVN #1 said the resident's head of bed was elevated, her eyes were closed and she made sounds. She stated CR #1's respirations were faint and shallow. Interview on [DATE] at 9:45 a.m., a family member of Resident #1 said she and another family member were in Resident #1's room for a visit the morning of [DATE]. Resident #1 is CR #1's roommate. She described CR #1's breathing as gurgling in agony. She stated CR#1 was congested and yelled and screamed constantly. The family member said she left for work but the other relative stayed with Resident #1. She stated the relative texted her and said the roommate was drowning in her own phlegm. The family member said LVN #1 would not have given the [MEDICATION NAME] injection to CR #1's roommate any time before 10 a.m. She said it most certainly was after 10 a.m. She stated the relative that was there then texted her at 11:16 a.m., saying I think my (Resident #1's) roommate (CR #1) just took her last breath and died . The family member continued by saying she had informed staff on [DATE] that CR #1 was drowning in her own phlegm and no one would come to check on her. Interview on [DATE] at 11:51 a.m., the DON said she believed the facility was in an immediate jeopardy situation because LVN#1 did not respond timely to CR#1's change in condition and should not have left the resident when she was assessed with [REDACTED]. The DON said she expected LVN#1 to stay with the resident, call for help and initiate CPR. Interview on [DATE] at 12:56p.m., the Facility Administrator said she was aware CR #1 passed away on [DATE] but did not know any of the events leading to the incident. The Administrator said as of today ([DATE]), she had been made aware that MA #2 passed medications and noted that CR #1 had swallowing difficulty which she reported to LVN #1 who did not promptly respond to the resident's change in condition. The Administrator further said LVN #1 had been terminated from the facility. Record review of facility's policy on change in condition or status, revised [DATE], read in part our facility shall promptly notify the resident's his or her attending physician and representative of change in the resident's medical/mental condition and or status. The nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician when there has been a significant change in the resident's condition. A significant change of condition is a decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease related intervention, impact more than one area of the resident's health status and requires interdisciplinary review or revision of care plan. On [DATE] at 4:35p.m., an IJ was identified and the facility Administrator and DON were notified. The IJ was removed on [DATE]. The facility submitted and implemented the following plan to remove the IJ on [DATE]: Plan to remove immediacy: On [DATE] the facility initiated an in-service on identifying change of condition, remaining with a resident when in distress and calling for help with all care staff. Staff involved in the care of the resident during the code have been interviewed and statements received. The 24 HR reports from both stations have been reviewed again on [DATE] for the last 7 days to ensure that all change of conditions were identified and addressed. On [DATE] & [DATE] the nurse managers went to each resident individually and did a visual observation to ensure that all residents were in stable condition and no additional changes of condition were identified. The medical director was notified on [DATE] and gave orders to draw magnesium levels, CMP, and do EKG's on all residents on antipsychotic medications and consent forms were updated. Labs were drawn on [DATE] and are pending results and EKG's are pending at this time. All families of residents on antipsychotics were called by nurse managers on [DATE] and given additional education on the risks of antipsychotic use in the elderly and consent forms have been updated accordingly. The MARS and TARS were reviewed by nurse managers on [DATE] for this month of May to observe any vital sign trends and any identified trends were given to the pharmacy consultant for medication review and physician notification with any recommendations. Pharmacy consultant is reviewing all residents on antipsychotic medications for appropriate diagnosis, necessity of medication, and gradual dose reduction will be completed by [DATE]. The charge nurse, LVN #1, who was assigned to the resident, was terminated for failure to respond timely and appropriately to identify change of condition on [DATE]. In-serviced all departments available that a resident's code status can be located on the first page of the chart by Red Page for DNR and Green page for full code, face sheet, physician orders, on the MARS/TARS, and/or behind the advanced directive tabs in the medical record. Nursing staff available were in-serviced on how to handle a code on [DATE]. Nursing staff will not be allowed to come to work until training has been received on how to handle a code. How to handle a code will be included in the New Hire Orientation Process effective immediately. 1. Personal protective equipment, including gloves, masks, gowns and eyewear. 2. Pocket face masks, Ambu bags (,[DATE] L capacity), and/or mouth shields. 3. The basic life support (BLS) sequence of events is referred to as C-A-B (chest compressions, airway, and breathing). This has been revised from the previous sequence of A-B-C (airway, breathing, chest compressions). Call for help, stay with resident and prepare them for initiation of CPR, someone announces code blue over intercom, calls 911 and notifies family and physician. 4. Begin CPR if the adult victim is unresponsive and not breathing normally (ignoring occasional gasps) without assessing the victim's pulse. 5. Following initial assessment, begin CPR with chest compressions rather than opening the airway and delivering rescue breathing. 6. Use AED. 7. All rescuers trained or not, should provide chest compressions to victims of [MEDICAL CONDITION]. 8. Delivering high-quality chest compressions is essential: 1. Push hard to a depth of at least 2 inches (5 cm) at a rate of at least 100 compressions per minute. 2. Allow full chest recoil after each compression. 3. Minimize interruptions in chest compressions. Follow up: IDT for unnecessary medication review and [MEDICAL CONDITION] medication: review will be done weekly starting [DATE] (attendees: Nurse Managers, MDS/PPS, DON, ED, Pharmacy Consultant) Nurse Managers and/or designee will follow up with recommendations from IDT. Next week IDT will review follow up notes from previous meeting. First meeting will be held on Friday [DATE] at 10:30 a.m. and weekly thereafter. New Admit/Re-admit: Chart Audit will be completed on all new admits and readmits to ensure accuracy of orders, required follow up, and medications Nurse Managers and DON were in-serviced on the process [DATE]. Clinical Stand Up (current meeting format with the following focuses added)- 24 hr reports will be reviewed every morning in the clinical stand up meeting for changes of condition and proper treatment and follow up (start effective immediately). Weekend Nurse Manager will review all 24hr reports for changes of condition and proper treatment and follow up. Any areas of concerned will be addressed immediately. All new doctor's orders for antipsychotic medications will be reviewed by DON or designee to ensure appropriate diagnoses, necessity of medication and consent forms have been completed. Initiated [DATE] All findings will be reported to the QAPI Committee for further insight and direction. Monitoring: The surveyor monitored the plan to remove the immediate jeopardy on [DATE] and [DATE] as follows: Monitoring began on [DATE]. LVNs, RNs and MAs were interviewed on two shifts on changes in condition identification, communication/report to charge nurse, physician notification, and proper assessment following changes in condition. Record review of the facility In-Services revealed: [DATE] - thirteen staff members were trained on proper assessment, monitoring of residents with a change in condition and staying with resident when unresponsive, initiation of CPR and prompt ways of identifying code status and to call 911. Staff were to notify the DON or designee of any identified changes in condition. [DATE] - more than 60% of the facility's nursing staff members had been trained on assessment and prompt intervention when notified of any changes in resident's condition. Interview on [DATE] at 9:00 a.m., ADON #1 stated she completed chart audits, evaluated all residents in the facility for changes in condition, and the pharmacy consultant had completed medication review of all residents on [MEDICAL CONDITION] medications. She found that staff were implementing the appropriate and current plan. All residents on [MEDICAL CONDITION] medication had drug reduction initiated and the responsible parties were contacted to discuss the potential affects as well any black box warnings. Record review of in-services dated [DATE], [DATE] and [DATE] revealed ADON and unit managers trained all staff scheduled to work [DATE], [DATE] and [DATE]. Interviews with 3 MAs, and 7 CNAs on [DATE] between 7:30a.m., and 9:00a.m., revealed they received training on how to notify their charge nurse of any change identified in a resident during care and to ensure another manger was made aware of the change too, when to notify a charge nurse of anything usual noted about any patient, and if the nurses did not respond immediately to call the DON designee or the administrator. Interview on [DATE] at 8:50 a.m., the facility corporate nurse stated the facility would be continuing to monitor the DON and staff to ensure the plan was implemented and effective. She further reported she would continue to monitor the facility approved plan of removal to ensure the safety of the residents. She said she was monitoring and evaluating all changes in conditions, as well as those with newly prescribed [MEDICAL CONDITION] medications to ensure staff were implementing the plan. She also stated the facility's medical director was involved with the plan. After monitoring the implementation of the plan, the IJ was removed. The Administrator was informed the IJ was removed on [DATE] at 10:43 a.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate jeopardy. The facility was continuing to monitor their plans to ensure residents' physicians were promptly consulted following changes in condition, psychoactive drugs were being monitored and staff were being trained on procedures including assessing, reporting resident changes in condition, initiating CPR and drug interactions. Facility census dated [DATE] revealed 45 residents resided on halls 500, 600 and 800.

Based on interview, and record review, the facility failed to consult with the resident's physician when a change in condition occurred in one of 36 residents (CR #1) reviewed for residents rights. CR #1's physician was not notified of a blood pressure reading of ,[DATE] on [DATE]. An immediate jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy. This failure affected one resident who died in the facility and placed 45 residents on three of the nine halls (halls 500, 600, and 800) of the facility at risk of not receiving services necessary with a change in condition which could lead to a decline in their health. Findings include: Intake # 7 Record review of CR #1's face sheet revealed a [AGE] year old female admitted to the facility on [DATE], readmitted [DATE] and died in the facility [DATE]. Further review of CR #1's face sheet revealed the following Diagnosis: [REDACTED]. Record review of CR #1's admission assessment MDS dated [DATE] revealed CR#1's BIMS score was 12 out of 15. Further review of this MDS revealed CR #1's had [MEDICAL CONDITION], required extensive assistance for bed mobility, transfer, locomotion, toilet use but was independent with eating (set up help only). CR #1 also required limited assistance with personal hygiene. Record review of CR #1's MAR indicated [REDACTED]. Further review of this MAR indicated [REDACTED]. Record review of CR #1's physician order [REDACTED]. Interview on [DATE] at 11:00a.m., MA #1 was asked what she wrote on the MAR indicated [REDACTED]. MA #1 stated she could not read what she wrote. MA #1 said she did not notify the nurse that CR #1's blood pressure was ,[DATE] on [DATE] and she administered the [MEDICATION NAME]. Record review of CR #1's MAR indicated [REDACTED]. Record review of CR #1's progress notes revealed four entries on [DATE] which did not address the resident's diastolic blood pressure of 47. Further review of progress notes revealed a note written by LVN #1 which read received in bed but arousable, respirations regular even and unlabored on ,[DATE] liters of oxygen via nasal cannula in place. Vital signs 98.9, 84,,[DATE], and 98% on 3 liters. Total care rendered with ADL. Position changes assisted in and out of bed with Hoyer lift by two staff members. Patient is incontinent of bowel and bladder, skin kept clean and dry. Patient history of diabetic mellitus, acute kidney disease, dementia, [MEDICAL CONDITION], hypertension, anxiety, cognitive deficits following [MEDICAL CONDITION] disease, [MEDICAL CONDITION] and left sided weakness. Patient disrupts living environment by constantly calling and crying out, sleeping in short intervals, continued on [MEDICATION NAME] therapy and is monitored for bleeding, total care rendered frequently. Patient participated with therapy and therapist stated that patient is very confused because patient did not recognize her. Assisted back to bed after lunch, patient slept for about two hours. Patient was assisted with super in bed, tolerated well, fair to good appetite noted. Monitored frequently, bed locked in low position with call light in reach. Record review of CR #1's progress note dated [DATE] at 8:23p.m., revealed a note written by LVN #1 at the end of her 12 hour shift on [DATE] which read report given this AM regards to patient was yelling just about all night long, this is usual behavior, noted patient quiet at that time. After breakfast went in to give roommate [MEDICATION NAME] as ordered, noted a cough and congestion and gurgling, medication aide stated she was not able to give morning medication, she noted some difficulty in swallowing, informed that blood pressure was ,[DATE], heart rate was 55 and speech difficult to understand, eyes open and able to focus, responded to name, cried out at times, second set vitals taken 96 temporal, heart rate 53, respiration ,[DATE], oxygen saturation 80% on 5 liters of oxygen via nasal cannula, call placed to physician at 10:45a.m., left message on service with vital signs. Went back to room to assist roommate, noted resident coughing, called RN to do assessment of patient, also informed unit supervisor (Unit Manager #1) that patient condition has changed and going to call physician. Noted patient coughing more, second call placed to physician, message left on service. Patient may need to go to the ER for evaluation, awaiting return call, went to clean utility room to get a suction machine at 11:09a.m., took it back to patient's room and noted patient appeared not to be breathing, called for assistance by RN and code blue was called, staff arrived in force, two nurse practitioners with code team, 6 staff members in room, CPR was initiated at 11:16a.m., crash cart to room at 11:17a.m., ventilation started at 11:17a.m., 911 called at 11:18a.m., also patient son was called at this time and was informed patient had a change of condition, he stated he was across town and will call family that was close. Also called daughter and informed of condition change, after speaking to son. Daughter in law arrived at 11:30a.m., and was informed patient had passed away, son arrived at 11:55a.m., patient was pronounced by NP at 11:29a.m. call placed to physician and message left on service that patient had expired and pronounced 11:29a.m. Interview on [DATE] at 10:50a.m., LVN #1, who was CR#1's charge nurse on [DATE], said she was not notified of any abnormal blood pressures for CR #1 on [DATE]. LVN #1 stated she expected MAs to notify the charge nurse of any changes in condition so she could follow up on them. Interview on [DATE] at 1:15p.m., Unit manager #1 said MAs were trained to notify charge nurses or any manager when any abnormal vital signs were noted on any residents. She agreed the medication aide should have notified the LVN #1 (CR#1's charge nurse) of CR #1's change in blood pressure on [DATE] so LVN #1 could notify the physician. Interview on [DATE] at 11:51 a.m., the DON said she believed the facility was in an immediate jeopardy situation because LVN#1 did not respond timely to CR#1's change in condition and should not have left the resident when she was assessed with [REDACTED]. The DON said she expected LVN#1 to stay with the resident, call for help and initiate CPR. Interview on [DATE] at 12:56p.m., the Facility Administrator said she was aware CR #1 passed away on [DATE] but did not know any of the events leading to the incident. The Administrator said as of today ([DATE]), she had been made aware that MA #2 passed medications and noted that CR #1 had swallowing difficulty which she reported to LVN #1 who did not promptly respond to the resident's change in condition. The Administrator further said LVN #1 had been terminated from the facility. Record review of facility's policy on notice of resident rights and responsibilities revised [DATE] did not address the above concerns. Record review of facility's policy on change in condition or status, revised [DATE], read in part our facility shall promptly notify the resident's his or her attending physician and representative of change in the resident's medical/mental condition and or status. The nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician when there has been a significant change in the resident's condition. A significant change of condition is a decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease related intervention, impact more than one area of the resident's health status and requires interdisciplinary review or revision of care plan. On [DATE] at 4:35p.m., an IJ was identified and the facility Administrator and DON were notified. The IJ was removed on [DATE]. The facility submitted and implemented the following plan to remove the IJ on [DATE]: Plan to remove immediacy: On [DATE] the facility initiated an in-service on identifying change of condition, remaining with a resident when in distress and calling for help with all care staff. Staff involved in the care of the resident during the code have been interviewed and statements received. The 24 HR reports from both stations have been reviewed again on [DATE] for the last 7 days to ensure that all change of conditions were identified and addressed. On [DATE] & [DATE] the nurse managers went to each resident individually and did a visual observation to ensure that all residents were in stable condition and no additional changes of condition were identified. The medical director was notified on [DATE] and gave orders to draw magnesium levels, CMP, and do EKG's on all residents on antipsychotic medications and consent forms were updated. Labs were drawn on [DATE] and are pending results and EKG's are pending at this time. All families of residents on antipsychotics were called by nurse managers on [DATE] and given additional education on the risks of antipsychotic use in the elderly and consent forms have been updated accordingly. The MARS and TARS were reviewed by nurse managers on [DATE] for this month of May to observe any vital sign trends and any identified trends were given to the pharmacy consultant for medication review and physician notification with any recommendations. Pharmacy consultant is reviewing all residents on antipsychotic medications for appropriate diagnosis, necessity of medication, and gradual dose reduction will be completed by [DATE]. The charge nurse, LVN #1, who was assigned to the resident, was terminated for failure to respond timely and appropriately to identify change of condition on [DATE]. In-serviced all departments available that a resident's code status can be located on the first page of the chart by Red Page for DNR and Green page for full code, face sheet, physician orders, on the MARS/TARS, and/or behind the advanced directive tabs in the medical record. Nursing staff available were in-serviced on how to handle a code on [DATE]. Nursing staff will not be allowed to come to work until training has been received on how to handle a code. How to handle a code will be included in the New Hire Orientation Process effective immediately. 1. Personal protective equipment, including gloves, masks, gowns and eyewear. 2. Pocket face masks, Ambu bags (,[DATE] L capacity), and/or mouth shields. 3. The basic life support (BLS) sequence of events is referred to as C-A-B (chest compressions, airway, and breathing). This has been revised from the previous sequence of A-B-C (airway, breathing, chest compressions). Call for help, stay with resident and prepare them for initiation of CPR, someone announces code blue over intercom, calls 911 and notifies family and physician. 4. Begin CPR if the adult victim is unresponsive and not breathing normally (ignoring occasional gasps) without assessing the victim's pulse. 5. Following initial assessment, begin CPR with chest compressions rather than opening the airway and delivering rescue breathing. 6. Use AED. 7. All rescuers trained or not, should provide chest compressions to victims of [MEDICAL CONDITION]. 8. Delivering high-quality chest compressions is essential: 1. Push hard to a depth of at least 2 inches (5 cm) at a rate of at least 100 compressions per minute. 2. Allow full chest recoil after each compression. 3. Minimize interruptions in chest compressions. Follow up IDT for unnecessary medication review and [MEDICAL CONDITION] medication: review will be done weekly starting [DATE] (attendees: Nurse Managers, MDS/PPS, DON, ED, Pharmacy Consultant) Nurse Managers and/or designee will follow up with recommendations from IDT. Next week IDT will review follow up notes from previous meeting. First meeting will be held on Friday [DATE] at 10:30 a.m. and weekly thereafter. New Admit/Re-admit: Chart Audit will be completed on all new admits and readmits to ensure accuracy of orders, required follow up, and medications Nurse Managers and DON were in-serviced on the process [DATE]. Clinical Stand Up (current meeting format with the following focuses added)- 24 hr reports will be reviewed every morning in the clinical stand up meeting for changes of condition and proper treatment and follow up (start effective immediately). Weekend Nurse Manager will review all 24hr reports for changes of condition and proper treatment and follow up. Any areas of concerned will be addressed immediately. All new doctor's orders for antipsychotic medications will be reviewed by DON or designee to ensure appropriate diagnoses, necessity of medication and consent forms have been completed. Initiated [DATE] All findings will be reported to the QAPI Committee for further insight and direction. Monitoring: The surveyor monitored the plan to remove the immediate jeopardy on [DATE] and [DATE] as follows: Monitoring began on [DATE]. LVNs, RNs and MAs were interviewed on two shifts on changes in condition identification, communication/report to charge nurse, physician notification, and proper assessment following changes in condition. Record review of the facility In-Services revealed: [DATE] - thirteen staff members were trained on proper assessment, monitoring of residents with a change in condition and staying with resident when unresponsive, initiation of CPR and prompt ways of identifying code status and to call 911. Staff were to notify the DON or designee of any identified changes in condition. [DATE] - more than 60% of the facility's nursing staff members had been trained on assessment and prompt intervention when notified of any changes in resident's condition. Interview on [DATE] at 9:00 a.m., ADON #1 stated she completed chart audits, evaluated all residents in the facility for changes in condition, and the pharmacy consultant had completed medication review of all residents on [MEDICAL CONDITION] medications. She found that staff were implementing the appropriate and current plan. All residents on [MEDICAL CONDITION] medication had drug reduction initiated and the responsible parties were contacted to discuss the potential affects as well any black box warnings. Record review of in-services dated [DATE], [DATE] and [DATE] revealed ADON and unit managers trained all staff scheduled to work [DATE], [DATE] and [DATE]. Interviews with 3 MAs, and 7 CNAs on [DATE] between 7:30a.m., and 9:00a.m., revealed they received training on how to notify their charge nurse of any change identified in a resident during care and to ensure another manger was made aware of the change too, when to notify a charge nurse of anything usual noted about any patient, and if the nurses did not respond immediately to call the DON designee or the administrator. Interview on [DATE] at 8:50 a.m., the facility corporate nurse stated the facility would be continuing to monitor the DON and staff to ensure the plan was implemented and effective. She further reported she would continue to monitor the facility approved plan of removal to ensure the safety of the residents. She said she was monitoring and evaluating all changes in conditions, as well as those with newly prescribed [MEDICAL CONDITION] medications to ensure staff were implementing the plan. She also stated the facility's medical director was involved with the plan. After monitoring the implementation of the plan, the IJ was removed. The Administrator was informed the IJ was removed on [DATE] at 10:43 a.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility was continuing to monitor their plans to ensure residents' physicians were promptly consulted following changes in condition, psychoactive drugs were being monitored and staff were being trained on procedures including assessing, reporting resident changes in condition, initiating CPR and drug interactions. Facility census dated [DATE] revealed 45 residents resided on halls 500, 600 and 800.