Every finding on record at Fallbrook Rehabilitation and Care Center

Based on interview, and record review, the facility failed to ensure the Comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment including both comprehensive and quarterly review assessments to reflect current condition. 1 out of 3 residents, reviewed for care plan revision. The facility failed to ensure Resident #1's care plan was revised and updated. Resident #1 signed self out of the facility on 7/4/26 but was gone for more than one hour which cause LVN to start facility protocol for unaccounted residents. This failure could place residents at risk of not having personalized plans developed to address their specific care needs.Record Review of Resident #1's face sheet dated August 18, 2026, revealed a [AGE] year-old male who is responsible for self with no legal guardian or POA was admitted on [DATE] and readmitted on [DATE] and discharged on 8/1/2026. Prior to discharge Resident #1's face sheet revealed he was admitted with diagnosis included of sepsis (body reacts violent to an infection), cerebral infarction (stroke), metabolic encephalopathy(brain dysfunction), COPD (long-term lung disease), hypertension (high blood pressure), paroxysmal atrial fibrillation (irregular and fast heart rhythm), end stage renal disease (final stage of kidney disease), muscle weakness (reduced ability to exert force), abnormalities of gait and mobility (change in how a person walks or move), kidney failure (inability to filter waste from blood), and altered mental status (change in normal thinking).Record Review of resident #1's Elopement and Wandering assessment dated [DATE] listed Resident #1 as high alert for elopement, but no Elopement assessment for 7/4/26 was found when resident #1 eloped from facility and was found at gas station as documented in progress note in his electronic health record.Record Review of sign in and sign out book shows Resident #1 signed self out on 7/4/2026, but further review of progress note dated 7/4/2026 shows that nurse documented that when resident was gone from the facility for more than an hour that she started missing resident protocol and resident was found at gas station.Record Review of resident #1's Order Summary revised 7/4/2026 indicated an order from doctor stating that Resident #1could not, go out on LOA without family, this order was put in place by doctor after unaccounted resident protocol was started on 7/4/2026 when resident was out of the nursing facility for more than an hour and found at gas station.Record Review of resident #1's BIMS assessment dated [DATE] reveals his BIMS to be an 8 with moderate impairment.Record Review of Resident #1's progress notes dated 7/4/26 at 11:20 am completed by LVN A showed resident signed self out and after resident was gone for more than an hour LVN A started facility protocol for unaccounted residents without delay. Record Review of resident #1's Care Plan dated May 5, 2026, does not indicate any behaviors for elopement. Next Care Plan dated August 3, 2026, captures 2nd elopement from when resident #1 eloped on 8/1/26, but there is no revised care plan for when resident #1 signed self out on 7/4/2026, but after he was gone from the nursing facility for more than an hour LVN A started facility protocol for unaccounted resident.In an attempted phone interview on to Resident #1 on 8/18/26 at 9:11 a.m. the phone was answered by a female who stated that resident #1 was in the hospital; unable to speak to resident #1 because he is not in the nursing facility upon entrance. The number called was the number listed on nursing facility face sheet.In an attempted phone interview to EMS Ambulance Staff 1 on 8/18/26 at 9:12 a.m., there was no answer and message left asking for a call back.In an interview on 8/18/26 at 9:35 a.m. CNA A stated that she started working at the facility on July 8, 2026. She stated that she was working August 1, 2026. She stated that she did not know how Resident #1 got out of the facility, but she was told that another resident let him out of the building. She stated she did not know how that other resident had the code to get out. She stated she was working at her assigned station, and another staff asked her if she had seen resident #1, She stated that she had not seen Resident #1, and she and the assigned CNA for Resident #1 got into separate vehicles to go look for him. She stated that while driving she saw ambulance at Thrift store and thought to herself that, resident #1 must be at Thrift store because why is the ambulance there. She said that is where she found Resident #1, so she called his assigned CNA to let her know that Resident 1 was at Thrift store. When she was informed that Resident #1 was missing it took 15 minutes for her to find him, but to her knowledge he was missing for about an hour or two. She stated the last time she saw Resident #1 was around or about after breakfast and when she found him it was around 10 am. She reports that when she found resident #1 at Thrift store, he was already on the stretcher with ambulance, but she is not sure if he had any injuries. She stated to her knowledge resident #1 came back to the facility, but he is not in the facility now. She stated an in-service for the elopement on 8/1/2026 was done on either Monday or Tuesday to remind staff to put eyes on residents every 20 to 30 minutes. She stated that she had been informed that resident #1 had eloped in the past, but she was not working at the nursing facility when he had eloped. She stated she had been told by other staff that resident #1 had always said he would go home.In an interview on 8/18/26 at 9:57 a.m. CNA B stated that she had been working at this nursing home since the end of June 2026. She stated that she checks on residents every two hours. She stated that she was working on August 1, 2026, and believe that the nurse wanted to give resident #1 something so that is the reason staff were looking for him. She stated she walked around the building and informed staff that resident #1 was not in the building. She stated she asked his assigned CNA if she knew where he was and the CNA responded she did not know. She stated that she repeated to staff that resident #1 is not in the building and then she and other staff went to walk around inside and outside the building and could not find resident #1. She stated she was asking staff what the code for missing residents was, but she had forgotten the code was on back of her badge. She stated that when the nurse was looking for resident #1 it was after breakfast and before lunch around 10am. She stated a staff member got in their car, and they found resident #1 at Thrift store. She stated a resident that let himself out stated resident 1 followed him outside. She stated that there was no receptionist at desk and that staff were not told there was no receptionist to monitor the front. She stated she did not recall an in-service and was told resident #1 is not coming back and has not seen him in the facility since August 1, 2026.In an interview on 8/18/26 at 10:21 a.m. the DON stated that she had been working at facility since July 20, 2026. She stated that she received a call around 10 am informing her that resident #1 was missing from the building. She stated that she was informed that resident #1 followed another resident out of the building from a side door not the front door. She stated that once she was informed that resident #1 was missing, she started the code and while working from home as she lives 12 minutes away, she proceeded to drive to the facility. She stated by the time they found resident #1 he was at Thrift store, so she went to Thrift store, and she and ambulance staff completed an assessment together and that there were no injuries to resident #1. She stated that she does not know who called the ambulance, but she was told by facility staff that resident #1 was found at thrift store. She stated that resident #1 was taken to the hospital and never returned to the facility. She stated that resident #1 was discharged from the hospital and was sent to another nursing facility and that she was not sure the name and that the only reason she knows this information is because police called facility on 8/4/2026 and stated that resident #1 was trespassing and was asking for staff to come pick him up. She stated staff informed police that resident #1 was no longer their resident, so she believed that resident #1 eloped from the facility that the hospital sent him to after he was discharged from the hospital. She stated that she is not sure of the reason that hospital sent resident #1 to another facility but assumed it was because of the elopement and that he needed a more secure facility. She stated to her knowledge resident #1 is at another facility, she is not sure of the name but feels someone knows the name (she started to text other staff). She stated that resident #1 did not leave out of main entrance and went out a side door, but there is an alarm, but she is not sure if alarm was turned off or not, but since then all codes for all doors have been changed every week and that in-service was done with all staff asking staff to have residents sign in and out at the front desk with receptionist during the hours when receptionist is working and also informed staff not to give out the codes to the doors. She obtained name of new facility and stated that resident #1 is currently at another facility close by.In an interview on 8/18/26 at 1:01 p.m. the SW stated that she had been working at this nursing home for 3 1/2 to 4 years. She stated that she is familiar with resident #1. She stated that she was informed that he eloped from the facility on 8/1/2026. She stated that she thinks that he had eloped before, but she was not sure and asked if she could go retrieve her computer. She returned with her computer and stated that resident #1 eloped from the building on 7/4/26 and says that sometimes he signs himself out. She stated that she does not do Care Plans the MDS nurse does, but she wants to say that a care plan was done for when resident #1 signed self out of the building on 7/4/26. She reports that she does not see a care plan for 7/4/26 and stated risk to resident if a care plan is not done is minimal risk because staff is familiar with resident #1 and stated she did not really understand the question when asked what is the risk to resident when there is no care plan or updated care plan. After rephrasing the question, she stated that there is risk to residents if there is no updated care plan can be elopement and staff would not be aware of how to care for residents and will let residents leave the facility. She stated that outside the facility other people would not know the resident if he eloped. She stated on admission that she had no history from resident or his family that he has history of elopement.In a phone interview on 8/18/26 at 1:24 p.m. the MDS nurse stated that she had been working at this nursing facility since April 10, 2026. She stated that she is familiar with resident #1. She stated that she was made aware of resident elopement from building on 7/4/26 and 8/1/2026. She stated that resident #1 could not sign himself in and out of the building and would typically sit in the lobby. She stated that resident #1's last BIMS was a 5 and he could not safely sign out. She stated that it was a typo and that she did remember to update care plan for 7/4/26 and think she put it in the wrong resident care plan. She stated, she is typically the one to complete care plans and that she is the only one and is assigned to work 14 buildings and only human as to the reason care plan was not done on July 4, 2026, and that he made a typo and may have put in wrong resident's care plan. She stated that the risk of not having a care plan done for residents is that staff would not have instructions for how to keep residents safe.In an interview on 8/18/26 at 1:41 p.m. the ADON stated that she had been working at this nursing facility since May 1, 2026. She stated she was familiar with resident #1. She stated she did hear about elopement of resident #1 and that she was informed that resident got out of the building and was found at Thrift store and transported to hospital as a precautionary measure per facility investigation. She stated that there was another time in July 2026 when he eloped, and he was found at a gas station. She stated that a care plan was not done in July 2026, and she cannot answer why it was not done. She stated that the MDS nurse was responsible for updating the care plans. She stated risk to residents for not having a care plan can create a safety issue for residents.In an interview on 8/18/26 at 1:46 p.m. the DON stated that she started working at this facility on July 20, 2026, and was not working at the facility when resident #1 eloped on 7/4/26. She stated that it is the responsibility of the MDS nurse to complete care plans. She stated she was unable to answer anything related to resident #1's elopement on 7/4/26 because she was not working at this facility then. She stated if there are no care plans the risk to residents is same issue happening again such as elopement.In an interview on 8/18/26 at 1:50 p.m. the ADM stated that he had been working at this facility for 5 days. He stated he is aware of resident #1's elopement on 8/1/26 and that he has not been given any information by any staff of his elopement on any other days. He stated that his expectation is that care plans should be completed upon admission of a resident and updated any time there is a change of condition for resident and/or incident regarding a resident. He stated that the MDS Nurse is responsible for completing care plans. He stated that risk of residents for no care plans is that with his BIMS he should not be able to sign in and out and at-risk elopement that can be harmful to residents.Record Review of Care Plan Policy. The policy stated that a care plan would be completed upon admission, quarterly, and as needed,

Based on interviews and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 2 (Resident #27 and Resident #40) out of 8 residents reviewed for reporting. -The facility failed to report to the State Survey Agency (SSA) Immediately, but not later than 24 hours when Resident #27 had an unwitnessed fall on 05/03/2026. -The facility failed to report to the State Survey Agency (SSA) Immediately, but not later than 24 hours when Resident #40 reported neglect after she waited 4 hours to be repositioned in bed on 06/28/2026 and EMS (Emergency Medical Services) were contacted. --The staff failed to report to the Administrator immediately when Resident#27 had an unwitnessed fall on 05/03/2026, was moved CNA X prior to being assessed on 05/03//2026, went unassessed until 05/05/2026, and observed with a bruise to the left eye 05/05/2026. -The staff failed to report to the Administrator immediately when Resident #40 reported neglect after she waited 4 hours to be repositioned in bed on 06/28/2026 and EMS (Emergency Medical Services) were contacted. This failure could place residents at risk of not having complaints and concerns reported resulting in ongoing abuse, neglect, and exploitation. Findings included: Resident #27Record review of Resident #27's face sheet revealed a [AGE] year-old male who admitted into the facility on [DATE], readmission date on 04/24/2026, with a principal diagnosis of acute myocardial infarction (death of heart muscle tissue due to a sudden blockage of blood flow in a coronary artery). Record review of Resident #27's MDS, dated [DATE], revealed the resident had a BIMS score of 2 indicating residents' cognition was severely impaired. Record review of progress note dated 05/05/2026 read in part, Resident #27 noted with left eye, below the lower lid, left hand and above the eyebrow bruised areas, assessment completed, no swelling or pain. NP and RP notified today. Record review of Resident #27's progress noted dated 05/05/2026 read in part, NP visited and ordered to transfer Resident #27 to the hospital for further evaluation. CT scan of head, maxillofacial and the left hand. Record review of Resident #27's undated care plan, revealed:Focus: [Resident #27] is at risk for falls. Goal: [Resident #27] will remain free from serious injury related to falls.Interventions: Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair.Will continue to monitor closely for any delayed symptoms or changes in condition.Redirect resident back to nurse station when seen wandering to prevent any fall occurrence.Initiate a scheduled toileting program with increased frequency for every 2 hours and as needed to reduce urgency and unassisted bathroom attempts. In an interview with the Administrator on 07/01/2026 at 9:04 a.m., he stated Resident #27 had an unwitnessed fall on 05/03/2026 but he did not learn about the fall until 05/05/2026 or 05/06/2026. He stated he did not report it because he thought he could combine his investigation with a separate report he had already called in. He said did not do a separate intake. He said that staff are trained to report allegations of abuse and neglect to the Administrator immediately. He said that staff failed to reported Resident #27's unwitnessed fall to him on 05/03/2026.In an interview with CNA-X on 07/01/2026 at 9:34 a.m., she stated Resident #27 had an unwitnessed fall during her shift on 05/03/2026 , and she reported the fall to the weekend supervisor. She did not know if the Weekend Supervisor reported the incident to the Administrator or DON. She said that she had been trained on abuse and neglect, and all allegations should be reported to the Administrator immediately. She said that she did not report it to the Administrator. She did not answer when asked why she did not report it immediately to the Administrator. In a telephone interview with Family Member of Resident #27 on 07/01/2026 at 9:56 a.m., she said she learned the resident had a fall on 05/03/2026 after reviewing electronic monitoring of the resident's room. She stated the facility did not notify her until 05/05/2026 which was the day the resident was sent out to the hospital for his fall. She stated she no longer had to video surveillance because she did not have a [NAME] card at the time of the incident. In an interview with CMA-Q on 07/01/2026 at 10:45 a.m., she stated Resident #27 had an unwitnessed fall and he was observed on the floor, she stated she notified the weekend supervisor. She did not know if the Weekend Supervisor reported the incident to the Administrator or DON. She said that she had been trained on abuse and neglect, and all allegations should be reported to the Administrator immediately. She said that she did not report it to the Administrator. In an interview with the DON on 07/01/2026 at 12:05 p.m., he stated he was not sure exactly how many days later he learned about Resident #27's fall but he knows it was days later after the fall occurred. He stated Resident #27 was observed with a bruise on his face and that led the facility to start an investigation. He said that staff are trained to report allegations of abuse and neglect to the Administrator immediately. He said that staff failed to reported Resident #27's unwitnessed fall to the Administrator on 05/03/2026. In an interview with the Weekend supervisor on 07/02/2026 at 12:56 p.m., he stated Resident #27 did not have a fall on his shift and denied that anyone had ever notified him that the resident had a fall. He said that he was trained to report allegations of abuse and neglect to the Administrator immediately. He said that if staff had notified him of Resident #27's fall he would have reported it to the Administrator immediately. Record review of TULIP did not reflect an incident reported to the SSA with regards to Resident #27 fall on 05/03/2026. Resident #40Record review of Resident #40's Face Sheet (undated) revealed, a [AGE] year-old female who was admitted to the facility on [DATE] as her own responsible party with principal diagnoses of acute respiratory failure with hypoxia (when the lungs cannot deliver sufficient oxygen to the blood) and secondary diagnosis to include mild intermittent asthma (chronic respiratory condition where the airways become inflamed). Record review of Resident #40's quarterly MDS assessment dated [DATE] revealed in section C a BIMS score of 14 indicating she was cognitively intact. Resident #40 was triggered for active pulmonary diagnosis of asthma and respiratory failure. Record review of Resident #40's undated Care Plan with last review/revised date 06/30/2026 that read in part. Focus: Resident #40 has altered respiratory status/difficulty breathing. Goal: Resident #40 will maintain normal breathing pattern as evidenced by normal respirations, normal skin color, and regular respiratory rate/pattern through the review date. Intervention: Administer medication/puffers as ordered. Monitor for effectiveness and side effects. Medications as ordered. Notify MD of worsening clinical condition, adverse reactions. Monitor for s/sx of respiratory distress: Record review of Resident#40's Electronic Medical Records (EMR) did not reflect a nursing progress note, change in condition, or assessment was completed on 06/28/2026 with regards to EMS being contacted by Resident #40 or that Resident #40 alleged neglect. Record review of TULIP did not reflect an incident reported to the SSA with regards to Resident #40 alleging neglect on 06/28/2026. In an interview and observation on 06/30/2026 at 10:26 a.m., Resident #40 said that on 06/28/2026 she wanted to be repositioned in her bed and pressed her call light. She said that CNA L said that she would return to reposition her, CNA L never returned, and it felt like hours had gone by. She said that when CNA L did not return, she dialed 911 and said that she had trouble breathing. She did not tell any of the staff about her wait time, she just called EMS. She said that EMS arrived, said she was fine, and repositioned her in the bed. She said that she did not have trouble breathing. An observation was made during the interview of there to be a camera in the room. She said that a relative has access to the camera footage. In a telephone interview on 07/01/2026 at 10:29 a.m., the Family Member of Resident #40 said that on 06/29/2026 she spoke to Resident #40, and Resident #40 said that she had to call 911 because she had difficulty breathing. She said that Resident #40 told her that she wanted to be repositioned in the bed to help with her breathing, but after waiting four hours she decided to call 911. She said that Resident#40 told her that when EMS arrived they repositioned her in the bed, and did not take her to the hospital. She said that Resident#40 has a camera in the room, she had not viewed the camera footage, and she had not spoke to anyone at the facility about the incident. She said that she would review the camera footage, she said that she would send a copy of the footage to the SSA. The footage was not received. In an interview on 07/01/2026 at 11:12 a.m., LVN M said that she worked from 6:00am-6:00pm on 06/29/2026. She said that at the start of the shift LVN N reported that on 06/28/2026 during the 6:00pm-6am shift Resident #40 called 911 so that she could be repositioned in the bed, and felt that she had waited for staff for too long. She said that Resident #40 told her she had been neglected because she had to wait for 4 hours. She said that Resident #40 never said that she had respiratory issues on 06/28/2026. She said that she did not document what was told to her by Resident #40 or LVN N. She said that she had been trained on Abuse and Neglect Policy, and allegations should be reported to the Administrator immediately. She said that she should have reported the allegations to the Administrator when the information was received, and she did not do so because she assumed that LVN N completed a report. In an interview on 07/01/2026 at 2:34 p.m., LVN N said that she did work on 06/28/2026 from 6:00pm-6:00am. She said that Resident#40 did not have a change in condition during the shift, and EMS did not come to the facility for any reason during the shift. She said that she did not tell anyone that EMS came to the facility for Resident#40. She said that she had been trained on Abuse and Neglect, and all allegations should be report to the Administrator immediately with DON as back up. In an interview on 07/02/2026 at 10:14 a.m., DON said that that he received a call from LVN N at 12:00 a.m. on 07/02/2026, and LVN N said that during report on 06/28/2026, RN O who worked the previous shift reported Resident #40 had called 911. He said that LVN N told him that Resident #40 called 911 because she had waited for to long for the assigned nurse and aide (RN O and CNA L) to respond to the call light. He said that he contacted RN O who said that Resident #40 did call 911 on 06/28/2026 during the 6:00am-6:00pm shift because she felt she waited too long to be repositioned when pressing the call light. He said that staff are trained to report all allegations of abuse and neglect immediately to the Administrator with the DON as backup. He said that he reported the incident to the Administrator immediately on 07/02/2026, and RN O was suspended pending an investigation. He said that he considered the allegations made by Resident #40 as neglect, and it should have been reported by staff on 06/28/2026. He said that the risk of not reporting is that the abuse or neglect could continue. In an interview on 07/02/2026 at 10:35 a.m., the Administrator said that he was the abuse coordinator and he uses the HHS PL for reporting guidelines. He said that staff are trained to report allegations of Abuse and Neglect to the Administrator immediately with the DON as back up. He said that he was notified by the DON on the morning of 07/02/2026 that Resident #40 reported neglect after not receiving care timely resulting in Resident #40 calling 911. He said that he initiated a report to the SSA on 07/02/2026 with suspension of RN O. He said that the assigned aide on 06/28/2026, CNA L was terminated on 06/30/2026 due to unrelated circumstances. He said that the incident should have been reported on 06/28/2026 when the incident happened. He said that the risk of not reporting was the abuse or neglect could continue. In a phone interview on 07/02/2026 at 2:15 p.m., CNA L said that her last day at the facility was on 06/30/2026, and she worked a double on 06/28/2026 from 6:00am-10:00pm. She said that during the 2:00pm-10:00pm shift she saw EMS leave the room of Resident #40 and leave the facility and she told RN O who did not know why EMS was at the facility. She said that RN O spoke with Resident #40 who said that she had waited for too long to be repositioned, so she called 911. She said that she had been trained to report allegations of abuse and neglect immediately to the administrator. She said that she did not make a report because there was not a delay in responding to Resident #40's call light, and the resident had a brief change 15-30 minutes prior to EMS arrival. In a telephone interview on 07/03/2026 at 8:25 a.m., RN O said that she had been trained to report all abuse and neglect to the Administrator immediately with the DON as back up. She said that the risk of not reporting is that the abuse could continue. She said that she worked on 06/28/2026 from 6:00am-6:00pm. She said that during the shift CNA L told her that she saw EMS leaving the room of Resident #40, but there was not a resident on the stretcher. She said that she went to speak with Resident #40 because she had been fine. She said that she had just observed approximately 30 minutes prior staff leaving the room of Resident #40 for a brief change. She said that when she spoke to Resident #40, she said that 911 was called because she felt her call light had been on far too long to be repositioned, and EMS repositioned her and left. She said that she educated Resident #40 on the misuse of EMS. She said that she did not report the incident to the Administrator or DON because there had been no abuse or neglect because there was no delay in care. She said that she had been suspended pending an investigation. She then said that she did report to incident during the morning stand up meeting with all Department heads present and she gave the information during shift change to LVN N. Record review of facility policy titled Abuse, Neglect and Exploitation dated 05/01/2025 read in part, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.Definitions:.Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.VII. Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes:a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. Record review of Long-Term Care Regulatory Provider Letter (PL) 2024-14 dated 08/29/2024 titled Title: Abuse, Neglect, Exploitation, Misappropriation of Resident Property and Other Incidents that a Nursing Facility Must Report to the Health and Human Services Commission read in part .2.0 Policy Details & Provider Responsibilities, 2.1 Incidents that a NF(Nursing Facility) Must Report to HHSC(Health and Human Services Commission) A NF must report to CII( Complaint and Incident Intake ) the following types of incidents, in accordance with applicable state and federal requirements:. Misappropriation. 2.4 Reportable Incidents and Timeframes, This table describes required reporting timeframes for each incident type. It also describes events a NF is not required to report: . Do Report: an incident that does not result in serious bodily injury but that involves any of the following: neglect, exploitation, a missing resident, misappropriation of resident property. Immediately, but not later than 24 hours after the incident occurs or is suspected. Misappropriation: HHSC rules define misappropriation as, the taking, secretion, misapplication, deprivation, transfer, or attempted transfer to any person not entitled to receive any property, real, or personal, or anything of value belonging to or under the legal control of a resident without the effective consent of the resident or other appropriate legal authority, or the taking of any action contrary to any duty imposed by federal or state law prescribing conduct relating to the custody or disposition of property of a resident. CMS (Centers for Medicare and Medicaid Services) defines misappropriation of resident property as, the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent.

Based on observations, interviews, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests for 2 of 2 hallways (Halls 100 and 200), 1 of 26 rooms (room [ROOM NUMBER]), and the kitchen reviewed for pest. The facility had live flies in areas of the facility including Hall 100, Hall 200, and room [ROOM NUMBER].-The facility failed to ensure the kitchen was free of pest when a fly was observed to land on uncovered bread prepared for the lunch meal service on 07/01/2026. This failure could place residents at risk for foodborne illness, disease, decreased health, safety and decreased quality of life.Findings included: Record review of Resident #3's Face Sheet dated 07/03/2026 revealed, a [AGE] year-old female who was admitted to the facility on [DATE] with principal diagnoses of chronic respiratory failure with hypoxia (a condition when the lungs are long-term unable to properly transfer oxygen into the bloodstream, causing dangerously low blood oxygen) with secondary diagnosis of end state renal disease(ESRD most severe stage of chronic kidney disease with a decrease in function with inability to filter blood and remove waste). Record review of Resident #3's quarterly MDS assessment dated [DATE] revealed in section C a BIMS score of 13 indicating she was cognitively intact. In section I Resident#3 was triggered for active pulmonary diagnosis of respiratory failure, and ESRD. Record review of Resident #3's undated Care Plan with last review/revised date 04/28/2026 that read in part. Focus: Resident#3 is on Enhanced Barrier Precautions for dialysis port Gown and Gloves required for HIGH-CONTACT Resident Care Activities. Goal: The resident will remain free from infection through the review date. Intervention: Monitor/document/report PRN any s/sx of infection: Fever; Redness; Drainage or swelling around wounds or catheter sites; Cough, respiratory symptoms; Dysuria(pain, burning, or discomfort during urination), hematuria(the presence of red blood cells in the urine), flank pain and foul smelling urine. Monitor/document/report PRN abnormal laboratory values (e.g., white blood cell count and differential, serum protein, serum albumin, and cultures). Monitor/document/report to MD s/sx of delirium: Changes in behavior, Altered mental status, Wide variation in cognitive function throughout the day, Communication decline, Disorientation, Periods of lethargy, Restlessness and agitation, Altered sleep cycle. The resident is at risk for contracting infections due to impaired immune status. Keep the environment clean and people with infection away. Use UNIVERSAL PRECAUTIONS as appropriate.Focus: Resident#3 is on oxygen therapy r/t Respiratory failure and asthma OXYGEN: at 3 LPM per Nasal Cannula continuously - Monitor every shift related to CHRONIC RESPIRATORY FAILURE WITH HYPOXIA.Goal: Resident#3 will have no s/sx of poor oxygen absorption through the review date. Interventions: Administer Oxygen as ordered. In an observation on 06/30/2026 at 09:36am, there was 1 fly observed flying in the room of Resident#3. The fly was observed to land on the head of Resident#3 who swatted the fly, the fly was observed to exit the room in the hallway. In an interview on 06/30/2026 at 9:37am, Resident#3 said that the facility has an issue with flies. She said that that flies were always in the room, but she had not told anyone about the flies. In an observation of hall 200 on 06/30/2026 at 9:40am, there was 1 fly in the hallway passing by the room of Resident#36 who seated in the door of her room. In an interview on 06/30/2026 at 9:41am, Resident#36 said that flies were always in the facility and her room. She said that that she had not told anyone about the flies. In an observation of hall 100 on 06/30/2026 at 9:58am, there were approximately 3 flies flying in the hallway. Observation on 07/01/2026 at 11:39 a.m. of the Dietary Manager to prepare bread for the lunch meal service, leave the bread uncovered, a fly to landed on the bread, the Dietary Manager used her hand to swat the fly away, discard the bread, and use proper hand hygiene. In an interview on 07/01/2026 at 11:42 a.m., [NAME] P said that food should be covered immediately after it is prepared. She said that the kitchen should be free of flies. She said that flies can cause cross contamination and food borne illness. In an interview on 07/01/2026 at 11:48 a.m., the Dietary Manager said that pest control comes to the facility monthly to treat the facility and the Administrator was the oversight for pest control. She said that there should not be flies in the facility to include the kitchen. She said that flies can cause cross contamination and food borne illness. She said that the bread had to be thrown out and she would prepare more for the lunch meal service. She said that food should be covered after it is prepared. In an interview on 07/01/2026 at 12:01pm with the DON, who said there should never be flies anywhere in the facility. He said that if flies were to land on a resident it could cause a risk for infection control. He said that there should never be flies anywhere in the facility. He said that flies can cause cross contamination and food borne illness if observed in the kitchen. He said that pest control comes to treat the facility monthly and the Administrator was the oversight for pest control. He said that he would differ to the Administrator with regards to the effectiveness of the pest control system. In an interview on 07/01/2026 at 12:19pm with the Administrator who said that he was the oversight for pest control. He said that pest control comes to treat the facility monthly. He said that if flies were observed in the facility it would not be concerning, and flies are common in the facility during the summer. He said that flies and other pests could enter the facility when any outside door was opened. He said that he felt that the current pest control system was effective. He said that he did not know the risk of flies landed on a resident while in the facility and would differ to the nursing department. He said that the risk of flies in the kitchen could be food contamination and foodborne illness. Record review of the facility's monthly invoice/service invoices for March, April, May, June, and July of 2026 revealed that pest control serviced the facility monthly. Record review of the policy titled, Food Safety Requirements, dated 08/01/2025read in part, It is the policy of this facility to procure food from sources approved or considered satisfactory by federal, state, and local authorities. Food will also be stored, prepared, disturbed and served in accordance with professional standards for food service safety. Definitions: contamination means the unintended presence of potentially harmful substances including, but not limited to microorganisms, chemicals, or physical objects.Foodborne illness refers to an illness caused by the ingestion of contaminated food or beverages.1. Food safety practice shall be followed throughout the facility's entire food handling process.8. Additional strategies to prevent foodborne illness include, but are not limited to a. preventing cross contamination of foods.Record review of the policy titled, Pest Control Program, dated 09/01/2022read in part, It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents. Definition: Effective pest control program is defined as measures to eradicate and contain common household pests (e.g., bed bugs, lice, roaches, ants, mosquitos, flies, mice, and rats).4. Facility will utilize a variety of methods in controlling certain seasonal pest, i.e. flies. These will involve indoor and outdoor methods that are deemed appropriate by the outside pest service and state and federal regulations.

Based on observation, interview, and record review, the facility failed to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention for 1 of 3 residents (Resident #27) reviewed for notification of changes. The Weekend Supervisor failed to notify the physician and RP when Resident #27 had an unwitnessed fall on 05/03/2026.These failures could place residents at risk of delay in treatment, worsening of conditions, hospitalization, and responsible party not being informed in care decisions.Findings include:Record review of Resident #27's face sheet revealed a [AGE] year-old male who admitted into the facility on [DATE], readmission date on 04/24/2026, with a principal diagnosis of acute myocardial infarction (death of heart muscle tissue due to a sudden blockage of blood flow in a coronary artery).Record review of Resident #27's MDS, dated [DATE], revealed the residents had a BIMS score of 2 indicating residents' cognition was severely impaired. Record review of progress note dated 05/05/2026 documented by RN-C read in part, Resident #27 noted with left eye, below the lower lid, left hand and above the eyebrow bruised areas, assessment completed, no swelling or pain. NP and RP notified today.Record review of Resident #27's progress noted dated 05/05/2026 documented by RN-C read in part, NP visited and ordered to transfer Resident #27 to the hospital for further evaluation. CT scan of head, maxillofacial and the left hand.Record review of Resident #27's hospital discharge records dated 05/06/2026 revealed no fractures and normal CT scans.Record review of Resident #27's undated care plan, revealed:Focus: [Resident #27] is at risk for falls. Goal: [Resident #27] will remain free from serious injury related to falls. Interventions: Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair.Provider notified of incident, As part of the post fall intervention plan, a review of the patients' psychotropic medications have been initiated to evaluate potential effects on balance and fall risk. Will continue to monitor closely for any delayed symptoms or changes in condition. Redirect resident back to nurse station when seen wandering to prevent any fall occurrence.Initiate a scheduled toileting program with increased frequency for every 2 hours and as needed to reduce urgency and unassisted bathroom attempts. In an interview with CNA-X on 07/01/2026 at 9:34 a.m., she stated Resident #27 had an unwitnessed fall during her shift on 05/03/2026 , and she reported the fall to the weekend supervisor. She did not know if the Weekend Supervisor reported the incident to the Administrator or DON. She said that she had been trained on abuse and neglect, and all allegations should be reported to the Administrator immediately. She said that she did not report it to the Administrator. She did not answer when asked why she did not report it immediately to the Administrator.In an interview with CMA-Q on 07/01/2026 at 10:45 a.m., she stated Resident #27 had an unwitnessed fall and he was observed on the floor, she stated she notified the weekend supervisor. She did not know if the Weekend Supervisor reported the incident to the Administrator or DON. She said that she had been trained on abuse and neglect, and all allegations should be reported to the Administrator immediately. She said that she did not report it to the Administrator. In an interview with the DON on 07/01/2026 at 12:05 p.m., he stated he was not sure exactly how many days later he learned about Resident #27's fall but he knows it was days later after the fall occurred. He stated Resident #27 was observed with a bruise on his face and that led the facility to start an investigation. He said that staff are trained to report allegations of abuse and neglect to the Administrator immediately. He said that staff failed to reported Resident #27's unwitnessed fall to the Administrator on 05/03/2026. In an interview with the Weekend supervisor on 07/02/2026 at 12:56 p.m., he stated Resident #27 did not have a fall on his shift and denied that anyone had ever notified him that the resident had a fall. He said that he was trained to report allegations of abuse and neglect to the Administrator immediately. He said that if staff had notified him of Resident #27's fall he would have reported it to the Administrator immediately.In a phone interview with NP-W on 07/02/2026 at 1:29 p.m., he stated he was informed Resident #27 had a fall on 05/05/2026 when the resident was observed with bruising. He stated they were trying to determine what happened so ultimately the resident was sent out to the hospital. He stated the resident did not have any fractures and he was readmitted back to the facility. He stated he should have been contacted on the day of the fall, and his recommendation would have been to send the resident out to hospital that day. Record review of facility policy, Notification of changes dated 12/05/2025 read in part, .Compliance Guidelines: The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification.1. Accident. S. resulting in injury b. Potential to require physician intervention. 2. Significant change in the resident's physical, mental, or psychological condition.

Based on observation, interview, and record review, the facility failed to ensure that resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and resident choice for 1 of 3 residents (Resident #27) reviewed for falls. The facility failed to ensure Resident #27 was assessed after an unwitnessed fall. This failure placed residents at risk of delay in care, worsening of injuries. Findings included:Record review of Resident #27's face sheet revealed a [AGE] year-old male who admitted into the facility on [DATE], readmission date on 04/24/2026, with a principal diagnosis of acute myocardial infarction (death of heart muscle tissue due to a sudden blockage of blood flow in a coronary artery).Record review of Resident #27's MDS, dated [DATE], revealed the resident had a BIMS score of 2 indicating residents' cognition was severely impaired. Record review of progress note dated 05/05/2026 read in part, Resident #27 noted with left eye, below the lower lid, left hand and above the eyebrow bruised areas, assessment completed, no swelling or pain. NP and RP notified today.Record review of Resident #27's progress noted dated 05/05/2026 read in part, NP visited and ordered to transfer Resident #27 to the hospital for further evaluation. CT scan of head, maxillofacial and the left hand.Record review of Resident #Resident #27's undated care plan, revealed:Focus: [Resident #27] is at risk for falls. Goal: [Resident #27] will remain free from serious injury related to falls. Interventions: Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair.Will continue to monitor closely for any delayed symptoms or changes in condition. Redirect resident back to nurse station when seen wandering to prevent any fall occurrence.Initiate a scheduled toileting program with increased frequency for every 2 hours and as needed to reduce urgency and unassisted bathroom attempts.In an interview with the Administrator on 07/01/2026 at 9:04 a.m., he stated Resident #27 had an unwitnessed fall on 05/03/2026 but he did not learn about the fall until 05/05/2026 or 05/06/2026. He stated the weekend supervisor did not report the fall and there was no documentation that the fall occurred. He stated the resident was assessed when he learned about the fall and the physician and family was contacted. He stated the resident was sent out to the hospital and returned to the facility the following day. He stated the residents test results came back normal. He stated he interviewed the weekend supervisor, and he denied that anyone had informed him that the resident had a fall. He stated he spoke to other staff members during his investigation, and they reported that the weekend supervisor was informed that the resident had a fall. In an interview with CNA-X on 07/01/2026 at 9:34 a.m., she stated Resident #27 had an unwitnessed fall during her shift on 05/03/2026 and it was reported to the weekend supervisor. She stated the resident was observed on the floor in his room. She stated she did not observe any marks or bruises on the resident, and he was not complaining of any pain. She stated when the incident reported to the Weekend supervisor, he did not do anything. She stated he did not assess the resident; he remained sitting at the nurse's station. She stated the weekend nurse informed her to put the resident back in bed. She stated she picked the resident up and put him back in bed. She stated that she knew that the resident should have been assessed by the nurse prior to being moved but because the weekend supervisor gave her directive to pick him up, so she did what she was told. She stated she should have called for another nurse or contacted administration instead of moving the resident. She stated she did not report the incident to anyone else. In a phone interview with Family member of Resident #27 on 07/01/2026 at 9:56 a.m., she said she learned the resident had a fall on 05/03/2026 after reviewing electronic monitoring of the resident's room. She stated the facility did not notify her until 05/05/2026 which was the day the resident was sent out to the hospital. She stated she no longer had to video surveillance because she did not have a [NAME] card at the time of the incident. She stated she did not see anyone assess the resident, but she did see the aid pick the resident up off the floor after walking by him to fix the bed. She stated the nurse could be heard in the video stating, Not today, Resident #27, Not today Resident #27. In an interview with CMA-Q on 07/01/2026 at 10:45 a.m., she stated Resident #27 had an unwitnessed fall and he was observed on the floor, she stated she notified the weekend supervisor. She stated the weekend supervisor did not do anything when she informed him that the resident was on the floor; she stated he remained sitting at the nurse's station. She stated she the CNA assigned to the resident went to check on the resident and she did not know what happened afterwards because the resident was not assigned to her so she went on to complete her duties. She did not know if the Weekend Supervisor reported the incident to the Administrator or DON. She said that she had been trained on abuse and neglect, and all allegations should be reported to the Administrator immediately. She said that she did not report it to the Administrator. In an interview with the DON on 07/01/2026 at 12:05 p.m., he stated he was not sure exactly how many days later he learned about Resident #27's fall but he knows it was days later after the fall occurred. He stated Resident #27 was observed with a bruise on his face and that led the facility to start an investigation. He stated through the investigation they learned that Resident #27 had a fall. He stated the Weekend supervisor was working the day the resident had the fall and it was not reported to anyone or documented. In an interview with the Weekend supervisor on 07/02/2026 at 12:56 p.m., he stated Resident #27 did not have a fall on his shift and denied that anyone had ever notified him that the resident had a fall. He said that he was trained to report allegations of abuse and neglect to the Administrator immediately. He said that if staff had notified him of Resident #27's fall he would have reported it to the Administrator immediately.In a telephone interview with NP-W on 07/02/2026 at 1:29pm, he stated he was informed Resident #27 had a fall on 05/05/2026 when the resident was observed with bruising. He stated they were trying to determine what happened so ultimately the resident was sent out to the hospital. He stated the resident did not have any fractures and he was readmitted back to the facility. He stated he should have been contacted on the day of the fall, and his recommendation would have been to send the resident out to hospital that day. Interview/Observation with Resident #27 on 07/02/2026 at 8:02am with Resident #27, he was observed sitting in bed with bed in lowest position, call light in reach, and fall matt in place. Resident #27 stated he did not remember having a fall and asked Surveyor if he had a fall. He stated the staff treated him good and stated the staff were not rude to him. He stated he felt safe at the facility. Record review of the facility's dated revised 08/01/2025 policy titled Fall Risk Assessment revealed, It is the policy of this facility to provide an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. 1. The risk assessment will be completed by the nurse or designee. when a significant change in identified. Record review of the facility's dated 05/06/2026 in- service training: Responding to Resident Falls-No Resident Left Unattended revealed: 1. Immediate Priorities When a fall occurs-Safety first- The resident must never be left alone on the floor for any reasonStay with the resident until a licensed nurse arrives and completes an assessmentCall for help immediately-use the call light, radio, or nearest staff member.2. What staff must do. Notify the nurse right away-A licensed nurse must assess the resident before any movement or transfer.3. What staff Must Not Do:Do not attempt to life or move the resident before the nurse assesses themDo not leave the resident to go get help. Call out, use your radio, or send another staff member.Do not allow the resident to get up on their own.

Based on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, for 1 (100-hall med cart) of 4 med carts reviewed for medication storage. The 100-hall nursing medication cart had an insulin pen labeled for Resident #1 and was not labeled with an open date.This deficient practice could place residents at risk of not receiving expired medications and or the intended therapeutic benefit of their medications, resulting in a decline in health status.Findings included:In an observation on 7/01/2026 at 2:00 p.m., with the ADON, the 100-hall nursing medication cart assigned to RNA revealed an insulin pen with 180 units/ml for Resident #1 without open date information available.In an interview on 07/02/2026 at 10:32 a.m., the DON stated he has been working for 1 year 8 months in the facility. He stated he has 15 years of Nursing Experience. DON stated they have a pharmacy requisition binder with pharmacy receipts, if they get an insulin, he will have to go through the binder to see when it was delivered and that they store it for up to 60 days. He stated they have a delivery log and a record of medication delivery. DON stated that nurses are obligated to check on expiration dates before administering medication. He stated that nurse managers take time to go through the cart. He also stated the DON, the ADON and pharmacy, including nurses on the floor frequently check the medication cart. DON stated that ADON checks medications cart to ensure what is not supposed to be in the cart is removed. He stated that the medication is frequently reordered and doesn't have to run out. He stated that if a medication is running low, 3-5 days before, if there is refill, the pharmacy will send it or if refills are needed the doctor will send another prescription as needed. DON stated that if the medication is expired, they are supposed to take it out and put it in the destruction box. He stated that new insulin pens are kept in medication storage room and refrigerated insulins are in the refrigerator. He stated that residents' names are already on the insulin pen as it comes from the pharmacy, the nurse will just add the date once it is open. DON stated that sometimes the label on the insulin pen can fall off and they are supposed to put it back on it and make sure it is secure. He stated that there is always a label on the insulin pen and that you cannot write the resident name on the pen, you just put an open date on it. He stated that the insulin pen is supposed to last for 30 days once it is open. DON stated that his expectation is to have an open date on the insulin pen. He stated that if the pen is given with no date on it, it could be expired and they cannot give insulin with no date on it. DON stated that the risk of giving expired medications to patients has a wide range of reactions and that it would be based on patients' immune system and allergies. He stated if an Insulin pen has no date, it must be discarded and the doctor must be notified.In an interview on 07/02/2026 at 11:04 a.m., with ADON, she stated she has been working in the facility since May 2026, full time, ADON for 2 years and LVN for 17 years. She stated Insulin is supposed to have patients name and an open date. She stated that some insulin pens in the storage box or E-kit don't have orders labeled. Insulin pens coming directedly from the pharmacy have a label on them. ADON stated that medications in the E-kit are for emergencies if the medication that was ordered is running late, didn't come or is run out. She stated that nurses will hand write the name of the resident on the insulin pen if the pen comes from the E-kit and they must also write the open date. ADON stated if there is no date on an insulin pen, the nurse must remove it from the medication cart and discard it. She stated the risk of giving the medicine with no open date is that the medication can be expired and it can cause complications like death, some type of changes and other complications. ADON stated that nurses need to go by the policy, be prudent nurses and be more alert and communicate. She stated that the pharmacy comes every 2 weeks to refill the E-kit, the box is good until 07/6/2026. She stated that they check medication carts every day but beginning of the month is the main day to check all the carts. ADON stated checking medications carts for expired medications is everybody's job; nurses, ADON and medication aids. She stated that only medications that are supposed to be given are on the cart. She stated that all insulin pens must have a resident name and the open date.In an interview on 07/02/2026 at 11:34 a.m., with RN A, she stated she has been working at the facility for 1 year and has been an RN for 20 years. She stated that she did not open the insulin pen it. She used it. RN A stated it was her fault because she did not check for the expiration date on the insulin pen when she gave it in the morning. She stated the insulin pen was recently open because resident #1 get 22 units twice a day. She stated that if she finds an expired medication in the medication cart, she will notify ADON and she will tell her what to do. She stated that this was the first time this incident happened. RN A stated that the risk of giving expired medication is that the medicine will not be effective. She stated that ADON is the one supposed to be checking the medications carts for expired medications. She stated she is supposed to check the expiration date on the medications she is given but that ADON is supposed to check the whole cart for expired medications.Record review of facility's Administering Medications policy, revised April 2019, indicated that 12. The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container.Vials and Ampules of injectable medications. b. The date opened and the initials of the first person to use the vial and recorded on multidose vials) on the vial label or an accessory label affixed to that purpose.

Based on interviews, and record review, the facility failed to ensure residents were free from abuse and neglect for 1 of 5 residents (CR#1) reviewed for ADL Care.The facility failed to ensure CR#1 was free from neglect when she was told to poop in her diaper and left to sit in her feces for 2 hours.This failure could place residents at risk of developing skin associated wounds needing continued medical assistance.FindingsRecord review of CR#1's undated face sheet revealed a [AGE] year-old female who was originally admitted to the facility on [DATE] and discharged from the facility on 3/30/2026. Resident #3 had a diagnosis of type 2 (obtained later in life) Diabetes with hyperosmolarity (body doesn't make enough insulin in the body); legally blind (unable to see), dependence on renal dialysis (treatment for people with failing kidneys), hypertension (high blood pressure).Record review of CR#1's Baseline Care Plan dated 3/28/26 revealed the following:Focus: Resident Has an ADL self-care performance deficit dash data initiated 3/28/26Goal: This area is blankInterventions: The date is totally dependent on staff to provide all of her necessary needs. Date started 3/28/26Record review of CR#1's Discharge MDS dated [DATE] revealed, CR#1's BIMS score was left blank. According to Section GG - Functional Abilities, CR#1 required partial/moderate assistance (Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs and provides [NAME] than half the effort) in the following areas: Oral hygiene, toileting, shower/bath, upper and lower body dressing, personal hygiene; CR#1 required Substantial/Maximal assistance (Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) in Toilet transfer, and tub/shower transfer.Record review of facility investigation report completed on 3/31/26 indicated CR#1 decided to leave against the medical advice of the facility physician. CNA A was suspended pending the investigation. The results were confirmed.Record review of CNA A's Incident statement dated 3/31/26 revealed at 10:40 PM CNA A responded to CR#'s call light at which time CR#1 told CNA A her call light had been on about an hour. CNA A denied this was accurate. According to CNA A 's incident report at this time the resident informed him that she was on antibiotics which may contribute to frequent bowel movements. CNA A stated at 1:30 AM CR #1 called again and he provided incontinent care because she had another bowel movement. CNA A stated at 2:15 AM he was caring for another resident and when he exited that resident room at 2:30 AM he noticed CR#1's called light was on again. CNA A stated at this time he provided care for CR#1. He stated during care she was on the telephone with FM B and he stated FMB told her that it was not that long of a period for her wait for care.During a telephone interview on 4/28/26 at 3:30pm with FM B she stated CR#1 arrived to the facility on Friday or Saturday and it was horrible for her on that night shift. She stated CR#1 is legally blind, which is a result of her diabetes. She stated the CNA A would take almost an hour to respond to CR#1's call light. She stated CR#1 would call her throughout the night crying. FM B stated on 3/29/26, Sunday evening early morning, she was on the phone with CR#1 who was telling her she was sitting in her feces for the last two hours. FM B stated she was on the phone when CAN A came in the room and she heard him say, I hope you don't do this all night. FM B stated this was after CR#1 had been sitting in her feces for 2 hours. FM B stated she spoke with administrator and DON and told them she would be discharging from that facility. FM B stated CR#1 was traumatized by the degrading way CNA A spoke with her and how he made her feel.During a telephone interview on 4/29/26 at 9:48am with CR#1 who stated she is totally blind. CR#1 stated she arrived at the facility on Saturday 3/28/26 afternoon. During the night shift, CR#1 stated when she pushed her call light it took 45 minutes for CNA A to answer her call light. CR#1 stated she was taking antibiotics, which made her have multiple bowel moments throughout the day and night. CR#1 stated each time she pushed her call light on the night shift, it would take over 40 minutes for CNA A to answer. CR#1 stated CNA A appeared to get frustrated with her as indicated by him telling her he had other residents to tend to and she was not his only resident. She informed CAN A that she could walk with assistance and he could assist her to the bathroom if it would make it easy for him. CR#1 stated she asked him why does it take him over 40 minutes to answer the call light and he stated he actually has 2 hours to answer because his rounds are completed every two hours. After an hour, CR#1stated she pushed her call light and when CNA A came in her room, she asked him to help her to the bathroom and he told her to poop in her diaper and wait. CR#1 stated the next day on 3/29/26, when CNA A arrived for his night shift (10:00am-6:00am), she pushed her call light and it took 30-40 minutes for him to come. She stated he did not come right away. She stated she sat in her feces from 1:00am-3:00am. CR#1 stated she called FM A during this time and told her she was still sitting in her poop. She stated this was humiliating and she was traumatized. She stated FM B came to pick her up on Monday 3/30/26 early morning. She stated she felt disgusting and nasty. She stated she never wants to return to a place (Nursing facility) like this.During an interview on 4/28/2026 at 5:17pm with Administrator he stated he gets phone calls in the middle of the night from residents that staff are not answering call lights. He stated he has left his own home and came to the facility to answer call lights. He stated based on census there are enough staff. He stated they have terminated staff for not doing their jobs. He stated good workers are difficult to find. He stated call lights are a challenge and a work in progress. He stated in-service training is completed monthly for the quality of care. Administrator stated adverse effect of not answering call lights is bad because residents depend on light for their needs. He states he is in continuous communication with staff for call lights. The administrator stated the facility generated report was not confirmed but could not provide a reason why he confirmed it on his investigation. The Administrator stated he spoke with the FM regarding CR#1 and her leaving. He stated the FM stated CR#1 stated that the CNA took over and hour each time she pushed her call button for assistance. He stated he spoke with CNA A who denied the incident. He stated all staff and residents have his personal number and called him regarding call lights. He stated the call lights are a continuous issue and he is working on it. He stated he has terminated some staff, completed in-service training on others and has hired some as well. He stated call light have been an ongoing problem. The administrator stated he is the abuse coordinator. Regarding CNA A, the Administrator stated he had returned to work.During an interview on 4/28/2026 at 5:25pm with DON, care should be completed before the call light is turned off. Adverse effect with not answering call lights. It could be pain, get out of bed by themselves. States definition of neglect is to provide care within standards of practice and if we don't then it is neglect. The adverse effect of neglect a patient can feel abandoned psychologically or physical impairment, bed sores, patient may try to get up by themselves and possibly fall.Several attempts to contact CNA A were unsuccessful; however, Administrator stated CNA A is out of the country at this time and is not available by telephone.Record Review of the facility's abuse, neglect, and exploitation dated 2024 reveals:Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident [NAME] are necessary to avoid physical harm, pain, mental anguish or emotional distress.

Based on interviews, and record review, the facility failed to provide services and make reasonable accommodations to meet the Residents needs and preferences, for 4 of 5 residents reviewed for quality of life (CR#1, Resident #2, Resident #3, and Resident #4) reviewed. Resident rights Facility failed to ensure nursing staff responded to resident call lights within a reasonable time frame. Interviews were CR #1, Resident #2, Resident #3, and Resident #4 revealed their call lights frequently went unanswered for up to one hour or longer.This should practice had the potential to place residents at risk for unmet needs, including delays in receiving assistance with medical care in the event of an emergency.Findings include:Record review of CR#1's undated face sheet revealed a [AGE] year-old female who was originally admitted to the facility on [DATE] and discharged from the facility on 3/30/2026. CR#1 had diagnoses of type 2 (obtained later in life) Diabetes with hyperosmolarity (body doesn't make enough insulin in the body); legally blind (unable to see), dependence on renal dialysis (treatment for people with failing kidneys), hypertension (high blood pressure).During a telephone interview on 4/28/26 at 3:30pm with FM B she stated CR#1 arrived at the facility on Friday or Saturday and it was horrible for her on that night shift. She stated CR#1 was legally blind, which was a result of her diabetes. She stated the CNA A would take almost an hour to respond to CR#1's call light. She stated CR#1 would call her throughout the night crying. FM B stated on 3/29/26, starting on Sunday evening a little after 11:00pm and on early morning (Monday morning approximately 1:00am), CR#1 telephoned her and began telling her she was sitting in her feces for the last two hours. FM B stated she was on the phone when CNA A came in the room and she heard him say, I hope you don't do this all night. FM B stated this was after CR#1 had been sitting in her feces for 2 hours. FM B stated she spoke with administrator and DON and told them she would be discharging from that facility. FM B stated CR#1 was traumatized by the degrading way CNA A spoke with her and how he made her feel.During a telephone interview on 4/29/26 at 9:48am with CR#1, she stated she was totally blind. CR#1 stated she arrived at the facility on Saturday 3/28/26 afternoon. During the night shift, CR#1 stated when she pushed her call light it took 45 minutes for CNA A to answer her call light. CR#1 stated she was taking antibiotics, which made her have multiple bowel moments throughout the day and night. CR#1 stated each time she pushed her call light on the night shift, it would take over 40 minutes for CNA A to answer. CR#1 stated CNA A appeared to get frustrated with her as indicated by him telling her he had other residents to tend to and she was not his only resident. She informed CNA A that she could walk with assistance and he could assist her to the bathroom if it would make it easy for him. CR#1 stated she asked him why does it take him over 40 minutes to answer the call light and he stated he actually has 2 hours to answer because his rounds were completed every two hours. After an hour, CR#1stated she pushed her call light and when CNA A came in her room, she asked him to help her to the bathroom and he told her to poop in her diaper and wait. CR#1 stated the next day on 3/29/26, when CNA A arrived for his night shift (10:00am-6:00am), she pushed her call light and it took 30-40 minutes for him to come. She stated he did not come right away. She stated she sat in her feces from 1:00am-3:00am. CR#1 stated she called FM A during this time and told her she was still sitting in her poop. She stated this was humiliating and she was traumatized. She stated FM B came to pick her up on Monday 3/30/26 early morning. She stated she felt disgusting and nasty. She stated she never wants to return to a place (Nursing facility) like this.Record review of Resident #2's undated Face Sheet revealed she was a [AGE] year-old female who was originally admitted to the facility on [DATE] and readmitted [DATE]. Resident #2 had active diagnoses of Acute Respiratory Failure with Hypoxia (respiratory failure is a life-threatening, short-term condition where the lungs cannot adequately oxygenate the blood, Hypertension (Blood pushes too hard against artery walls), Diabetes (body doesn't make enough insulin in the body), Cerebrovascular Accident (it occurs when blood flow to the brain is interrupted or blood vessel bursts, Hemiplegia and Hemiparesis' follow Cerebral Infarction affecting the Left side (this condition causes reduced strength, sensory deficits, and balance issues, Seizures (are uncontrolled electrical disturbances in the brain, causing symptoms like convulsion, blank staring or altered sensations. Record review of Resident #2's MDS dated [DATE] revealed she had a BIMS score of 15, which meant cognitively intact., The resident was totally dependent on staff for most of her ADL's, which were incontinent care (bathing, and changing,), rolling from left to right from a lying position, and personal hygiene.Record Review of Resident #2's Care Plan dated 07/21/2025 revealed the following:Focus: Resident #2 was incontinent of bladder and bowel (Date Initiated: 04/20/2022; Revision on 01/14/2026).Goal: Resident #2 will remain clean, dry and free and dignity will be maintained (Date initiated: 04/09/2020; Revision on 01/14/2026; Target date 06/22/2026).Interventions: Monitor for incontinence often, encourage resident to use bell to call for assistance (Date initiated: 07/21/2025). During an interview on 04/27/2026 at 11:16 am with Resident #2 she stated she has had a lot of issues with nursing staff on 2-10 shift and weekend staff, who refuse to answer her call light when needing incontinent care. Resident #2 stated nursing staff come into her room and turn off call light then leave without providing care. Resident #2 stated they never change her diaper; they just leave her in urine and sometimes feces for long periods which makes her feel bad Resident #2 stated her dignity concern by nursing staff on 2-10 shifts and weekends had been ongoing for a while. Resident #1 stated she's left in bed soaked because the 2-10 shift and weekend staff will not answer her call light or if they come into her room, they turn off call light, leave and never return. Resident #2 stated she spoke with the 2-10 charge nurse about her call light not being answered, including weekend staff. Resident #2 stated she also told FM A about the issues with staff not answering her call light on 2-10 shift and weekends. Resident #2 stated she felt neglected, embarrassed and ashamed. Resident #2 stated FM A had specific times and days the issues started. FM A stated talking to administrator and nursing staff has gotten her nowhere. During telephone interview on 04/27/2026 at 2:10 pm with FM A revealed Resident #2's call button was ignored and staff refused to acknowledge that Resident #2 needed assistance and care. FM A stated, the call light issues were mainly the 2-10 shift. FM A stated the 2-10 shift CNAs leave resident lying in bed in her diaper because they don't answer the call button. She stated staff will come in the room and just turn the call light off then leave right out without providing any care to Resident #2. FM A stated 2-10 nursing staff refuse to change or clean Resident #2 when she was soiled. FM A stated she has reached out to the administrator and nursing staff several times, but nothing has been done. She explained that due to staff not answering call lights Resident #2 will call the front desk hoping that someone will answer resident's call light, but the phone was never answered. FM A stated this was also an ongoing problem on the weekend about nursing staff refusing to change Resident #2 when she uses her call bell to call for help. FM stated Resident #2 does not have any pressure sores yet, but it was a concern because they were not answering call light to change Resident #2's brief timely. Record review of Resident #3 's undated Face Sheet revealed she was a [AGE] year-old female who was originally admitted to the facility on [DATE] and readmitted [DATE]. Resident #3 had an active diagnosis of Chronic Obstructive Pulmonary disease, Unspecified (Chronic Obstructive Pulmonary Disease (COPD) is a progressive, incurable lung disease-primarily caused by smoking-that restricts airflow, making it difficult to breathe. Unspecified Asthma, Uncomplicated (it is a chronic respiratory condition documented when clinical details are insufficient to classify the asthma's severity or control. Uncomplicated means the patient is not currently experiencing an acute asthma attack, worsening symptoms. Morbid Obesity (severe overweight due to excess calories and when body mass index is greater than 40) Anemia (is a blood disorder characterized by insufficient healthy red blood cells or hemoglobin to carry adequate oxygen to tissues, causing fatigue, weakness, pale skin, and shortness of breath) Hypertension (Blood pushes too hard against artery walls) thrombosis and EMBOLISM.Record Review of Resident #3's Care Plan dated 06/05/2024 revealed the following:Focus: Resident #3 is at risk for falls r/t impaired mobility, impaired cognition, muscle weakness, abnormalities of gait and mobility, lack of coordination, bed confinement (Date Initiated: 06/06/2024; Revision on 04/22/2026).Goal: Resident #3 The resident will reduce the risk for further incidents and be free of incident and be free of injury through the next review date (Date initiated: 06/05 /2024; Revision on 01/16/2026; Target date 04/25/2026).Intervention: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance (Date initiated: 04/10/2025; Revised on 4/10/2025).Record review of Resident #3's MDS revealed a BIM score of 15, which indicate Resident #3 had normal thinking and memory (no or very little impairment). The MDS revealed Resident #3 used a wheelchair and was totally dependent on nursing staff for toilet hygiene, showers, upper & lower body dressing, sit to lying, chair and bed transfer.During an interview on 4/28/2026 at 2:29 pm with Resident #3 she stated she has call light issues with nursing staff not responding to her call lights when needing to be changed or put back into her bed. Resident #3 stated she doesn't have any issues reaching call light, but when she pushes it, no one ever comes. Resident #3 stated the longest she has waited for someone to answer call light was two hours. Resident #3 stated she feels bad when she soils her brief, then depending on CNAs to clean her up. Resident #3 stated she also must wait a long time to be put back into bed after being up all day. Resident #3 stated she was in a lot of pain at times.Record review of Resident #4's undated Face Sheet revealed he was a [AGE] year-old male who was originally admitted to the facility on [DATE] and readmitted [DATE]. Resident #4 had active diagnoses of Diabetes (body doesn't make enough insulin in the body), Peripheral Autonomic Neuropathy (is damage to the nerves outside the brain and spinal cord that control involuntary bodily functions, such as heart rate, blood pressure, digestion, and sweating), Morbid Obesity (is due to excessive calories), Insomnia is a sleep disorder ( difficulty falling asleep, staying asleep, or waking too early,)Neuromuscular dysfunction of the bladder (it causes incontinence, retention, or frequent urges) Muscle weakness (is a reduced ability to exert force with muscles), Cerebral Palsy (it results in symptoms like stiffness, involuntary movements, and poor coordination).Record Review of Resident #4's Care Plan dated 02/21/2024 revealed the following:Focus: Resident # is at risk for falls r/t mobility, psychoactive medications (Date Initiated:02/21/2024 ; Revision 02/24/2026). Goal: Resident # 4 The resident will be free from any signs/symptoms of hypoglycemiathrough the review date. (Date initiated: 04/06/2025; Revision on 04/24/2026; Target date 06/04/2026).Intervention: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident need prompt response to all requests for assistance (Date initiated: 04/18/2024; Revised on 05/02/2025).Record review of Resident #4's MDS dated [DATE] revealed she has a BIMS score of 15, which meant he was cognitively intact, indicating normal thinking and memory with little to no impairment. Resident was totally dependent on staff for most of her ADL's, which were incontinent care (bathing, and changing,), rolling from left to right from a lying position, and personal hygiene.During an interview with Resident #4 he stated (10:00pm-6:00am) which is considered the night shift has a serious issue with answering call lights. This is a big problem. Resident #4 stated call light goes without being answered for over an hour. Resident #4 stated he has had to call nurse station from his own cell phone to get someone to answer his call light.During an interview on 4/28/2026 at 5:17pm with the Administrator he stated he gets phone calls in the middle of the night from residents that staff were not answering call lights. He stated he has left his own home and came to the facility to answer call lights. He stated based on census there were enough staff. He stated they have terminated staff for not doing their jobs. He stated good workers were difficult to find. He stated call lights were a challenge and a work in progress. He stated in-service training was completed monthly for quality of care. The Administrator stated adverse effect of not answering call lights was bad because residents depend on light for their needs. He stated he was in continuous communication with staff for call lights. During an interview on 4/28/2026 at 5:25pm, the DON stated care should be completed before the call light was turned off.The DON stated the adverse effect for not answering call lights could be residents are in pain and need a nurse, or they could attempt to get out of bed by themselves and fall. The DON stated the definition of neglect is not providing care within standards of practice; and if we don't do it, then it is neglect. An additional adverse effect of neglect is a patient can feel abandoned psychologically or physical impairment, bed sores, patient may try to get up by themselves and possibly fall.Record Review of Resident Rights policy dated February 2021 revealed, Employee show treat all residents with kindness, respect, and dignity.1. federal and state laws that guarantee certain basic rights to all residents of this facility. These rights include the residents' right to:a dignified existence.be treated with respect, kindness, and dignity.f. Communications with access to people and services, both inside and outside the facility.h. Be supported by the facility in exercising his or her rights.

Based on observation, interview, and record review, the facility failed to ensure nursing staff possessed the appropriate competencies and skill sets necessary to provide safe care for 1 of 3 residents reviewed for nursing services (Resident #1).The facility failed to ensure CNA G implemented safe transfer measures on 02/13/2026 at 4:00 a.m. when she attached the lift sling to the handling strap, instead of the sling attachment loop. Resident #1 experienced a fall and sustained a fractured clavicle during a mechanical lift transfer. The DON was unable to demonstrate proper mechanical lift transfer technique or clearly explain required safety measures.The facility was unable to provide documentation verifying that CNA G, CNA A, CNA B, or other direct care staff had demonstrated competency in mechanical lift transfers prior to performing resident care.On 02/23/2026 at 2:11p.m. an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 02/25/2026, the facility remained out of compliance at a severity level of at a potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. The lack of competency validation contributed to improper sling attachment during transfer, resulting in Resident #1 sustaining a fractured clavicle, and placed other residents requiring mechanical lift transfers at risk for serious injury, including fractures, head trauma, internal injury, or death. Findings included:Record review of Resident #1's face sheet, dated 02/22/2026, revealed a [AGE] year-old female admitted [DATE], diagnosis included cerebral palsy (is a group of conditions that affect movement and posture caused by brain damage before birth) other abnormalities of gait and mobility, muscle wasting and atrophy, muscle weakness (generalized), contracture, unspecified joint.Record review of Resident #1's MDS, dated [DATE], indicated a BIMS score of 14, indicating no cognition impairment. Record review of fall risk assessment for Resident #1, dated 02/13/2026, indicated a score of 22.0 indicating high risk for falls.Record review of Resident #1's care plan, dated 01/18/2026, reflected:Focus Area: Resident #1 is at raise 4 falls related to limited mobility weakness and altered mental status.Goal: Resident #1 We'll be free of falls are injuries related to falls through the next review date.Interventions /Tasks: Ensure mechanical lift straps are secure and not broken, All straps in place, mechanical live is charged before transferring Resident#1 with two person assist.Focus Area: Resident #1 has an ADL self-care performance deficit related to limited mobility and weakness.Interventions /Tasks: Resident #1 one requires mechanical lift with two-person staff assistance for transfer.Record review of Resident #1 's X- Ray results (performed at the facility) of left shoulder, dated on 02/13/2026 with evaluation time 2:55 p.m. and reported time of 3:06p.m., revealed a fractured clavicle.Record review of Resident #1 hospital documentation for Resident #1, dated 02/13/2026, revealed:Resident #1's clavicle X- Ray at 8:21 p.m., suspected mid fractured clavicle, mildly displaced.CT scan at 9:58 p.m. of shoulder confirmed findings of a fractured distal end of the left clavicle (a break near the shoulder end of the collarbone). Record review on 02/22/2026 of staff training and competency records revealed: No documentation of mechanical lift competency validation for direct care staff, including CNA G, CNA A, CNA B. No documented competency validation for nursing staff responsible for supervising transfers, including the DON. No structured system to verify staff competency prior to independently performing mechanical lift transfers. No record provided identifies the number of residents requiring mechanical lift transfers in the facility.CT scan at 9:58 p.m. of shoulder confirmed findings of a fractured distal end of the left clavicle (a break near the shoulder end of the collarbone). During an interview on 02/21/2026 at 5:15 p.m., Resident #1 stated she was being transferred by CNA G using a mechanical lift when she fell from the lift. Resident #1 stated she immediately experienced pain and reported pain to Nurse K. She stated there was only one staff member who implemented the mechanical lift transfer but CNA S arrived and assisted by getting the nurse after the fall occurred. Resident #1 stated she was not moved prior to Nurse K's assessment. Resident #1 stated there was usually two person assisting when being transferred with the mechanical lift. She stated CNA G was attempting to get her out of bed early and she did not believe CNA G asked for another person to assist. She stated pain was being managed with medication prior to being transferred to the hospital. She stated she was later transferred to the hospital as she was informed of left fractured clavicle. She stated the pain was managed with medication. She stated the facility replaced the sling after the incident, but the new sling being used after the incident caused pain, described as a knife stabbing to her right leg during each transfer. She stated since the incident on 02/13/2026, two staff members started transferring her with the mechanical lift. Resident #1 reported she did not feel safe when the new sling was used. Resident #1 stated that she had not notified the facility of concern related to the sling. During an interview on 02/21/2026 at 10:19 a.m. , the Administrator stated he and the DON were notified by Nurse K of the incident at 5:30 a.m. on 02/13/2026 by Nurse K. He stated he was informed the sling strap (handle) broke during transfer. The administrator was the abuse coordinator. He stated he is responsible for conducting facility incident investigations. He stated and investigation was initiated on 02/13/2026. He stated during the investigation Resident #1 was assessed and reported no pain. He stated Resident#1's medical provider was notified of the fall immediately by Nurse K. He stated he was informed by Nurse K that no order was given as Resident #1 denied pain and it was witnessed fall. He stated Resident #1 report pain at approximately 9:50 a.m. and was assessed with skin bruising near the left shoulder. He stated Nurse M administered pain medication to manage Resident#1's pain. He stated Nurse M notified the medical provider of the onset of pain and bruising, and an order was given to obtain an X- Ray of the left shoulder. He stated X -Ray results was received by the facility at approximately 3:00 p.m., and revealed that Resident #1 sustained a fractured clavicle as a result of the fall. The Administrator stated the medical provider was notified of the results by Nurse M, and orders were given for additional pain medication and transfer Resident #1 to the hospital for further evaluation. He stated medical transport was requested and Resident #1 was transferred to the hospital at approximately 4:00 p.m. on 02/13/2026. The Administrator stated that the facility immediately removed the mechanical lifts sling from Resident #1's room and the facility clinical area mechanical lifts sling. He stated that the outcome of his investigation determined the root cause of the incident was due to staff error of transferring. He stated CNA G attached the mechanical lift sling to the handling strap, instead of the sling attachment loop. He stated staff had been trained on safe mechanical lift transfer. He stated during his investigation CNA G was suspended for three days. He stated he was informed that there were two staff members who implemented the transfer, CNA G and CNA S. He stated that CNA G error caused injury to Resident #1. He stated that all direct care staff were responsible for ensuring mechanical lifts sling are safe and used properly. He stated that DON was responsible for ensuring all direct care staff was trained by the DOR. The administrator stated that he was not aware how the DON tracked training and compliance. During an interview on 02/21/2026 at 11:00 a.m. the DON stated the DOR was responsible for training staff but was unable to explain how competencies were validated or tracked and the system for ensuring all direct care staff were trained. The DON stated he was responsible for ensuring all nursing staff were skilled and knowledgeable of mechanical lift safety. He stated he was not aware if the DOR was informed of Resident #1's fall incident. The DON could not explain who was responsible for inspecting the slings and straps to determine if they were worn or safe to use during resident transfers. The DON could not explain how often were mechanical lift and slings was inspected for safety. He stated when staff were not trained properly the residents were placed at risk of harm.During an interview on 02/21/2026 at 3:45p.m., the DOR stated he provided a mechanical lift in-service to direct care staff on 02/14/2026. The DOR stated he was not trained by the facility on the mechanical lifts and sling used by the facility. He stated he was unaware of the manufacture models, the different slings used by the facility, and if each sling used for resident transfers were compatible with the facility mechanical lift. DOR stated he was not familiar with the facility Mechanical lifts competency and evaluation checklist. He stated he had not used or implemented the facility competency and evaluation checklist when he trained facility staff. DOR stated he used prior knowledge and experience related to mechanical lift to train staff. DOR stated he was not aware of the facility residents requiring mechanical lift transfers and the documentation could be found in clinical record. DOR could not explain where the information could be found in the clinical record. DOR stated he was informed of Resident #1's fall but was not informed that the fall was due to knowledge deficiency or staff error. He stated no specific trained related to Resident #1 incident was provided to staff. He stated when staff were not trained properly the residents were placed at risk of harm.During interviews on 02/21/2026, between 12:50 p.m. - 6:45 p.m., CNA A and CNA B, CNA C and Nurse M, and Nurse D stated they had been recently in-serviced on resident mechanical lift transfers but denied completing mechanical lift competency and validation. Staff could not explain proper use of the mechanical lift and sling that was required to safely transfer resident. During an attempted telephone interview attempted on 02/21/2026 at 3:15 p.m., CNA G was left a voicemail requesting a return call, but no return call. During an attempted telephone interview on 02/21/2026 at 3:23 p.m., CNA S was left a voicemail requesting a return call, but no return call.During an observation on 02/21/2026 at 12:16 p.m., the DON did not demonstrate proper use of the mechanical lift that was required to safely transfer residents. He did not lock the wheels of the mechanical lift, failed to position mechanical lift sling correctly. He was unable to clearly explain required safety measures during mechanical lift use. He could not clearly explain the facility's system in place to ensure proper use of mechanical lift. During an observation and interview on 02/21/2026 at 4:16 p.m., Resident #1 was transferred by CNA A and CNA B. Observation revealed they did not demonstrate proper use of the mechanical lift that was required to safely transfer resident. CNA A and CNA B did not ensure mechanical lift wheel were not locked prior to attachment of the mechanical lift sling used to transfer Resident #1. CNA A and CNA B did not center the mechanical lift sling under Resident #1 proper to transferring Resident #1 from the chair to the bed. Resident #1 stated she felt pain associated with improper positioning during the transfer. CNA A and CNA B were unable to demonstrate or clearly explain required safety measures during mechanical lift use.During an interview on 02/21/2026 at 12:16 p.m. and 02/22/2026 at 9:13 a.m., the DON was asked for a facility policy and procedure check list regarding mechanical lifts and safe resident transfers but was not provided.During an interview on 02/22/2026 at 1:00 p.m., Nurse M stated that she was the nurse assigned to care for Resident #1 on 02/13/2026 morning post fall. She stated that she was informed during hand off shift report by Nurse K that Resident #1 had fallen a couple hours prior to the start of Nurse M's shift at 6:00 a.m. She stated she was informed that Resident #1 denied pain and discomfort during Nurse K ongoing assessments. She stated she was informed that Resident #1 had not being given pain medication, the medical provider was notified, and no new orders had been given. She stated during her initial assessment of Resident #1 she denied pain. She stated when she assessed Resident #1 at approximately 10:00 a.m. she noticed left should area was bruised and Resident # 1 mild pain noted. Nurse M stated she notified the provider and was given an order for X-Ray. She reported ongoing mild pain pending the X-Ray and pain medication was given approximately at 12:30 p.m. and additional medication at approximately 2:00 p.m. Nurse M stated that Resident #1's pain was alleviated on assessment. Nurse M stated she could not recall what time the X-Ray was imagining but she recalled being notified of the results between 3:00p.m and 4:00 p.m. with findings of a fracture with mild clavicle displacement. She stated she informed the medical provider of the findings and was provided with order for non-emergent transport to local hospital. During an interview on 02/22/2026 at 3:00 p.m., Nurse K stated that she cared for Resident #1 on 02/12/2026 night shift and was the nurse on duty at the time of Resident #1's fall incident. She stated she was informed by CNA S on 02/13/2026 at approximately 4:30 a.m. that Resident #1had fallen during mechanical lift transfer from bed to chair. She stated she found Resident #1 on the floor alert and position on her back. She stated she assessed Resident #1 immediately and Resident #1 denied pain. She stated at the time of her initial assessment there was no discomfort, pain, or skin discoloration observed. She stated mechanical lift sling was under Resident #1's body as she assessed Resident #1. She stated she was informed that the sling strap broke during transfer. She stated another sling was used to transfer Resident #1 back to bed after the incident. She stated she was present in Resident #1's room during the post fall transfer but did not witness the transfer at the time of the fall. She stated Resident #1 informed her that CNA G and CNA S were transferring from bed and she had fallen during the transfer. Nurse K stated she was not informed by Resident #1 that there was only one staff member there during the initial transfer. Nurse K stated when she arrived in Resident #1 room, both CNA G and CNA S were there in Resident #1 room with her. Nurse K stated she was informed that CNA G connected the mechanical lift sling to the mechanical lift. Nurse K stated she did not investigate the mechanical lift, but she did recall the strap being broken. She stated she notified the medical provider of the fall on 02/13/2025 at 4:56 a.m. after completing Resident #1's assessment and ensuring Resident was safe. On 02/23/2026 at 2:11p.m. an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 02/25/2026, the facility remained out of compliance at a severity level of at a potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness. The facility's Plan of Removal was accepted on 02/24/2026 at 11:27am and included the following interventions: The Immediate Jeopardy findings were identified in the following area:F 726 - Competent Nursing Staff The Administrator/DON/Corporate Nurse reviewed the Safe Handling of Resident Transfers policy. No changes were identified to be needed at this time. Resident #1 was assessed on 02/13/2026, notifications made and resident sent to the hospital for further evaluation. The resident returned to the facility 02/13/2026 has had follow up appointments made to continue care with orthopedic aftercare. Follow up appointment. 02/25/2026. Resident #1 resides in the facility with no further identified injuries or changes in condition noted. The Corporate Nurse will provide re-education to nursing staff whom were directly involved in the resident's fall prior to their next scheduled shift, prior to them performing direct care on safe resident transfers when utilizing mechanical lifts. An emphasis will be placed on ensuring residents are appropriately secured with mechanical lift pad straps prior to transfer as well as ensuring straps are in proper condition prior to use by inspecting for safety prior to use per manufacturer instructions. Education will be validated via facility mechanical lift competency checklist. Manufacturer instructions for mechanical lift sling inspection will be placed on each mechanical lift for employee reference. The Corporate Nurse will provide re-education to the DON and DOR on safe resident transfers when utilizing mechanical lifts. An emphasis will be placed on ensuring residents are appropriately secured with mechanical lift pad straps prior to transfer as well as ensuring straps are in proper condition prior to use by inspecting for safety prior to use per manufacturer instructions. Education will be validated via facility mechanical lift competency checklist. Residents who use mechanical lifts will have their care plan reviewed by the DON/Designee to ensure appropriate transfer status is identified in their care plan. New admissions will be reviewed by the IDT in the morning clinical meeting to identify their transfer needs and care plan these needs. Residents identified to have had a change in condition affecting mobility status will be discussed by the IDT and changes will be made as appropriate to their transfer status and care plan. Care planned interventions including transfer status will also be placed on the resident Kardex to ensure direct care staff are able to view resident specific needs. Nursing and Therapy staff will be educated prior to their next scheduled shift, prior to all direct care staff performing direct care and reviewing the Kardex to identify resident specific needs.Actions to Prevent Occurrence/Recurrence: The Corporate Nurse/Consultant Nurse will then educate the DON/ADON/Administrator on the facility orientation checklist for nursing staff. Education will be validated via facility mechanical lift competency checklist. Mechanical lift/sling training will take place at orientation for new nurses and nurse aides. Training will be completed prior to staff transferring a resident using the lift/sling. The Corporate Nurse, DON, DOR or designee will then re-educate nursing staff and therapy staff prior to their next scheduled shift, prior to them performing direct care on appropriate transfer and safe handling of residents during mechanical lift transfers. An emphasis will be placed on ensuring residents are appropriately secured with mechanical lift pad straps prior to transfer as well as ensuring straps are in proper condition prior to use by inspecting for safety prior to use per manufacturer instructions. Education will be validated via facility mechanical lift competency checklist. (Anticipated date of education initiation: 2/23/2026) The Administrator or DON will sign off on new nursing staff employees that the completion of the orientation checklist to include validation of competencies completed for nursing staff prior to being moved from their orientation status. The DON or designee will audit mechanical lift transfers twice weekly x 4 weeks, then weekly x4 weeks then monthly x1 month. The Administrator implemented a QAPI PIP as a means to gather and process information from the monitoring rounds. Findings will be reported at the monthly QAA meeting for a minimum of 3 months.Monitoring:Record review of the facility's staff education in-service training and competency record, dated 02/23/2026, 02/24/2026 and 02/25/2024, revealed appropriate transfer and safe handling of residents during mechanical lift transfers was provided to staff. Staff were evaluated at a satisfactory level and determined safe to implement mechanical lift transfers. Record review of QAPI sign-in sheetRecord review on 02/25/2026 of census counts was verified and revealed that a census count was completed for residents requiring mechanical lift transfers and signed off on by the Administrator. Record review on 02/25/2026 of facility mechanical lift competency checklist was updated and used to train staff. The record of evaluation and indicated all trained was able to demonstrate safe transfer at a satisfactory level to implement resident transfers. Interviews on 02/23/2026 - 02/25/2026 on both shifts with staff (Housekeeper A, 4 CNAs, 2 Nurses, 1 CMA, ADON, DON, DOR, and Administrator on 6 a.m.-6 p.m. dayshift, and 3 CNAs, 2 Nurse on 6 p.m. - 6a.m, night shift) were able to verify in-services and to validate their understanding of the information presented. Direct care staff were able to explain how to implement safe mechanical lift transfers, where to find the information in the clinical record identifying residents who require mechanical lift transfers. During observations of mechanical lift transfer on 02/25/2026, 4 CNAs and 3 Nurses confirmed staff were able to demonstrate safe mechanical lift transfers using the steps outlined in the procedure evaluation checklist. Record review of the facility staff education in-service training revealed CNA G (staff involved in the resident's fall) was trained as of 02/24/2026. Interview telephone interview on 03/09/2025 at 3:19pm, CNA G was able to verbalize her knowledge of implementation of safe mechanical lift transfers. CNA G verbalized the steps identified in the procedure evaluation checklist. CNA G could explain where to find the information in the clinical record identifying residents who require mechanical lift transfers. On 02/23/2026 at 2:11p.m. an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 02/25/2026, the facility remained out of compliance at a severity level of at a potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.

Based on observation, interview, and record review, the facility failed to ensure that residents received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents reviewed for accidents (Resident #1). The facility failed to ensure CNA G implemented safe transfer measures on 02/13/2026 at 4:00 a.m. when she attached the lift sling to the handling strap, instead of the sling attachment loop. Resident #1 experienced a fall and sustained a fractured clavicle during a mechanical lift transfer. On 02/22/2024 at 8:22p.m. an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 02/25/2026, the facility remained out of compliance at a severity level of at a potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place resident at risk of not receiving appropriate supervision leading to injuries, hospitalization, or death.Findings included:Record review of Resident #1's face sheet, dated 02/22/2026, revealed a [AGE] year-old female admitted [DATE], diagnosis included cerebral palsy (is a group of conditions that affect movement and posture caused by brain damage before birth) other abnormalities of gait and mobility, muscle wasting and atrophy, muscle weakness (generalized), contracture, unspecified joint.Record review of Resident #1's MDS, dated [DATE], indicated a BIMS score of 14, indicating no cognition impairment. Record review of fall risk assessment for Resident #1, dated 02/13/2026, indicated a score of 22.0 indicating high risk for falls.Record review of Resident #1's care plan, dated 01/18/2026, reflected:Focus Area: Resident #1 is at raise 4 falls related to limited mobility weakness and altered mental status.Goal: Resident #1 We'll be free of falls are injuries related to falls through the next review date.Interventions /Tasks: Ensure mechanical lift straps are secure and not broken, All straps in place, mechanical live is charged before transferring Resident#1 with two person assist.Focus Area: Resident #1 has an ADL self-care performance deficit related to limited mobility and weakness.Interventions /Tasks: Resident #1 one requires mechanical lift with two-person staff assistance for transfer. Record review of Resident #1 's X- Ray results (performed at the facility) of left shoulder, dated on 02/13/2026 with evaluation time 2:55 p.m. and reported time of 3:06p.m., revealed a fractured clavicle.Record review of Resident #1 hospital documentation for Resident #1, dated 02/13/2026, revealed:Resident #1's clavicle X- Ray at 8:21 p.m., suspected mid fractured clavicle, mildly displaced.CT scan at 9:58 p.m. of shoulder confirmed findings of a fractured distal end of the left clavicle (a break near the shoulder end of the collarbone). During an interview on 02/21/2026 at 5:15 p.m., Resident #1 stated she was being transferred by CNA G using a mechanical lift when she fell from the lift. Resident #1 stated she immediately experienced pain and reported pain to Nurse K. She stated there was only one staff member who implemented the mechanical lift transfer but CNA S arrived and assisted by getting the nurse after the fall occurred. Resident #1 stated she was not moved prior to Nurse K's assessment. Resident #1 stated there was usually two person assisting when being transferred with the mechanical lift. She stated CNA G was attempting to get her out of bed early and she did not believe CNA G asked for another person to assist. She stated pain was being managed with medication prior to being transferred to the hospital. She stated she was later transferred to the hospital as she was informed of left fractured clavicle. She stated the pain was managed with medication. She stated the facility replaced the sling after the incident, but the new sling being used after the incident caused pain, described as a knife stabbing to her right leg during each transfer. She stated since the incident on 02/13/2026, two staff members started transferring her with the mechanical lift. Resident #1 reported she did not feel safe when the new sling was used. Resident #1 stated that she had not notified the facility of concern related to the sling. During an interview on 02/21/2026 at 10:19 a.m. , the Administrator stated he and the DON were notified by Nurse K of the incident at 5:30 a.m. on 02/13/2026 by Nurse K. He stated he was informed the sling strap (handle) broke during transfer. The administrator was the abuse coordinator. He stated he is responsible for conducting facility incident investigations. He stated and investigation was initiated on 02/13/2026. He stated during the investigation Resident #1 was assessed and reported no pain. He stated Resident#1's medical provider was notified of the fall immediately by Nurse K. He stated he was informed by Nurse K that no order was given as Resident #1 denied pain and it was witnessed fall. He stated Resident #1 report pain at approximately 9:50 a.m. and was assessed with skin bruising near the left shoulder. He stated Nurse M administered pain medication to manage Resident#1's pain. He stated Nurse M notified the medical provider of the onset of pain and bruising, and an order was given to obtain an X- Ray of the left shoulder. He stated X -Ray results was received by the facility at approximately 3:00 p.m., and revealed that Resident #1 sustained a fractured clavicle as a result of the fall. The Administrator stated the medical provider was notified of the results by Nurse M, and orders were given for additional pain medication and transfer Resident #1 to the hospital for further evaluation. He stated medical transport was requested and Resident #1 was transferred to the hospital at approximately 4:00 p.m. on 02/13/2026. The Administrator stated that the facility immediately removed the mechanical lifts sling from Resident #1's room and the facility clinical area mechanical lifts sling. He stated that the outcome of his investigation determined the root cause of the incident was due to staff error of transferring. He stated CNA G attached the mechanical lift sling to the handling strap, instead of the sling attachment loop. He stated staff had been trained on safe mechanical lift transfer. He stated during his investigation CNA G was suspended for three days. He stated he was informed that there were two staff members who implemented the transfer, CNA G and CNA S. He stated that CNA G error caused injury to Resident #1. He stated that all direct care staff were responsible for ensuring mechanical lifts sling are safe and used properly. He stated that DON was responsible for ensuring all direct care staff was trained by the DOR. The administrator stated that he was not aware how the DON tracked training and compliance. During an interview on 02/21/2026 at 11:00 a.m. the DON stated the DOR was responsible for training staff but was unable to explain how competencies were validated or tracked and the system for ensuring all direct care staff were trained. The DON stated he was responsible for ensuring all nursing staff were skilled and knowledgeable of mechanical lift safety. He stated he was not aware if the DOR was informed of Resident #1's fall incident. The DON could not explain who was responsible for inspecting the slings and straps to determine if they were worn or safe to use during resident transfers. The DON could not explain how often were mechanical lift and slings was inspected for safety. He stated when staff were not trained properly the residents were placed at risk of harm.During an interview on 02/21/2026 at 3:45p.m., the DOR stated he provided a mechanical lift in-service to direct care staff on 02/14/2026. The DOR stated he was not trained by the facility on the mechanical lifts and sling used by the facility. He stated he was unaware of the manufacture models, the different slings used by the facility, and if each sling used for resident transfers were compatible with the facility mechanical lift. DOR stated he was not familiar with the facility Mechanical lifts competency and evaluation checklist. He stated he had not used or implemented the facility competency and evaluation checklist when he trained facility staff. DOR stated he used prior knowledge and experience related to mechanical lift to train staff. DOR stated he was not aware of the facility residents requiring mechanical lift transfers and the documentation could be found in clinical record. DOR could not explain where the information could be found in the clinical record. DOR stated he was informed of Resident #1's fall but was not informed that the fall was due to knowledge deficiency or staff error. He stated no specific trained related to Resident #1 incident was provided to staff. He stated when staff were not trained properly the residents were placed at risk of harm.During interviews on 02/21/2026, between 12:50 p.m. - 6:45 p.m., CNA A and CNA B, CNA C and Nurse M, and Nurse D stated they had been recently in-serviced on resident mechanical lift transfers but denied completing mechanical lift competency and validation. Staff could not explain proper use of the mechanical lift and sling that was required to safely transfer resident. During an attempted telephone interview attempted on 02/21/2026 at 3:15 p.m., CNA G was left a voicemail requesting a return call, but no return call. During an attempted telephone interview on 02/21/2026 at 3:23 p.m., CNA S was left a voicemail requesting a return call, but no return call.During an observation on 02/21/2026 at 12:16 p.m., the DON did not demonstrate proper use of the mechanical lift that was required to safely transfer residents. He did not lock the wheels of the mechanical lift, failed to position mechanical lift sling correctly. He was unable to clearly explain required safety measures during mechanical lift use. He could not clearly explain the facility's system in place to ensure proper use of mechanical lift. During an observation and interview on 02/21/2026 at 4:16 p.m., Resident #1 was transferred by CNA A and CNA B. Observation revealed they did not demonstrate proper use of the mechanical lift that was required to safely transfer resident. CNA A and CNA B did not ensure mechanical lift wheel were not locked prior to attachment of the mechanical lift sling used to transfer Resident #1. CNA A and CNA B did not center the mechanical lift sling under Resident #1 proper to transferring Resident #1 from the chair to the bed. Resident #1 stated she felt pain associated with improper positioning during the transfer. CNA A and CNA B were unable to demonstrate or clearly explain required safety measures during mechanical lift use.During an interview on 02/21/2026 at 12:16 p.m. and 02/22/2026 at 9:13 a.m., the DON was asked for a facility policy and procedure check list regarding mechanical lifts and safe resident transfers but was not provided.During an interview on 02/22/2026 at 1:00 p.m., Nurse M stated that she was the nurse assigned to care for Resident #1 on 02/13/2026 morning post fall. She stated that she was informed during hand off shift report by Nurse K that Resident #1 had fallen a couple hours prior to the start of Nurse M's shift at 6:00 a.m. She stated she was informed that Resident #1 denied pain and discomfort during Nurse K ongoing assessments. She stated she was informed that Resident #1 had not being given pain medication, the medical provider was notified, and no new orders had been given. She stated during her initial assessment of Resident #1 she denied pain. She stated when she assessed Resident #1 at approximately 10:00 a.m. she noticed left should area was bruised and Resident # 1 mild pain noted. Nurse M stated she notified the provider and was given an order for X-Ray. She reported ongoing mild pain pending the X-Ray and pain medication was given approximately at 12:30 p.m. and additional medication at approximately 2:00 p.m. Nurse M stated that Resident #1's pain was alleviated on assessment. Nurse M stated she could not recall what time the X-Ray was imagining but she recalled being notified of the results between 3:00p.m and 4:00 p.m. with findings of a fracture with mild clavicle displacement. She stated she informed the medical provider of the findings and was provided with order for non-emergent transport to local hospital. During an interview on 02/22/2026 at 3:00 p.m., Nurse K stated that she cared for Resident #1 on 02/12/2026 night shift and was the nurse on duty at the time of Resident #1's fall incident. She stated she was informed by CNA S on 02/13/2026 at approximately 4:30 a.m. that Resident #1had fallen during mechanical lift transfer from bed to chair. She stated she found Resident #1 on the floor alert and position on her back. She stated she assessed Resident #1 immediately and Resident #1 denied pain. She stated at the time of her initial assessment there was no discomfort, pain, or skin discoloration observed. She stated mechanical lift sling was under Resident #1's body as she assessed Resident #1. She stated she was informed that the sling strap broke during transfer. She stated another sling was used to transfer Resident #1 back to bed after the incident. She stated she was present in Resident #1's room during the post fall transfer but did not witness the transfer at the time of the fall. She stated Resident #1 informed her that CNA G and CNA S were transferring from bed and she had fallen during the transfer. Nurse K stated she was not informed by Resident #1 that there was only one staff member there during the initial transfer. Nurse K stated when she arrived in Resident #1 room, both CNA G and CNA S were there in Resident #1 room with her. Nurse K stated she was informed that CNA G connected the mechanical lift sling to the mechanical lift. Nurse K stated she did not investigate the mechanical lift, but she did recall the strap being broken. She stated she notified the medical provider of the fall on 02/13/2025 at 4:56 a.m. after completing Resident #1's assessment and ensuring Resident was safe. On 02/22/2026 at 8:22p.m. an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 02/25/2026, the facility remained out of compliance at a severity level of at a potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of theirThis was determined to be Immediate Jeopardy (IJ) on 02/22/2026 at 8:22p.m. The Administrator was notified. The Administrator was provided with the IJ template on 02/22/2026 at 8:22p.m. The following Plan of Removal submitted by the facility was accepted on 02/23/2026 at 3:14pm. F 689 Quality of Care:The facility failed to ensure that residents received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents reviewed for accidents (Resident #1). The facility failed to ensure CNA G implemented safe transfer measures on 02/13/2026 at 4:00am when she attached the lift sling to the handling strap, instead of the sling attachment loop. Resident #1 experienced a fall and sustained a fractured clavicle during a mechanical lift transfer. The facility identified immediate action to correct the system failures to ensure all residents receive appropriate supervision, and assistance devices to prevent accidents injuries, hospitalization, or death: The Corporate Nurse will provide re-education to nursing staff who were directly involved in the resident's fall prior to their next scheduled shift, prior to them performing direct care on safe resident transfers when utilizing mechanical lifts. An emphasis will be placed on ensuring residents are appropriately secured with mechanical lift pad straps prior to transfer as well as ensuring straps are in proper condition prior to use by inspecting for safety prior to use per manufacturer instructions. Education will be validated via facility mechanical lift competency checklist. Manufacturer instructions for mechanical lift sling inspection will be placed on each mechanical lift for employee reference. The Corporate Nurse will provide re-education to the DON and DOR on safe resident transfers when utilizing mechanical lifts. An emphasis will be placed on ensuring residents are appropriately secured with mechanical lift pad straps prior to transfer as well as ensuring straps are in proper condition prior to use by inspecting for safety prior to use per manufacturer instructions. Education will be validated via facility mechanical lift competency checklist. Residents who use mechanical lifts will have their care plan reviewed by the DON/Designee to ensure appropriate transfer status is identified in their care plan. New admissions will be reviewed by the IDT in the morning clinical meeting to identify their transfer needs and care plan these needs. Residents identified to have had a change in condition affecting mobility status will be discussed by the IDT and changes will be made as appropriate to their transfer status and care plan. Care planned interventions, including transfer status, will also be placed on the resident Kardex to ensure direct care staff are able to view resident specific needs. Actions to Prevent Occurrence/Recurrence: The facility will take the following actions to prevent an adverse outcome from reoccurring. The Corporate Nurse/Consultant Nurse will then educate the DON/ADON on the facility orientation checklist for nursing staff. Education will be validated via facility mechanical lift competency checklist. The Corporate Nurse, DON, DOR or designee will re-educate nursing staff and therapy staff prior to their next scheduled shift, prior to them performing direct care on appropriate transfer and safe handling of residents during mechanical lift transfers. An emphasis will be placed on ensuring residents are appropriately secured with mechanical lift pad straps prior to transfer as well as ensuring straps are in proper condition prior to use by inspecting for safety prior to use per manufacturer instructions. Education will be validated via facility mechanical lift competency checklist. (Anticipated date of education initiation: 2/23/2026) The DON or designee will audit mechanical lift transfers twice weekly x 4 weeks, then weekly x4 weeks then monthly x1 month. A QAPI PIP has been initiated to report on the above monitoring and auditing procedures. All findings from the PIP will be presented at the monthly QAA meeting. Monitoring/auditing and reporting will continue for a minimum of three months.Monitoring of the plan for the removal included the following:Record review of the facility's staff education in-service training and competency record, dated 02/23/2026, 02/24/2026 and 02/25/2024, revealed appropriate transfer and safe handling of residents during mechanical lift transfers was provided to staff. Record review of QAPI sign-in sheetRecord review on 02/25/2026 of census counts was verified and revealed that a census count was completed for residents requiring mechanical lift transfers and signed off on by the Administrator. Record review on 02/25/2026 of facility mechanical lift competency checklist was updated and used to train staff. The record of evaluation and indicated all trained was able to demonstrate safe transfer at a satisfactory level to implement resident transfers. Interviews on 02/23/2026 - 02/25/2026 on both shifts with staff (Housekeeper A, 4 CNAs, 2 Nurses, 1 CMA, ADON, DON, DOR, and Administrator on 6 a.m.-6 p.m. dayshift, and 3 CNAs, 2 Nurse on 6 p.m. - 6a.m, night shift) were able to verify in-services and to validate their understanding of the information presented. Direct care staff were able to explain how to implement safe mechanical lift transfers, where to find the information in the clinical record identifying residents who require mechanical lift transfers. During observations of mechanical lift transfer on 02/25/2026, 4CNAs and 3Nurses confirmed staff were able to demonstrate safe mechanical lift transfers using the steps outlined in the procedure evaluation checklist. The Administrator was informed the Immediate Jeopardy was removed on 02/25/2025 at 4:25 p.m. The facility remained out of compliance at a severity level of potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview and record review the facility failed to ensure develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 5 residents (Resident #6) reviewed for care plans .The facility failed to ensure a care plan was developed to address Resident #6's need for an escort to appointments.This failure could place residents at risk of not receiving appropriate care and interventions to meet their needs. Findings include :Record review of Resident #6's face sheet, reflected a [AGE] year-old male who was originally admitted to the facility on [DATE] and last re-admitted on [DATE]. Resident #6 had medical diagnoses which included unspecified dementia (mild, with agitation) (declining brain function related to thinking and judgement that is severe enough to impact daily life without behavioral disturbance, psychotic disturbance, mood disturbance), hypertension (high blood pressure), dysphagia (difficulty swallowing), hemiplegia and hemiparesis following cerebral infarction affecting left dominant side (left-side paralysis after a stroke), depression (prolonged periods of sadness and hopelessness), Human Immunodeficiency Virus Disease (HIV being a virus that attacks cells that help the body fight infections making a person more vulnerable to other infections and diseases), cognitive communication deficit and blindness in one eye.Record review of Resident #6's Annual MDS , dated 12/09/2025, reflected he was rarely or never understood and a BIMS assessment for cognitive intactness was not conducted. Resident #6 was totally dependent on staff for toileting, showering, and footwear and required total assistance with mobility in bed. Resident #6 was coded for short-term and long-term memory problems and was severely impaired related to daily decision making and having a wheelchair.Record review of Resident #6's care plan, dated 01/14/2026, reflected he had an ADL self-care performance deficit with interventions which included resident being totally depending on 1-2 staff to provide 2-3 baths weekly and as necessary and requiring mechanical lift with 2 staff members assistance for transfers. Resident #6 had impaired cognitive function/dementia or impaired thought processes with interventions which included cuing, reorienting and supervising as needed and keeping the resident's routine consistent and trying to provide consistent caregivers as much as possible in order to decrease confusion. Resident #6 had a seizure disorder r/t unspecified convulsion with interventions which included giving medications as ordered and post-seizure treatment including turn on side with head back, hyper-extended to prevent aspiration, keep airway open, after seizure take vital signs and neuro check, monitor for aphasia , headache, altered LOC , paralysis, weakness, pupillary changes.Record review of Resident #6's care plan meeting dated 01/08/2026 reflected that the RP was invited and attended. No concerns, issues or changes from last care plan was documented.Record review of Resident #6's medical records, reflected there was no documentation of Resident #6's clinic visit on 12/31/2025 in the progress notes, assessments or uploads . Observation and attempted interview with Resident #6 on 01/14/2026 at 10:00 AM, revealed he was in a low bed facing the wall and appeared to be resting with his eyes closed. Resident #6 appeared to be well-groomed, with dry flakes on his face. There were no odors or clutter in Resident #6's room. Resident #6 did not respond to questions.Interview with Clinic Staff A on 1/12/2026 at 3:44 PM, she said she worked at the clinic and that NP F reported to her that Resident #6 seemed out of it when he arrived at the facility and he did not have his health information with him. It was reported to Clinic Staff A that NP A called Resident #6's RP, who said a facility staff should have gone with Resident #6. Clinical Staff A stated Resident #6's appointment was 12/31/2025 at 2:30 PM. Observation and interview with Resident #6's RP on 1/14/2026 at 10:49 AM, she said she was aware Resident #6 had an appointment, and the facility did not tell her she needed to attend the clinic with Resident #6. The facility told the RP they would get him to the appointment. The RP said Resident #6 was unable to talk about what was going on with him and she brought this to the facility's attention on 1/8/2026 during a care plan meeting and now the facility just started to consistently send someone out with Resident #6 to appointments. Interview with Resident $6's RP at 12:30 PM , she said she never went to any recent appointments and on 12/31/2025 the clinic called the RP because Resident #6 could not recite his birthday and social security number at his appointment, and the clinic also told her they tried to call the facility but were unable to reach anyone. Resident #6 was being fed by the RP, and he did not respond to any questions from the RP.Interview with LVN C on 1/14/2026 at 11:20 AM, she said Resident #6's RP was usually informed of his appointments, but a staff member could go with him if needed.Intreview with LVN C on 1/14/2026 at 3:01pm , LVN C said she remembered seeing Resident #6 going out to an appointment on 12/31/2025. LVN C thought Resident #6's RP would have been there and LVN C was unsure if the RP went with Resident #6 to his appointments all the time . Interview with the SW on 1/14/2026 at 11:26 AM, she said he role of escorts was to relay information to the facility regarding changes and to be there for safety precautions. Resident #6's appointment was either 12/30/2025 or 12/31/2025 but she did not have a record to be sure so she would request it from the clinic. The SW said the facility typically sent someone with Resident #6 to appointments and he should have been with someone during his December 2025 appointment and the SW forgot to put escort in his record on the main page with updates so nurses knew to send someone with a resident to appointments. The SW said it was an oversight and that was why the facility changed their system of locating escorts for residents to reviewing resident off-site appointments at the start of each week. The SW said the facility implemented a new system recently to review appointments in the morning meeting to ensure escorts were sent out with residents to their appointments and that was the way the facility was going to track this process for escorts going forward. Resident notes were requested on 1/14/2025 at 11:26 AM from the SW for the 12/31/2026 and no documentation was received as of exit.Interview with the Administrator on 1/14/2026 at 12:05 pm, he said some residents could go to their appointments on their own and some had an aide go with them and there was no specific policy on having an escort to off-site appointments. He said if residents needed an escort , the facility would coordinate. Sometimes families made the appointment and let the facility know so they could schedule an aide to follow the resident to their appointment. If the facility called the RP and they could not go, the facility would look at the residents' BIMS and call extra staff in for that day. Starting 01/05/2026, the facility's procedure was during every morning meeting the IDT team which included the SW and Nursing team would review appointments and schedule. The Administrator said there was an issue with one of the residents who went to a doctor's appointment and there was no one there to help stand him up for his injection. The resident's RP brought up the concerns. The Administrator said the SW was the person who always called the RP to check on the resident's appointment. The Administrator did not think there was any negative outcome because someone loaded the resident into the transport van and brought their face sheet and a list of medical records to the clinic. Interview with the Administrator on 1/14/2026 at 2:20pm , he said there was a communication breakdown and even if the family usually accompanied the resident, the facility should have communicated and ensured they had an escort go with the resident even if it was a doctor's appointment. The Administrator said having an escort should have been documented somewhere in the resident record . The Administrator said there was no policy on accompanying residents to appointments. Resident #6's notes for the 12/31/2025 clinic visit were requested from the administrator on 1/14/2026 and no documentation was received as of exit.Interview with the MDS Nurse on 1/14/2026 at 1:14 PM revealed she was aware Resident #6 had an appointment at a clinic, and an aide was supposed to be with him, but she did not know who that was. Nursing would be able to schedule an escort if residents needed one. Nurses should still know how to tell the staff to prepare an escort. The MDS Nurse said she did not think there'd be a need to have an escort documented in residents' care plans since all the staff were aware which residents needed an escort, but she would do so for residents who required it. The MDS Nurse said Resident #6 had a BIMS of 00 and was rarely or never understood so he should have been accompanied and there was always a risk of going on his own, but she could not specify what the risk was. Interview with the DON and Administrator on 1/14/2026 at 4:39 PM, the DON said if Resident #6 was going to a clinic, he would have been supervised by the driver on the way to the clinic and at the clinic there should be staff to assist him as needed. The Administrator said the RP cancelled Resident #6's appointment and rescheduled it for 12/31/2025 and even if it was a holiday the facility should have made sure to accommodate that.

Based on observation. interview and record review the facility failed to ensure 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 3 residents (Resident #6) reviewed for adequate supervision and accident hazards.The facility failed to ensure Resident #6 had an escort to a clinic visit on 12/31/2025 at 2:30 PM.This failure could place residents at risk of injury and lack of support during off-site visits. Findings include:Record review of Resident #6's face sheet, reflected a [AGE] year-old male who was originally admitted to the facility on [DATE] and last re-admitted on [DATE]. Resident #6 had diagnoses which included unspecified dementia (mild, with agitation) (declining brain function related to thinking and judgement that is severe enough to impact daily life without behavioral disturbance, psychotic disturbance, mood disturbance), hypertension (high blood pressure), dysphagia (difficulty swallowing), hemiplegia and hemiparesis following cerebral infarction affecting left dominant side (left-side paralysis after a stroke), depression (prolonged periods of sadness and hopelessness), Human Immunodeficiency Virus Disease (HIV being a virus that attacks cells that help the body fight infections making a person more vulnerable to other infections and diseases), cognitive communication deficit and blindness in one eye.Record review of Resident #6's AnnualMDS, dated [DATE], reflected he was rarely or never understood and a BIMS assessment for cognitive intactness was not conducted. Resident #6 was totally dependent on staff for toileting, showering, and footwear and required total assistance with mobility in bed. Resident #6 was coded for short-term and long-term memory problems and was severely impaired related to daily decision making and having a wheelchair.Record review of Resident #6's care plan, dated 01/14/2026, he had an ADL self-care performance deficit with interventions which included resident requiring mechanical lift with 2 staff members assistance for transfers. Resident #6 had impaired cognitive function/dementia or impaired thought processes with interventions which included cuing, reorienting and supervising as needed and keeping the resident's routine consistent and trying to provide consistent care givers as much as possible in order to decrease confusion. Resident #6 had a seizure disorder r/t unspecified convulsion with interventions which included giving medications as ordered and post-seizure treatment which included turn on side with head back, hyper-extended to prevent aspiration, keep airway open, after seizure take vital signs and neuro check, monitor for aphasia (difficulty speaking), headache, altered LOC, paralysis, weakness, pupillary changes.Record review of Resident #6's medical records, reflected there was no documentation of Resident #6's clinic visit on 12/31/2025 in the progress notes, assessments or uploads.Observation and attempted interview with Resident #6 on 01/14/2026 at 10:00am, he was in a low bed facing the wall and appeared to be resting with his eyes closed. Resident #6 appeared to be well-groomed, with dry flakes on his face. There were no odors or clutter in Resident #6's room. Resident #6 did not respond to questions.Interview with Clinic Staff A on 1/12/2026 at 3:44pm, she said she worked at the off-site clinic and that NP F reported to her that Resident #6 seemed out of it when he arrived to the facility and he did not have his health information with him. It was reported to Clinic Staff A that NP A called Resident #6's RP who said a facility staff should have gone with Resident #6. Clinical Staff A confirmed that Resident #6's appointment was 12/31/2025 at 2:30pm.Interview with NP F on 1/12/2026 on 3:55pm, she said she was the NP in the room during Resident #6's appointment on 12/31/2025 at 2:30pm. Resident #6 was not responsive and was not oriented and he was by himself. Resident #6 was able to answer a little bit but NP A had to call Resident #6's RP. Resident #6 was soiled when he arrived. Medical assistants at the facility were unable to assist Resident #6 in a standing position to change him. NP F did not know the name of the person who picked up and dropped off Resident #6. NP F said the driver told her Resident #6's RP was supposed to be coming but the RP told NP A no one relayed this information to her.Interview with Resident #6's RP on 1/14/2026 at 10:49am, she said she was aware Resident #6 had an appointment, and the facility did not tell her she needed to attend the clinic with Resident #6. The facility told the RP they would get him to the appointment. The RP said Resident #6 was unable to talk about what is going on with him and that she brought this up to the facility's attention on 1/8/2026 during a care plan meeting.Observation and interview with Resident #6 and his RP on 1/14/2026 at 12:30pm, she said she never went to any recent appointments and that on 12/31/2025 the clinic called the RP because Resident #6 could not recite his birthday and social security number at his appointment, and the clinic also told her they tried to call the facility but were unable to reach anyone. Resident #6 was being fed by the RP, and he did not respond to any questions from the RP.Interview with LVN C on 1/14/2026 at 11:20am, she said Resident #6's RP was usually informed of his appointments, but a staff could go with him if needed. In a later interview at 3:01pm, LVN C said she remembered seeing Resident #6 going out to an appointment on 12/31/2025. LVN C thought Resident #6's RP would have been there at the appointment and LVN C was unsure if the RP went with Resident #6 to his appointments all the time.Interview with the SW on 1/14/2026 at 11:26am, she said the role of escorts was to relay information to the facility regarding changes and to be there for safety precautions. Resident #6's appointment was either 12/30/2025 or 12/31/2025 but she did not have a record to be sure so she would request it from the clinic. The SW said the facility typically sent someone with Resident #6 to appointments and he should have been with someone during his December 2025 appointment and that the SW forgot to put escort in his record on the main page containing updates so nurses knew to send someone, which was the old process. The SW said it was an oversight and that was why the facility changed their system of locating escorts for residents to reviewing resident off-site appointments at the start of each week. The SW said the facility implemented a new system recently to review appointments in the morning meeting to ensure escorts were sent out with residents to their appointments. The SW was requested on 1/14/2025 at 11:26am for Resident #6's notes for the 12/31/2026 and no documentation has been received as of exit.Interview with the Administrator on 1/14/2026 at 12:05pm, he said some residents could go to their appointments on their own and some had an aide go with them and there was no specific policy on having an escort to off-site appointments. He said if residents needed an escort, the facility would coordinate that. Sometimes families made the appointment and let the facility know so they could schedule an aide to follow the resident to their appointment. If the facility called the RP and they could not go, the facility would look at the residents' BIMS and call extra staff in for that day. Starting 01/05/2026, the facility's procedure was during every Morning meeting the IDT team including the SW and Nursing team would review appointments and schedule. The Administrator said there was an issue with one of the residents who went to a doctor's appointment and there was no one there to help stand him up for his injection. The resident's RP brought up the concerns. he said the Social Worker was the person who always called the RP to check on resident's appointment. The Administrator did not think there was any negative outcome because someone loaded the resident into the transport van and brought their face sheet and list of medical records to the clinic.Interview with the Administrator on 1/14/2026 at 2:20pm, he said there was a communication breakdown and even if the family usually accompanied the resident, the facility should have communicated and ensured they had an escort go with the resident even if it was a doctor's appointment. The Administrator said having an escort should have been documented somewhere. The Administrator said there was no policy on accompanying residents to appointments. The Administrator was requested on 1/14/2026 at 12:05pm for Resident #6's notes for the 12/31/2026 and no documentation has been received as of exit.Interview with the MDS Nurse on 1/14/2026 at 1:14pm, she was aware Resident #6 had an appointment at a clinic and that an aide was supposed to know with him, but she did not know who that was. Nursing would be able to schedule an escort if residents needed one. Nurses should still know how to tell the staff to prepare an escort. The MDS Nurse said she did not think there'd be a need to have an escort care-planned since all the staff were aware which residents needed an escort. Resident #6 had a BIMS of 00 and was rarely or never understood so he should have been accompanied and that there was always a risk of going on his own, but she could not specify what the risk was.Interview with the DON and Administrator on 1/14/2026 at 4:39pm, the DON said if Resident #6 was going to a clinic, he would have been supervised by the driver of the van to the facility and at the clinic there would be staff present so he was always supervised. The Administrator said the RP cancelled Resident #6's appointment and rescheduled it for 12/31/2025 and even if it was a holiday the facility should make sure to accommodate that.A policy on supervision was requested from the Administrator and DON on 1/14/2026 at 12:16pm by e-mail, it was not provided as of exit.

Based on observation, interview, and record review, the facility failed to maintain medical records on each resident that are complete and accurately documented for 1 (Resident #68) of 5 residents reviewed for accurate records.-The facility failed to document showers for Resident #6 on 12/30/2025, 1/1/2026, 1/3/2026, 1/6/2026, 1/6/2026, 1/10/2026 and 1/13/2026.-The facility failed to upload documents or have progress notes related to Resident #6's clinic visit on 12/31/2025.This failure could put residents at risk of changes in condition such as skin injury or breakdowns not being detected and treated and resident progress not being tracked. Findings include:Record review of Resident #6's face sheet reflected a [AGE] year-old male who was originally admitted to the facility on [DATE] and last re-admitted on [DATE]. Resident #6 had diagnoses which included unspecified dementia (mild, with agitation) (declining brain function related to thinking and judgement that is severe enough to impact daily life without behavioral disturbance, psychotic disturbance, mood disturbance), hypertension (high blood pressure), dysphagia (difficulty swallowing), hemiplegia and hemiparesis following cerebral infarction affecting left dominant side (left-side paralysis after a stroke), depression (prolonged periods of sadness and hopelessness), Human Immunodeficiency Virus Disease (HIV being a virus that attacks cells that help the body fight infections making a person more vulnerable to other infections and diseases), cognitive communication deficit and blindness in one eye.Record review of Resident #6's Annual MDS, dated [DATE], reflected he was rarely or never understood and a BIMS assessment for cognitive intactness was not conducted. Resident #6 was totally dependent on staff for toileting, showering, and footwear and required total assistance with mobility in bed. Resident #6 was coded for short-term and long-term memory problems and was severely impaired related to daily decision making and having a wheelchair.Record review of Resident #6's care plan, dated 01/14/2026, he had an ADL self-care performance deficit with interventions which included the resident being totally depending on 1-2 staff to provide 2-3 baths weekly and as necessary and required a mechanical lift with 2 staff members assistance for transfers. Resident #6 had impaired cognitive function/dementia or impaired thought processes with interventions which included cuing, reorienting and supervising as needed and keeping the resident's routine consistent and trying to provide consistent caregivers as much as possible in order to decrease confusion. Record review of Resident #6's bathing schedule, for the last 30 days reflected Resident #6's bath did not occur or family and/or non-facility staff provided care 100% of the time for that activity: 12/30/2025, 1/1/2026, 1/3/2026, 1/6/2026, 1/6/2026, 1/10/2026, 1/13/2026.Record review of Resident #6's skin checks reflected:-1/5/2026, skin intact. No skin concerns noted at this time. There were no new wounds identified. It was signed by WCN on 1/7/2026.-1/14/2026, skin intact. Dry skin to the face and bilateral feet. Moisturizer applied. It was signed by WCN on 1/14/2025 at 3:21 PM.Record review of Resident #6's medical records reflected there was no documentation of Resident #6's clinic visit on 12/31/2025 in the progress notes, assessments or uploads.Interview with Clinic Staff A on 1/12/2026 at 3:44 PM, she said she worked at the clinic and confirmed that Resident #6 had an appointment on 12/31/2025 at 2:30pm. NP A reported to her that Resident #6 seemed out of it when he arrived at the facility and he did not have his health information with him and they tried calling the facility but no one picked up.Observation and attempted interview with Resident #6 on 01/14/2026 at 10:00 AM, he was in a low bed facing the wall and appeared to be resting with his eyes closed. Resident #6 appeared to be well-groomed, with dry flakes on the sides of his nose. There were no odors or clutter in Resident #6's room.Observation and interview with Resident #6's RP on 1/14/2026 at 10:49 AM, she said she never gave Resident #6 a shower because that would be part of the facility's responsibility. The RP uncovered Resident #6's feet which appeared to be dry with flakes on the side of his feet. The RP also said Resident #6 had a clinic visit on 12/31/2025. Resident #6 was being fed by the RP, and he did not respond to any questions from the RP.Interview with the SW on 1/14/2026 at 11:26 AM, she said Resident #6's appointment was either 12/30/2025 or 12/31/2025 but she did not have a record to be sure so she would request it from the clinic. Resident notes were requested from the SW was requested on 1/14/2025 at 11:26 AM from the SW for the 12/31/2026 and no documentation was received as of exit.Interview with CNA G on 1/14/2026 at 11:33 AM, revealed she had not given a shower to Resident #6 yet, and she said showers were documented in the shower sheet.Interview with LVN C on 1/14/2026 at 3:01 PM, LVN C said Resident #6's family did not provide showers and she did not remember signing off on shower sheets. LVN C was unable to locate shower sheets for Resident #6 for December 2025. The last shower sheet was on 11/20/2025 with no skin conditions documented.Interview with the ADON on 1/14/2026 at 3:15 PM, she said Resident #6 received bed baths on Tuesdays, Thursdays and Saturdays and the aides completed shower sheets and nurses would in turn collect those sheets to give to the ADON. The aides were supposed to double-document, meaning once on the physical shower sheet which had space for skin documentation and the second place, they would document was in the resident's medical records. The ADON said there were no reports of Resident #6 refusing showers. The ADON said if shower sheets were not documented then they did not happen, but she knew aides were giving Resident #6 showers or bed baths.Interview with the DON and Administrator on 1/14/2026 at 4:39 PM, the DON said Resident #6 received his showers and it was just not documented. The DON said the aides got busy and did not create a shower sheet, and the showers were done even if they were not documented. The DON denied Resident #6 never received a shower in December 2025 and said it just wasn't documented and said with high staff turnover the facility lagged in documentation. The DON said if Resident #6 was going to a clinic, he would have been supervised by the driver on the way to the clinic and at the clinic there should be staff to assist him as needed. The Administrator said the RP cancelled Resident #6's appointment and rescheduled it for 12/31/2025 and even if it was a holiday the facility should have made sure to accommodate that. Documentation on Resident #6 regarding his appointment on 12/31/2025 was requested on 1/14/2026 at 2:32pm and no documentations was received as of exit.Record review of the facility's policy on Activities of Daily Living, last reviewed or revised on 4/23/2025, read in part, Care and services will be provided for the following activities of daily living; 1. bathing, dressing, grooming and oral care . Refusal of care and treatment by the resident or his/her representative to maintain functional abilities after efforts by the facility to inform and educate about the benefits/risks of the proposed care and treatment; counsel and/or offer alternatives to the resident or representative . A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene .

Based on observation, interview, and record review, the facility failed to ensure residents, who was dependent on assistance for activities of daily living, received necessary and timely care and services, including repositioning, incontinence care, and bathing, in accordance with professional standards of practice for 1 of 5 residents reviewed (Resident #1).On 01/13/2026, the facility failed to ensure Resident #1 received repositioning, incontinence care, or a scheduled bed bath.This failure could place residents at risk of not receiving timely hygiene care and demonstrated inadequate oversight of staff responsibilities related to activities of daily living.Record review of Resident #1's face sheet, dated 01/03/2026, reflected the resident was a 57 -year-old female who was admitted to the facility on [DATE], with diagnoses of acute respiratory failure with hypoxia (inadequate oxygenation of the blood), morbid (severe) obesity due to excess calories (having a body mass index of 40 or higher)., paralytic syndrome following cerebral infarction (condition that result in loss of motor function, often due to damage to the nervous system).Record review of Resident #1's MDS assessment, dated 10/02/2025 revealed a BIMS score of 14 indicating cognition was intact (thinking is normal). Resident #1 was dependent - (helper does all the effort. Residents do none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity) with all activities of daily living, including repositioning, incontinence care, and bathing. Section H - Bladder and Bowel: Resident #1 as coded 3, indicating Urinary /Bowel Continence Always incontinent (no episodes of continent voiding/ bowel movements). Section M - Skin Conditions - indicated Resident #1 was resident at risk of developing pressure ulcers/injuries. Record review of Resident #1's care plan, dated 12/23/2025, reflected: Focus Area: Resident is frequently incontinent of Bladder and Bowel. Goal: Resident will remain clean, dry and odor free and dignity will be maintainedover next 90 daysInterventions /Tasks: Monitor for incontinent, often/PRN, change promptly and apply a protective skin barrier to skin. Focus Area: Residents require assistance with ADLGoal: Will maintain a sense of dignity by being clean, dry, odor free and well-groomed over next 90 days.Interventions /Tasks: Toileting: Total assistance of two staff members. Personal Hygiene: Total assistance of two staff members. Bed Mobility: Extensive assistance of 2 staff members. Dressing: Extensive assistance of 2 staff members.Focus Area: The resident has an ADL self-care performance deficit. Goal: The resident will maintain/improve level of functioning.Interventions /Tasks: BATHING/SHOWERING: Provide sponge bath when a full bath or shower cannot be tolerated. BED MOBILITY: The resident requires extensive assistance by two person staff to turn and reposition in bed. DRESSING: The resident is dependent on staff to dress.Record review of the Shower/bathing schedule revealed that Resident #1 was scheduled to receive a bed bath on Tuesday/Thursday/Saturday- Days (6:00 AM-2:00 PM) shift. Schedule also indicated showers were to be done according to assignment and shift time.Review of CNA J's ADL documentation, on 01/13/2026 for the 6:00 AM-2:00 PM shift failed to demonstrate that Resident #1 received repositioning, incontinence care, or a scheduled bed bath.Interview on 01/03/2026 at 2:56 PM, Resident #1 while lying in bed in the supine (on back) position stated she requested assistance to have her soiled brief changed and a bed bath earlier during the morning shift (6:00 AM to 2:00 PM). Resident #1 stated the care was not provided. Resident #1 further stated she later informed CNA E that she required soiled brief change and continued to wait for assistance. Resident #1 reported there were days when she called for assistance and no staff came to her, and there were days when no one checked on her until approximately 6:00 PM. Resident #1 stated that she had not been repositioned even once during the morning shift. She stated that staff (Nurse G, DON, CNA J and CNA E) had checked in on her throughout the day, but no one had repositioned her. She stated she was supposed to get a bed bath during the morning shift but was not offered a bath this morning. She stated she had communicated the need to have her brief changed to CNA J hours prior and again within the past hour to CNA E who started his shift at 2pm. She stated she had not communicated the need to Nurse G and the DON. Resident # 1 denied skin breakdown related to delayed care. In an interview conducted on 01/03/2026 at 3:06 PM, Nurse E stated he reminded CNA J multiple times (10:30AM, 12:30PM, and 1:30PM) during the morning shift to provide Resident #1 with a bed bath and helped. Nurse E stated CNA J assured him she would complete the care prior to shift ending. Nurse E stated when he spoke with CNA J at approximately 2:15PM she later stated she had arranged for CNA E to help her with Resident #1's bed bath. He stated residents should be repositioned at least every two hours. Nurse E stated he was not informed that Resident #1 did not receive repositioning, incontinence care, or a bed bath during the shift. Nurse E stated that there were adequate staff available if help was needed. Nurse E stated he was immediately arranging for two other staff members to implement care as he could not locate CNA J and did not want to delay care longer. Nurse E stated it was the care staff responsibility to ensure resident needs were met timely. Nurse E stated the delay in care placed Resident #1 at risk for skin breakdown. Interview on 01/03/2026 at 3:21 PM, CNA J stated that during her scheduled shift from 6:00 AM to 2:00 PM, she did not reposition Resident #1, did not provide incontinence care (soil brief change), and did not provide a bed bath. She stated Resident #1 was scheduled to have a bed bath during the morning shift. She stated that Resident #1 informed her that she needed to be changed but she required help in providing care to Resident #1 as Resident #1 required 2-3 staff assistance when providing care. She stated she had not asked for assistance during her scheduled shift from 6:00 AM to 2:00 PM but was scheduled to work an additional shift, the evening shift (2:00PM - 10:00). She stated she went to lunch and had planned to provide care after lunch with CNA E during the evening shift. She stated residents should be repositioned at least every two hours. She did not explain why she did not request help, and why care was delayed. She stated the facility had provided training on incontinence care, repositioning, and bed baths. She stated that when a resident care is delayed it could place Resident #1 at risk of harm and neglect. In an interview conducted on 01/03/2026 at 4:48 PM, the DON stated it was the facility's expectation that staff reposition dependent residents at least every two hours and as needed, and that staff had been trained on incontinence care, repositioning, and ADL care. The DON stated he checked on Resident #1 at varies between 10:00 AM and 2:00 PM on 01/13/2026; however, he was not made aware that the required care had not been provided. The DON stated it was the responsibility of all staff to ensure the residents' needs were met timely. He stated the DON and Administrator were responsible for overseeing residents' satisfaction related to quality of care. He stated quality of care satisfaction is monitored during daily safety rounds conducted by the DON, the Administrator and Leadership Staff. He stated delayed care placed Resident #1 at risk for skin breakdown.Observation on 01/03/2026 at 4:13 PM, of care provided to Resident #1, soiled (wet) brief was removed. No foul odors were noted at the time of observation. Resident #1's bed bath revealed intact skin with no observed pressure injuries or areas of skin breakdown. Resident #1 Record review of the facility policy implemented 09/01/2021 and reviewed/revised 08/01/2025, titled Bathing a Resident, revealed that it is the practice of the facility to assist residents with bathing to maintain proper hygiene and help prevent skin issues.Record review of facility policy implemented 09/01/2021 and reviewed/revised 04/23/2025, titled Activities of Daily Living (ADLs), revealed that the facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable.Care and services will be provided for the following activities of daily living:1. Bathing, dressing, grooming and oral care;2. Transfer and ambulation;3. ToiletingRecord review of facility policy implemented 09/01/2021 and reviewed/revised 09/01/2021, titled Turning and Repositioning, revealed that the facility will, implement turning and repositioning as part of our systematic approach to pressure injury prevention and management. This policy establishes responsibilities and protocols for turning and repositioning.Turning and repositioning is a primary responsibility of nursing assistants. However, all nursing staff are expected to assist with turning and repositioning. The facility has established routine turning and repositioning schedules consisting of every 2-4 hours, on the even hour. A maximum of thirty minutes before or after the scheduled time will be allotted for compliance with the schedule.

Based on observation, interview, and record review, the facility failed to ensure medication carts were secured for 3 of 5 medication carts (MC #1, MC #2, and MC #3) reviewed for drug storage and labeling.The facility failed to ensure MC #1, MC #2 and MC #3 were locked, medications secured, and not accessible to other staff, residents, or visitors. This failure could place residents at risk of having unauthorized access to medications, decreased effectiveness of medication, or missing medications.Findings included:During an observation on 11/18/2025 at 4:39p.m., revealed MC #1 and MC #2, was on the wall across from the nurses' station, and unlocked. The nurse was going through medication on both medication carts when she walked off and went down the hall and into a resident's room. When the LVN A walked off she left three blister packs of medication on top of MC #1. She also left MC #1 and MC #2 unlocked while a resident was sitting next to MC #1. MC #1 and MC#2 both contained residents' prescription drugs, over the counter medications like Tylenol Ibuprofen, and vitamins, and narcotics in a locked box in the medication cart.During an observation on 11/19/2025 at 12:55p.m., revealed MC #3, was on the wall across from the nurses' station and unlocked. The nurse was sitting at the nurse's station talking to another staff member. The LVN B did not see the surveyor open the drawers and take pictures. MC #3 had residents' prescription drugs, mucus extended release5, stool softener, oral pain relief gel, allergy relief and syringes. During an interview with LVN A on 11/18/2025 at 4:42p.m., she had been trained on medication storage. She said the policy for the medication carts was the medication cart must always be locked when not around it. She said she was responsible for ensuring the medication carts were locked. She said if the medication carts were left unlocked and unattended a resident could get into the cart. She said the DON monitored to ensure the medication carts were locked. She said the DON monitored the medication carts by observations. She said she left the medication out and MC#1 and MC#2 unlocked because she had to go check on a resident. She said she should have locked both carts and put the medication up. During an interview with LVN B on 11/19/2025 at 12:56p.m., she had been trained on medication storage. She said the policy for the medication carts was the medication cart must always be locked when staff were not using the cart. She said the nurses were responsible for ensuring the medication carts were locked. She said if the medication carts were left unlocked and unattended anyone could get into the cart. She said the DON monitored to ensure the medication carts were locked. She said the ADM monitored the medication carts through observations. She said MC #3 was left open by another nurse, but it was her medication cart. She said she did not see the surveyor opening the drawers on the medication cart. During an interview with the DON on 11/20/2025 at 2:38p.m., he said he had been trained on medication storage. He said the policy for the medication cart was that it needed to be locked and the narcotics needed to be double locked. He also said the medication cart was to be locked anytime staff walked away from it. He said if the medication was left unlocked and unattended something could come up missing and a resident would not get their medications. He said the DON and ADM monitors to ensure staff are locking the medication carts. He said the DON and ADM monitored through observation. He also said any staff could monitor the medication carts and let the nurse know the cart was unlocked. He said he did not know why the medication carts were unlocked. He also said he did not know why the nurse left medication on top of MC #1. During an interview with the ADM on 11/20/2025 at 12:58p.m., he said he had been trained on medication storage. He said the policy for medication storage the medication cart had to be locked any time staff walked away from the cart. He said the medication cart should be locked anytime the nurse turned away from the medication cart. He said if the mediation cart was left unlocked or unattended someone could take something from the medication cart. He also said the resident would not have their medications and the facility would have to reorder the medication. He said the person who was on the medication cart was responsible for ensuring the cart was locked. He also said the DON monitored to ensure staff were locking the medication carts. He said the DON would monitor through observations. He said he did not know why the medication carts were unlocked. He also said he did not know why LVN A left medication on top of the medication cart when she walked away. Record review of Medication Storage Policy dated 9/1/2021, revealed It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security.

Based on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 1 (CR #1) of 6 residents reviewed for quality of care. -On 09/14/25, CNA A failed to tell Nurse A specifically what was wrong with CR #1. Nurse A failed to assess or provide medical care for CR #1 for approximately two hours, after CNA A asked her to check on CR #1 around 6:30 p.m. CNA A called 911 on 09/14/25 around 8:46 p.m. after CR #1 was noted to have a fever of 103 F, nausea/vomiting, doubled over with pain of 10/10, and was grayish in color. CR #1 was diagnosed at the hospital with fever, left heel wound infection, complicated UTI, and AKI. An Immediate Jeopardy (IJ) was identified on 10/07/25. The IJ Template was provided to the facility on [DATE] at 2:05 p.m. While the IJ was removed on 10/09/25, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal (POR). This failure could place residents at risk of not receiving necessary medical care, a decline in health, and/or experiencing emotional and physical distress. The findings included: Record review of CR #1's admission Record, dated 09/16/25, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included type 2 diabetes mellitus (high levels of blood sugar in the blood) with chronic kidney disease, degenerative disease of nervous system (conditions that affect the nerve cells in the brain and spinal cord), other chronic pancreatitis (long-standing inflammation of the pancreas), depression, and muscle weakness. Record review of CR #1's Quarterly MDS Assessment, dated 08/28/25, revealed a BIMS score of 13, indicating intact cognition. Further review revealed the resident required the assistance of 2 or more helpers with toileting and chair/bed-to-chair transfer, and partial assistance with showering/bathing. Record review of CR #1's Care Plan, undated, revealed he had an ADL self-care performance deficit and required hands on assistance bathing/showering, bed mobility, dressing, and transferring. Record review of CR #1's progress notes, dated 09/14/25 at 20:50 (8:50 p.m.), entered by Nurse A, revealed in part CNA called 911 resident complaining of vomiting and chest pain.Blood pressure 143/84, pulse 81, respiration 18, temp 102.2, and O2 sat 99. As nurse was leaving room EMT and police coming in hallway with CNA stating she called them. 2105 [9:05 p.m.] time on stretcher to ambulance. Record review of the hospital report, ADM DT: 09/15/25, Note Date: 00:34 (12:34 a.m.), admission Date: 09/14/2025, revealed in part .presented from [nursing facility name] with complaints of flu-like symptoms, nausea, vomiting, chest pain associated with vomiting, and abdominal pain. The patient reports the abdominal pain as severe, rated 10/10 (pain scale used for assessing pain intensity, where 0 indicates no pain and 10 represents the worst pain imaginable) and similar to his previous h/o pancreatitis.On exam the patient is AAOx4 [patient is fully aware of their identity, location, time, and situation, reflecting a high level of cognitive function], in no apparent distress. Record review of hospital report, ADM DT: 09/15/25, note dated 09/15/25 at 15:24 (3:24 p.m.), revealed in part .Assessment: #Fevers, #L heel wound, #complicated UTI w/ suprapubic catheter, #AKI. Further review, note date: 09/21/25 22:16 [10:16 p.m.], revealed in part .09/19/2025: Echogram with pelvic angiogram [diagnostic procedure that uses X-ray images to visualize blood vessels and identify any blockages or narrow spots], bilateral lower extremity angiogram, spur retrieval stent of left peroneal artery [self-expanding stent with integrated balloon dilation technology, allowing for temporary support of the artery and improved blood flow], IVUS [minimally invasive procedure that uses sound waves to assess blood vessels from the inside]. During a telephone interview on 09/16/25 at 7:27 a.m., CNA A said she did not know what time she told Nurse A to check on CR #1 on 09/14/25 but when she told her she said okay she was going to get to him, but she never checked on him. She said CR #1 was normally grumpy and aggressive but on this day, 09/14/25, he was doubled over, his skin color was grayish, he looked tired and just did not look like himself at all. She said she also heard CNA B, and Residents #2 and #3, tell Nurse A (did not know what time) about CR #1 not feeling well while she was helping other residents in the hallway. She said she heard Resident #2 tell Nurse A (did not know what time) that CR #1 was asking for her to come to his room because he was not feeling well, but she said she told Resident #2 not to worry about it that she would take care of it. She said she went back to his room, and CR #1 was on his bed, sitting up but slouched all the way over and throwing up. She said she took his temperature with her personal thermometer, and he had a fever of 103 F. She said CR #1 was saying my chest hurts, my chest hurts, please call the ambulance. She said he told her his pain level was a 10 out of 10. She said over an hour had passed and she never saw Nurse A go into his room to check on him but said she was helping other residents during this time but heard them tell the nurse that he did not feel well. She said she called 911 from her cell phone at 8:46 p.m. and yelled out for Nurse A. She said Nurse A went to CR #1's room and asked him how he was feeling. She said the resident could barely talk, and that he just kept saying call the ambulance. She said she left CR #1's room and went to the hallway to give 911 the address to the facility, and they arrived maybe within 5 minutes. She said Nurse A denied being told that something was wrong with CR #1. During an interview on 09/16/25 at 11:17 a.m., the DON said Nurse A called him on 09/14/25 and said she did not have the chance to reassess CR #1 because the CNA (he said he could not remember CNA's name and would have to look at the schedule) told her she had called 911. He said the CNA should have let the nurse know the resident was not feeling well so the nurse could have assessed and taken proper clinical action. He said he spoke to Nurse A and she said CNA A never told her that CR #1 was not feeling well. During an interview on 09/16/25 at 1:09 p.m., Resident #2, said on 09/14/25 she heard and saw CNA A tell Nurse A that she needed to go and check on CR #1 between 7:00/8:00 p.m. She said Nurse A was at the nurse's station on the computer and told CNA A she would check on CR #1 in a minute. She said about 1-1 1/2 hours later the ambulance arrived at the facility. During an interview on 09/16/25 at 9:50 a.m., Resident #3 said He said he never heard anyone tell the nurse that CR #1 needed to be checked on. He said he saw a nurse (did not know her name) come out of CR #1's room around 9:00 p.m. on 09/14/25. During an observation and interview on 09/17/25 at 10:09 a.m., revealed CR #1 was at the hospital lying in bed, watching television. He said he did not remember what time he started feeling bad on Sunday, 09/14/25. He said he was in a lot of pain from his waist down, he was vomiting, his chest was also hurting, and his pain level was at a 10. He said he told the nurse aide he was feeling bad but said he did not remember when he told her or what her name was because she was new. He said he did not get a chance to ask the nurse for anything because she never came and checked on him. He said he pressed his call light, waited for about an hour, but the nurse did not go to his room until about 2-3 minutes before the ambulance got to the facility. He said the nurse aide said she was going to call the ambulance. He said he heard the nurse at the facility tell the ambulance driver he had a fever but did not remember the nurse's name. He said the hospital had yet to tell him what was wrong with him, but said they told him they were going to admit him. He said the doctor told him he was not going to be discharged today, 9/17/25. He said the facility did not call his family member/RP/emergency contact #1 and she did not know he was in the hospital. During a telephone interview on 09/17/25 at 11:41 a.m., Nurse A said someone, a CNA, (she did not know who) approximately right before 9:00 p.m. on 09/14/25, said that girl called 911 . She said at that point she did not know who the CNA was referring to. She said she stopped passing medications, locked the cart, and went around the corner to the nurse's station on hall 200. She said she looked to her right, out the window, and saw flashing lights coming from the ambulance. She said CNA A said she called 911 because CR #1 was projectile vomiting. She said she went to CR #1's room and asked him what was going on and he said he was vomiting. She said she told him she needed to take his vital signs. She said she started taking his vitals and told him she could call the doctor to get some medication for nausea. She said CR #1 said it was not going to help because he was going to throw it back up. She said by the time she finished taking his vital signs, EMTs were coming in the room. She said she then left the room. She said another set of EMTs came in with police officers and they went to CR #1's room, and she stayed at the nurse's station. She said less than 5 minutes after EMTs arrived, they took the resident. She said CNA A did not tell her that CR #1 was not feeling well, and/or she needed to check on him. She said there was one little puddle of vomit on the floor, and said he was not projectile vomiting, but said she did not actually see him vomit. She said he had a fever of 102 F but everything else was okay. She said no residents reported to her that CR #1 was feeling unwell. During an interview on 09/17/25 at 1:04 p.m., Nurse B said she worked the 6:00 a.m. to 6:00 p.m. shift on 09/14/25 and was assigned to CR #1. She said she left her shift around 6:30 p.m. She said when she was grabbing her bag to leave, CNA A came around the corner toward the 200-hall nurse's station and said out loud (she said CNA A did not say anyone's name) when you have a moment can you check on CR #1?. She said Nurse A acknowledged the fact that CNA A said to check on CR #1 by saying ok out loud. She said CNA A did not give any details. She said she saw CR #1 throughout the day on 09/14/25 for blood sugar checks, but he was fine throughout her shift. She said no one ever asked her to check on him and the resident never voiced any concerns to her. During an interview on 09/18/25 at 8:52 a.m., the Administrator said he tried contacting CNA A to find out what happened and why she decided to call 911 instead of letting the nurse initiate the call. He said CNA A texted him that Nurse A was mad at her because she called 911 and that she told Nurse A CR #1 was projectile, and Nurse A did nothing. He said he asked CNA A what she meant by projectile, but she did not respond. He said he checked the resident's room on Monday morning, 09/15/25, around 10:00 a.m. and did not see any signs of projectile vomiting and he checked the resident's clothes, which were still in his room because the resident sent his laundry out to be washed, and he did not see any signs or vomit on his clothes. He said he talked to Nurse B, and she said she did not see anything abnormal during her shift. He said Nurse B, said she went and checked CR #1's blood sugar around 5:30 p.m. and tried to flush his catheter but he refused. He said he talked to the night nurse, Nurse A, and she said she received a report from Nurse B, and there was no change in condition for CR #1. He said Nurse B said she was told the resident was in and out of the facility as usual. During a follow-up interview on 09/30/25 at 2:43 p.m., the DON said when a resident was complaining of pain, they assessed the resident by asking them how much pain they were in on a scale of 1 to 10. He said if the resident was non-verbal, they looked for facial grimacing or assessed through touch. He said pain was a priority, but he said he could not assign an amount of minutes to when it should be addressed by the nurse but said they should respond as soon as possible. During a follow-up interview on 09/30/25 at 4:30 p.m., the NP said he would have directed the staff to give the resident Mylanta because it could have been due to GERD, and they could have done nitroglycerin (nitrate medicine that relaxes blood vessels and prevents or treats chest pain), and a baby aspirin. He said 9 times out of 10 symptoms would be relieved. He said it was hard to tell what negative effects could result from waiting for 1-1 1/2 hours. He said the resident had prostate issues, got UTIs, and those could cause a lot of symptoms. During a follow-up telephone interview on 09/30/25 at 4:39 p.m., CNA A said she did not tell Nurse A CR #1 had a fever or was throwing up. She said later (she could not provide a time) after she told Nurse A that CR #1 was not feeling well, she heard CNA B tell Nurse A Mr. [CR #1's last name] is asking for you. He is not feeling very well. During an interview on 09/30/25 at 5:00 p.m., CNA B said she was not assigned to CR #1's hall on 09/14/25 but saw his light on around 8:00/8:30 p.m. She said she went inside his room, and he asked her to get the nurse and that maybe she needed to call the ambulance, but he did not say why, and she said she did not ask why. She said she told CR #1 okay and she went to Nurse A and told her CR #1 had his light on and he needed her to call the ambulance. She said Nurse A said okay. She said she went back to her assigned hall and about 10 minutes later, she saw EMS coming out of his room. She said CNA A said the resident had been asking for the nurse, he needed an ambulance, so she called 911. During a telephone interview on 10/02/25 at 4:18 p.m., the Physician said complicated UTI symptoms would be vague and could maybe range from a fever, chills, and/or blood in the urine. He said he would have ordered a CBC, CMP, a similar panel to what they would order at the hospital, and EKG. He said if the resident had a fever of 102 F, he would also get a chest x-ray, urinalysis, and blood culture. He said he would have ordered that first and start the resident on antibiotics and have the nurse call him back within 30 minutes to an hour with an update. He said AKI did not have any symptoms and was based on a blood test. He said it was a broad term and did not present symptoms. He said it could be caused from dehydration but most likely from the resident being anemic. During a follow-up telephone interview on 10/03/25 at 7:58 a.m., the Physician said from what he gathered, CR #1's symptoms were vague, and he said he did not believe there would be any negative effects resulting from staff waiting for 1-2 hours to address resident's change in condition. Record review of the facility's Notification of Changes policy, date reviewed/revised 12/08/24, revealed in part .The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, resident's representative when there is a change requiring notification.2. Significant change in the resident's physical, mental or psychological condition such as deterioration in health, mental or psychosocial status. This may include: a. Life-threatening conditions, or b. Clinical complications.Additional considerations: 1. Competent individuals.c. When a resident is mentally competent, such a designated family member should be notified of significant changes in the resident's health status because the resident may not be able to notify them personally, especially in the case of sudden illness or accident. Record review of the facility's Registered Nurse Job Description, undated, revealed in part .follows the nursing model to promote holistic care for the residents.assesses for changes in residents' status. The DON was notified on 10/07/25 at 2:05 p.m. that an IJ was identified due to the above failures and the IJ template was provided. The following Plan of Removal (POR) was accepted on 10/08/25 at 11:01 a.m.: Immediate Jeopardy Removal Plan F-684 - Quality of Care 10/8/2025 Tag Cited: F-684Quality of Care Issue Cited: The facility failed to ensure treatment and care was provided to Resident #1 [resident name/CR#1] consistent withprofessional standards of practice. Nurse A [nurse's name] failed to assess or provide medical care for CR #1 [resident's name] for approximately two hours on 09/14/25, after CNA A [aide's name] notified that CR #1 [resident's name] experienced a change of condition around 6:30 p.m. CNA A [aide's name] called 911 on 09/14/25 around 8:45 p.m. after CR #1 [resident's name] was noted to have a fever of 103 [degrees Fahrenheit], nausea/vomiting, doubled over with pain of 10/10, and was grayish in color. CR #1 [resident's name]was diagnosed at the hospital with fever, left heel wound infection, complicated UTI, and AKI This immediate jeopardy removal plan is submitted as the facility's immediate actionable plan to remove the likelihood that serious harm to a resident will occur or recur from alleged deficient practice. The facility failed to ensure treatment and care was provided to Resident #1 consistent with professional standards of practice 1. Identification of Residents Affected or Likely to be Affected:The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. (Completion/ Date: 10/7/2025) Resident #1 [CR#1] returned to facility on 9/24/2025 with orders for intravenous antibiotics. All other orders were to resume as previously prescribed. The DON/ADON reviewed the 24-hour report for the last 72 hours to ensure all changes of conditions including nausea, vomiting and fever were assessed and the provider notified appropriately to ensure residents receive proper and quality care to prevent infections and diminished health. The DON/ADON audited nursing progress notes from 9/14-9/16/2025 for current residents. No new changes in condition that did not already have physician notification and intervention were identified. The Attending Physician and Medical Director were notified of IJ on 10/7/2025 at 2:49 pm. 2. Actions to Prevent Occurrence/Recurrence:The facility took the following actions to prevent an adverse outcome from reoccurring. (Completion Date: 10/7/25) The facility policy and procedures related to change of condition were reviewed by the Director of Nursing, Administrator, Regional Nurse Consultant on 10/7/2025, no revisions deemed necessary at this time. Nurse A is no longer employed by the facility. The facility separated with Nurse A on 9/19/2025 due to failure to complete 90-day introductory phase. The DON/ADON/Corporate Nurse will provide education to Nursing Staff in person, via phone, via facility messaging platform, or prior to next shift. Nursing staff will not be permitted to provide resident care until education is received. This education will include definitions of what a change of condition is including signs and symptoms of infection including nausea, vomiting and fever, circumstances where the clinical teams must be notified, when staff must notify nurses of changes in condition and when the nurse must notify medical providers and when to notify responsible parties. This education emphasizes that CNAs are to report observations and resident concerns to the nurse. They will then recheck with the resident to see if their concerns have been addressed, and then reconfirm with the nurse on duty if the resident still has concerns. If the resident or CNA have concerns that their notification has not been addressed, the CNA will call the DON/ADON/NHA to report the concern so that facility leadership may address the situation to ensure timely follow up and notification to the MD. The facility has posted a Call with Concern sheet with the appropriate numbers that may be contacted listed at the nursing stations. This education will emphasize notification to the nurse on resident concerns, and follow up assessment by the licensed nurse, with follow up notification to the medical provider. Licensed Nurses will validate their understanding of education by reviewing and demonstrating the use of the E-Interact Change in Condition Evaluation tool in Point Click Care [cloud-based healthcare software platform that helps manage clinical, financial, and administrative tasks] with the DON/ADON/Designee prior to working their next scheduled shift. The Director of Nursing or designee will continue to monitor/audit Changes of Condition and Signs and Symptoms of infection including fever by reviewing the 24-hour report during morning clinical meetings three times weekly for four weeks, then weekly for eight weeks. A QAPI PIP has been initiated to report on the above monitoring and auditing procedures. All findings from the PIP will be presented at the monthly QAA meeting. Monitoring/auditing and reporting will continue for a minimum of three months. Quality of CarePurpose: To ensure that all changes of condition are addressed immediately and appropriate action taken.Instructions: Review 24-hour reports in clinical meetings for all changes of condition as well as any signs or symptoms of infection including nausea, vomiting and fever and ensure that they are addressed immediately.Date of 24-hour report reviewAudit/Monitoring Resident Name Change of Condition/ Signs and Symptoms of infection including nausea, vomiting, fever Identified Actions taken to address Change of ConditionComments/Corrective Action. On 10/08/25-10/09/25, surveyors confirmed the facility implemented their plan or removal (POR) to sufficiently remove the IJ by the following: Observation on 10/09/25 at 3:25 p.m., revealed Call with Concern sheets posted with the Administrator's, DON's, and ADON's phone numbers. Record review of a 24-hour report, dated 10/07/25 and 10/08/25, revealed 5 recorded changes of condition for residents that were addressed. Record review of the eInteract Change in Condition Evaluation tool used by Licensed Nurses to demonstrate and validate their understanding of education was completed. Record review of the In-Service Summary / Report of Education, dated 10/07/25, reflected 34 staff members were educated on reporting and following up on what a change of condition is including signs and symptoms of infection including nausea, vomiting and fever, circumstances where the clinical teams must be notified, when staff must notify nurses of changes in condition and when the nurse must notify medical providers and when to notify responsible parties. Education included finding the nurse on duty immediately, being clear and specific on what was seen or heard, when and where it happened, any changes from resident's usual condition, and checking back with the nurse to confirm the concern was addressed. In addition, it included reporting to another nurse or the nurse supervisor/DON/ADON the change in condition if the nurse was busy and that resident safety is a shared responsibility. Record review of the In-Service Summary / Report of Education, dated 10/07/25, reflected 12 nurses were educated on addressing any significant deviation from a patient's baseline health status, which could by physical, cognitive, behavioral, or functional. The nurse must identify, assess and report changes to the MD/NP immediately to prevent complications, improve safety, and guide treatment. Changes in condition included but were not limited to: Nausea and vomiting, pain, new behavior, lack of behavior, headache, dizziness, diarrhea, abnormal vitals, needing extra help with ADL, decrease mobility, resident expressing I don't feel good, and/or seizures. Record review of the In-Service Summary / Report of Education, dated 10/07/25, reflected 37 staff members were educated on being alert for signs of a change in a resident's condition, such as unusual behavior (like confusion, agitation, or withdrawal), changes in mobility (moving slower, limping, or needing more help), noticeable skin issues (paleness, flushing, bruising, or swelling), changes in appetite or refusal to eat, increased sleepiness or trouble waking up, vomiting and nausea, complaints of feeling unwell, dizzy, or in pain, chest pain and any signs of incontinence or changes in bathroom habits; the resident expressing concerns about illness or sadness. Ensuring to report any of these symptoms to the nurse in charge. Record review of the Change of Condition Demonstration Audit Tool, dated 10/08/25, reflected 8 staff members received demonstration, return demonstration, and notification MD/NP/RP/Progress Note. Record review of the In-service Tracking form, dated as of 10/07/25, reflected 117 staff members were contacted in-person, by telephone, or through voicemail, for in-service training over being alert for signs of a change in a resident's condition, such as unusual behavior, changes in mobility, changes in appetite or refusal to eat, increased sleepiness or trouble waking up, vomiting and nausea, resident complaints of feeling unwell, dizzy, or in pain, chest pain and any signs of incontinence or changes in bathroom habits; the resident expressing concerns about illness or sadness; and/or ensuring to report any of these symptoms to the nurse in charge. Record review of the 24-hour report for the last 72 hours, dated 10/05/25 to 10/08/25, reflected all changes in conditions were assessed and provider was notified appropriately. Record review of nursing progress notes from 09/14/25 to 09/16/25, reflected no new identified changes in condition that did not already have physician notification and intervention. Record review of the QAPI Ad-HOC Meeting sign-in sheet, dated 10/08/25, reflected the meeting was held at 11:30 a.m. and 14 staff members were in attendance. Interviews were conducted on 10/08/25 between 11:53 a.m. and 12:09 p.m. and on 10/09/25, between 2:01 p.m. and 3:30 p.m., with staff from all shifts (6:00 a.m.to 6:00 p.m., 6:00 p.m. to 6:00 a.m., 6:00 a.m. to 2:00 p.m., 2:00 p.m. to 10:00 p.m., and 10:00 p.m. to 6:00 a.m.). Staff interviewed included the following: Nurses D, E, and F, MAs A and B, and CNAs C, D, E, F, G, and H. All staff interviewed verbalized an understanding of being alert for signs of a change in a resident's condition, signs and changes to look for, reporting and following up with the nurse, and following chain in command when there is a concern. The DON was informed that the Immediate Jeopardy was removed on 10/09/25 at 3:34 p.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that was not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview, and record review, the facility failed to immediately consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 (CR #1) of 6 residents reviewed for resident rights. - Nurse A did not immediately notify CR #1's physician when he had a change in condition and was sent out to the hospital via 911 on 09/14/25. -Nurse A did not notify CR #1's family member/RP/emergency contact when he had a change in condition and was transported to the hospital on [DATE]. The failures could place residents at risk of not receiving appropriate care and required notifications being made when there is a change in their condition. Findings included: Record review of CR #1's admission Record, dated 09/16/25, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included type 2 diabetes mellitus (high levels of blood sugar in the blood) with chronic kidney disease, degenerative disease of nervous system (conditions that affect the nerve cells in the brain and spinal cord), other chronic pancreatitis (long-standing inflammation of the pancreas), depression, and muscle weakness. Further review revealed resident was listed as RP, family member was listed as RP/emergency contact #1, and another family member was listed as POA-Care/emergency contact #2 (no phone number listed). Record review of CR #1's Quarterly MDS Assessment, dated 08/28/25, revealed a BIMS score of 13, indicating intact cognition. Record review of CR #1's progress notes, dated 09/14/25 at 20:50 (8:50 p.m.), entered by Nurse A, revealed in part CNA called 911 resident complaining of vomiting and chest pain.Blood pressure 143/84, pulse 81, respiration 18, temp 102.2 [degrees Fahrenheit], and O2 sat 99. As nurse was leaving room EMT and police coming in hallway with CNA stating she called them. 2105 [9:05 p.m.] time on stretcher to ambulance. No other documentation/notes were found that indicated doctor or RP was notified. Record review of hospital record, dated 09/14/25, revealed in part .presented from [nursing facility name] with complaints of flu-like symptoms, nausea, vomiting, chest pain associated with vomiting, and abdominal pain. The patient reports the abdominal pain as severe, rated 10/10 [pain scale used for assessing pain intensity, where 0 indicates no pain and 10 represents the worst pain imaginable] and similar to his previous h/o pancreatitis.On exam the patient is AAOx4 [patient is fully aware of their identity, location, time, and situation, reflecting a high level of cognitive function], in no apparent distress. During a telephone interview on 09/16/25 at 7:27 a.m., CNA A said she did not know what time she told Nurse A to check on CR #1 on 09/14/25 but when she told her, she said okay she was going to get to him, but she never checked on him. She said CR #1 was normally grumpy and aggressive but on this day, 09/14/25, he was doubled over, his skin color was grayish, he looked tired and just did not look like himself at all. She said she also heard CNA B, and Residents #2 and #3 tell Nurse A about CR #1 not feeling well while she was helping other residents in the hallway. She said she heard Resident #2 tell Nurse A that CR #1 was asking for her to come to his room because he was not feeling well, but she said she told Resident #2 not to worry about it and that she would take care of it. She said she went back to his room, and CR #1 was on his bed, sitting up but slouched all the way over and throwing up. She said she took his temperature with her personal thermometer, and he had a fever of 103 F. She said CR #1 was saying his chest hurt, and to please call the ambulance. She said he told her his pain level was a 10 out of 10. She said over an hour had passed and she never saw Nurse A go into his room to check on him. She said she called 911 from her cell phone at 8:46 p.m. and yelled out for Nurse A. She said Nurse A went to CR #1's room and asked him how he was feeling. She said the resident could barely talk, and that he just kept saying to call the ambulance. She said she left CR #1's room and went to the hallway to give 911 the address to the facility, and they arrived maybe within 5 minutes. She said Nurse A denied being told that something was wrong with CR #1. During an observation and interview on 09/17/25 at 10:09 a.m., revealed CR #1 was at the hospital lying in bed, watching television. He said he did not remember what time he started feeling bad on Sunday, 09/14/25. He said he was in a lot of pain from his waist down, he was vomiting, his chest was also hurting, and his pain level was at a 10. He said he told the nurse aide he was feeling bad but said he did not remember when he told her. He said he did not get a chance to ask the nurse for anything because she never came and checked on him. He said he pressed his call light, waited for about an hour, but the nurse did not go to his room until about 2-3 minutes before the ambulance got to the facility. He said the nurse aide said she was going to call the ambulance. He said he heard the nurse at the facility tell the ambulance driver he had a fever but did not remember the nurse's name. He said the hospital had yet to tell him what was wrong with him but said they told him they were going to admit him. He said the doctor told him he was not going to be discharged today, 9/17/25. He said the facility did not call his family member/RP/emergency contact #1 and she did not know he was in the hospital. During a telephone interview on 09/17/25 at 11:41 a.m., Nurse A said she called the NP/physician listed on the CR #1's Face Sheet after EMTs took the resident. She said she did not speak to them and probably left them a message. She said she did not contact the resident's RP/emergency contact and that she had no reason for not making the contact. During a telephone interview on 09/17/25 at 1:23 p.m., the NP said he was notified via text (does not know by who) on Monday, 09/15/25, that on Sunday, 09/14/25, CR #1 had nausea, was throwing up, complaining about chest pain, and that the nurse aide had called 911. He said had he been notified when symptoms had been occurring, he could have done some kind of intervention. He said each case was different and he still did not know all the details about what happened on Sunday with the resident. He said he did not know if the on-call service was notified on Sunday. During an interview on 09/18/25 at 9:48 a.m., the DON said the family and physician should be notified immediately once the resident was stable and safe. He said Nurse A did not document that she contacted CR #1's RP/emergency contact #1 in her progress note. He said he gave both emergency contacts a courtesy call on Monday, 09/15/25, to see if they had any concerns or if they needed him to do anything but both of their phones had a message saying they were not taking calls at that time. He said not contacting a resident's RP/emergency contact would not have an ill effect on the resident. During a follow-up telephone interview on 09/18/25 at 11:35 a.m., the NP said he checked with the on-call service and with the physician and the physician said he was not notified and there was no record that the on-call service was called. During a telephone interview on 09/18/25 at 4:03 p.m., with CR #1's family member/RP/emergency contact #1 she said the facility did not call her to tell her CR #1 was sent to the hospital. She said CR #1 called her on 09/16/25 and told her he was in the hospital. Record review of the facility's Notification of Changes policy, date reviewed/revised 12/08/24, revealed in part .The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, resident's representative when there is a change requiring notification.2. Significant change in the resident's physical, mental or psychological condition such as deterioration in health, mental or psychosocial status. This may include: a. Life-threatening conditions, or b. Clinical complications.Additional considerations: 1. Competent individuals.c. When a resident is mentally competent, such a designated family member should be notified of significant changes in the resident's health status because the resident may not be able to notify them personally, especially in the case of sudden illness or accident.

Based on observation, interview and record review the facility failed to ensure the resident has a right to a dignified existence and maintain good grooming at resident request in a timely manner for two out of four residents (Resident#2 and Resident #1) reviewed residents rights. The facility failed to provide timely incontinent care for Resident #2 and Resident #1 and it affected the resident's feelings. This deficient practice could place residents at risk of skin breakdown and reduced feelings of self-worth Record review of Resident #2's face sheet revealed a [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #2 had diagnoses which included morbid (severe) obesity (A BMI of 40 plus), diabetes mellitus (high blood sugar), hypertension (high blood pressure), and need assistance with personal care. Record review of Resident #2's Quarterly MDS assessment, dated 06/28/25, revealed a BIMS score of 14 of 15, which indicated intact cognition. Resident #2 needed extensive to total care with ADL assistance with one staff assist. Record review of Resident #2's care plan, revision dated 09/05/25, read in part . [Resident #2] had incontinent of bladder and bowel. Intervention: clean peri area with each incontinence episode, check on resident every two hours and assist with toileting as needed. resident had self-care performance deficit related to impaired mobility. was on antibiotic therapy for UTI on Cipro 500mg PO BID for 5 days . During an observation on 09/04/325 at 2:15 p.m., the Treatment nurse and CNA M provided a head-to-to-skin assessment for Resident #2. When CNA M opened the resident's incontinent brief, it revealed Resident #1's brief was saturated with urine, and the inside of the brief was brown in color. During an interview on 09/04/25 at 2:07 p.m., Resident #2 said she was provided incontinent once today around 10:15 a.m. or 10:30 a.m., when she had a bowel movement, and nobody had come to ask her if she was wet. Resident #2 said the staff did not change her often, and that contributed to her having UTIs often. Resident #2 stated she told the aide she was wet before lunch, and the aide said she was coming to change her, but she did not come back, and her shift had ended, and she had gone home without changing her. Resident #2 said she felt uncared for because she was left in a dirty incontinent brief for hours. During an interview on 09/04/25 at 2:32 p.m., LVN P said CNA O was Resident #2's aide. LVN P said the aide should check the resident and see if the resident was wet at least every two hours. She said Resident #2's brief was soaked, and the resident would have redness, an open area, and a UTI. LVN P said CNA O did not tell her Resident #2 had not been changed when she asked if she had provided incontinent care for Resident #2. During an interview on 09/04/25 at 2:45 p.m., the Treatment Nurse said Resident #2's incontinent brief was soaking wet with urine, and it appeared Resident #2 was not changed recently. The Treatment Nurse said Resident #2's skin could break down, develop rashes, pressure ulcers, and UTI if the aide did not provide timely incontinent care for the resident. She said the aides were responsible for checking on the resident during rounds at least every two hours. She said the floor nurse was responsible for monitoring the aides throughout the shift to ensure the aides were providing care for the residents. The Treatment Nurse said she had an in-service on incontinence care during the all-staff meeting last week, Thursday (08/28/29), and she educated the staff on the importance of making rounds every two hours, changing the residents' incontinent briefs, and making sure the residents were kept dry to prevent skin breakdown and UTI. During an interview on 09/05/25 at 2:52 p.m., CNA M said Resident #2's incontinent brief was very wet, and the inside of the brief was brown, which showed Resident #2 had not been changed for more than two hours. CNA M said the aides made rounds every two hours and as needed. She said Resident #2 could get a bed sore, redness or infection. CNA M said she had a skills check, and it included ADLs, and the treatment nurse educated aides to make rounds every two hours and change the resident to prevent skin breakdown or UTI. During an interview on 09/08/25 at 10:05 p.m., the Corporate Nurse said the aides were responsible for providing incontinent care and were supposed to make rounds every two hours per standard of care. She said if Resident #2 was not changed promptly, the resident's skin could get red, and there was potential for UTI. The Corporate Nurse stated if she was a resident, she would not feel good if she were left on a wet incontinent brief for hours. During a telephone interview on 09/08/25 at 3:54 p.m., CNA O said she did not work with Resident #2 on 09/04/25 because she no longer worked at the facility. She said she had not worked in the facility at all in September 2025. During an interview on 09/08/25 at 5:10 p.m., the DON stated he would go and verify if he had given CNA O's name in error, because they had another aide with the same first name but a different last name. The DON did not provide the other aide's name before the state surveyor exited. 2. Record review of Resident #1's face sheet revealed a [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses which included morbid (severe) obesity (A BMI of 40 plus), diabetes mellitus (high blood sugar), hypertension (high blood pressure), and cerebral infraction (brain attack caused by a blockage in a blood vessel). Record review of Resident #1's Quarterly MDS assessment, dated 07/31/25, revealed a BIMS score of 00 of 13, which indicated severely impaired cognition. Resident #1 needed total care with ADL assistance with two staff assist. Record review of Resident #1's care plan, revision dated 08/11/25, read in part . [Resident #1] was frequently incontinent of bladder and bowel. Intervention: monitor for incontinent often and PRN, change promptly and apply a protective barrier to the skin. During an observation and interview on 09/04/25 at 3:35 p.m., revealed Resident #1 was in bed and covered with a sheet. Resident #1 said the aide from the morning shift had not changed her today, but the night aide changed her before she left, which was early in the morning, and she could not recall the exact time. Resident #1 said she asked LVN P to tell her aide to come and change her between 10:00 a.m. and 11:00 a.m., and the aide had not come to change her up till now. Resident #1 said she felt dirty and upset because the aides did not change her on time because they have to get another staff member because she was on the heavy side. During observation on 09/04/25 at 4:00 p.m., revealed when CNA L and CNA T opened Resident #1's incontinent brief, the resident's incontinent brief was saturated with urine, and the inside of the brief was brown. When CNA L turned Resident #1 to the left, it revealed the two-draw sheets were soaked with urine, and the air mattress was soaked with urine from the resident's lower back to her middle thigh area. During an interview on 09/04/25 at 4:09 p.m., LVN P said Resident #1 told her she wanted her incontinent brief changed at 11:00 a.m., because the morning aide had not changed her incontinent brief today. LVN P said she told the aide to go and change Resident #1 when she came out of Resident #1's room around 11:05 a.m. LVN P said she was not aware the aide did not provide incontinent care for the resident. LVN P said Resident #1 would feel terrible, and it was not accepted. Everybody should be checked and changed, regardless of the resident's size. LVN P said the aides were supposed to make rounds every two hours and as needed for incontinent care. LVN P said Resident #2 could develop UTI and skin breakdown if she was left on incontinent brief for extend time. During an interview on 09/04/25 at 4:49 p.m., CNA L said the aides were supposed to make rounds every two hours to check and change the resident. CNA L stated when she unfastened Resident #1's incontinent brief, it revealed the incontinent brief was very soaked, and when she turned the resident to her left, it revealed the two draw sheets and the air mattress were also soaked with urine. CNA L said Resident #1 could have skin breakdown or an infection because she had not been changed for hours. During an interview on 09/04/25 at 5:21 p.m., CNA T said Resident #1 was her resident. CNA T said Resident #1 was not her original resident. CNA T said when she became aware Resident #1 was assigned to her, she came to provide incontinent care. CNA T said aides were supposed to make rounds for incontinent care every two hours. CNA T said Resident #1's incontinent brief was very wet and soaked with urine, as well as the two draw sheets, and the air mattress. CNA T said Resident #1's skin could break down. During an interview on 09/05/25 at 9:17 a.m., the DON said aides should make rounds for incontinent care at least every two hours. The DON said the residents were not supposed to ask the aide to provide incontinent care because that was part of ADL care. The DON said the aides should make rounds every two hours. The DON said Resident #1 was a heavy wetter, and when she voided, she voided a lot because she drank a lot of water. The DON said if the continent brief was brown, it could mean the urine had been on the incontinent brief for an extended time. The DON said Resident #1 could develop moist-associated skin damage, and the resident would not feel good being left on a wet incontinent brief. During an interview on 09/05/25 at 1:07 p.m., the Administrator said the aides should make rounds for incontinent care every two hours according to the facility's policy. The Administrator said the staff should also make PRN rounds for incontinent care. He said if Resident #1 was left in a wet incontinent brief, it could cause skin breakdown and infection. He said Resident #1 would feel uncomfortable and dirty. Record review of the facility's policy on activities of daily living, dated revised 04/23/25, and implemented 09/01/25, read in part .care and services will be provided for the flowing activities of daily living: 3. Toileting.policy explanation and compliance guideline #2. A resident who is unable to carry out activity of daily living will receive the necessary services to maintain . grooming .

Based on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received necessary services to maintain good nutrition, grooming, and personal and oral hygiene for two of 4 residents (Resident#2 and Resident #1) reviewed for ADLs. The facility failed to provide timely incontinent care for Resident #2 and Resident #1. This deficient practice could place residents at risk of skin breakdown and reduced feelings of self-worth.Findings include: 1. Record review of Resident #2's face sheet revealed a [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #2 had diagnoses which included morbid (severe) obesity (A BMI of 40 plus), diabetes mellitus (high blood sugar), hypertension (high blood pressure), and need assistance with personal care. Record review of Resident #2's Quarterly MDS assessment, dated 06/28/25, revealed a BIMS score of 14 of 15, which indicated intact cognition. Resident #2 needed extensive to total care with ADL assistance with one staff assist. Record review of Resident #2's care plan, revision dated 09/05/25, read in part . [Resident #2] had incontinent of bladder and bowel. Intervention: clean peri area with each incontinence episode, check on resident every two hours and assist with toileting as needed. resident had self-care performance deficit related to impaired mobility. was on antibiotic therapy for UTI on Cipro 500mg PO BID for 5 days . During an observation on 09/04/325 at 2:15 p.m., the Treatment nurse and CNA M provided a head-to-to-skin assessment for Resident #2. When CNA M opened the resident's incontinent brief, it revealed Resident #1's brief was saturated with urine, and the inside of the brief was brown in color. During an interview on 09/04/25 at 2:07 p.m., Resident #2 said she was provided incontinent once today around 10:15 a.m. or 10:30 a.m., when she had a bowel movement, and nobody had come to ask her if she was wet. Resident #2 said the staff did not change her often, and that contributed to her having UTIs often. Resident #2 stated she told the aide she was wet before lunch, and the aide said she was coming to change her, but she did not come back, and her shift had ended, and she had gone home without changing her. Resident #2 said she felt uncared for because she was left in a dirty incontinent brief for hours. During an interview on 09/04/25 at 2:32 p.m., LVN P said CNA O was Resident #2's aide. LVN P said the aide should check the resident and see if the resident was wet at least every two hours. She said Resident #2's brief was soaked, and the resident would have redness, an open area, and a UTI. LVN P said CNA O did not tell her Resident #2 had not been changed when she asked if she had provided incontinent care for Resident #2. During an interview on 09/04/25 at 2:45 p.m., the Treatment Nurse said Resident #2's incontinent brief was soaking wet with urine, and it appeared Resident #2 was not changed recently. The Treatment Nurse said Resident #2's skin could break down, develop rashes, pressure ulcers, and UTI if the aide did not provide timely incontinent care for the resident. She said the aides were responsible for checking on the resident during rounds at least every two hours. She said the floor nurse was responsible for monitoring the aides throughout the shift to ensure the aides were providing care for the residents. The Treatment Nurse said she had an in-service on incontinence care during the all-staff meeting last week, Thursday (08/28/29), and she educated the staff on the importance of making rounds every two hours, changing the residents' incontinent briefs, and making sure the residents were kept dry to prevent skin breakdown and UTI. During an interview on 09/05/25 at 2:52 p.m., CNA M said Resident #2's incontinent brief was very wet, and the inside of the brief was brown, which showed Resident #2 had not been changed for more than two hours. CNA M said the aides made rounds every two hours and as needed. She said Resident #2 could get a bed sore, redness or infection. CNA M said she had a skills check, and it included ADLs, and the treatment nurse educated aides to make rounds every two hours and change the resident to prevent skin breakdown or UTI. During an interview on 09/08/25 at 10:05 p.m., the Corporate Nurse said the aides were responsible for providing incontinent care and were supposed to make rounds every two hours per standard of care. She said if Resident #2 was not changed promptly, the resident's skin could get red, and there was potential for UTI. The Corporate Nurse stated if she was a resident, she would not feel good if she were left on a wet incontinent brief for hours. During a telephone interview on 09/08/25 at 3:54 p.m., CNA O said she did not work with Resident #2 on 09/04/25 because she no longer worked at the facility. She said she had not worked in the facility at all in September 2025. During an interview on 09/08/25 at 5:10 p.m., the DON stated he would go and verify if he had given CNA O's name in error, because they had another aide with the same first name but a different last name. The DON did not provide the other aide's name before the state surveyor exited. 2. Record review of Resident #1's face sheet revealed a [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses which included morbid (severe) obesity (A BMI of 40 plus), diabetes mellitus (high blood sugar), hypertension (high blood pressure), and cerebral infraction (brain attack caused by a blockage in a blood vessel). Record review of Resident #1's Quarterly MDS assessment, dated 07/31/25, revealed a BIMS score of 00 of 13, which indicated severely impaired cognition. Resident #1 needed total care with ADL assistance with two staff assist. Record review of Resident #1's care plan, revision dated 08/11/25, read in part . [Resident #1] was frequently incontinent of bladder and bowel. Intervention: monitor for incontinent often and PRN, change promptly and apply a protective barrier to the skin. During an observation and interview on 09/04/25 at 3:35 p.m., revealed Resident #1 was in bed and covered with a sheet. Resident #1 said the aide from the morning shift had not changed her today, but the night aide changed her before she left, which was early in the morning, and she could not recall the exact time. Resident #1 said she asked LVN P to tell her aide to come and change her between 10:00 a.m. and 11:00 a.m., and the aide had not come to change her up till now. Resident #1 said she felt dirty and upset because the aides did not change her on time because they have to get another staff member because she was on the heavy side. During observation on 09/04/25 at 4:00 p.m., revealed when CNA L and CNA T opened Resident #1's incontinent brief, the resident's incontinent brief was saturated with urine, and the inside of the brief was brown. When CNA L turned Resident #1 to the left, it revealed the two-draw sheets were soaked with urine, and the air mattress was soaked with urine from the resident's lower back to her middle thigh area. During an interview on 09/04/25 at 4:09 p.m., LVN P said Resident #1 told her she wanted her incontinent brief changed at 11:00 a.m., because the morning aide had not changed her incontinent brief today. LVN P said she told the aide to go and change Resident #1 when she came out of Resident #1's room around 11:05 a.m. LVN P said she was not aware the aide did not provide incontinent care for the resident. LVN P said Resident #1 would feel terrible, and it was not accepted. Everybody should be checked and changed, regardless of the resident's size. LVN P said the aides were supposed to make rounds every two hours and as needed for incontinent care. LVN P said Resident #2 could develop UTI and skin breakdown if she was left on incontinent brief for extend time. During an interview on 09/04/25 at 4:49 p.m., CNA L said the aides were supposed to make rounds every two hours to check and change the resident. CNA L stated when she unfastened Resident #1's incontinent brief, it revealed the incontinent brief was very soaked, and when she turned the resident to her left, it revealed the two draw sheets and the air mattress were also soaked with urine. CNA L said Resident #1 could have skin breakdown or an infection because she had not been changed for hours. During an interview on 09/04/25 at 5:21 p.m., CNA T said Resident #1 was her resident. CNA T said Resident #1 was not her original resident. CNA T said when she became aware Resident #1 was assigned to her, she came to provide incontinent care. CNA T said aides were supposed to make rounds for incontinent care every two hours. CNA T said Resident #1's incontinent brief was very wet and soaked with urine, as well as the two draw sheets, and the air mattress. CNA T said Resident #1's skin could break down. During an interview on 09/05/25 at 9:17 a.m., the DON said aides should make rounds for incontinent care at least every two hours. The DON said the residents were not supposed to ask the aide to provide incontinent care because that was part of ADL care. The DON said the aides should make rounds every two hours. The DON said Resident #1 was a heavy wetter, and when she voided, she voided a lot because she drank a lot of water. The DON said if the continent brief was brown, it could mean the urine had been on the incontinent brief for an extended time. The DON said Resident #1 could develop moist-associated skin damage, and the resident would not feel good being left on a wet incontinent brief. During an interview on 09/05/25 at 1:07 p.m., the Administrator said the aides should make rounds for incontinent care every two hours according to the facility's policy. The Administrator said the staff should also make PRN rounds for incontinent care. He said if Resident #1 was left in a wet incontinent brief, it could cause skin breakdown and infection. He said Resident #1 would feel uncomfortable and dirty. Record review of the facility's policy on activities of daily living, dated revised 04/23/25, and implemented 09/01/25, read in part .care and services will be provided for the flowing activities of daily living: 3. Toileting.policy explanation and compliance guideline #2. A resident who is unable to carry out activity of daily living will receive the necessary services to maintain . grooming .

Based on observation, interview and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Resident #1) reviewed for incontinent care. The facility failed to ensure CNA L and CNA D properly cleaned Resident #1 during incontinent care. This failure could place residents at risk for pain, infection, injury, and hospitalization. Findings include: Record review of Resident #1's face sheet revealed a [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses which included morbid (severe) obesity (A BMI of 40 plus), diabetes mellitus (high blood sugar), hypertension (high blood pressure), and cerebral infraction (brain attack caused by a blockage in a blood vessel). Record review of Resident #1's Quarterly MDS assessment, dated 07/31/25, revealed a BIMS score of 13 of 15, which indicated moderately impaired cognition. Resident #1 needed total care with ADL assistance with two staff assist. Record review of Resident #1's care plan, revision dated 08/11/25, read in part . [Resident #1] was frequently incontinent of bladder and bowel. Intervention: monitor for incontinent often and PRN, change promptly and apply a protective barrier to the skin. Observation on 09/04/25 at 4:00 p.m., revealed incontinent care was provided for Resident #1 by CNA L and CNA T. CNA T did not separate Resident #1's labia while she provided incontinent care. CNA T cleaned Resident #1 four times by putting her hand between the resident's closed peri area, without looking at or visualizing the labia. Resident #1 said ouch it hurts and the incontinent wipes had bright red blood. During an interview on 09/04/25 at 4:09 p.m., LVN P said CNA T was supposed to separate Resident #1's labia and wipe from front to back. She said CNA T should have separated the labia to make sure the area was cleaned and see if there was any open area to prevent infection and skin impairment. LVN P said CNA T was supposed to tell her that Resident #1 had blood from the labia area so she could assess Resident #1. She said the blood could be coming from irritation in the labia from sitting on the urine-soaked incontinent brief for an extended period of time. During an interview on 09/04/25 at 5:02 p.m., CNA L said CNA T should have separated Resident #1's labia and cleaned the sides and center. CNA L said Resident #1's labia should be separated so CNA T could see if Resident #1 had an open area where the blood on the wipes was coming from and made sure she cleaned the resident properly to prevent the resident from getting an infection. CNA L said CNA T should have stopped and called LVN P when Resident #1 said it was hurting and there was blood on the wipes. During an interview on 09/04/25 at 5:38 p.m., CNA T said she was supposed to open Resident #1's labia and wipe each side and then the middle, but she did not because she forgot. CNA T said she just wiped the middle without separating Resident #1's labia. She said she wiped out blood three or four times when she cleaned Resident #1's labia area. CNA T said Resident #1 could get an infection if the resident's labia area were not cleaned thoroughly. LVN T said she would tell LVN P after she had provided incontinent care for Resident #1. During an interview on 09/05/25 at 9:31 a.m., the DON said he expected CNA T to stop providing incontinent care and call LVN P when Resident #1 said, ouch, it hurts, and she also wiped-out blood from Resident #1's vagina area. The DON said CNA L and CNA T were educated to spread the labia and wipe one side, discard the wipe, use another wipe and wipe the other side, then discard it, and finally use another wipe and wipe in the middle. The DON said CNA L and CNA T should see the labia area and make sure there were no changes to the skin, and if CNA T did not clean the labia area properly, Resident #1 could have a UTI. The DON said Resident #1 had not had a UTI since she was admitted to the facility on [DATE]. Record review of the facility's, undated, policy on perineal care read in part . it is the practice of this facility to provide perineal care to all incontinent residents.and needed in order to promote cleanliness and comfort, prevent infection.facility explanation and compliance guideline. Female. 11.c.separate the resident's labia with one hand and cleanse perineum with the other hand by wiping in direction from front to back.

Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and resident's choice for 1 of 7 (Resident #1) reviewed for Quality of Care. 1.The facility failed to call emergency services and have Resident #1 immediately transferred to the hospital, on 08/09/25 when she experienced a change in condition at 11:30 a.m., including a blood pressure reading of 203/98 and a change in mental status. The facility failed to monitor Resident #1 after the change in condition was noted and used a non-emergency ambulance service, which resulted in a delay in her receiving emergency care until after 1:13 p.m., approximately one hour and 51 minutes after her initial change in condition. Resident #1 was noted to have a blood glucose level of 44 upon arrival to the hospital and was treated for Hypoglycemia (a condition in which the body's blood sugar level goes below the standard range). An Immediate Jeopardy (IJ) was identified on 08/14/25 at 5:35 p.m. The IJ template was provided to the facility on [DATE] at 5:35 p.m. While the IJ was removed on 08/16/25, the facility remained out of compliance at a scope of isolated with a severity level of the potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed residents who had a change in condition at risk of prolonged pain, worsening of condition, prolonged recovery, and possible death. Findings included: Record review of Resident #1's face sheet dated 08/12/25 revealed a Resident #1 was a [AGE] year-old female admitted to the NF on 06/03/25 and readmitted on [DATE]. Resident #1's diagnoses included Cerebrovascular Disease (A group of conditions that affect the blood vessels in the brain), Type 2 Diabetes, Hypertension (High blood pressure), Psychotic disorder, Dementia Chronic Kidney Disease, Conversion Disorder with seizures (involves the experience of real, physical seizures that mimic epileptic seizures but have no underlying medical or neurological cause). Record review of Resident #1's Initial MDS assessment dated [DATE] revealed a BIMS score of 07, which indicated severe cognitive impairment. Section GG of the MDS revealed the resident used a wheelchair and walker for mobility devices. The resident required supervision or touching assistance (helper provides verbal cues and/or touching/steading and/or contact guard assistance as resident completes activity, Assistance may be provided throughout the activity or intermittently) for eating, oral and personal hygiene. The resident requires partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for upper body dressing, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed to chair transfer and toilet transfer. The resident requires substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) for toileting hygiene, shower/bathe self, lower body dressing, and putting on/taking off footwear. Record review of Resident #1's care plan dated 06/03/25 revealed, * Focus: The resident has hypertension. Goal: The resident will remain free from signs and symptoms of hypertension. Interventions: Give anti-hypertensive and medications as ordered. Monitor for side effects such as orthostatic hypotension (A form of low blood pressure that happens when standing up from sitting or lying down) and increased heart rate (Tachycardia) and effectiveness. * Focus: The resident uses insulin. Goal: The resident will be free from any signs or symptoms of hyperglycemia (high blood glucose (blood sugar) or hypoglycemia (A condition where the blood sugar (glucose) levels drop below normal) through the review date. Interventions: Administer insulin ordered by physician. Monitor/document for side effect and effectiveness. Blood glucose monitoring per physician orders. Monitor/document/report PRN any signs or symptoms of hyperglycemia: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abdominal pain, Kussmaul breathing ( A deep rapid, and labored breathing pattern often associated with metabolic acidosis, a condition where the body has too much acid), acetone breath (smells fruity), stupor coma(distinct states of impaired consciousness). Monitor/document/report PRN any signs or symptoms of hypoglycemia: Sweating, Tremor, increased heart rate (Tachycardia), Pallor (An abnormal or unusual paleness of the skin or mucous membranes, indicating a lack of color that is different from a person's normal complexion), Nervousness, Confusion, slurred speech, lack of coordination, staggering gait. Rotate site of insulin injections and document site of administration. Monitor for alteration in skin integrity. Record Review of physician orders based on Resident #1's MAR revealed Resident #1 had orders for: MetFORMIN HCl Tablet 1000 MG-(Give 1 tablet by mouth two times a day for diabetes with a start date of 06/02/25). Metoprolol Tartrate Oral Tablet 50 MG-Give 1 tablet by mouth two times a day for hypertension hold for SBP less than 110 and HR less than 55 with a start date of 06/03/25). AmLODIPine Besylate Tablet 10 MG-Give 1 tablet by mouth one time a day for hypertension hold for less than 110 or HR less than 55 with a start date of 06/04/25). HydrALAZINE HCl Tablet 25 MG-Give one tablet by mouth three times a day for hypertension hold for SBP less than 110 or HR less than 55 with a start date of 06/03/25). Record review of Resident #1's MAR for August 2025 revealed: On 08/09/25 Resident #1 received MetFORMIN HCl 1000 MG AT 9:00 a.m. On 08/09/25 Resident #1 received Metoprolol Tartrate Oral Tablet 50 MG at 9:00 a.m. On 08/09/25 Resident #1 received AmLODIPine Besylate Tablet 10 MG at 9:00 a.m. The residents blood pressure was documented as 144/78 and pulse was 76. On 08/09/25 Resident #1 received HydrALAZINE HCl Tablet 25 MG at 9:00 a.m. Record review of Resident #1's progress notes for August 2025 revealed: * On 08/09/25 at 11:30 AM, RN-A documented, Resident found lying in bed, family at bedside. Resident breathing without difficulty, no difficulty in swallowing, moving right arm, pupils respond to light, no verbal response, responds to pain, vital signs 203/98-78-20 (blood pressure) blood sugar 178, family insists we send to ER, MD notified and received order to send to hospital for evaluation. Record review of Resident #1's electronic health record revealed: On 08/09/25 at 11:30 a.m., Resident #1's blood sugar at 176, the residents blood sugar was not taken again. On 08/09/25 at 11:30 a.m., Resident #1's blood pressure was 203/98. The residents blood pressure was 144/78 at 12:47 p.m. and 144/78 at 12:54 p.m. Record review of the hospital's history of present illness for Resident #1 dated 08/09/25, the resident's blood glucose was 44 upon arrival to thehospital. The resident was admitted to the hospital for hypoglycemia. In an interview with Resident #1 on 08/14/25 at 10:57 a.m., she stated everything was going well. She stated the staff checked on her regularly. She stated she went to the hospital recently. She stated she did not know what happened. She stated she did not know what happened but reported that her daughter was with her. She stated she was feeling fine and stated the staff had been checking on her regularly. She stated she liked living at the facility and stated the staff are nice to her. In an interview with RN-A on 08/14/25 at 11:14 a.m., she stated she checked on the resident at 5:30 a.m. on 08/09/25 and Resident #1 was doing fine. She stated at approximately 11:30 a.m. on 08/09/25, a family member of the resident informed her that she was concerned about the resident. She stated she took the resident's blood pressure, and it was 203/98 and the resident's blood sugar was 178. She stated she contacted the on-call physician, and she was informed to send the resident to the hospital. She stated about 45 minutes later she checked the resident's blood pressure again and it was 180/78. She stated the resident was sent out via ambulance transportation. She stated she did not call 911 because the resident was breathing. She stated the resident was responding to touch, swallowing and moving her arms, but was not talking. She stated the resident left to go to the hospital before 1:00 p.m. In an interview with CNA B on 08/14/25 at 11:53 a.m., she stated Resident #1ad a change in condition on 08/09/25. She stated she did not know the exact time of the change in condition, but she remember that it occurred after breakfast. She stated the resident was not really talking and her normal baseline was usually alert and oriented. She stated the resident was sent out to the hospital, but she could not remember what time she was sent out. Interview with the DON on 08/14/25 at 12:24 p.m., he stated Resident #1 was sent out the hospital due to an elevated blood pressure. He stated he was not working the day the resident was sent out. He stated usually if a resident was alert and moving, the resident was sent out via transportation but if something else was going on with the resident they would be sent out via 911. In an interview with on-call Physician on 08/14/25 at 1:06 p.m., he stated RN-A informed him that Resident #1 had a change in condition, reporting a blood pressure of 203/98. He stated he told RN-A to send the resident to the hospital. He stated it was the facility's decision on which form of hospital transportation was used, but he would assume they would use the fastest method. He stated he assumed that 911 was called and was not aware that the ambulance transportation was called. He stated the risk of a resident not going out the hospital during a change in condition would depend on the resident and the situation In an interview with the Administrator on 08/14/25 at 1:51 p.m., he stated he was not employed at the facility when the resident was sent out but reported he was able to obtain information regarding the call outs and pick up from the transportation center. He stated RN-A contacted the ambulance transportation company at 11:22 a.m. and they arrived to pick the resident up at 1:13 p.m. A policy on change in condition was requested, and he stated there was no policy related to change to change only notification of changes. In an interview with Family Member #1 on 08/14/25 at 3:04 p.m., she stated she was with Resident #1 the day that she was sent out to the hospital. She stated she entered the resident's room at approximately 11:00 a.m. She stated the resident appeared to be in a deep sleep. She stated the resident was lying in bed with her eyes closed and it sounded as if she was snoring. She stated she called the resident's name several times, but she did not respond. She stated she began to shake the resident to get her to arise and she did not move. She stated she notified the nurse. She stated RN-A came into the room and attempted to wake the resident. She stated the resident did not move. She stated the resident's blood sugar was taken, and it was 86. She stated RN-A gave the resident a glucose stick and rubbed her throat to help her swallow but she would not swallow. She stated RN-A stated that she would contact the physician and asked if she wanted 911 to be called and she responded yes. She stated RN-A then stated that it would take an hour for the ambulance to arrive. She stated RN-A never returned to check on the resident. She stated 911 never arrived but reported an ambulance transportation company came instead. She stated the ambulance transportation company arrived around 1:30 p.m. Record review of the facility's Notification of Changes revised 12/08/24 revealed: The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. 2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status: This may include: a. Life threatening conditions, or b. Clinical complications This was determined to be an Immediate Jeopardy (IJ) on 08/14/2025 at 5:35 p.m. The Administrator, DON, Director of Risk and Regulatory, and the Senior Administrator were notified. The Administrator, DON, Director of Risk and Regulatory, and the Senior Administrator were provided with the IJ template on 08/14/2025 at 5:35 p.m. A Plan of Removal was requested at that time. The following Plan of Removal submitted by the facility was accepted on 08/15/25 at 1:54 p.m.: The facility failed to transfer [Resident #1], who had a change in condition at 11:30am in a timely manner. The facility failed to call 911 emergency services to immediately transport [Resident #1] to a higher-level of care for evaluation and treatment 1. Identification of Residents Affected or Likely to be Affected:The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. (Completion/ Date: 8/14/25) [Resident #1] returned to facility on 8/12/25 with no ill effects related to alleged deficiency. DON/Regional /Nurse Consultant reviewed 24-hour report for the last 7 days to ensure all changes of conditions including transfers to acute care were addressed in a timely manner. An audit was conducted on all transfers from the last 7 days to acute care to ensure there was no delay in services. Attending Physician and Medical Director were notified of IJ on 8/14/2025 at 08:40pm. 2. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. (Completion Date: 8/14/25) Facility policy and procedures related to change of condition were reviewed by Director of Nursing, Administrator, Regional Nurse Consultant and Senior Administrator on 8/14/2025, no revisions deemed necessary at this time. DON/Corporate Nurse/Consultant Nurse provided education to nurse involved in alleged incident with 1:1 education related to notifications of change of condition and monitoring of resident while resident remains in facility until transfer occurs or change of condition resolves. Education included definitions of what a change of condition is, circumstances where the clinical teams must be notified, and when the nurse must notify medical providers and when to notify responsible parties. When to call 911 versus non-emergency transportation as appropriate for the identified change of condition. Frequent assessment of resident to address change of condition including specific assessments to be completed when resident has a diagnosis of Diabetes and appropriate interventions (for example, checking blood sugars frequently to assess for hypoglycemia or hyperglycemia). DON/Corporate Nurse/Consultant Nurse provided education to all staff in person, via phone, via facility messaging platform, or prior to next shift on facility policies and procedures related to changes of condition and to report to licensed nurse the findings for immediate assessment. Education included definitions of what a change of condition is, circumstances where the licensed nurse or Director of Nursing must be notified, and when to notify responsible parties if appropriate. DON/Corporate Nurse/Consultant Nurse provided education to all licensed nurses in person, via phone, via facility messaging platform, or prior to next shift on facility policies and procedures related to changes of condition and seeking immediate medical care as to not delay services. Education included definitions of what a change of condition is, circumstances where the clinical teams must be notified, and when the nurse must notify medical providers and when to notify responsible parties. When to call 911 versus non-emergency transportation as appropriate for the identified change of condition. Frequent assessment of resident to address change of condition including specific assessments to be completed when resident has a diagnosis of Diabetes and appropriate interventions (for example, checking blood sugars frequently to assess for hypoglycemia or hyperglycemia). The Director of Nursing or designee will continue to monitor/audit Changes of Condition and Hospital Transfers by reviewing the 24-hour report during morning clinical meetings three times weekly for four weeks, then weekly for eight weeks. A QAPI PIP has been initiated to report on the above monitoring and auditing procedures. All findings from the PIP will be presented at the monthly QAA meeting. Monitoring/auditing and reporting will continue for a minimum of three months. * Monitoring of the plan of removal included the following: Record review of an Audit/Monitoring dated 08/11/25-08/14/25 revealed residents were reviewed for change in condition, actions taken to address change in condition. The document reflected if the resident were sent out via 911 or non-emergent transportation, was there any delays, comments/corrective action. There were no identified concerns in the audit. Record review of the Summary Report of Education dated 08/14/25 revealed all facility staff were educated on Notifications of Change in Condition by the DON and Senior Administrator. The document revealed in part, The purpose of this policy is to ensure the facility promptly informs the residents, consults the resident's physician; and notifies consistent with his or her authority, resident's representative when there is a change requiring notification (life threatening conditions, Clinical complications, need to alter treatment significantly, right to privacy, circumstances requiring notification and additional considerations). Record review of the Summary Report of Education dated 08/14/25 revealed all licensed staff were educated on Changes of condition and seeking immediate medical care as to not delay services by calling 911 if needed for transportation as appropriate for the identified change in condition by the DON. The document revealed in part, The purpose of this policy is to ensure the facility promptly informs the residents, consults the resident's physician; and notifies consistent with his or her authority, resident's representative when there is a change requiring notification (life threatening conditions, Clinical complications, need to alter treatment significantly, right to privacy, circumstances requiring notification and additional considerations). Record review of Summary Report of Education dated 08/15/25 revealed licensed staff were educated on Monitoring and assessment to be done when a resident who is diabetic has a change in condition by the DON. The document revealed in part, Hypoglycemia Management-It is the policy of this facility to ensure effective management of a resident who experiences a hypoglycemic episode (Definition, Policy explanation, Compliance guidelines, asymptomatic and responsive residents, symptomatic (lethargic, drowsy) but responsive (conscious) residents). Record review of In-service Summary/Report of Education of 1:1 with the DON and RN A dated 08/14/25 revealed RN A was educated on change of condition-monitor resident vital signs, document-all-clinical changes, monitor resident until 911 arrives, document time start and finish, call NP/MD, DON, and RP. Interviews were conducted with staff on 08/14/25 between 5:35 a.m. until 12:00 p.m. including RN A, CNA B, LVN C, CNA D, LVN E, RN F, CNA G, CNA H, CNA I, Medication Aide J, CNA K, LVN L, LVN M, LVN N, Medication Aide O, LVN P, and CNA Q to verify the in-services were conducted and to validate the staff understanding of the information presented to them. No concerns were found regarding understanding of requirements, training material and expectations. RN A, CNA B, LVN C, CNA D, LVN E, RN F, CNA G, CNA H, CNA I, Medication Aide J, CNA K, LVN L, LVN M, LVN N, Medication Aide O, LVN P, and CNA Q were able to explain the importance of monitoring the residents that had a change in condition, calling 911 when the residents have a change in condition (high/low blood sugar and high/low blood pressures), taking residents vitals until 911 arrived, staying with the resident until 911 arrived, and documenting all changes. The Administrator was informed the Immediate Jeopardy was removed on 08/16/2025 at 12:02 p.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (Resident #21) reviewed for free of accidents, hazards, supervision, and devices., in that: The facility failed to ensure Resident #21 who the facility staff knew he was at risk for fall and update fall precaution interventions after several falls resulting in injuries to the head. An IJ was identified on 02/09/24. The IJ template was provided to the facility on [DATE] at 7:15 p.m. While the IJ was removed on 02/11/24 at 12:50 p.m., with the Administrator, DVP and DVP Clinical. The facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of isolated due to the facility staff had not been trained on identifying residents at risk for fall, preventions, and interventions, and modification and care plan falls. This failure could affect residents who were fall risk and place them at risk for physical harm, pain, mental anguish, or emotional distress. Findings included : Review of Resident #21's face sheet revealed Resident #21was a [AGE] year-old male who was admitted to the facility on [DATE], re-admission on 08/04/23 with a diagnosis of Atrial fibrillation, (irregular and often very rapid heartbeat) , cerebral palsy (weakness or problem with using the muscles), history of falls, and epilepsy(unprovoked seizures). Record review of Resident #21's quarterly MDS assessment, dated 02/07/2024, revealed a BIMS score of 04 out of 15, which indicated the resident's cognition was severely impaired. Further review of Resident #21's MDS revealed the resident required supervision assistance with one staff for transfer and dependent on one staff assistance with putting and taking off footwear. Further review of Resident #21 MDS revealed the resident had one fall snice admission. Record review of Resident # 21 order summary report revealed the following: PT to evaluate and treat under PASRR active date 08/25/23, OT to evaluate and treat under PASRR active date 08/25/23, ST to evaluate and treat under PASRR active date 08/25/23, Fall mat placed next to bed every shift active date 12/18/23. Record review of the facility incident report on falls for Resident #21 revealed the following: 7/22/23 - Unwitnessed fall - in resident room, Mental Status: disoriented, Hematoma was on forehead and transported to 911. 10/22/23 - Unwitnessed fall-in resident room, Mental Status: oriented to time, place and person, abrasion to his forehead, I was sitting on my bed putting my shoes on and fell . 12/18/23 - Unwitnessed fall- in resident room, Mental Status: disoriented, large hematoma above left eye trying to get out of bed to wheelchair. 2/1/24 - Unwitnessed fall - in resident room, and hematoma was on forehead. Record review of Resident #21's care plan revealed the care plan was not updated following falls 07/22/23, 10/22/23, 12/18/23.Intervention:be sure call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all request for assistance. Further review of Resident #21's care plan revealed resident was at risk for fall related to confusion, deconditioning, gait/balance problem, and history of fall. Intervention: fall mat placed next to bed during all shift was not care planed. During an observation on 02/06/24 at 9:57 a.m., Resident #21 was sitting in a wheelchair in his room, and the call light was on the nightstand and was not within reach. Resident #21 had dark red-purple bruises from the middle of his forehead to the left of his nose, left eyes, and cheeks. He also had a black line about 1 inch thick across his forehead. Resident #21 also had a hematoma about the size of a tennis ball. During an observation on 02/08/24 at 2:39 p.m., Resident #21 was sitting in his room in his wheelchair, and the call light was not within reach. During an interview on 02/09/24 at 12:21 p.m., the DON said Resident #21 had several falls, in which he had some head injuries, and they have done all they could to prevent Resident #21 from falling except for a helmet for the protection of his head. The DON said Resident #21 bed should be at the lowest position whenever he was in bed, and she did not know if his bed was on the lowest position when fell because all his fall were unwitnessed. The DON said all the interventions were care planned. During an observation and interview on 02/09/24 at 1:30 p.m., Resident #21 was in his room sitting in his wheelchair, and the call light was not within reach; it was on the nightstand. Resident # 21 said he fell from the bed but could not remember what day it was or if the bed was low. During an observation and interview on 02/09/24 at 1:34 p.m., LVN R said Resident #21 falls frequently. LVN R said Resident #21's call light was on the nightstand far from Resident #21, and he could not reach it if he wanted to use it. LVN R said the DON and ADON are responsible for implementing any changes in the care plan. During an observation and interview on 02/09/24 at 1:41 p.m., the DON and ADON went into Resident #21's room and the DON said they saw the call light on the nightstand, and Resident #21 could not reach the call light if he wanted to use it. The DON said the call should be within reach whenever the resident was in the room. During an interview on 02/09/24 at 1:43 p.m., CNA F said she just picked up the tray from Resident #21's room and did not notice Resident #21's call light was not within reach. CNA F said Resident #21 could fall if he tried to reach for his call light, and he could not call for assistance if he wanted to call because the call light was not within reach. During an interview on 02/09/24 at 3:03 p.m., the ADON said she saw that Resident #21's call light was not within reach of the resident. The ADON said Resident #21 was at risk of falling and could fall if he tried to reach for the call light. The ADON said all of Resident #21's falls should have been care planned and intervention modified. The ADON said she did not know why the falls were not care planed, she said the intervention should be modified with each fall, and she was not responsible for care planning the falls and it was the responsibility of MDS coordinator and social worker. During an interview on 02/09/24 at 3:23 p.m., The DON said any nurse could update the care plan, and all of Resident # 21's falls should have been care planed and intervention modified as needed. The DON said she would investigate and update the surveyor later. During an interview on 02/09/24 at 3:28 p.m., the Corporate Nurse said that all of Resident #21's falls should be care planned and that she would investigate and find out the root cause of his falls so that an intervention could be put in place. During an interview on 02/09/24 at 3:36 p.m., the SW said she had not had any care plan meeting with Resident #21's family about his falls. SW said she was aware of the falls because she would see Resident #21 had a knot on his head and bruises. During an interview on 02/09/24 at 3:41 p.m., the MDS Coordinator said the DON and ADON updated the care plan, and she only coded the MDS. The MDS coordinator stated that the GG section of MDS did not require any coding for staff assistance for Resident #21's bed mobility. The MDS coordinator said the DON and the ADON were responsible for putting and modifying interventions in the care plan. During an interview on 02/09/24 at 3:44 p.m., the Director of Rehabilitation said Resident #21 has been in therapy since March last year, and they are working on his endurance, balance, and memory. The Director of Rehabilitation said he does not work with Resident #21 and would talk to his staff if any recommendation was made for Resident #21. The Director of Rehabilitation said if his department made any recommendations, the nursing department would be responsible for care planning, intervention, and monitoring of Resident #21. Record review of facility policy on fall clinical protocol dated 2001 MED PASS, Inc. (Revised March 2018) read in part .cause identification . #3 The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified .treatment/management .#1 Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling .monitoring and follow-Up .#1 . the staff, with the physician 's guidance, will follow up on any fall with associated injury . #2 .the staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of fall .#4 if the individual continue to fall, the staff and the physician will re- evaluate the situation and reconsider possible reasons for the resident's falling(instead of, or in addition to those that have already been identified) and also reconsider the current interventions . This was determined to be an Immediate jeopardy (IJ) on 02/09/24 at 7:15 p.m. The Administrator was notified. The Administrator was provided with the IJ template on 02/09/24 at 7:15p.m. The following Plan of Removal submitted by the facility was accepted on 02/10/24 at 9:34 a.m. PLAN OF REMOVAL Name of facility: Fallbrook Rehabilitation and Care Center Date: 02/09/2024 F 689 - The facility failed to ensure that Resident #21 received adequate supervision and assistive devices to prevent accidents. The facility failed to update fall precaution interventions after several falls resulting in injuries to a resident. Immediate action: The Medical Director was notified of the Immediate Jeopardy status on 02/09/2024 at 7:50 pm. Resident #21 promptly had a new fall risk assessment done by ADON 02/09/2024. Resident #21 is currently receiving Physical, Occupational and Speech therapy 5 days a week. Resident's care plan updated to include fall mat, bed to be kept in low position, and verification that call light was in reach 2/9/2024. The Director of Nurses, Assistant Director of Nurses will review all fall risk assessment and update care plans to ensure appropriate interventions are in place and this will be completed by 2/10/2024. Regional nurses will review all current resident fall history and verify falls and fall interventions are captured on care plan by 2/10/2024. Therapy will review all residents who have fallen in the last 90 days to ensure residents have been screened and therapy will implement additional interventions as indicated (to be completed by 2/10/2024). Therapy will provide any needed training to nursing staff for interventions. Rehab director attends fall management meeting during stand-up meeting and will provide any screen and therapy plan information related to resident's falls to nursing staff. Nursing management. To include DON, ADON, MDS, will update care plan and CNA guidance in Point click care. Charge nurses will ensure recommended interventions related to resident's falls are followed and DON, ADON will provide oversight by making rounds daily, All nursing staff, which includes all nurses and nurse aides, will be in-service to ensure call bells are within resident's reach by Nursing manager by 2/10/2024; Nurse staff All nursing staff, which includes all nurses and nurse aides, will not be allowed to start shift until completing in-service training. Facility Plan to ensure compliance quickly Director of Nurses, Assistant Director of Nurses, and Nurse Supervisor will provide education to nursing staff by 2/10/2024 to notify physician and RP and to promptly implement an intervention after fall by updating resident's care plan. The Director of Nurses, Assistant Director of Nurses, and MDS Nurse will review falls in morning meeting and ensure that the nursing staff has updated the care plan, and the physician was notified. IDT team will review the fall intervention implemented by nurses in morning meeting. Education will be completed by the Director of Nurses, Assistant Director of Nurses, and Nurse Supervisor by 02/10/2024 for all nurses and certified nurse aids on importance of ensuring call lights are in resident's reach. CNAs will be educated on ensuring call lights are in resident's reach when doing Q 2-hour rounds. Charge nurses will verify that CNAs have place call bell in reach when their doing rounds. IDT team will do rounds 5 days a week to verify call bells are within resident's reach and document on IDT round sheet. Staff will not be allowed to start shift until completing in-service training. Nursing staff (licensed and certified) will be re-educated on call bell system to include call bell placement by 2/10/2024. Administrator, DON, ADON, and Nurse Supervisor will Inservice Nursing staff/aides on falling star program, which includes stars on name room plate and bands on devices. Interventions will be listed in nurse/CNA care plan in Point click care. Inservice to be completed 2/11/2024Staff will not be allowed to start shift until completing in-service training. QAPI meeting was held 2/9/2024 by the facility IDT team, which included Administrator, DON, ADON, CNO, Housekeeping supervisor, social worker, Human resources to review policy/procedure Fall management program. Surveyor monitored the plan of removal for effectiveness as follows: A record review of the facility removal plan revealed the medical director was notified of the IJ on 2/09/24 at 7:50 p.m. A record review of the risk assessment revealed all residents were reviewed on 02/10/23 by the corporate nurse for fall risk assessment. Record review of the facility in service revealed the DON and ADON in-service the nurses and CNAs on fall prevention, care plans/Kardex (electronic health record) for personalized interventions, identifying residents at risk for falls, falling star/yellow bands, fall prevention and updating the care plan on 02/10/24. A record review of the progress note revealed Residents with falls for the past 90 days were reviewed by the therapy on 02/10/24 and they are currently in therapy. A record review of fall risk assessment revealed Resident #21 had a new fall risk assessment done by ADON on 02/09/2024. A record review of Resident #21's care plan revision dated 02/09/24 revealed the following up date: with a fall mat, bed in a low position, all the falls were care-planned and currently on PT, OT, ST, under PASRR 5 times a week indefinitely since March 2023. During observations on 02/11/24 from 10:00a.m. to 2:00 p.m., revealed residents(Resident #21, Resident #18, and Resident #25) on the fall list had their call lights attached to the bed, and one Resident #24 was in bed, and she could reach her call light. During interviews on 02/10/24 between 11:21 a.m. and 8:48 P.m., two CNAs and three nurses from the night shift were interviewed on the facility in service and training on fall precautions, interventions, identification of residents at risk of falls, care plan modification of intervention and who was responsible for updating care plans. All staff interviewed were able to verbalize understanding of plan of removal, facility policies, procedures and in-services received. During an interview on 02/11/24 between 9:00 a.m. and 9:30 a.m., one CNA, one nurse from the day shift, and The MDS coordinator were interviewed on the facility in service and training on fall precautions, interventions, identification of residents at risk of falls, care plan modification of intervention and who was responsible for updating care plans. All staff interviewed were able to verbalize understanding of plan of removal, facility policies, procedures and in-services received. During an interview on 02/11/24 at 9:57 a.m., the DON said she was checking to ensure that all the in-services were done because she did some training, and the Social Worker and the Administrator did some of the in-services. The DON said she provided training for the aides not to move any resident observed on the floor but to call the nurse so the nurse could assess the resident. The DON said she also trained the aides to look at the Kardex for residents at risk for falls, and the Kardex also showed the aides the different types of interventions for each resident. The DON said Kardex told the aides that the resident should have a nonskid stocking, a yellow falling star on the door, and the resident should wear a yellow band. The DON said the nurses were given the same training as the aides, and they were also trained on how to update the care plan if any resident had a fall. The DON said the nurses were in serviced on assessing a resident during a fall, notifying the physician, carrying out the physician's order, and also notifying the responsible party and nurse management. During an interview on 02/11/24 between 10:00 a.m. and 11:00 a.m., two CNAs and three nurses from the day shift were interviewed on the facility in service and training on fall precautions, interventions, identification of residents at risk of falls, care plan modification of intervention and who was responsible for updating care plans. All staff interviewed were able to verbalize understanding of plan of removal, facility policies, procedures and in-services received. During an observation on 02/11/24 at 11:17 a.m., it revealed Resident #21 was sitting in his wheelchair in his room close to the foot of the bed close to the door, and the call light was clipped on the linen close to the resident, and he could reach the call light. During an interview on 02/11/24 at 12:11 p.m., the Administrator said he was aware of Resident #21 falls, and they discussed them during IDT meets. The Administrator said they had changed Resident #21's fall precautions, and his care plan has been updated. The Administrator said he assisted with the in-service training for the aides and nurses on falls; they have amended the fall program and implemented the falling star and general intervention for falls but did not go into details about the care plan. The Administrator said the DON and the ADON conducted in-service the staff on updating the care plan, and he told the staff to follow up with the DON any time they had any falls. On 02/11/24 at 12:50 p.m., the Administrator, the DON, the VP of operation, and DVP Clinical were notified the Immediate Jeopardy was removed. However, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimum harm that is not immediate Jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview and record review the facility failed to ensure a Resident #28 who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain nutrition, grooming and personal and oral hygiene for 1 (Resident #28) of 4 residents reviewed for ADL's and quality of life. The facility failed to ensure Resident #28 was provided incontinent care in a timely manner, which resulted in decreased skin integrity. This failure affected one resident (Resident #28) and placed residents requiring assistance with incontinent care at risk of not have the assistance with personal care which could cause pain, skin breakdown, lack of dignity and low self-esteem. Findings: Record review of the facility face sheet revealed that Resident #28 was a [AGE] year-old male, admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included acute respiratory failure with hypoxia (a condition where you don't have enough oxygen in the tissues in your body (hypoxia) or when you have too much carbon dioxide in your blood (hypercapnia) You might also hear people use the term acute hypoxemic respiratory failure (AHRF)), morbid obesity with aveolar hypoventilation (Obesity hypoventilation syndrome is a respiratory consequence of morbid obesity that is characterized by alveolar hypoventilation during sleep and wakefulness), type 2 diabetes (Type 2 diabetes is a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel) and lymphedema (build-up of fluid in soft body tissues when the lymph system is damaged or blocked). Record review of Resident #28's care plan dated initiated 10/16/2021 revealed a care plan for ADL's and limited physical mobility r/t weakness, confusion, limited mobility with interventions/task Resident #28 requires total assistance with toilet use and personal hygiene. A care plan for bowel and bladder incontinence dated initiated and revised on 1016/2021 r/t activity intolerance, confusion and impaired mobility with a goal target date of 3/29/2024 to refrain free of skin break down due to incontinence and brief use through the target date, interventions and task included use MD's order for Nystatin powder and to check frequently for incontinence. Wash rinse and dry perineum (cleaning the private areas of a patient), change clothing PRN and after incontinence episodes. Record review of Resident #28's quarterly MDS assessment dated [DATE]th, 2024, revealed he had a BIM score of 14, indicating he was cognitively intact. Resident #28 was also coded as being impaired on both sides, upper and lower extremities for functional limitation range in motion dependent on 2 or more helpers (staff) to complete the activities of bathing, showering, toileting hygiene, dressing the upper and lower body, putting on and removing footwear, he also required partial to moderate assistance to roll to the left sides and lye back down on the bed. Resident 3 28 was totally dependent on staff to transfer from bed to chair or wheelchair. Resident #28 was frequently incontinent of bladder and bowel. Resident #28 was coded to be a risk for pressure ulcers. Record review of physician orders for February 2024 included orders for Nystatin Powder 100000 UNIT/GM ,Apply to inner thighs, scrotum, abd topically everyday shift for Incontinence; Rash. May Apply Zinc skin barrier after each incontinent episode to help reduce skin impairments. Prior to wound treatment evaluate resident for Pain: everyday shift for Wound Care After wound treatment evaluate resident for pain: everyday shift for Wound treatment. Record review of Resident #28's weekly wound assessments for January 2024 through February 7, 2024, revealed no wound assessment for his perennial, scrotum and folds areas. Record review of the facility grievance/complaint form dated 2/7/2024 revealed that Resident #28 filed a grievance that he did not receive care. Resolved by the DON assisting CNA's with providing care and disciplinary action scheduled with CNA assigned Resident #28. During an observation and interview on 2/07/2024 at 8:03 am, with Resident #28, laying in his bed, he said that the CNA's do not want to do their job. He said he pushed his call-light at 4:00 pm yesterday and the staff did not come and assist him until 9:00 pm. He said that he has wounds on his bottom and that the staff make him wait and sit in his feces for so long that it dries up on his bottom and they have to scrape the feces off. He said it does not feel good to sit in that at all. He added if he could clean himself, he would but he cannot. During an observation and on 02/07/24 at 1:30 pm, it was revealed that Resident #28's under abdominal fold, scrotum, left, and right groin were very red, macerated, and there were tiny opens on all areas. One of the areas on under the abdomen measured about 1.0x1.0 cm. Resident #28 said that it hurts whenever RN A or CNA N cleaned the groin areas, scrotum, and abdominal area. Observation at this time of RN A and CNA N which wiped Resident #28 and the wipes had thick white substance and it had a musty odor. During an interview on 02/07/24 at 1:20 pm, CNA N said she had not provided incontinent care for Resident #28 since she came to work today at 6:30 a.m. CNA N said Resident #28 had to call her if he needed to be changed, and she had not gone and checked on Resident #28 for incontinent care. CNA N said she was supposed to make rounds for incontinent care on all residents every two hours. During an interview on 02/07/24 at 1:24 pm, RN B said she did Resident #28's skin assessment sometimes and the wound care nurse does it at times. RN B said Resident #28 needed two to three staff assistance for incontinent care. RN B said Resident #28 did not have any redness or open area on his buttocks or peri area when she did his skin assessment two weeks ago. RN B said none of the aides had told her that the resident had any open area on his peri area. During an interview on 02/07/24 at 2:32 pm, LVN H said Resident #28's scrotum, groin areas were very moist and excoriated with some openings. LVN H said she had worked with Resident #28 last week on Friday and Saturday and she did wound care on his feet, and she did not check his groin area. LVN H said urine could cause Resident #28 to have redness and excoriation. LVN H said if the aides did not make rounds often Resident #28 could get redness and excoriation. LVN H said the charge nurses are responsible for monitoring the aides to make sure they are providing care for residents, LVN H said the DON and ADON monitor the nurses when they make rounds. During interview on 02/07/24 at 3:03 pm, CNA N said she worked with Resident #28 on 02/06/24 and the groin, under the abdominal folds and scrotum was the same as today but she did not tell her charge nurse yesterday. CNA N said she did not tell RN B, but she saw the redness with her today. CNA N said she did not mention this to anybody because the aide she took over from on 02/06/24 did not tell her about the areas on Resident #28 she assumed the nurses were aware of the skin condition. During an interview on 02/08/24 at 10:42 am, the Wound Care Nurse said she does Resident #28's weekly skin assessment, and she did not see any redness, macerated area, any opening on his groin or abdominal folds. She said she became aware of the area yesterday. During an interview on 02/08/24 at 10:54 am, the DON said she became aware of the red macerated area when she came to Resident #28's room. Then DON said she smelled the foul odor and ammonia in the resident room. The DON said the wound care nurse assessments for Resident #28 from January 2024 through February 2024 did not mention Resident #28 had any skin issues on his groin or under his abdomen. The DON said the facility has a new wound care company and the wound care doctor was not notified about the skin condition. Interview on 02/08/24 at 10:57 am, with Resident #28's primary physician, he said he was notified about the change in skin condition yesterday twice. He said Resident #28 was an obese resident and all the folds could cause the areas to stay wet and the intervention of Barrier cream may not prevent the area from being moist and red or open. He said there was no other intervention in place to prevent the area from being moist or red. The physician said the facility also have a wound care doctor who should be taking care of wound and skin issues. Record review of the facility policy and procedure entitled Perineal Care dated revised February 2018 read in part . Purpose, the purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition .Preparation: 1.Review the resident's care plan to assess for any special needs of the resident .wash and rinse the rectal area thoroughly, including the area under the scrotum, the anus, and the buttocks .dry area thoroughly .document any discharge, odor, bleeding, skin care problems or irritation, complaints of pain or discomfort .report other information in accordance with facility policy and professional standards of practice. Record review of the facility policy and procedure entitled Activities of Daily Living (ADL's) Supporting dated revised March 2018 read in part .residents who are unable to carry out activities of daily living independently will receive the services to maintain good nutrition, grooming, personal and oral hygiene .appropriate care and services will be provided for residents who are unable to carry out ADL's independently .in accordance with the plan of care including support and assistance with: hygiene (bathing) .elimination (toileting) .A resident's ability to perform ADL's will be measured using clinical tools including the MDS and the following MDS definitions .totally dependent: full staff performance on an activity with no participation by the resident for any aspect of the ADL activity . Record review of the facility policy and procedure entitled Call System, Resident dated September 2022 read in part .residents are provided with the means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation .calls for assistance are answered as soon as possible but no longer than 5 minutes . Record review of the facility policy and procedure entitled Dignity dated February 2021 read in part . Policy Statement: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem Policy Interpretation and Implementation: Residents are treated with dignity and respect at all times .demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents, for example: promptly responding to a resident's request for toileting assistance. The following Plan of Removal submitted by the facility was accepted on Friday 2/9/2024 at 2:00 pm. Plan of Removal (POR) PLAN OF REMOVAL Name of facility: Fallbrook Rehabilitation and Care Center Date: 02/08/2024 F 677 - The facility fail to ensure that residents who are unable to carry out Activities of Daily Living (ADLs) receive the necessary services to maintain nutrition, grooming, and personal and oral hygiene. The facility failed to ensure that incontinent care was provided timely Immediate action: Resident #28 was assessed, and incontinent care provided immediately when identified on 02/07/2024. Nurse aide (CNA N) was provided one on one re-educated in providing peri care at least every 2 hours and as needed on 2/07/2024 at 1:30pm The Director of Nurses, Assistant Director of Nurses, Wound Nurse and Nurse Supervisor initiated a sweep on all residents to verify that incontinent care was done on all residents by 10 pm tonight, 02/08/2024. The primary physician(s) will be notified of any newly identified skin integrity issues related to the skin sweep and orders will be obtained as appropriate. The resident responsible party will be notified of any findings, and treatment plan(s). Two new skin areas were found during sweep. One was redden area to a resident's back and other was redden area to a resident's neck along trach collar area secures. Family and provider notified, and orders obtained An audit of the skin identification forms for current residents were completed by the Director of Nursing, Assistant Director of Nursing, Wound Nurse and Nurse Supervisor to ensure CNA skin sheets were completed by 10 pm 02/08/2024. Two new skin areas were found during sweep. One was redden area to a resident's back and other was redden area to a resident's neck along trach collar area secures. Family and provider notified, and orders obtained Facilities Plan to ensure compliance quickly. Education provided and to be completed by Director of Nurses, Assistant Director of Nurses, Wound Nurse, and Nurse Supervisor by 11:59pm 02/09/2024 for all nurses and certified nurse aids on ADLs, shower sheet completion, answering call lights, Peri Care, and Q 2-hour resident rounding. Education also includes what to do when skin issues are identified and what to do if pain occurs during any type of care. IDT will make rounds twice a day and charge nurses will make rounds every 2 hours. Nurse managers will validate randomly throughout day that charge nurses are making rounds to check that Residents' skin is dry and clean to prevent skin breakdown. Specific training on system which includes assessment and treatment of skin folds. CNAs/Nurses will not be allowed to work until they've received the training. All CNAs will have skill checks completed by Director of Nurses, Assistant Director of Nurses, and Nurse Supervisor on peri care to validate incontinent care protocol is followed appropriately by 02/09/2024. Nursing staff (licensed and certified) will be re-educated on the Skin Management System by Director of Nurses, ADON, Treatment Nurse and Nurse manager with the target completion date of 02/09/2024. Nursing staff members will not be allowed to work their oncoming shift until this education is completed. Nursing staff will be re-educated by Assistant Director of Nursing and Wound Nurse on the stop and watch tools and the skin identification form. Education will be completed prior to nursing staff commencing their next assigned shift. This education will be completed by 02/09/24. Any nursing employee not present will complete the in-service prior to starting their next shift. The nurse will verify that the skin identification sheets are completed by the CNAs when bathing and/or showering residents and that any identified issue is addressed. The physician and responsible party will be notified of any identified skin issues and the treatment plan(s). The Director of Nurses will provide education on this process to all nursing staff by 02/09/24. Nursing employee will not be allowed to start shift until complete the in-service. QAPI meeting was held 2/8/2024 by The facility IDT team, which included Administrator, DON, ADON, CNO, Housekeeping supervisor, Social worker, Human resources to review policy/procedure for ADL care. Monitoring: Record review on 2/10/2024 of POR binder including CNA skills competencies, the POR for F677, Head to toe assessments for the current residents, IDT rounds and in-services, policies and procedures for: Proper Procedure for Head-to-Toe Assessments, Skin Assessments, Skin Management System, Perineal Care, Activities of Daily Living Supporting, Call System-Resident, Peri-Care/Assisting Meals/Incontinent Care, given to all staff on 2/8/2024-2/9/2024 and the Stop and Watch -QAPI Interviews on training: assessments, skin sheets, change of skin, documentation, communication, physician orders. Observations on 2/9/2024 through 2/11/2024 at various times in the day revealed that Resident #28 was resting in his room, watching football, he would give a thumbs up when asked how he was feeling. Observations on 2/9/2024 through 2/11/2024 at various times of the day of staff making rounds, checking to see if any resident needed anything. Interviews: Interviews with staff were conducted between 2/9/2024 through 2/11/2024 on multiple shifts with the Administrator, DON, ADON, VP, DVP, MDS Coordinator,Wound Care Nurse, RN's: A, B,C LVN's:A,B,C,D,E,P,R CNA's:A,B,C,D,E,F,G,H Staff were able to verbalize understanding of plan of removal, facility policies, procedures and in-services received. Interview answers with CNA's: in-services included assessing skin, notifying nurse/nurse manager, to checking under the skin folds and placing barrier cream on them, documentation in PCC, (the electronic medical file system) the skin assessment and also notifying the nurse, answering the call-lights timely, witnessed staff not answering call-lights if, would report it. perineal and incontinence in-services, knocking on door, greeting the resident and telling them what you are going to do, setting up supplies, closing privacy curtains, assessments are from front to back all creases and in between, when you see anything different notify the charge nurse, fill out the stop and watch form for any skin difference, skin checks are performed every time a resident is changed, the treatment nurse comes out daily and to assess different residents. Interview answers varied from staff, LVN's said in-services received included skin treatment initiation, being informed by CNA of changes in skin, notification to family and the doctor, performing head to toe assessments including abdominal folds, to initiate care plan for said area, skin swipes, dry skin, skin barrier was to applied daily, prn and after every episode of incontinence, do a change of condition form. Interviews with RN's included assessment of the resident when they come from the hospital, charting/documentation, when anyone observes a skin issue, document and make a treatment plan. Call doctor, RP and get an order. During an interview on 2/10/2024 at 1:02 pm with the Administrator he said the team were aware of a broken system with skin prior to survey when HHSC surveyors came. The QAPI team did the PIP on January 30th, 2024 he added that the responsibility for skin integrity were interdisciplinary in the process, primarily he, the DON, treatment nurse, Social Worker and therapy, each person had their specific role. The team started addressing skin integrity immediately to addressing with skin assessments, they did not have time to follow through Braden timely, assessments basically before HHSC surveyors came in. During an interview on 2/10/2024 at 1:49 pm with the DON, she said she was already aware of break in system with the skin issues and that the team had begun performing skin audits, was training with wound care nurse discussed in QAPI, IDT, physician, PIP, Resident #28, skin assessment was due 2/7/24 and she (the wound care nurse) had not gotten a chance to get to Resident #28, was working the other hall. Resident #28's assessment was due on the 7th of February, If the assessment was due that day and hadn't been conducted that day, she hadn't identified on that day yet because it (the newly identified skin area issue) had not been identified on prior skin assessments it ( the skin issue)was not there in the abdominal fold. They did identify the skin area and put treatment put in place, they are also in process of changing the wound care nurse, they have in-serviced the staff and did a 100 percent skin audit on residents. She said that a care plan was added, and a comprehensive care plan should be in place for specific Resident #28's perineal area to include under the folds. She said that any nurse at the facility is responsible for care plans and said a negative outcome could be skin impairment, infection, and delayed treatment. On 2/10/2024 at 3:00 pm received and reviewed with VP, including skin sweep 100 percent, in-services/policies and procedures, all staff signatures, question/test/stop and watch. All staff in-serviced. 2 people identified with redness in skin sweep. Treat/care plan.

32422 Based on observation, interview and record review, the facility failed to ensure that Resident #1 received treatment and care in accordance with professional standards of practice for one resident (Resident #28) of 5 residents reviewed quality of care and skin . The facility failed to assess, report, and obtain new physician orders due to a change in resident #28's skin condition of the perineal (private area of a patient) groin and buttock to the physician. This failure affected one resident (Resident #28) out of 4 residents reviewed for skin issues and had the potential to place residents at risk skin break down, infection and discomfort. Findings included: Record review of the facility face sheet revealed that Resident #28 was a [AGE] year-old male, admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included acute respiratory failure with hypoxia (a condition where you don't have enough oxygen in the tissues in your body (hypoxia) or when you have too much carbon dioxide in your blood (hypercapnia) You might also hear people use the term acute hypoxemic respiratory failure (AHRF)), morbid obesity with aveolar hypoventilation (Obesity hypoventilation syndrome is a respiratory consequence of morbid obesity that is characterized by alveolar hypoventilation during sleep and wakefulness), type 2 diabetes (Type 2 diabetes is a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel) and lymphedema (build-up of fluid in soft body tissues when the lymph system is damaged or blocked). Record review of Resident #28's care plan dated initiated 10/16/2021 revealed a care plan for ADL's and limited physical mobility r/t weakness, confusion, limited mobility with interventions/task Resident #28 requires total assistance with toilet use and personal hygiene. A care plan for bowel and bladder incontinence dated initiated and revised on 1016/2021 r/t activity intolerance, confusion and impaired mobility with a goal target date of 3/29/2024 to refrain free of skin break down due to incontinence and brief use through the target date, interventions and task included use MD's order for Nystatin powder and to check frequently for incontinence. Wash rinse and dry perineum (cleaning the private areas of a patient), change clothing PRN and after incontinence episodes. Record review of Resident #28's quarterly MDS assessment dated [DATE]th, 2024, revealed he had a BIM score of 14, indicating he was cognitively intact. Resident #28 was also coded as being impaired on both sides, upper and lower extremities for functional limitation range in motion dependent on 2 or more helpers (staff) to complete the activities of bathing, showering, toileting hygiene, dressing the upper and lower body, putting on and removing footwear, he also required partial to moderate assistance to roll to the left sides and lye back down on the bed. Resident 3 28 was totally dependent on staff to transfer from bed to chair or wheelchair. Resident #28 was frequently incontinent of bladder and bowel. Resident #28 was coded to be a risk for pressure ulcers. Record review of physician orders for February 2024 included orders for Nystatin Powder 100000 UNIT/GM ,Apply to inner thighs, scrotum, abd topically everyday shift for Incontinence; Rash. May Apply Zinc skin barrier after each incontinent episode to help reduce skin impairments. Prior to wound treatment evaluate resident for Pain: everyday shift for Wound Care After wound treatment evaluate resident for pain: everyday shift for Wound treatment. Record review of Resident #28's weekly wound assessments for January 2024 through February 7, 2024, revealed no wound assessment for his perennial, scrotum and folds areas. Record review of Resident #28's Braden Scale assessment dated [DATE] revealed that his skin is constantly moist: Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time the patient is moved or turned, chairfast: ability to walk severely limited or non-existent. During an observation and on 02/07/24 at 1:30 pm, it was revealed that Resident #28's under abdominal fold, scrotum, left, and right groin were very red, macerated (soften or become softened by soaking in a liquid), and there were tiny opens on all areas. One of the areas on under the abdomen measured about 1.0x1.0 cm. Resident #28 said that it hurts whenever RN A or CNA N cleaned the groin areas, scrotum, and abdominal area. Observation at this time of RN A and CNA N which wiped Resident #28 and the wipes had thick white substance and it had a musty odor. During an interview on 02/07/24 at 1:24 pm, RN B said she did Resident #28's skin assessment sometimes and the wound care nurse does it at times. RN B said Resident #28 needed two to three staff assistance for incontinent care. RN B said Resident #28 did not have any redness or open area on his buttocks or peri area when she did his skin assessment two weeks ago. RN B said none of the aides had told her that the resident had any open area on his peri area. During an interview on 02/07/24 at 2:32 pm, LVN H said Resident #28's scrotum, groin areas were very moist and excoriated with some openings. LVN H said she had worked with Resident #28 last week on Friday and Saturday and she did wound care on his feet, and she did not check his groin area. LVN H said urine could cause Resident #28 to have redness and excoriation. LVN H said if the aides did not make rounds often Resident #28 could get redness and excoriation. LVN H said the charge nurses are responsible for monitoring the aides to make sure they are providing care for residents, LVN H said the DON and ADON monitor the nurses when they make rounds. During interview on 02/07/24 at 3:03 pm, CNA N said she worked with Resident #28 on 02/06/24 and the groin, under the abdominal folds and scrotum was the same as today but she did not tell her charge nurse yesterday. CNA N said she did not tell RN B, but she saw the redness with her today. CNA N said she did not mention this to anybody because the aide she took over from on 02/06/24 did not tell her about the areas on Resident #28 she assumed the nurses were aware of the skin condition. During an interview on 02/08/24 at 10:42 am, the Wound Care Nurse said she does Resident #28's weekly skin assessment, and she did not see any redness, macerated area, any opening on his groin or abdominal folds. She said she became aware of the area yesterday. During an interview on 02/08/24 at 10:54 am, the DON said she became aware of the red macerated area when she came to Resident #28's room. Then DON said she smelled the foul odor and ammonia in the resident room. The DON said the wound care nurse assessments for Resident #28 from January 2024 through February 2024 did not mention Resident #28 had any skin issues on his groin or under his abdomen. The DON said the facility has a new wound care company and the wound care doctor was not notified about the skin condition. During an interview on 02/08/24 at 10:57 am, with Resident #28's primary physician, he said he was notified about the change in skin condition yesterday twice. He said Resident #28 was an obese resident and all the folds could cause the areas to stay wet and the intervention of Barrier cream may not prevent the area from being moist and red or open. He said there was no other intervention in place to prevent the area from being moist or red. The physician said the facility also have a wound care doctor who should be taking care of wound and skin issues. Record review of the facility policy and procedure entitled Resident Examination and assessment dated revised February 2014, read in part .physical examination: skin: intactness, moisture, color, texture and presence of bruises, pressure sores, redness, edema, rashes. Activity level: able to perform ADLs; and degree of assistance required . Documentation The following information should be recorded in the resident's medical record: The date and time the procedure was performed, all assessment data obtained during the procedure, how the resident tolerated the procedure .Notify the physician of any abnormalities such as .wounds or rashes on the resident's skin; and report other information in accordance with facility policy and professional standards of practice. Record review of the facility policy and procedure entitled Skin Management System no date provided, read in part .head to toe assessments should be completed weekly .skin assessments include the review of all skin areas from the top of the head/scalp to the toes including examination of skin folds .and any crevices that may exist .the Certified Nurse Aide will notify the Treatment Nurse or Charge Nurse of any newly identified skin or pain issues .residents who are incontinent of bladder or bowel will be provided incontinent care every 2 hours as needed .residents who rely on nursing staff for positioning will be turned and repositioned every 2 hours as needed . The following Plan of Removal submitted by the facility was accepted on Friday 2/9/2024 at 2:00 pm. PLAN OF REMOVAL (POR) Name of facility: Fallbrook Rehabilitation and Care Center Date: 02/08/2024 F-684 - The facility failed to assess, report, and obtain new order due to a change in resident # 28's skin condition of the groin and buttock to the physician. The facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice. Immediate action: Resident #28 was promptly assessed once skin issue identified by Director of nurses, Physician and RP was notified; treatment orders were obtained, and resident's care plan updated to reflect change in condition. One on one education provided to CNA N regarding reporting skin issues by DON on 2/7/2024 The Director of Nurses, Assistant Director of Nurses, Wound Nurse and Nurse Supervisor initiated a head-to-toe skin sweep on all residents that will be completed by 10 pm tonight, 02/08/2024. The primary physician(s) will be notified of any newly identified skin integrity issues and orders will be obtained as appropriate. The resident responsible party will be notified of any findings, and treatment plan(s). An audit of all current resident records will be completed by the Director of Nursing, Assistant Director of Nursing, Wound Nurse, and Nurse Supervisor to ensure a weekly head to toe skin assessment order is in place by 11:59pm 02/09/2024. An audit will be completed by the Director of Nursing, Assistant Director of Nursing, Wound Nurse, and Nurse Supervisor to ensure that any residents with an identified skin issue on existing skin assessment has an appropriate treatment order in place by 11:59pm, 02/09/2024. Facilities Plan to ensure compliance quickly. Education initiated by Director of Nurses, Assistant Director of Nurses, Wound Nurse, and Nurse Supervisor at 9 pm 02/09/2024 for all nurses and certified nurse aids on ADLs, answering call lights, performing timely Peri Care, and Q 2-hour resident rounding. Education will also include what to do when skin issues are identified and what to do if pain occurs during any type of care. Nurses will be educated by the Director of Nurses on Provider and responsible party notifications when a change in condition or treatment plan occurs by 02/09/2024. Nursing staff (licensed and certified) will be re-educated on the Skin Management System starting on 02/09/024 by DON and target completion date of 02/09/2024. Nursing staff members will not be allowed to work their oncoming shift until this education is completed. On- going competency of the Skin Management System will be monitored by asking oral/verbal questions, rounding and auditing of documentation and orders in the electronic medical record. Nursing staff will be re-educated by Assisted Director of Nurses (ADON), DON, Nurse manager concerning the skin identification form. CNAs will be responsible for completing the skin identification form. CNA will complete skin identification form after every resident's shower on facility skin identification form. CNAs will turn form in to charge nurse before end of shift. The charge nurse will take appropriate action to address any skin issues identified on skin form. DON, ADON & Nurse manager will oversee sheet identification sheet completion by reviewing skin identifications form in morning clinical meeting. Education will be completed prior to nursing staff commencing their next assigned shift. This education will be completed by 02/09/24. Any nursing employee not present will complete the in-service prior to starting their next shift. New or readmitted residents will have a head-to-toe skin assessment completed by the on-duty Admitting Nurse upon admission. The physician and responsible party will be notified of any identified skin issues and the treatment plan(s). The Wound Nurse will follow up on all new or readmitted resident skin assessments on her next scheduled shift and alert the Wound Care Physician of her findings, obtaining any treatment order changes at this time. The Director of Nurses will provide education on this process by 02/09/24. Any nursing employee not present will complete the in-service prior to starting their next shift. QAPI meeting was held 2/8/2024 by the facility IDT team, which included Administrator, DON, ADON, CNO, Housekeeping supervisor, Social Worker, Human resources to review policy/procedure for ADL care. Monitoring: Record review on 2/10/2024 of POR binder including CNA skills competencies, the POR for F677, Head to toe assessments for the current residents, IDT rounds and in-services, policies and procedures for: Proper Procedure for Head-to-Toe Assessments, Skin Assessments, Skin Management System, Perineal Care, Activities of Daily Living Supporting, Call System-Resident, Peri-Care/Assisting Meals/Incontinent Care, given to all staff on 2/8/2024-2/9/2024 and the Stop and Watch -QAPI Observations on 2/9/2024 through 2/11/2024 at various times in the day revealed that Resident #28 was resting in his room, watching football, he would give a thumbs up when asked how he was feeling. Observations on 2/9/2024 through 2/11/2024 at various times of the day of staff making rounds, checking to see if any resident needed anything. Interviews: Interviews with staff were conducted between 2/9/2024 through 2/11/2024 on multiple shifts with the Administrator, DON, ADON, VP, DVP, MDS Coordinator,Wound Care Nurse, RN's: A, B,C LVN's:A,B,C,D,E,P,R CNA's:A,B,C,D,E,F,G,H Staff were able to verbalize understanding of plan of removal, facility policies, procedures and in-services received. Interview answers with CNA's: in-services included assessing skin, notifying nurse/nurse manager, to checking under the skin folds and placing barrier cream on them, documentation in PCC, (the electronic medical file system) the skin assessment and also notifying the nurse, answering the call-lights timely, witnessed staff not answering call-lights if, would report it. perineal and incontinence in-services, knocking on door, greeting the resident and telling them what you are going to do, setting up supplies, closing privacy curtains, assessments are from front to back all creases and in between, when you see anything different notify the charge nurse, fill out the stop and watch form for any skin difference, skin checks are performed every time a resident is changed, the treatment nurse comes out daily and to assess different residents. Interview answers varied from staff, LVN's said in-services received included skin treatment initiation, being informed by CNA of changes in skin, notification to family and the doctor, performing head to toe assessments including abdominal folds, to initiate care plan for said area, skin swipes, dry skin, skin barrier was to applied daily, prn and after every episode of incontinence, do a change of condition form. Interviews with RN's included assessment of the resident when they come from the hospital, charting/documentation, when anyone observes a skin issue, document and make a treatment plan. Call doctor, RP and get an order. On 2/10/2024 at 1:02 pm with the Administrator he said the team were aware of a broken system with skin prior to survey when HHSC surveyors came. The QAPI team did the PIP on January 30th, 2024 he added that the responsibility for skin integrity were interdisciplinary in the process, primarily he, the DON, treatment nurse, Social Worker and therapy, each person had their specific role. The team started addressing skin integrity immediately to addressing with skin assessments, they did not have time to follow through Braden timely, assessments basically before HHSC surveyors came in. During an interview on 2/10/2024 at 1:49 pm with the DON, she said she was already aware of break in system with the skin issues and that the team had begun performing skin audits, was training with wound care nurse discussed in QAPI, IDT, physician, PIP, Resident #28, skin assessment was due 2/7/24 and she (the wound care nurse) had not gotten a chance to get to Resident #28, was working the other hall. Resident #28's assessment was due on the 7th of February, If the assessment was due that day and hadn't been conducted that day, she hadn't identified on that day yet because it (the newly identified skin area issue) had not been identified on prior skin assessments it ( the skin issue)was not there in the abdominal fold. They did identify the skin area and put treatment put in place, they are also in process of changing the wound care nurse, they have in-serviced the staff and did a 100 percent skin audit on residents. She said that a care plan was added, and a comprehensive care plan should be in place for specific Resident #28's perineal area to include under the folds. She said that any nurse at the facility is responsible for care plans and said a negative outcome could be skin impairment, infection, and delayed. treatment. Interview and record review on 2/10/2024 at 3:00 pm received and reviewed with VP, including skin sweep 100 percent, in-services/policies and procedures, all staff signatures, question/test/stop and watch. All staff in-serviced. 2 people identified with redness in skin sweep. Treat/care plan.

Based on observation, interview and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 of 12 residents (Resident #1) reviewed for pharmaceutical services in that: - The facility failed to administer IV antibiotic as ordered by the physician when Resident #1's insurance did not cover the cost for resident to receive the ordered IV antibiotic therapy (Amphotericin B and Avycaz) to treat unresolved infections for 5 days. -The facility failed to review Resident #1's Physician orders and MAR to ensure that all medications were being administered according to physician's orders. An IJ was identified on 8/4/23. The IJ template was provided to the facility on [DATE] at 5:03 p.m. While the IJ was removed on 8/8/23, the facility remained out of compliance at a scope of isolated and a severity level of potential for harm that is not immediate due to the facilities need to evaluate the effectiveness of corrective systems These failure places the residents at risk of worsened infection. Findings: Record review of Resident #1's face sheet revealed a [AGE] year-old female admitted to the Nursing facility on 02/06/2023 with diagnoses that included the following: cardiac arrest (sudden, unexpected loss of heart function, breathing, and consciousness), respiratory failure (difficult to breathe on your own), with hypoxia (absence of oxygen in the body), type 2 diabetes mellitus, heart disease, heart failure, hypertension (high blood pressure), Gastroesophageal reflux disease (digestive disease), and gastrostomy (opening into the stomach wall, made surgically for the introduction of nutrition). Record review of Resident #1's MDS assessment dated [DATE] revealed that resident had BIMS score of 3 indicating that resident cognition was severely impaired. Further review revealed that resident was totally dependent upon staff for activities of daily living. Record review of Resident #1's Care plan (dated 07/26/2023) revealed that resident was being care planned for isolation precautions secondary to infection of C-Auris (fungus that can cause a serious health threat) and she is resistant to antifungal medications with interventions that included to administer medications as ordered. Record review of Resident #1's Nursing Progress Notes dated 07/12/2023 documented by LVN A revealed in part: .Change in condition blood pressure 110/64, pulse 110 irregular, respirations 22, temperature 98.7 .The physician was notified .orders received to get CXR, UA, CBC, and CMP .07/13/2023 EMS called for transport to the hospital for blood transfusion .Hgb 5.5 Record review of Resident #1's CBC with differential (test that measures the total number of white cells in the blood) dated 07/13/2023 revealed the following -WBC: 19.4 norm (4.0-10.0) -RBC: 2.32 norm (3.93-5.22) -Hgb: 5.5 norm (11.2-15.7) -Hct: 18.6 norm (34.1-44.9) Record review of Resident #1's STAT CMP dated 07/12/2023 revealed the following: -BUN: 75 norm (3-23) -Creatine: 1.30 norm (0.60-1.20) Record review of Resident #1's admitting diagnosis to the hospital on 07/13/2023 was septic shock (widespread infection in the body that is life threatening), candida auris (a species of fungus that grows as yeast in the body), candidemia (yeast in the body blood stream), bacteremia (bacteria in the blood), cavity pneumonia (lung infection), acute or chronic respiratory failure, anemia (low blood) requiring transfusions. Record review of Resident #1's hospital discharge instructions dated 07/25/2023 to continue IV Avycaz for two more weeks and reassess for further duration. Continue IV Amphotericin until 08/03/23 . Call physician for temperature greater than 100.5. Record review of Resident #1's Nursing Progress notes revealed that resident was admitted back to the NF on 07/26/23. Record review of Resident #1's Physician orders included the following: -Ceftazidime-Avibactam (Avycaz) IV 2.5 gm every 8 hours related to pneumonia for 14 days until finished date of order 07/26/2023 -Amphotericin B Lipid IV 450mg one time a day related to Candidiasis for 7 days until finish order date 07/26/2023 -Zoysn 3.375 gm IV every 8 hours for 10 days for pneumonia dated 07/31/2023. Record review of Resident #1's Physician orders revealed an order dated 07/27/2023 created by LVN A revealed in part: -ceftazidime-Avibactam intravenous solution reconstituted 2.5 gm every 8 hours intravenously every 8 hours related to pneumonia and Amphotericin B Lipid intravenous suspension 5mg/ml use 450mg intravenously one time a day related to candidiasis for 7 days until finish 450mg in 250ml were placed on hold. Further review revealed that the attending physician for Resident #1 signed the order on 08/02/2023. Record review of Resident #1's MAR for the month of July 2023 revealed that the medications Amphotericin B and Ceftazidime-Avibactam were never administered to Resident #1. Further review revealed that the IV antibiotic Zoysn 3.375mg was first administered on 07/31/2023. Interview with LVN A on 08/03/2023 at 12:53pm said she was the nurse that readmitted Resident #1 back to the NF on 07/26/2023. LVN A said she called the physician to do a medication reconciliation. LVN A said the physician said to continue with all orders. LVN A said when she returned on 07/27/2023 for the night shift no IV antibiotics were available and therefore she reached out to the pharmacy that informed her that resident insurance did not cover the cost of the medications Amphotericin B 450mg and Avycaz 12.5 mg IV. LVN A said on 07/31/2023 the physician was making rounds and she asked the physician what she wanted to do about Resident #1's antibiotic therapy. LVN A said the physician said she would have to reviewed Resident #1's medical records first. LVN A said the attending physician ordered the IV medication Zoysn 3.375g IV to be administered every 8 hours and said she needed to speak with the ADON. Record review of Resident #1's Nursing Progress Notes dated 07/31/2023 documented by the ADON revealed in part: .Spoke with responsible party of Resident #1 regarding resident current condition. We reviewed resident medication as well as the changes from the MD today to start Zoysn IV ABT therapy current condition. Interview on 08/03/2023 at 1:08pm via phone the pharmacy tech said the pharmacy filled an order for Zoysn 3.375mg on 07/31/2023. The pharmacy tech said the NF sent an order to be filled on she believed 07/26/2023 or 07/27/23 for Amphotericin B IV every 24 hours and Avycaz 2.5mg IV every 8 hours. The pharmacy tech said Resident #1's insurance was Medicaid which did not cover the cost for the medications (Amphotericin B and Avycaz IV). The pharmacy tech said the NF was notified about Resident #1's insurance not covering the IV antibiotics and to ask the physician what other IV antibiotic they would like to prescribe for Resident #1. Interview on 08/03/2023 at 1:53pm via phone the attending physician said she made rounds at the NF on 07/31/2023 and saw that the IV antibiotics Amphotericin B and Avycaz were pending. The attending physician said the facility did not tell her that the insurance would not pay the cost of Resident #1's IV antibiotics amphotericin B and Avycaz. The physician did not place the antibiotic ion hold prior to 8/2/23 and was unaware Resident #1 had not received the antibiotic. The attending physician said she reviewed Resident #1's hospital records and saw that the hospital at one time was administering the IV antibiotic Zosyn 3.375gm and therefore, placed Resident #1 on this IV antibiotic every eight hours for 2 weeks. The attending physician said because there was a delay of resident not receiving her IV antibiotics for 5 days, it placed resident at risk for her pneumonia becoming worse. The attending physician said she had assessed Resident #1 and did not see any clinical changes in her medical condition. The attending physician said she would continue to monitor Resident #1 and order diagnostic testing deemed necessary. Interview on 08/03/2023 at 2:13p.m. the ADON said she called Resident #1's RP regarding the changes made with resident IV antibiotic therapy. The ADON said when a resident is admitted to the NF, the admitting nurse must verify all orders with the physician and the orders were put in the system to be filled by the pharmacy. The ADON said it was the night nurse manger on duty that followed up to ensure all orders had been placed in the system. The ADON said new admissions were discussed in the morning meetings, but the nursing staff never informed her that the insurance did not cover the cost of Resident #1's IV medications Amphotericin B and Avycaz. The ADON said it was herself and the DON that reviewed the resident MARS for missed medications daily. The ADON said because Resident #1's IV medications Amphotericin B and Avycaz were placed on hold, it would not have generated in the system as missed medication. Observation on 08/03/2023 at 3:24pm Resident #1 was in bed with no roommate on isolation precautions. Resident was not interview able. Resident #1 was resting in bed quietly on an air mattress with head of bed elevated, no distress observed. Further observation was made of resident receiving gastrostomy feedings. Resident had a trach connected to a vent with no concerns identified. Resident had an isolation signage on the doorway entrance regarding infection control precautions. There was PPE readily available at the doorway entrance. Interview on 08/03/2023 at 4:00pm RN C said he was the Nurse Manager working the night shift on 07/26/2023 when Resident #1 was readmitted back to the NF. RN C said if a resident is a readmission or a new admission, the physician is notified, and a medication reconciliation is done with the physician. RN C said the orders are put in the system so that the pharmacy can fill prescribed medications and then deliver the medications as soon as possible to the NF. RN C said he was never aware that there was an issue with Resident #1's insurance not covering the cost of Resident ordered IV antibiotics amphoteric b and Avycaz. RN C said no medications should be placed on hold without a doctor's order. RN C said if there was an issue with resident insurance not paying for a specific medication, the logical thing to do is to call the physician to see what alternative medication could be prescribed for the resident. Further interview on 08/03/2023 at 5:34pm LVN A said that on 07/27/2023 she informed the attending physician NP of the pharmacy reporting that Resident #1's ordered IV antibiotic Amphoteric B and Avycaz was not covered by resident insurance. LVN A said it was the attending physician NP that gave the order to hold the ordered IV antibiotics. LVN A said the next few days, she was off work and when she returned, she asked the attending physician what she wanted to do about the IV antibiotics on hold. Interview on 08/04/2023 at 7:00pm Administrator said she called the attending physician of Resident #1 before resident was readmitted to the NF informing resident physician that resident insurance did not cover the ordered antibiotics. The Administrator said resident attending physician was aware and said that Resident #1 needed to have the ordered IV antibiotics and that she would order further cultures as resident had completed her IV antibiotics. The Administrator said she got approval from the Corporate Office to pay the cost of Resident #1's ordered IV antibiotics. Interview on 08/05/2023 at 1:40pm the attending physician NP said that on 07/26/2023 she had received a group text from LVN A around 5:44pm. The NP said LVN A informed that Resident #1 was returning from the hospital and that the IV antibiotics Amphotericin B and Avycaz were not going to be covered by the resident insurance. The NP said the attending physician was also on the group text as well. The NP said the physician said she would have to review Resident #1's medical records to see if the medications could be changed. The NP said she told the physician about the organisms that the IV antibiotics were treating, and that the physician said the antibiotics could not be changed. The NP said she did not know what happened after that. The NP said she was new to the facility and had been working at the NF for about a month. The NP said when she was coming to the facility, Resident #1 had not been added to her list as one of the residents to see initially. The NP said she was at the facility on 07/27/2023 and the nursing staff had informed her that Resident #1 had been readmitted to the NF. The NP said although Resident #1 was not on her list of residents to see on 07/27/203, she went in Resident #1's room to do a quick assessment and resident was stable (lung sounds were clear, trach intact, vital signs stable with no identified concerns). The NP said because of the group text that was had on 07/26/2023 and speaking with the physician later, she thought Resident #1's IV antibiotics Amphotericin B and Avycaz had been resolved. The NP did not place the antibiotic on hold and was unaware the medication was not administered to Resident #1. The NP said the next time she saw Resident #1 again was on 08/02/2023. The NP said the delay in administering Resident #1's IV antibiotics as ordered placed resident at higher risk for increased infections and becoming septic making it more difficult to treat the organisms. The NP said the antibiotics Amphotericin B and Avycaz were very strong antibiotics and that the hospital placed resident on the antibiotics for a reason. The NP said the antibiotic Zoysn was compatible to treat the bacteria pneumonia but not the antifungal. Further interview on 08/05/2023 at 2:40pm via phone the attending physician said the IV medication Zoysn could help Resident #1 and that she would be coming to the facility on [DATE] to reassess resident and do something different regarding Resident #1's care. The attending physician said she told the NF that they had to continue resident on the ordered antibiotics. The attending physician said she did not know that Resident #1 was not receiving the IV antibiotics Amphotericin B and Avycaz. The attending physician said she signed off on a lot of orders and did not recall signing orders to hold Resident #1's ordered IV antibiotics. Interview on 08/06/2023 at 12:17pm the CNO said she was now the NF interim DON since 08/05/2023. The CNO said it was the CEO that gave the Administrator the approval to have the ordered IV antibiotics Amphotericin B and Avycaz be administered to Resident #1. The CNO said she was not aware of Resident #1's insurance not covering the cost for the ordered IV antibiotics until an IJ was called on 08/04/2023. The CNO said the previous interim DON resigned on 07/28/2023 without notice. The CNO said the previous DON worked at the NF on 07/24/23-07/26/2023 and was off on 07/28/2023. The CNO said on 07/28/2023 she received an e-mail from the DON that she would not be returning to the facility. The CNO said the NF has hired a new DON that would be starting to work on 09/05/2023. The CNO said the reason she believed that the NF was in an IJ was because of the following: The facility failed to make sure that Resident #1 was receiving the ordered antibiotics after being readmitted back to the NF from the hospital. The CNO said when the IV antibiotic was placed on hold the NF should have followed up with the physician right away to see what was an alternative medication that could have been administered. The CNO said it was ultimately the NF's responsibility to ensure that the resident (s) needs were being met. Interview on 08/06/2023 at 12:35pm the CEO said the Administrator of the NF had contacted her prior to Resident #1 being readmitted back to the NF informing her that Resident #1 would be returning to the NF on expensive medications that the resident insurance would not be covering. The CEO said she gave the Administrator the approval to order the IV medications for Resident #1 and that the NF would be covering the cost. The CEO said that was normal protocol and did not know if the NF had a policy on covering the cost of treatment when a resident insurance did not pay. Attempted interview on 08/06/2023 via phone at 1:02pm and at 1:50pm on 08/08/2023 with the previous DON, no answer, left voicemail with a call back number. Interview on 08/08/2023 at 9:12am via phone the Infectious Disease Doctor said after reviewing Resident #1's medical records the IV medications Amphotericin B and Avycaz were not to be substituted and that resident should have received the medications as ordered. The Infectious Disease Doctor said although he could not predict what would happen to Resident #1 with the delay in not receiving the prescribed ordered IV antibiotics for 5 days, it did place resident at risk of her disease process worsening. Record review of the NF Medication Administration Policy (no date or revision date) revealed in part: .Medications are administered in accordance with prescriber orders . Record review of the NF Medication Therapy Policy revised April 2007 revealed in part: The Physician will identify situations where medications should be tapered, discontinued, or changed to another medication, for example .when a medication is not approved by the payer source, and when a medication is being prescribed to treat, or in anticipation of, an adverse consequence of another prescribed drug . An IJ was identified on 8/4/23. The IJ template was provided to the facility on [DATE] at 5:03 p.m. While the IJ was removed on 8/8/23, the facility remained out of compliance at a scope of isolated and a severity level of potential for harm that is not immediate due to the facilities need to evaluate the effectiveness of corrective systems PLAN OF REMOVAL F 755 Date: 08/04/2023 Immediate Action: Immediate Jeopardy called for F755- Pharmacy Svcs./ Procedures/ Pharmacist/ Records. The facility will conduct an audit of all patients with anti-infective orders to ensure that ordered meds are on site and being administered. The facility will audit all on hold orders and review those noted with the appropriate primary care physician to determine any actions needed that may include the DC, re-start and/or change of said medication., RN, BSN, will complete the audit before midnight tonight, 08/04/23. The Medical Director, primary care physician, and patient responsible parties will be notified regarding any patients with missed, new, changed and/or discontinued medications. , RN, BSN, will complete the notifications with the assistance of charge nurses on duty. This audit and notifications will be completed before midnight tonight, 08/04/23. Facility Plan to Ensure Compliance Quickly (and Ongoing): Nursing staff (licensed) will be re-educated on medication management including ordering, and a focus on how to deal with medications not covered by the patient's insurance and on-hold orders. In-servicing will also include the importance of notifying the physician to obtain any additional orders that may be needed for medications not administered for any given reason. When a patient's insurance denies any medication, nurse management and the administrator need to be notified so they can resolve the issue with the assistance of the physician. The facility will either pay for the medication in question or if appropriate a new medication will be ordered. Nurse education that on-hold orders need to be resolved within 72 hours of hold with the assistance of the physician and/or extender is in progress. The resolution is to discontinue the medication or re-start the medication. Nurse Managers were educated to check on-hold orders daily via EHR system to ensure that any medication or treatment on hold is resolved timely. Education will begin on 08/05/23 and include all charge nurses with the completion target date of Sunday, 08/06/23. Any nursing employee not available for education by 08/06/23 will complete the in-service at the start of their next shift. Nurses will need to demonstrate understanding of the process on what to do when meds are denied by the insurance company verbally and through testing/ questionnaire., RN, BSN and , LVN, ADON will conduct the education and tracking of completion. On- going competency of Medication Management will be monitored by asking oral/verbal questions, daily auditing of documentation, related to anti-infective, and on-hold orders. This in service will occur upon hire, and quarterly moving forward. This will be tracked by LNFA, and , LVN, ADON monthly to ensure education is completed and said standards are met. The surveyor confirmed the plan of removal had been implemented sufficiently to remove the IJ by the following: Interview with RN D said she worked full time at the NF 7am-7pm and had been in-serviced on the following: when the NF receives a new admission or readmit, call the physician to do a medication reconciliation and to place the orders in the system for pharmacy to fill the medications. If the resident medication is not covered under the resident insurance, call the Administrator right away as well as the doctor and responsible party documenting in the Nursing Progress Notes, and the 24-hour report sheet as well as providing a verbal report at shift change. RN D said she was also in-serviced that a medication could not be on hold for more than 72-hours and to follow up with the physician. RN D said she had to take a test on medication administration. Interview on 08/06/2023 at 1:55pm RN E said she had been in-serviced on medication administration and medication errors. RN E said she was in-serviced on not to hold medications without a physician order. RN E said if the resident insurance did not cover a prescribed medication, she had been in-serviced to notify the administrator, doctor, and the RP. RN E said she would ask the doctor if he or she wanted to order another medication that was compatible. RN E said she was in-serviced to document all actions taken in the Nursing Progress Notes, 24-hour report sheet, and give the oncoming nurse a verbal report of the actions taken. RN E said if a medication is placed on hold by the physician, she would have to follow-up with the doctor no later than 72-hours to see what alternative medication the physician wanted to order for the resident. RN E said she would also inform the Nurse Manager so that this could be shared in the NF morning meetings. RN E said she had to take a medication test. Interview on 08/06/2023 at 2:42 pm LVN F said he worked at the NF 7am7pm as a supervisor. LVN F said he had been in-serviced on medication administration that if a doctor had placed a medication on hold, the nurse needed to follow-up with the doctor no later than 72-hours to get the matter resolved. LVN F said if a resident insurance did not cover a particular medication, a nurse needed to let the administrator and doctor be made aware so that the doctor could possibly order a different medication to treat the resident and if not, the facility would have to pay the cost. LVN F said the nurse needed to document everything in the Nursing Progress Notes and on the 24-hour report sheet and give a verbal report to the oncoming nurse. LVN F said the resident RP needed to be made aware of what all had taken place. Interview on 08/07/2023 at 5:15a.m. LVN G via phone said she worked at the NF full time on the 7p-7a shift and had received in-service on medications that entailed orders and making sure that medication was available. LVN G said if a medication was not available or the resident insurance did not cover a medication, the administrator and the doctor needed to be notified right away to see if the doctor wanted to order a different medication. LVN G said if the doctor gave an order to hold a particular medication, the nurse needed to follow-up with the doctor on that medication that was on hold no more than 72-hours to see what changes the physician wanted to make and document all actions taken in the Nursing Progress Notes, 24-hour report sheet, and give a verbal report to the nurse coming on duty. LVN G said she had to take a medication administration test as well. LVN G said the resident RP was to be notified of what was going on. Interview on 08/07/2023 at 5:30am LVN H via phone said he worked the 7p-7a shift and had been in-serviced on medication administration to notify the doctor and administrator if a medication was not available or not covered by the resident insurance. LVN H said if a medication was placed on hold, the nurse needed to follow-up with the doctor no later than 72 hours and to document all actions taken. LVN H said this had to be documented in the Nursing Progress Notes, 24-hour report sheet, and a verbal report had to be given to the nurse coming on duty. Interview on 08/07/2023 at 5:38am LVN I via phone said she worked the night shift 7p-7a full time at the NF. LVN I said she had been in-serviced on the management of medication administration that if a doctor gave an order to hold a medication, the nurse needed to follow-up with the physician within 72 hours to see if he wanted to discontinue the medication or order another medication. LVN I said if a resident insurance did not cover a medication or the medication was not available, the administrator and the doctor needed to be informed right away in order to get the matter resolved. LVN I said the nurse needed to call the RP to let them know what all was going on. LVN I said she was also in-serviced on the importance of documenting in the Nursing Progress Notes, 24-hour report sheet all actions taken as well as providing a verbal report to the oncoming nurse. Interview on 08/07/2023 at 7:30am LVN J via phone said he worked at the NF full time 7p-7a and had been in-serviced on medication administration that if the doctor placed a medication on hold, the nurse needed to follow-up with the doctor no later than 72 hours to see what changes the doctor wanted to make. LVN J said if a resident medication was not available or there were some issues with the resident insurance not covering the medication, the nurse needed to notify the administrator and the doctor to see what changes needed to be made to resolve the issue and to document in the Nursing Notes what all had taken place. Interview on 08/07/2023 at 9:20am LVN K via phone said she worked 7p-7a shift and had received in-service on medication administration if a medication was not available to contact the administrator and doctor to try and get it resolved. LVN K said she had also been in-serviced on following up with the doctor within 72-hours on all medication orders that had been placed on hold and document in the Nursing Progress notes. LVN K said she had to provide the oncoming nurse a verbal report regarding the matter. Interview on 08/07/2023 at 11:38am via phone LVN L said she worked at the NF on the 7p-7a shift and had received in-service on medication administration that if a medication was not available or insurance was not covering the cost of medication, the administrator and the doctor needed to be called right away to see if there was alternative medication that could be prescribed for the resident. LVN L said medications on hold had to be followed-up with the doctor within 72 hours and documented in the Nursing Progress Notes as well as on the 24-hour report sheet. LVN L said she had to include this in her shift verbal report to the oncoming nurse and notify the RP. Interview on 08/07/2023 at 1:45pm LVN A said she had been in-serviced on when she receives an order to hold a medication, a follow-up needed to be done with the physician within 72 hours to see if the physician wanted to discontinue the medication or order another medication. LVN A said if a resident insurance did not cover a particular medication to notify the administrator and the physician to see if the doctor wanted to order an alternative medication that the resident insurance would cover. LVN A said she would contact the pharmacist before calling the doctor to see what an alternative medication was covered by the resident insurance so that when she called the physician, she could provide this information as well. LVN A said she was also in-serviced to document all happenings in the Nursing Progress Notes, 24-hour report sheet and report to oncoming nurse verbally in shift report. LVN A said the resident RP also had to be notified of what was going on regarding the resident's care. Interview on 08/07/2023 at 2:15p.m. LVN M said she worked the morning shift 7am-7pm. LVN M said she had been in-serviced on medication administration, new admissions, and readmissions. LVN M said if a resident medication was placed on hold by the doctor, the nurse would need to follow-up with the doctor within 72-hours to see about getting the medication discontinued or a new medication that was compatible. LVN M said the administrator as well as the doctor had to be informed if a medication was not covered by the resident insurance or not available. LVN M said the nurse had to document all happenings in the Nursing Progress notes, 24-hour sheet and give a verbal report to the oncoming nurse. Interview on 08/07/2023 at 2:20p.m. RN N said he worked at the NF full time 7am-7pm and had been in-serviced on medication administration. RN N said if a resident insurance did not cover a certain medication or the medication was not available, the nurse must call the administrator and the doctor to see if there was alternative in resolving the matter such as the doctor ordering a medication that was compatible and covered by the resident insurance. RN N said if there was an order to hold a medication, he would have to call the doctor within 72-hours to get an order to discontinue the medication or an order for alternative medication. RN N said the resident RP also had to be notified and to document everything in the Nursing Notes and the 24-hour report sheet and informing the oncoming nurse verbally in shift report. On 08/08/2023 at 4:00pm the Administrator was informed that the IJ was removed, however, the facility remained out of compliance at a scope of isolated and a severity level of potential for harm that is not immediate due to the facilities need to evaluate the effectiveness of corrective systems

Based on interview and record review, facility failed to ensure residents received treatment and care in accordance with professional standards of practice for three (CR#9, CR#10, and CR#11) of four residents reviewed for treatment/services of pressure ulcers. 1. Facility failed to fully assess CR #9's wound to establish baseline for treatment and obtain treatment orders. 2. Facility failed to ensure CR#9 received wound care for six (6) days during his admission to the facility on [DATE] through 04/17/2023. 3. Facility failed to provide daily wound care to CR#9, CR#10, and CR#11 having multiple days of missed wound care, resulting in CR#11's wound deterioration. An Immediate Jeopardy (IJ) was identified on 06/09/2023. The IJ template was provided to the facility on [DATE] at 12:58 p.m. While the IJ was removed on 06/13/2023, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope of pattern due to failure occurred to multiple residents over multiple days and the facility's need to evaluate the effectiveness of the corrective systems. These deficiencies could expose residents to wound deterioration, worsening of condition, infection, sepsis, and hospitalization . Findings include: Review of face sheet revealed CR#9 was a [AGE] year-old male who was admitted to the facility on [DATE]. CR #9's diagnoses included metabolic encephalopathy, anemia, heart failure, type 2 diabetes mellitus, respiratory failure, tracheostomy, osteomyelitis, and muscle wasting. Record review of the progress note dated 04/12/2023 during admission revealed CR #9 had wounds identified as unstageable wound to sacrum and DTI (deep tissue injury) to right stump. Record review of CR #9's Physician Orders revealed there was no wound care orders for CR #9 the day of his admission on 04/12/2023 through 04/17/2023. Record review of CR#9's Progress Note dated 4/12/2023 during admission revealed Sacrum wound stage 4 noted to scrum. Coccyx wound noted, DTI to right hell, right toes are amputated, multiple bruises to upper and lower extremities, old healed wounds and scars to lower and upper extremities. Review of facility Admission assessment dated [DATE] did not reveal detail about CR #9's wound. The Admission Assessment only revealed the following: - Turgor: good - Skin color: normal for ethnic group - Temperature: warm - Moisture: normal - Condition: normal - New wounds: 5 Record review of Wound Care Doctor's assessment dated [DATE] revealed the following detail regarding CR #9's wound: - wound size as length = 7cm, width = 7cm, and depth = 1.3cm. - Surface Area: 49.00 cm2 - Exudate Moderate Sero - sanguinous - Thick adherent black necrotic tissue (eschar) 20 % - Thick adherent devitalized necrotic tissue 30 % - Slough 20 % - Granulation tissue 10 % Record review of the careplan dated 04/18/2023 revealed CR#9 had impairment to skin integrity with stage 4 pressure wound (severely damaged skin) to the sacrum. Record review of MDS (Minimum Data Safety) dated 04/17/2023 section M0100 through section M0300 revealed CR#9 has pressure injury. Review of TAR (Treatment Administration Record) for the month of April 2023 revealed there was no wound care treatment performed for CR#9 during his admission on 04/12/2023 through 04/17/2023 Record review of progress note dated 04/18/2023 revealed resident (CR#9) was sent to hospital on 04/18/2023 for change in condition. Record review of hospital emergency room note dated 04/20/2023 revealed CR #9 was brought to ER (emergency room ) on 4/18/2023 due to Cardiac arrest. Review of face sheet showed CR #10 was a [AGE] year-old female who was initially admitted to the facility on [DATE]. CR #10's current re-admission to the facility was on 04/26/2023, her diagnoses included type 2 diabetes mellitus, diabetic neuropathy, Peripheral Vascular disease, cerebral infarction, and metabolic encephalopathy. Record review of CR #10's Progress Note dated 10/04/2022 during initial admission to the facility revealed CR #10 have a stage 3 wound on her sacrum and left leg Record review of a careplan dated 03/21/2023 revealed CR#10 has a pressure ulcer to the sacrum and left thigh with potential for further skin breakdown related to disease process and immobility. Record review of the MDS (Minimum Data Safety) dated 03/13/2023 section M0100 revealed CR#10 has pressure injury. Review of the TAR (Treatment Administration Record) for the months of January 2023 through April 2023 revealed there was no wound care provided for CR #10 on the following dates: - 4/13/23. - 3/18/23, 3/26/23. - 2/7/23, 2/8/23, 2/10/23, 2/12/23, 2/24/23, 2/25/23. - 1/9/23, 1/14/23, 1/30/23. Record review of physician order dated 04/08/2023 revealed CR #10's order for sacrum wound as Cleanse stage 4 pressure wound to the sacrum with ns/wc. pat dry. apply collagen powder and alginate calcium w/silvercover w/bdr foam dressing daily and prn and order for left lateral thigh as Cleanse stage 4 pressurewound to the left lateral thigh with ns/wc. pat dry apply collagen powder cover w/bdr foam dressing daily and prn. Record review of physician order revealed, on 1/7/23 - 1/13/23 patient received Ceftaroline Fosamil Intravenous Solution Reconstituted (Ceftaroline Fosamil) Use 200 mg intravenously every 12 hours for Wound Infection for 5 Weeks. On 4/26/23 CR #10 received APTOmycin Intravenous Solution Reconstituted 500 MG (Daptomycin) intravenously every 48 hours for Wound Infection for 5 Weeks. Record review of CR#10 hospital records revealed CR#10 was hospitalized on [DATE] to 1/13/23- patient received prophylaxis Cefdinir Oral Capsule 300 MG (Cefdinir). Review of CR#11 face sheet revealed CR#11 was admitted to the facility on [DATE]. CR#11's diagnoses included anxiety disorder, osteomyelitis, hypertension, respiratory failure, stage 3 pressure ulcer of the left heel, pressure ulcer of left ankle, pressure ulcer of sacral region, and tracheostomy status. Record review of a careplan revision dated 02/10/2023 revealed CR#11 has a stage 4 sacral pressure ulcer and was at risk for wound becoming infected, worsening with poor response to treatment, and other complications to include at risk for additional pressure ulcers and skin breakdown related to contractures and muscle atrophy (decrease in size and wasting of muscle tissue) with impaired mobility and dependent on staff for turning and repositioning and all areas of mobility. Record review of MDS (Minimum Data Safety) dated 03/24/2023 section M0100 through section M0300 revealed CR#11 has a pressure injury. Review of TAR for the months of March 2023 and April 2023 revealed there were no wound care on 03/23/2023, 03/26/2023, and 4/16/2023. Review of Wound Care Doctors note revealed the following: - 0n 3/21/23 the following wounds deteriorated: Wound site #2 Stage 4 pressure wound of left, lateral ankle Wound site #9 stage 4 pressure wound sacrum Wound site #23 stage 4 pressure wound of the left, posterior elbow - On 3/7/23 the Wound site #9 stage 4 pressure wound sacrum deteriorated - On 2/14/23 Wound site #2 Stage 4 pressure wound of left; lateral ankle deteriorated - On 1/10/23 Wound site #9 stage 4 pressure wound sacrum deteriorated On 5/25/23 at 1:59PM during interview with the DON, she stated she started working at the facility since May 1st, 2023. She stated she did not know what happened to all these residents' wound care. She also stated there was a wound care nurse who was let go at the time she started working with the facility. She stated they got a new wound care nurse who just started this Monday (05/22/2023). She stated her expectation was for nurses to assess resident during admission, document everything that they assessed, and notify doctor for all necessary orders including wound care order, and that this deficient practice place resident at risk for infection. When Surveyor asked how this could affect the resident, DON stated oh you know it, don't test my intelligence On 05/24/2023 at 3:55PM, in an interview with RN C on the floor regarding wound care and who would be responsible for wound/skin assessment during admission and when the wound care nurse not in the building. RN C stated he started working at the facility about two months ago. He said he was not so familiar with the three residents (CR#9, CR#10, and CR#11). He stated if they had any admission the nurses on the floor would do skin assessment on all admissions, and if any resident was admitted with a wound, they would also do wound the assessment and contact the doctor for the order. He stated these three resident's wounds was being cared for by the wound care nurse and he was not familiar with their wound. On 05/25/2023 at 4:02PM Surveyor requested the contact number of 4 nurses, including CR#9's admitting nurse, for interview. The DON stated she would provide the contacts information. On 05/24/2023 at 4:14PM on the 200 hall, with LVN F, who was one of the nurses on the floor. She stated the floor nurses would do the skin assessment during admission. She also said they had a wound care nurse who was doing all resident's wound care. She stated nurses only did wound care when the wound care nurse was not in the building. Surveyor observed LVN F was in a hurry, she entered into a resident's room. On 05/25/2023 at 4:32PM during interview with the New Wound Care Nurse, she stated she had been working at the facility for almost 2 years as a floor nurse, but she started as a wound care nurse on Monday 05/22 2023. The Wound Care Nurse stated when she was working as the floor nurse, the expectation for the Floor nurses was to do patient assessment during admission, document, and notify physician for orders. She stated when wound care nurse comes, she would also do wound /skin assessment on all new admission. She stated, now that she became the wound care nurse, she also did the same thing - she stated she would always do skin assessment on all new admission. She said if resident did not get wound care, it could affect them by causing infection and the wound could get progressively worse. On 05/25/2023 at 4:52PM, Surveyor followed-up with the DON regarding the nurses' contact numbers, at this time she stated the HR was pulling the contacts. However, contact numbers were not provided. On 06/08/2023 at between 11:03AM through 11:50AM, Surveyor called the Wound Care Doctor multiple times, but his line was breaking up and did not go through. Surveyor asked the DON if the Wound Care Doctor had another contact number, the DON stated she did not know of any other number, she said the contact given to the Surveyor was the same number the facility used to contact the Wound Care Doctor. The DON stated further that the wound care Doctor would be in the building soon and Surveyor would be able to speak with him. On 06/08/2023 at 11:52AM, attempt made to interview LVN G, who was the admitting nurse of CR #9. LVN G stated she just lost her younger brother yesterday (06/07/2023), she stated she only came to the facility today (06/08/2023) to take time off. She said she was unable to concentrate to answer any question. On 06/08/2023 at 11:54AM, the DON notified the Surveyor that the Wound care Doctor just came in. Surveyor stepped out to talk to the Wound Care Doctor, but he stated he did not have time at the moment, he said, I have not been here in two weeks and that he needed to do rounds right away. He stated he would call surveyor today (06/08/2023) or tomorrow (06/09/2023). Surveyor requested Doctor to kindly try to call today (06/08/2023) and gave a business card to the Wound Care Doctor. On 06/08/2023 at 12:08PM Surveyor called the Former Wound Care Nurse, but there was no response, Surveyor left message on the voicemail. On 06/08/2023 at 12:27PM Surveyor called LVN H, a nurse on 300 hall, CR#10's hall. LVN H answered the phone but after few seconds, the line cut off. Surveyor called back but there was no response. Surveyor left voice message. On 06/08/2023 at 12:42PM Surveyor called LVN J, the nurse who cared for CR#9. Surveyor spoke with a lady who said she was a family member of LVN J and told Surveyor that LVN J would be around in about an hour and a half. On 06/08/2023 at 12:50PM Surveyor called DNP the call went straight to voicemail. Surveyor left a voice message. On 06/08/2023 at 12:53PM Surveyor attempted to called Respiratory Therapist who cared for CR#9 on the day CR #9 was sent to hospital. There was no response. On 6/8/2023 at 3:11PM, in an interview with the DNP, she stated she was not a DNP for state of Texas, she was a DNP for the state of Illinois. She said she only had RN license for Texas and not DNP for Texas. She said she was consulting at the facility as a regional consultant at that time. She stated she was told to sit for the position of DON at the facility because there was no DON at that time. The DNP said she was not aware of any of the residents having their wound care not done. She stated her area of specialization was ventilation., She said she was a consult at the facility to train/ in-service the nurses on ventilation. She stated her expectation as the DON while she was at the facility was that the wound care should be done according to the order. On 06/08/2023 at 3:18PM. Surveyor made another attempt to call the Respiratory Therapist who cared for CR#9 on the day CR #9 was sent to hospital. There was no response. On 06/08/2023 at 6:21PM. Surveyor attempted call to the Wound Care Doctor again, but the call did not get through. On 06/08/2023 at 6:28 PM, another attempt was made to call LVN J back but there was no response. On 06/08/2023 at 6:29PM, another attempt was made to reach out to the Former Wound Care Nurse again, but there was no response. On 07/05/2023 at 10:10AM Surveyor called the Former Wound Care Nurse in an attempt to interview her. There was no response, message was left on voice mail. On 07/05/2023 at 10:53AM in an interview with RN B, she said she had been working at the facility about 2 years and she worked 12 hours day shift. She stated CR#9's names was vague, she said she was not familiar with the resident probably because she did not work on the CR #9's hall - she said she worked 200 hall most of the time. She stated she was not sure if she worked with CR #9 once - she said she might have cared for the CR #9 maybe once in the past, but she can't recall. She stated she did not recall CR #9's wounds as well. RN B said she knew CR #11, and she could remember him on 200 hall where she usually worked. She stated they had a wound care nurse, who usually did wound assessment and wound care on all residents. She said she did not perform wound care for CR #11, and floor nurses did not usually perform wound care - she stated they always had wound care or treatment nurse who was responsible for that. She stated if she ever did wound care on any resident, it was very rare. RN B said when the treatment nurse was not there in the building, nurses would be responsible to do treatment. She stated if any resident was a re-admit, they still looked at wound and made documentation. She said if they admitted a new patient, they looked at the wound as well. She said usually they got orders from the hospital or wherever the resident was coming from and wound bring them over into the resident's record. She stated if they admitted a resident without wound care orders, they would call the doctor., She said they could call the residents PCP and get orders in place before the wound care nurse would take over. She stated she believed the deficient practice happened maybe because some of the new nurses were not really following the process. She stated they facility had done series of training for the nurses, and for the past month, they have been very strict about that. RN B stated they have wound care/ treatment nurses everyday in the facility. She stated if any of the nurses on schedule, or the treatment nurse did not come in, the ADON would step in to do wounds, even on weekends as well. She said Nurse 1, a PRN nurse also would come some weekends to do wounds too. She stated she never saw any wound dressing outdated. However, she said in the past, she heard some people talked about wound being outdated - she did not recall who she heard from, or which specific resident. She said they had a former wound care nurse who no longer worked at the facility. She said the former wound care nurse had an assistant/treatment Aide who used to work with the former wound care nurse, but both of them were no longer working at the facility anymore. RN B said the only time when nurses would have to look at wounds was during admission. She said the nurses did weekly skin assessment on all residents, and the treatment nurse would do weekly skin assessment on all residents with wound of stage II and above. She also stated each hall has each day of the week assigned when the residents would get skin assessments. On 07/05/2023 at 11:07AM, during an interview with LVN H, she stated she always worked day shift on the 300 hall. She said she recalled CR #10 had wounds. LVN H stated one time in the past, they said the resident had sepsis LVN H was not sure what was the cause. Nurse also said CR #10 got an antibiotic sometime in the past when she came back from the hospital, but she could not recall details. LVN H stated she did CR #10's wound one time when there was no wound care nurse in the building. She said CR #10's wound was not bad when she looked at it. LVN H stated if treatment nurse was not in the building and they admitted any resident with wound, the nurse on duty would be responsible to contact doctor for wound care order, and then treatment nurse would take over the wound care from there. She stated they would call the resident's doctor for orders. On 07/05/2023 at 11:13AM, Surveyor called LVN J, there was no response, Surveyor left Voice Message and send text message. On 07/05/2023 at 11:30AM, Surveyor called LVN G, the admitting nurse of CR #9 Phone did not ring. Surveyor called again, someone picked up but did not speak. Surveyor sent text message. On 07/05/2023 at 12:02PM, in an interview with the Wound Care Doctor. He stated he came to the building today (7/5/2023) for rounding because of the July 4th holiday, He stated he normally comes to the building on Tuesdays. He said he remembered the residents, CR#10 and CR#11. He stated he always did comprehensive notes with orders given for every patient. He also stated daily dressing for wounds should be done daily according to the order. He stated wounds are not expected to remain the same, he said wounds changes - drainage changes week to week, same thing with color and size. The Wound Care Doctor said he did not see any concern regarding residents wound in the building. He stated facility had low hospital admission rate for wounds, given the complexity of wounds they have. He stated resident CR#11's wound might have deteriorated at some point, but he would not expect the wound to keep deteriorating week after week for maybe 4 to 5 weeks, he said that would be a concern for him. He stated CR #11 had many wounds and he could recall each time CR #11 went to hospital he would come back with either more wounds or existing wounds deteriorating. The Wound Care Doctor stated CR #11 was frail, had multiple wounds and many co-morbidities, he said his wound care would take them about 30 - 40 minutes to do. The Wound Care Doctor stated he remembered CR#10. He said CR #10's wound was not bad. He said the resident was a dialysis patient and she would go to the hospital mostly for non-wound related issues. He said when these residents go to hospital, there were usually high probability that they would come back with deteriorating wounds. The Wound Care Doctor stated he did not recall CR #9. Surveyor reminded the Wound Care Doctor he had one visit with CR #9 on 04/18/2023 which was initial wound evaluation, and he gave orders for daily wound care for CR#9. Surveyor also inquired if the Wound Care Doctor, in his expertise, believed the resident could have benefited from daily wound care from the time/day of resident's admission, and what could have happened to these residents if their wounds was not cared for, and what his expectation was regarding wound care. The Wound Care Doctor stated he would not answer what could happen if residents missed some wound care days. He stated further that he did not want to go hypotheticals on what could have happened. He stated he would rather focus on what actually happened and the intervention they were giving to the residents. He stated in the case of CR #11 that, deterioration was probably because of resident's co-morbidities, he said but generally, wound deterioration is not expected to be seen week after week. He said wounds could deteriorate this week, remain the same next week and improve the week after. The Wound Care Doctor stated further that the new wound care nurse was a great nurse, he said he could see the passion in the nurse for her job. He said he had been working pretty well with the new wound care nurse. He stated however, that the former wound care nurse was not on the same pedestal with the new wound care nurse. He said he had some issues with the former wound care nurse - He did not say further what the issues were. On 07/05/2023 at 12:18PM Surveyor called Aide 1 who used to work with the former wound care nurse. There was no response, Surveyor left voice message and text. Surveyor called Nurse 1 - the PRN nurse who sometimes did wound care on weekends. There was no response. Surveyor left voice and text messages. On 07/05/2023 at 1:12PM in an interview with the New Wound Care Nurse. She stated she was initially employed as a floor nurse and, she usually worked on the 200 hall. She stated she did not know CR#9, she knew CR#10 but she did not usually work on CR#10's hall. She stated she knew CR#11, she stated when she was the floor nurse, she mostly worked opposite end of CR#11's room. She stated she did not care for CR#11's wounds. The New Wound Care Nurse said she sometimes would fill in for the treatment nurse if the treatment nurse was not in the building. She stated she became the treatment nurse May 22nd, 2023. She stated when she assumed the position, it was hard to say if any wound deteriorated or not because she did not know all of the residents wound condition before that time. She stated she could remember that wound documentation was all over the place. She stated documentation was not being done. She stated now that she became the treatment nurse, corporate looked behind her to make sure documentations were being done. The New Wound Care Nurse stated if she was not in the building, the floor nurse who admitted the resident would be responsible to get orders for wound and perform wound care whenever she was not in the building. She said most of the residents came in with wounds and were sick. She said if wound care was supposed to be done daily and not done, the wounds could deteriorate, get infected, and resident could even get sepsis. On 07/05/2023 at1:32PM in an interview with the ADON. She stated she would sometimes do wound care because she was a Certified wound care nurse. She stated she had done wound care in the past when the former wound care nurse was not in the building, and at that time the wounds she cared for looked good, and she had no concerns - The ADON did not recall the specific resident's wound she cared for at that time. She said they had a weekend wound care nurse (Nurse 2) who usually did wound care for residents in the facility. She stated the Nurse 2 did not work at the facility anymore. The ADON stated further that at the time the residents (CR#9, CR #10, CR #11) were in the building, she was not really looking into wounds at that time, because she had a lot of administrative duties to do. The ADON said CR #9 was in the building briefly and was admitted with wounds as she could see it in the record. She said the admitting nurses were responsible to make sure they get orders for new admission's wound. The ADON said she did not know the full detail/status of CR #9's wound. The ADON said she could vaguely recall CR#10. She said she did not know about resident's wound infection, she stated but she would look in the record. The ADON stated if the treatment nurse not in the building, and nobody else was designated to do wound care, the nurse on the floor would be responsible to do wound care. The Surveyor asked if the ADON thought there would be enough time for nurses to do all wounds on their floor coupled with the responsibility of giving meds and other nursing duties. The ADON stated yes she said because sometimes they only have about 6 to 7 residents on a hall and that would not be too much for the nurses to handle. The ADON stated if residents' daily wound care were not done daily as stated in physician order, the wound could deteriorate and get worse and cause harm to the patient. On 07/05/2023 at 2:07PM Surveyor called Nurse 2, the former weekend wound care nurse. There was no response, voice mail not set up. Surveyor sent text message. On 07/05/2023 at 3:01PM, the ADON said she went through recent notes and did not see anything about CR#10's wound infection, she said she had to dig deeper to find out about that. She stated CR #10 went out to hospital, during the last hospitalization , for other reason not wound related. The ADON said regarding the missed wound care days shown on the TAR, she stated she understood the Number one rule of nursing is, if it is not documented, it is not done. Record review of facility policy titled 'Skin System' no date, revealed in part, .skin assessment will be completed on day of admission and documented by the admitting nurse or treatment nurse upon admission (including re-admission) the admitting nurse will notify the physician and resident representative of any identified areas, implement treatment/ interventions and document An Immediate Jeopardy (IJ) was identified on 06/09/2023. The IJ template was provided to the facility on [DATE] at 12:58 p.m. While the IJ was removed on 06/13/2023, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope of pattern due to failure occurred to multiple residents over multiple days and the facility's need to evaluate the effectiveness of the corrective systems. The plan of removal was accepted on 06/10/2023. The plan of removal reflected the following: Immediate Jeopardy PLAN OF REMOVAL Immediate Action: Immediate Jeopardy called for Treatment/ Services to Prevent/ Heal Pressure Ulcers. The facility will conduct a head-to-toe skin assessment on each resident in the facility to ensure all residents with Non-Pressure and/or Pressure Ulcers are identified. The nurses to complete this task include the ADON, and the Treatment Nurse. This audit will be completed by 06/09/23 at midnight. Treatment orders will be audited to ensure that all existing wounds have a wound order in place. This audit will be completed by 06/09/23 at midnight. Nurses, Regional Nurse and Chief Nursing Officer will conduct this audit. The Medical Director, primary care physician, and resident responsible parties will be notified regarding any residents with new non pressure and/or pressure areas identified. Treatment Orders will be obtained and initiated for any newly identified areas. Nurses to complete this task will include the ADON, and the Treatment Nurse. This audit and notifications will be completed by 06/10/23 at 12 noon. The facility will provide the status of previously identified wounds to the PCP and Medical Director, noting any deterioration or healing progress. Nurses to complete this task will include the ADON, and the Treatment nurse. This audit will be completed by 06/10/23 at 12 noon. Facility Plan to Ensure Compliance Quickly (and Ongoing): Nursing staff (licensed and certified) will be re-educated on the Skin Management System starting on 06/10/23 by the Regional Nurse and the Chief Nursing Officer with the target completion date of 06/11/23. Nursing staff members will not be allowed to work their oncoming shift until this education is completed. On- going competency of the Skin Management System will be monitored by asking oral/verbal questions, rounding and auditing of documentation and orders in the electronic medical record. This in servicing will occur upon hire, and quarterly moving forward. This will be tracked by the Administrator and the DON monthly to ensure said standards are met. Nursing staff will be re-educated on the stop and watch tool and the skin identification form. Education will be completed prior to nursing staff commencing their next assigned shift. Nurses to complete this task will include the ADON, and the Treatment Nurse. This education will be completed by 06/11/23. Any nursing employee not present will complete the in-service prior to starting their next shift. The facility will conduct an audit to ensure that all residents have current Braden scores in place to reflect risk for Pressure Ulcer development and to ensure interventions are in place. Nurses completing this task include the Regional Nurse and the Chief Nursing Officer. This audit will be completed by 06/09/23 at midnight. New or readmitted residents with wounds will have a head-to-toe skin assessment completed by the Treatment Nurse. If the Treatment nurse is off, the Admitting Charge Nurse will complete the Head to Toe for Skin. The Nurse Managers, ADON, and Infection Preventionist, will do a follow up skin review no later than 24 hours post admission to confirm initial findings and to ensure the treatment order is in place, and that the physician and responsible party are aware of any identified wounds as well as the plan of care. Education on this process will be provided by the DON, and will be completed by Sunday, 06/11/23 at midnight. Any nursing employee not present will complete the in-service prior to starting their next shift. Surveyor confirmed the POR for the IJ by monitoring from 06/10/2023 through 06/13/2023 as follows: Record review of the in-services dated 06/08/23 to 6/12/23 revealed no concerns and nursing staff were trained on the following: Admission/Readmission skin assessments, Braden Scales, Skin Management Program, POC Kardex Compliance, Off-loading Devices, Nutritional Guidelines for Pressure Ulcers, Showers, Weekly Skin Assessments, Notification of Medical Director/Responsible Party/Registered Dietician Change in Condition, Contracture Management, Care Plans, Unavoidable Wounds, VOHRA Wound Care, Skills Check Observation, and Wound Reports. Record review of the facility POR Binder dated 06/09/23 revealed no concerns with: Weekly Skin Assessment Schedule Daily Audit Skin System tool Skin Report - Non-Pressure Ulcer w/ Physician Orders Skin Report - Pressure Injury w/ Physician Orders Braden Scaled for Predicting Pressure Ulcer Sore Risk - all residents Skin/Wound Progress Notes Skin Check Forms Skin Monitoring: Comprehensive CNA Shower Review On 06/10/2023 at 3:44pm RN B who stated she had been working at the facility for 2 years and stated they received in-service training today (06/10/2023) on skin assessment, admission assessment/orders. She stated they were trained regarding completing head to toe assessment and documentation for residents during admission, and to note any skin issues or wound. She stated they were taught to also make sure they notify the wound care doctor and receive wound care orders for any resident who have wound. She also said they were also taught to complete weekly skin assessment on all residents. On 06/10/2023 at 4:00pm LVN C said she started working at the facility since March 2022, said the DON did the training for her and other staffs today 06/10/2023 around 1:00pm. She stated they were

Based on observation, interview and record review the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the residents clinical condition demonstrated that it was not possible, or the resident's preferences indicated otherwise for one of six residents (Resident #36) reviewed for weight loss and nutrition. The facility failed to identify early, assess and modify interventions consistent with Resident #36's significant weight loss on 12/06/2022. The facility failed to notify the physician as appropriate in evaluating and managing Resident #36's significant weight loss on 12/06/2022. These failures could place the residents at risk of health complication related to nutritional and hydration. Findings included: Record review of Resident #36's Admission Record revealed a [AGE] year-old female admitted on [DATE] and originally admitted on [DATE]. Her diagnoses included: difficulty swallowing, diabetes, unstageable pressure ulcer to the sacrum, pneumonia, urinary tract infection, hypertension, muscle wasting, acute kidney failure, acute liver failure, encephalopathy (brain disorder), fluid in the lungs, irregular heartbeat, shingles, and urine retention. Further review of the Admission Record revealed Anasarca (generalized edema) was not listed as one of the diagnoses. Record review of Resident #36's Admission MDS dated [DATE] revealed the resident had adequate hearing, had no speech, rarely/never made herself understood, rarely/never understood others and had impaired vision. The resident was totally dependent on one to two staff assistance for all ADLs. The resident had an indwelling urinary catheter and was always incontinent of bowel. Section K of the MDS revealed a weight of 132 lbs., and a height of 69 inches. The resident had a feeding tube both while not a resident and while a resident at the facility. Further review of the MDS revealed Anasarca was not listed in Section 1, Active Diagnoses. Record review of Resident #36's electronic care plan, date initiated 10/15/2022 and revised on 12/13/2022, revealed the resident required tube feeding due to Dysphagia (difficulty swallowing). The goals were for the resident to maintain adequate nutritional and hydration status AEB weight stable, no s/sx of malnutrition or dehydration. Interventions were for the RD to evaluate quarterly and PRN, Monitor caloric intake, estimate needs, and make recommendations for changes to tube feeding as needed, date initiated on 10/15/2022. Further review of the care plan revealed there was no plan for potential weight loss r/t diuretic use or Anasarca. Record review of Resident #36's active physician orders as of 12/16/2022 revealed the following orders: *continuous enteral feeding formula Isosource 1.5 at a rate of 50cc/hour x 22 hours and every shift water to be set at 30cc/hour to run concurrently with enteral feeding. *Furosemide 20mg tablet to be given enterally two times a day to be given as a diuretic, order date 10/29/2022; *Multiple Vitamins-Minerals 5 ml in the morning for supplement, order date 11/02/2022, *Vitamin C 5ml in the morning for supplement, order date 11/02/2022 and *Zinc 220mg once a day for wound healing, order date 11/02/2022. Record review of Resident #36's October 2022 and November 2022 MAR revealed the following: *10/14/2022 through 10/25/2022, the resident was receiving enteral feeding of Nepro 1.8 at a rate of 50ml/hour. *10/30/2022 through 11/06/2022 the resident was receiving Peptamen 1.5 at 30ml/hour and water at 50ml/hour. Record review of Resident #36's October 2022 MAR revealed an order in October for weekly weights x 4 weeks from admission every Monday then monthly weights. There were no documented weights except on 10/31/2022. Record review of Resident #36's November 2022 MAR there were no documented weights except on 11/28/2022. Record review of Resident #36's December 2022 MAR did not have an order for weights. Record review of Resident #36's November 2022 and December 2022 MAR revealed on 11/07/2022 through 12/15/2022, the resident was receiving enteral feeding of Isosource 1.5 at a rate of 30ml/hour and 50ml/hour of water. Further review of the MAR revealed a new order for Isosource 1.5 at 50ml/hour was started on 12/15/2022. Record review of Resident #36's hospital records dated 10/10/2022 revealed on 10/14/2022 her weight was 123.2 lbs., and height was 62.5 inches. On 10/26/2022 her weight was 120 lbs., and her height was 62 inches. Further review of the resident's hospital records revealed a diagnosis to include Anasarca. Record review of Resident #36's weight log from October 2022 to December 2022 revealed the following: *12/15/2022 at 9:02 AM, 97 lbs. (Mechanical Lift), recorded by Unit Manager A,-7.5% change (comparison Weight 10/31/2022, 119.0 lbs., -18.5%, -22lbs) *12/06/2022 at 4:17PM (no device was listed), 97.8 lbs., recorded by Corporate Nurse, -7.5% change (Comparison weight 10/31/2022, 119.0 lbs., -17.8%, -21.2 lbs.) *11/28/2022 at 9:35 AM, 119 lbs. (Mechanical Lift) *11/01/2022 at 11:20 AM, 119 lbs. (Mechanical Lift) *10/31/2022 at 1:39 PM, 119 lbs. (Mechanical Lift) *10/31/2022 at 1:38 PM, 119 lbs. (Mechanical Lift) Further review revealed there was no recorded admission weight on 10/14/2022 or a weekly weight prior to hospital discharge on 10/25/2022. There was no recorded readmission weight on 10/29/2022. Record review of Resident #36's Dietician Comprehensive assessment dated [DATE] 12:55PM written by the RD, read in part: . Physical Information .Ideal Body Weight 130-160#, percent of ideal body weight 83% . Plan/Recommendations/Additional Comments - [AGE] year-old female admitted with dx of dysphagia. Wt. 132.4# Ht. 69 in. BMI= 19.5 diet - NPO receiving enteral feeding - Nepro 1.8 @ 50 ml.hr x 22 hours, off 5-7pm provides 1100 ml., 1980 kcal's, 89.1 grams protein, 799.7 ml free water, water flushes 50 ml flush every 4 hours + 30 ml before and after each medication., tolerating TF well current TF meeting calorie needs. Receiving Furosemide-there is an expected weight change. PES = increased calorie and protein needs r/t healing process AEB unstageable pressure ulcer to sacrum Observation on 12/13/2022 at 8:04 AM, resident #36 was in bed laying on her left side with a wedge under her back. The HOB was raised. Tube feeding of Isosource 1.5 was infusing continuously at 30ml/hour and water at 50ml/hour. The resident had a tracheostomy connected to the ventilator. The resident's eyes were closed, and she did not respond to verbal greeting. The resident's lips were dry, her face thin with sagging facial skin. Her wrists and forearms were thin. Here limbs were severely contracted. In an interview on 12/15/2022 at 11:29 AM, RN G stated she had been working at the facility for a year and started working with Resident #36 when she was in the 100 hall. RN G stated that she believed the Restorative Aides perform the weekly weights for the resident. Typically, the restorative aide weighs and then tells the nurse what the weight was. The nurse would be responsible for checking the weight and if needed, would consult the RD. The dietician would come twice a week and if there was a weight change, the dietician would switch the feedings and nurses would make adjustments on the order. RN G stated she did not notice any physical changes with Resident #36. She recalled Resident #36 was sent to the hospital for critical lab results. The restorative aide would enter the weights into the system and everyone including the RD would be notified of changes. The nurses are responsible for checking trends in weights. Both nurses and restorative aides would see the weight trends. A weight gain or weight loss of 5 lbs. in one week would grab her attention and she would notify the RD, MD and family member. RN G stated she was unaware of any weight loss or known conditions causing fluid retention for Resident #36. RN G stated she made skilled nurse assessment notes on her residents at least every shift. She said someone was always assessing Resident #36 physically especially when skin assessments were done weekly and when working with the Gtube. In an interview on 12/15/22 at 12:42PM, Unit Manager A stated she did not work closely with Resident #36 or any resident unless there was a clinical issue and there was no issue brought to her attention regarding this resident. She stated she did not weigh residents, but the RNA gave her a weight sheet that she referred to update resident weights in the EHR. She stated she was aware of who was in charge of the weight program but just knew the DON typically addresses weights and the RD reviewed patients' weights. If there was a significant weight loss or change in condition, the DON and RD would be notified immediately, as well as the physician and responsible party. She stated she did not notice any weight loss in Resident #36 because the last weight she entered was 97 lbs. on 12/14/2022, whereas the previous weight entered on 12/06/2022 was 97.8lbs which was not significant weight drop between the two dates. She stated she did look further back at any additional weights prior to 12/06/2022 for resident #36 as to review her weight history. When asked if she notified any parties about the Resident's weight, she stated she talked to the NP and notified her of resident #36's weight being 97lbs as a matter of fact, but not that there was any recent weight loss. She defined a significant weight as 5% or more, the time frame of the weight loss was dependent on the patient and the implications of weight loss that goes unaddressed was dependent on patient and their diagnoses. In an interview on 12/15/2022 at 2:52 PM, RD stated she was instructed to come to the facility because the State had questions. She stated she just saw Resident #36's weight loss today, was not notified by nursing staff about her weight loss but picked up on it on her own and spoke with the DON and Administrator. She stated the DON provided information on weight loss on a monthly basis and residents would verbally report weight concerns to her. If there was no significant change, she would at least do a monthly assessment but every now and then she would look at the residents if they appear on the list. With readmissions, she would automatically see the residents for a reassessment. The RD stated that within a week of Resident #36's admission she would have been seen. She would either check the EHR system to see which of her residents were readmitted or she would ask the admissions staff. She stated she did not know how Resident #36 was not reassessed and that she just missed it. She stated no one alerted her after the weight loss indicated on 12/06/22. The RD stated Resident #36 was on Nepro 1.8 at 50m/hour prior to hospitalization . She had expected weight loss because the resident was on Lasix IV while in the hospital and was presently on Lasix 20mg BID. D stated with Lasix the weight would still fluctuate, even if on oral Lasix. RD stated the resident returned on 10/29/2022. Normally the restorative aide would give her a list of residents' weights. If a resident had a Gtube, usually they were weighed weekly. RD stated if weights seemed unusual, she would ask for a reweigh or would go by the most recent recorded weight. RD stated that based on Resident #36's new weight and corrected height, the minimum calories for her would be 1500 for weight gain and BMI of 18 or above would be the goal. When asked about the risks for Resident #36 if changes to her diet were not made, the RD stated the resident would continue to lose weight. RD stated she would have reassessed and increased the enteral feeding. RD stated usually the facility would notify her of any significant weight loss and usually the facility would then do weekly weights. RD stated she was at the facility twice a week and did not recall if she was at the facility between 11/28/2022 and 12/06/2022. RD stated she did not remember if it was the DON or if it was another nurse who made her aware of the weight loss. In an interview on 12/15/2022 at 3:08 PM, RD was asked about the Comprehensive Assessment she wrote on 10/20/2022 and where she got the weight of 132.4 lbs., she stated she got the weight from the Restorative Aide. She did not remember which Restorative Aide. On 12/16/2022 at 7:30 AM, a request was made to the Administrator for the Restorative Aide Weight Logbook and was requested again from the DON on 12/16/2022 at 12:15 PM. No Restorative Aide Weight Logbook was submitted by the time of exit. In an interview on 12/16/2022 at 7:38 AM, RA C stated she was not done with completing training by PT and once done she would be the lead Restorative Aide. RA C started in the Restorative aide role on 12/08/2022, prior to that she was in a CNA role. RA C stated she was trained by the previous Restorative Aide lead who was no longer employed at the facility. RA C stated if weights were off by 3 lbs., she would reweigh and compare to previous weights. RA C stated she had never weighed Resident #36. RA C stated she received training using the Hoyer lift (mechanical lift) when she started as a CNA and that all CNAs should know how to use the Hoyer lift. RA C stated she would give the weight results to the DON and the DON had the Restorative Aide Weight Logbook. RA C stated everyone was weighed on the first of the month including Gtube residents and residents losing weight. RA C stated that her understanding was that residents were to be weighed weekly. RA C stated that Gtube residents should always come up weekly. RA C stated the nurse and RD would review the residents first and then give the Restorative aide a list. RA C stated as soon as a resident was admitted , the resident was weighed even if the admission was late at night. The weighing should be as close to the admitted as possible. In an interview on 12/16/22 at 8:25 AM, the Administrator stated the RD was given an admission report from the nursing department for residents on enteral feeds. She was not aware of the weight change not being reported after Resident #36'sweight of 97.8 lbs. was documented on 12/06/22 by the Corporate Nurse. She stated that the weight change should have been reported immediately to the RD and the physician. In an interview on 12/16/2022 at 8:35 AM the MDS Nurse stated that she told the RD, face to face last week, that Resident #36 had a significant weight loss. She stated that RD told her ok and that she will see her next week. MDS Nurse stated she did not document the conversation but that she should have. MDS Nurse stated the RD was responsible for notifying the MD and RP of the significant change. MDS Nurse stated it would be Unit Manager A who knew about Resident #36's weight of 97 lbs. was entered on 12/15/2022. MDS Nurse stated she did not know who entered the weight of 97.8 lbs. on 12/06/2022. MDS Nurse stated the facility had a change in Restorative Aides and was unsure if the weights entered were correct because of this change. MDS Nurse stated she was not the MDS nurse when Resident #36 was admitted , it was another MDS nurse who was no longer employed at the facility and that her plan was to review all resident's weights. MDS Nurse stated Resident #36 had the diagnosis of Anasarca and that was found in the hospital records. In a telephone interview on 12/16/2022 at 9:08 AM, Corporate Nurse was at the facility for one week during November/December to help out. Corporate Nurse stated she vaguely remembered that Resident #36's weight had decreased but actually looked up her orders and her diagnoses. Corporate Nurse stated Resident #36 had muscle wasting secondary to a stroke, was on Lasix and also had Anasarca (generalized body swelling) which affects the entire body, and it could be dramatic. Corporate Nurse stated on the day she weighed Resident #36, she talked to the aides who said the resident did not look different and asked for a reweigh. Corporate Nurse stated she did not get the reweight as she had to catch a plane and she left the same day she believed. Corporate Nurse stated she spoke to a nurse in the unit but did not remember any names because she had never worked at this facility before. Corporate Nurse stated she did look at Resident #36's records and recalled the diagnosis and this was all that she remembered. Corporate Nurse was asked about Resident #36's weight loss of 20 lbs. Corporate Nurse stated that a reweigh should have been done and that was the biggest issue. Corporate Nurse stated she knew the practitioner was supposed to be coming and she would have been made aware of the resident's weight by the staff. Corporate Nurse stated all the communication was verbal. When asked what the implications were if information was not documented, RN K stated she did not know what Texas rules and requirements were and that she had a Missouri state compact license. RN K stated she realized everything should be documented in order to follow through with the resident's needs and for the NP to be made aware. Corporate Nurse stated she spoke to the staff and assumed they would follow through. Corporate Nurse stated she did not know what the policy and procedure for documentation was for the facility. In an interview on 12/16/2022 at 9:59 AM, the DON stated the MDS Nurse would run a report when there was a significant change in weight. The RD would be alerted, the RD would make recommendations and the NP would be notified. The DON stated, she did not know but the MDS nurse would be the one to know if an SBAR would be triggered by a significant weight loss. In an interview on 12/16/2022 at 10:50 AM, MDS Nurse stated that yes, a significant weight loss would trigger an SBAR, and that Unit Manager A was responsible for initiating and writing the SBAR. MDS nurse stated that the SBAR should be written now for Resident #36. In a telephone interview on 12/16/2022 at 1:48 PM, the NP stated that Resident #36 was one of her residents she saw twice a week. NP stated she was first notified of the significant weight loss yesterday, 12/15/2022. NP stated that she spoke with the consulting dietician (RD) on 12/15/2022 so the dietician could make recommendations. NP stated she would leave the decision making for the RD. NP stated that Resident #36 should be gaining more weight and not losing weight because she is bedbound and that she will be ordering a battery of labs today (12/16/2022). NP stated she was not exactly sure why the resident was losing weight and that the liver failure could be an issue for weight loss. NP stated Resident #36 is her resident and would always need to know what is going on with her. NP stated they may not be weighing the resident the same way all the time and should be weighing with the same clothes and at the same time of day. NP stated she expected that residents get weighed upon admission and then said maybe weekly thereafter. NP stated she did not look at all the data on the resident all the time when visiting but if the facility brought a change to her attention, then she would address it. When asked if she was aware of the 97.8 lb. weight on 12/06/2022, what would she have done for the resident. NP stated she would have ordered the labs and consulted with the RD exactly like she did when she found on 12/15/2022. Record review of Resident #36's Dietician Comprehensive assessment dated [DATE] 11:30 AM written by the RD, read in part: .Demographics/Background .4. current diet order: NPO .B. Physical Information 1b. Most Recent Weight 97 lbs., date: 12/15/2022 9:42 AM, .ideal body weight 99 - 121 #, percent of ideal body weight 80% .current height=62 in Medications .Furosemide tablet 20mg, 1 tablet, enterally, two times a day, Pantoprazole Sodium Packet 40 mg, 1 packet, enterally, every 12 hours .Laboratory Data .Pre-Albumin 21.0 . Plan/Recommendations/Additional Comments - Review of weight loss, current wt. 12/11 = 97#, current Ht = 62 in ., BMI = 17.7 underweight .previous weight 11/28 = 119#; 10/21 = 119# there is a weight loss of 18.48%/22# x 30 days. There is an expected weight loss r/t liver disease and stroke. Resident was on Lasix 60 mg. IV with a BUN of 151 high in the hospital, currently the resident is on Lasix PO. There still an expected weight loss, recommend to increase enteral feeding Isosource 1.5 @50ml/hour x 22hours off from 5-7 pm with 30 ml water flush continuous, enteral feeding will provide 1100 ml, 1650 kcal's, 70.18 grams protein, 8386 ml free water/day, continuous 30 ml water flush before and after each medication administration, resident has a unstageable pressure ulcer to sacrum. Record review of Resident #36's progress notes from 12/06/2022 to 12/15/2022 revealed that the RD, NP, and RP were not notified of the significant weight loss after 12/06/2022 when the resident's weight was 97.8 lbs. or at any time prior to 12/15/2022 at 1:00 PM. Further review of the progress notes revealed the Dietician Comprehensive Assessments were not completed within 72 hours of admission, readmission or significant change of condition and the SBAR was not completed prior to 12/15/2022. Record review of the facility's policy and procedure titled Nutritional Management, dated 2022 read in part: Policy: The facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in the context of his or her overall condition. Definitions: Acceptable parameters of nutritional status refers to factors that reflect that an individual's nutritional status is adequate, relative to his/her overall condition and prognosis, such as weight, food/fluid intake, and pertinent laboratory values .Compliance Guidelines: .2. Identification/assessment: a. Nursing staff shall obtain the resident's height and weight upon admission, and subsequently in accordance with facility policy .c. A comprehensive nutritional assessment will be completed by a dietician within 72 hours of admission, annually and upon significant change in condition. Follow-up assessments will be completed as needed. Components of the assessment may include, but are not limited to: i. General appearance, ii. Height/weight .

Based on record review and interview, the facility failed to ensure residents received respiratory treatment and care in accordance with professional standards of practice for 2 of 15 residents ( CR#1 and CR #2) reviewed for respiratory, [CONDITION(S)] care and suctioning as evidenced by: The facility failed to ensure that the ventilator circuit for CR#1's ventilator, remained intact and connected. The facility failed to ensure CR #2's oxygen saturation rates were monitored during ventilator checks. These failures placed facility residents who are dependent on ventilators at risk of hypoxemia, hospitalization , and death. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was lowered on [DATE], the facility remained out of compliance at a scope of a pattern and severity of actual harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures placed facility residents receiving respiratory treatment and care at risk of harm including death. Findings include: Findings include: CR #1 Record review of CR #1's face sheet revealed the [AGE] year-old female resident was readmitted to the facility on [DATE] and expired at the facility on [DATE]. Record review of CR #1's face sheet had the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . The review further revealed CR #1 was completely oxygen dependent on her ventilator and was dependent on [CONDITION(S)]. The review further revealed CR #1 did not have the use of her arms and was dependent on staff for all her needs. Record review of CR#1's significant change MDS dated [DATE] revealed she required extensive assistance and was a total assist with bed mobility and transfers. Additionally, a BIMS score could not be obtained as the resident had no expressive language capacity. The MDS also revealed CR #1 was ventilator dependent. Record review of care plans dated [DATE] revealed CR # 1 was care planned for hemodialysis, use of a ventilator and for her [CONDITION(S)]. Interventions included mechanical ventilation .keep SP 02 sat > 92% .observe document respiratory rate, depth and quality. Check and document q shift as ordered. Suction as necessary. In a telephone Interview on [DATE] at 3:47 PM LPN N stated on [DATE], CR #1 returned from [CONDITION(S)] around 11:30 PM to 12:00 PM. She said CR #1 was in the Geri chair when she checked upon return to her room from [CONDITION(S)]. CR #1's respirations and breath sounds were normal; her vital signs were normal, and the ventilator circuitry was intact. LPN N said the RT G told her CR #1 had difficulty breathing but LPN N did not agree. She said RT G gave her breathing treatments and it took maybe ,d+[DATE]mins to complete the treatment. LPN N said she returned after breathing treatment was completed. CR #1 was not in any distress and her vital signs were WNL. LPN N said she returned in about one hour at change of shift. She said she gave CR #1 meds at 2:00 or 2:15 PM. She said CR #1 was looking good and ventilator tubing was connected to CR #1. CR #1 was put to bed by the aids around 1:45 PM. She told the CNAs to do this. LPN N returned to check on CR #1 at around 3:00 PM and she was not in any distress. She knew CR #1 was connected to the ventilator because the machine was not alarming. At 3:30 PM, LPN N went to the nurse station to chart. She said she saw the RT lady was doing her rounds then the RT came out to the hall and said to call a code. In an Interview on [DATE] at 1:43 PM with CNA S, she stated she had worked at the facility for 2 years and worked on [DATE]. On [DATE] , at approximately 4:00 PM, CNA S stated she heard RT G yell outside of CR #1's room. RT G at that time instructed CNAS to call the code. The DON and all the nurses came. Everyone performed CPR. 911 arrived in 10 minutes. She stated CPR was approximately 20 minutes in duration. CNA S stated she did the post-mortem care. CNA S stated she had worked with CR #1 before and described her as unable to self-turn, had a [CONDITION(S)] bag, was on [CONDITION(S)], was an [CONDITION(S)] and never responded to anything. She stated she had never seen CR #1 in distress. Most of the time she was asleep and never saw her awake. She did not have contractures and had never seen CR #1 with a gag reflex when turning or changing. The only way to knew she needed suctioning was hearing the gurgling sounds. In an interview on [DATE] at 5:00 PM RT G said she saw CR #1 when she returned from [CONDITION(S)] and she was in a neuro chair (Geri chair) and not in the bed. She said CR #1 was in mild distress. RT G gave her a breathing treatment and suctioned a moderate amount of pale colored secretions. There was nothing outstanding about the secretions. RT G noticed the ventilator circuit/tubing from the resident's [CONDITION(S)] was twisted and she untwisted it. The ventilator was on CR #1's left side and she wanted the circuit to be more in a straight line. After procedure CR #1 settled. She said the nurse came in the room after end of suctioning. RT G returned around 4:00 PM to do a check. The machine was alarming, the resident was in bed. The circuit was disconnected at the junction where the 5-inch flex tubing connects to the HME (heat and moisture exchange device). The circuit was laying across CR #1's chest. RT G re-connected the circuit and pressed reset button on ventilator. Then checked for a pulse and there was none. RT G then called for help and began CPR using the Ambu bag (bag valve mask used for manual resuscitation). In an interview on [DATE] at 9:40 AM, RT G said she did vent checks on [DATE] at 11:40 AM for CR #1 and at 1:10 PM (as documented on the flow sheet). She said CR #1 was still in the Geri chair at the time. She thinks CR #1 was in distress at the time because the circuit was twisted, and this was when she straightened it out and left CR #1 in stable condition. When she returned at 4:00 PM the back of the ventilator was facing the door, when usually the front of ventilator faces the door, alarms were audible, circuit was laying across her chest as if the ventilator was to her right side. The ventilator was on her left side. She stated CR #1 was not mobile and not able to move or use her hands. In a telephone interview on [DATE] at 10:49 AM, LPN N stated CR#1 was bedfast and not mobile. She stated she was aphasic and could not speak. LPN N said on [DATE] at 12:30 PM CR #1's ventilator was on her right side and that everything was on her right side. CR #1 was not in any distress; she was alert and did not notice any contractures. In an interview on [DATE] at 1:05 PM, CNA GG stated she had been at the facility for 3 months and worked 6:00 AM to 2:00 PM shift. She said she was at work when CR #1 passed away. She came in after 2:00 PM. CNA HH did rounds with CNA GG around 2:00 PM. CNA HH told her that CR #1's brief had been changed. CNA GG said during 2:00 PM rounds she observed CR #1 in bed, snoring and the ventilator was on the resident's left side (she did not provide care at this time). The concentrator and TF pump were also on the left side. The ventilator was in a diagonal position and the circuit tubing was draped over CR #1's left side towards the ventilator. The Geri chair was well away from the CR #1, the bed was in low position and the HOB was raised. In a telephone interview on [DATE] a confidential employee , who had been working with residents, stated, nurses were not trained for tracheostomies and ventilators and were uncomfortable working with them. There were issues with the RT department as well due to lack of training. The nurses were under the impression that all they needed to do was call the RT if needed. On [DATE] CR #1 was non-responsive, and they initiated a code blue. In a telephone interview on [DATE] at 7:20 PM, the Transporter who worked from [DATE] to [DATE]. CR #1's [CONDITION(S)] ended on [DATE] at 10:30 AM. CR #1 was transported back to her room by the transporter and a CNA. CR #1 was in the Geri chair, ventilator and oxygen concentrator was transported. The machines were plugged into wall outlets. The [CONDITION(S)] tubing remained connected before staff left the room. CR #1 was doing fine and was snoring. In an interview on [DATE] at 3:54 PM, CNA HH stated on [DATE] at 12:05 PM she and another CNA transferred CR #1 from chair to bed. By 2:00 PM CNA HH and second CNA did rounds and performed incontinent care for CR #1. CR #1 was turned towards the door, propping to left side using a wedge pillow. According to CNAHH, CR #1 appeared to be fine and in no distress. In an interview on [DATE] at 10:00 AM, the Treatment Nurse said she had worked at the facility for 90 days. She stated CR #1 was in bed and she cleaned CR #1's wounds on [DATE]. CR #1 had wounds to sacrum, elbow, left and right stumps and friction wounds to thigh/buttocks. She said she worked on the wounds before 2:00 PM. She said the WCT was assisting with the care. She said CR #1 was a hard turn, heavy, dead weight requiring 2 staff members one on each side of the bed. She said CR #1 has always been almost comatose, her arms were flaccid and could not move her own body. She said she had never seen CR #1 flinch. She said CR #1 did not have contractures, never moved her arms and never had facial grimaces. CR #1's eyes were open, and she was breathing fine. When turned to her right side, the treatment nurse was able to see all of CR #1's wounds. After care, CR #1 was turned towards the door and propped with a wedge pillow placed to upper back. The vent circuit was intact. The ventilator was on her left side with front of vent facing the door. In an interview [DATE] at 10:15 PM with the Director of Respiratory Services revealed it was quite difficult to separate the circuitry at the junction of the Heat Mechanism Exchange (HME). He demonstrated how one had to forcefully twist the circuitry in order to separate the tubing from the HME. In an interview on [DATE] at 1:09 PM, the Director of Respiratory Services stated based on CR #1's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . It would not take long for CR #1 to stop breathing. He compared CR #1 to a more stable resident who was alert that he was using as an example. He said CR #1 would desaturate (low blood oxygen concentration) rapidly if off the ventilator. In a telephone interview on [DATE] at 2:20 PM with CR #1's physician, he stated he believed CR #1 could have disconnected the vent tubing by herself by moving around in bed. The physician was reminded of the fact that CR #1 was unable to move her arms and had one leg amputated. He stated, you would be surprised what these patients can do. He further stated he will get with the facility to utilize medications for residents on vents/trachs to prevent further incidents. Record review of progress notes written by RT G on [DATE], read, Patient summary: Patient on AC-PC 35, RR 18, Peep 5, 8L 02. Shiley 6 [CONDITION(S)] in place, [CONDITION(S)] care done. Neb Txs done x2. Suctioned for moderate, thick secretions. SAT 100%, HR 96, RR 23. Emergency equipment set up at bedside. Patient in NAD will continue to monitor. Record review of progress notes written by RT G on [DATE], read, Respiratory Note addendum: 1600[4PM] came into patient's room to perform vent check-found patient in bed disconnected from vent with vent alarming. Vent re-connected, patient assessed no pulse found. Code called and CPR initiated 1603[4:03PM]. EMS pronounced patient @ 1652[4:52PM]. Record review of CR #1's Ventilator Flow Sheet revealed CR #1 was checked by RT G on [DATE] at 6:30 AM, 10:30 AM, 11:40 AM and 1:10 PM. At these times the SpO2 was between 100% and 99% and oxygen was at 6 L/min. The next time RT G did rounds was 4:00 PM when she found resident disconnected from ventilator and without a pulse. Record review of CR #1's progress note written by LPN N, effective date [DATE] at 11:51 AM and created on [DATE] at 9:12 PM read in part: During rounds upon arrival resident was in [CONDITION(S)]. At 11:30 AM Resident returned from [CONDITION(S)] awake, alert in Geri chair well connected with vent with all setting intact .oxygen 99%. Schedule medications administered via G tube tolerated well. RT was observed in resident room doing [CONDITION(S)] care suctioning. Per RT statement resident was having difficulty breathing, breathing treatment was administer per RT. In 15mins breathing treatment was in progress, no s/s of distress noted. 1:45PM, ,d+[DATE]pm CNAs were observed putting residents back to bed while making their final round from room to room. 2 PM change of shift was done on coming CNA was observed walking from one hall to another checking residents. At 3:00 PM resident was observed in bed resting no signs of distress noted. At 4:03 PM a code was called for room [ROOM NUMBER]. Upon arrival to room [ROOM NUMBER] RT, DON and unit manager were performing CPR, 911 arrived in room and took over. At 4:52 PM 911 personnel pronounce resident dead. MD made aware family notified too. CR #2 Record review of CR #2's admission record revealed a [AGE] year-old male, admitted on [DATE]. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #2's admission MDS dated [DATE] revealed he rarely or never made himself understood and rarely or never understood others. His cognitive skills for daily decision making were severely impaired. He required total assistance with two-person assist for bed mobility, transfers between surfaces, dressing and toilet use. He required total assistance with one person assist for eating and personal hygiene. Section O (special treatments, procedures, and programs) of the MDS revealed he was receiving oxygen therapy, suctioning, [CONDITION(S)] care and invasive mechanical ventilator while not a resident and while a resident. Record review of CR #2's care plan revealed Focus: Difficulty in understanding and making self-understood: date initiated [DATE]. Goal - CR #2's basic needs will be anticipated and met on a daily basis through the review date. Intervention - Anticipate and meet resident's needs. Responsible staff: nursing supervision and respiratory services. Focus - CR #2 has a [CONDITION(S)] and is at risk for potential complications such as weight loss, increased secretions, congestion, infection, and respiratory distress: date initiated [DATE]. Goal - CR #2 will have clear airways with adequate ventilation through the next review date. Interventions included in part: - provide oxygen, humidity, [CONDITION(S)] care, and tubing changes as indicated by physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Responsible staff: nursing supervisor and respiratory services. Record review of CR #2's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (no BP parameters were included). [MEDICATION(S)] Tablet, give 12.5mg via G-Tube every 12 hours for [CONDITION(S)], hold if BP <110 or HR <60. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .titrate Oxygen to keep SpO2 (peripheral capillary oxygen saturation) greater than 92%, order date [DATE]. Record review of CR #2's physician's visit note dated [DATE] read in part: .CR #2 was also seen and examined today to address concerns for abnormal chest x-ray results. Patient lab results show some abnormalities .Will continue to monitor closely due to changes in acuity of chronic diseases .chest x-ray results - pneumonia . In an interview on [DATE] at 10:49 AM, LPN N stated CR #2 had gone to in-house [CONDITION(S)], returned without receiving [CONDITION(S)] because BP was too low. LPN N administered the [MEDICATION(S)] (on [DATE] at 8:00 AM. There were no BP parameters for the [MEDICATION(S)] in the physician orders). On [DATE] at 6:45PM LPN N said she reported to the oncoming nurse (RN C) about CR #2's change in condition. LPN N said report was given to RN C or another nurse (no longer working at the facility). LPN N returned the next day on [DATE] at 6:45 AM the day CR #2 expired. She said a CNA (whose name she did not recall) and RT A were in CR #2's room. RT A had begun CPR. CR #2 was connected to the ventilator. LPN N said during report from night shift, RN C did not mention any vital sign results during the night. LPN N said the nurses were responsible for checking BPs and round in the morning starting with checking vital signs. She said around 3:00 PM she would round again and check her resident's vital signs as this was her routine - and expectation of duties of the night nurse Record review of CR #2's MAR/TAR revealed that RN C did not work with CR #2 on [DATE] at 7:00 PM to [DATE] at 7:00 AM instead it was LPN Q who had signed the MAR/TAR with her initials confirming that she worked on [DATE] at 7:00 PM to [DATE] at 7:00 AM. In a telephone interview on [DATE] at 10:42 AM, LPN Q said she started working at the facility on, [DATE] and always works nights 7p - 7a shift. She said honestly, she could not remember taking care of CR #2 on [DATE] to [DATE]. She said she did not remember a time when any nurse told her about a resident who had a change in condition and had [CONDITION(S)]. LPN Q stated her duties were as follows: she said at the start of her shift she always made rounds and visually checked the residents. She said the electronic chart had alert pop ups, an alert signal, that notified her if vital signs are scheduled and that was how she knew to check. If vital signs are not scheduled and she sees a reason to, then she will take a set of vitals as she would need this information before contacting the doctor. She said she gets her information from verbal report with the day shift nurse and from the 24-hour report. She does her audits using the 24-hour report to see if there was anything missed during the verbal report. The 24-hour report will have what the previous nurse did and if there were any new physician orders. She said if she were ever told about a resident who was on a ventilator with cold extremities and the RT was unable to obtain a SpO2, that would be an alert for her indicating a change in condition for the resident. In an interview on [DATE] at 2:15 PM CNA X stated she found CR #2 non-responsive when she came on duty. RT A came when she called for help. They found CR #2 connected to the ventilator. When she came on duty the night shift did not provide any report regarding his condition. In an interview on [DATE] at 11:35 AM, RT A said she had been working at the facility since 2017. She said on [DATE] she was able to get a pulse on CR #2 and his respirations were 24, but unable to obtain a SpO2. RT A said she did cover CR #2's hands with a blanket to help warm them up. She said she believed she told the nurse that she was unable to obtain a SpO2 on CR #2. She said CR #2 was non-responsive and had been this way since he had been in and out of the hospital maybe ,d+[DATE] times. RT A said it was normal practice to leave the resident if an SpO2 cannot be obtained, then return later. She said she suctioned CR #2, checked the ventilator settings, palpated for a heart rate at the antecubital (inner front surface of the forearm at the elbow) at obtained a pulse of 74 beats per minute. She said she explained to LPN G that there were no other changes. RT A said she tried to look at the rest of CR #2's body, his arms were cool, and hands were cold. She said he was covered with bed linen and typically RTs work with only the top part of a resident's body. She said she thinks his torso was neither hot nor cold, she could not remember. RT A said the nurse came and could not find a BP and this was when she knew there was a change in the resident's condition. In an interview on [DATE] at 11:45 AM, LPN G said she did not work with CR #2 on [DATE] because she did not work on the weekend. In an interview on [DATE] at 11:36 AM, the Director of Respiratory Services said he expects the RTs should tell the nurse and let them know that they were unable to obtain an oxygen saturation rate. If a resident was in any type of distress, we would want the nurse to call the MD. There may be a minute when you cannot obtain an oxygen saturation but there may be no apparent change in condition as well. He said he would try to get a second reading, tell the nurse, and see what the physician would want to do next or call the pulmonary director. If it was one of my therapists, I would tell them to address with the nurse. If unable to obtain an oxygen saturation twice in a row, the first thing to do would be to try and warm up the hands by putting them under cover. We do not have a P&P for care of ventilator residents, whatever the facility has was what we have. He said he was unfamiliar with CR #2. In an interview on [DATE] at 5:45 PM, RT G said she started working at the facility 70 days ago and she barely remembers working with CR #2. She said with a low BP she would not be able to get an oxygen saturation rate. Clinically, you can't get a saturation rate with low BPs. She said if still unable to obtain oxygen saturation, then she would probably suggest to the nurse that the resident should be sent out. In an interview on [DATE] at 12:50 PM, the interim DON said she started working at the facility on [DATE]. She said if the RT or the Nurse were unable to obtain an oxygen saturation rate for a resident on a ventilator and it's so low, they can't get a reading she expected they would need to contact the MD immediately for orders and let the MD say what to do next. She said they could try to warm up the fingers or try to get oxygen saturation on the toes. They can do an overall assessment, checking to see if the resident is turning blue or was pale and assess the pulse rate as well as obtaining a full set of vital signs to get a whole picture. They can also check capillary refill. Record review of change in condition form dated [DATE] at 8:04 AM, written by LPN N revealed CR #2 didn't get [CONDITION(S)] due to low BP of ,d+[DATE]. PRN [MEDICATION(S)] 10mg was administered. The physician was notified, and the recommendations were to monitor blood pressure, transfer out if blood pressure continued to be low. Blood pressures recheck was ,d+[DATE] (no time noted), no distress noted on assessment and MD made aware. Record review of CR #2's progress note written by RT G on [DATE] at 2:09 PM read in part: .Patient Summary: .9L O2. Shiley 8 [CONDITION(S)] in place, [CONDITION(S)] care done. Neb tx done x 1. Suctioned for moderate, thick secretions .Patient returned early from [CONDITION(S)] due to low BP. Could not obtain SATs on patient initially. When SATs were able to be obtained resident was ,d+[DATE]%, HR 67, RR 22. NAD (no apparent distress) noted. Will continue to monitor. Record review of CR #2's ventilator flow sheet entry by RT N revealed on [DATE] at 7:35 PM CR #2's SpO2 was 95%, at 10:45 PM it was 97%, on [DATE] at 1:15 AM it was 97%, at 5:30 AM it was 97% and at 6:50 AM RT A wrote too cold. The oxygen flow rate remained unchanged at 9L/min during all the checks. RT A wrote a note on the flow sheet. It read in part: Unable to measure pulse ox too cold/poor circulation due to shunt in both arms. 9:15 AM nurse called RT to resident room. No pulse, no BP, no respirations, CPR started . Record review of CR #2's MAR/TAR for [DATE] revealed on [DATE], [MEDICATION(S)] 12.5 mg was ordered to be given at 6:00 AM. There were no indications [MEDICATION(S)] was either given or held and there were no BP results documented. There was no indication that [MEDICATION(S)] was given as needed for [CONDITION(S)]. Record review of CR #2's progress note written by RT A on [DATE] at 7:30 AM read in part: .resident remained on a ventilator. Unable to measure pulse oximetry due to cold extremities, HR 70, RR 24. Treatment given as ordered. Will continue to monitor resident. Record review of CR #2's progress note written by RT A on [DATE] at 8:45 AM read in part: .Unable to measure O2 sat, due to hands being too cool, poor circulation in fingers, and [CONDITION(S)] shunts. Heart rate 70, RR 24. Treatment given as ordered. Will continue to monitor resident. Will continue to attempt to measure O2 Sat. Record review of CR #2's progress note written by LPN N on [DATE] at 9:10 AM read in part .at 9:15 AM this writer was called to resident room by the CNA to come quickly and assess resident, upon arrival resident was observed with no pulse no blood pressure. Code blue was called, CPR initiated, 911 called. 911 arrived and took over resident was pronounced at 9:29 AM . Record review of facility policy titled [CONDITION(S)] Care dated [DATE] read in part: .Policy: The facility will ensure that residents who need respiratory care, including [CONDITION(S)] care and tracheal suctioning, is provided such care consistent with professional standards of practice, the comprehensive person-centered care plan and resident goals and preferences . Record review of the facility's undated policy entitled, Oxygen Administration, read in part .4. The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders, such as, but not limited to: a. The type of oxygen delivery system. B. When to administer, such as continuous or intermittent and/or when to discontinue. C. Equipment setting for the prescribed blood flow rates. D. Monitoring of SpO2 (oxygen saturation) levels and/or vital signs, as ordered. E. Monitoring for complications associated with the use of oxygen . Record review of facility policy titled Notification of Changes dated [DATE] read in part: .Compliance Guidelines: The facility must inform the resident, consult with the resident's physician and /or notify the resident's family member or legal representative when there is a change requiring such notification; .2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health . Record review of facility's Resident Admission Agreement, revised on [DATE] read in part: .Upon such admission, the Resident and Resident Representative herby consent to such routine care and treatment as may be provided by the Facility, .or ordered by the Resident's attending physician (the Attending Physician) in accordance with the Resident's plan of care . An I.J. (Immediate Jeopardy) was identified on [DATE]. There was no Administrator for the building at this time. Consequently, the Regional Director of Operations who had been filling in as Administrator was notified of IJ on [DATE] at 4:49pm. IJ template was provided at this time and plan of removal was requested. Plan of Removal was accepted on [DATE] after several revision and read in part: All residents' (with ventilators and [CONDITION(S)]) tubing/circuit were changed on [DATE]. On [DATE], the QAPI committee reviewed the policy related to ventilator checks. Residents with Ventilators and [CONDITION(S)] will be rounded at least every two (2) hours. The RT's and the nurses will identify the residents who will need additional checks and/or more frequent ventilator checks/rounds and the indication and specific intervention will be incorporated into the residents' plans of care. The nurses and the RT's will be provided with training by the RDO (regional director of operations) /designee related to the policy, the expectations related to ventilator checks/rounds and responsibility related to the alarms. The training will be completed on or before [DATE]. In between ventilator checks and/or rounds, the RT's and nurses will respond to the alarms and assess the need for immediate intervention and/or need for additional assessment. The RT's office was relocated into the ventilator unit to further enhance accessibility. The facility will override the default settings for alarm volume setting for all mechanical ventilators; all ventilators' volume settings will all be set to the maximum level. These actions are in place as of [DATE]. On [DATE], the QAPI committee reviewed the policy related to obtaining oxygen saturation. The responsibility of the RT and nurse includes completing further assessment and if necessary, notifying the attending physician if unable to obtain oxygen saturation during assessments/checks. The nurses and the RT's will be provided with training by the RDO (regional director of operations)/designee related to the policy and the staff (RT's and nurses) responsibility related to oxygen saturation checks. The training will be completed on or before [DATE]. The RT's and nurses will not assume any job responsibilities until training has been received by them. The orientation program, which includes but not limited to training related to, 1) [CONDITION(S)]/[CONDITION(S)], 2) Oxygen Management, 3) suctioning, 4) Pulse Oximetry, 5) [CONDITION(S)] care, 6) Nebulizer, 7) [CONDITION(S)] tube change, 8) ventilator management, 9) Trilogy EVO and 10) Trilogy 100, for RT's was reviewed by the QAPI team on [DATE]. Revision was made to include further assessment if unable to obtain oxygen saturation and to notify the attending physician if deemed necessary. The director of respiratory therapy will provide the RT's with training related to the revision. The training will be completed on or before [DATE]. The RT's will not assume any job responsibilities until training has been received by them. Skill competency testing related to ventilator checks and pulse oximeter readings will be completed for all RT's. The competency validation tests will be completed by the director of respiratory therapists and will be completed on or before [DATE]. The RT's will not assume any job responsibilities until training has been received by them. The RT's and nurses will complete a minimum of every two-hour ventilator checks to ensure that ventilation equipment remains connected and intact. The RT's and nurses will identify the residents who will need additional ventilator checks for any identified clinical reason. Any specific and more frequent rounds/ventilator checks will be incorporated into the residents' plans of care. The RT's and nurses will be provided with training by the RDO/designee related to this process. The training will be completed on or before [DATE]. The RT's and nurses will not assume any job responsibilities until training has been received by them. On [DATE], the QAPI committee reviewed the policy related to change of condition and communication between staff, between staff and physician and between shifts when a resident has a change of condition. The nurses and RT's will receive training related to the policy and their responsibilities to communicate about resident's change of condition and communication of identified changes of condition to the attending physician. The training will be conducted b [TRUNCATED]

Based on record review and interview, the facility failed to ensure residents who require [CONDITION(S)] services, receive services consistent with professional standards of practice, the person-centered care plan and the resident's goals and preferences for 1 of 3 (CR #3) residents, reviewed for [CONDITION(S)]. The facility failed to ensure that CR #3 was dialyzed 3 times per week as ordered by her physician. The facility failed to consult the physician when CR #3 refused [CONDITION(S)] on [DATE]. CR #3 went 5 days without [CONDITION(S)]. The facility failed to ensure staff obtained pre [CONDITION(S)] blood pressure readings for CR #3 prior to her being transported to [CONDITION(S)]. The facility failed to administer CR#3's [MEDICATION(S)] prescribed for hypertension at 6:00 AM on [DATE], at 6:00 AM on [DATE], at 6:00 PM on [DATE] and on [DATE] at 6:00 AM. The facility failed to administer CR#3's ordered [MEDICATION(S)] patch for hypertension on [DATE] at 8:00 AM. The facility failed to ensure pre [CONDITION(S)] communication forms for CR #3's off-site [CONDITION(S)] were completed and accurate on [DATE] and on [DATE]. On [DATE], the [CONDITION(S)] sheet from the facility to the [CONDITION(S)] center was incomplete and read, BP 108 while the transportation services recorded CR#3's blood pressure prior to her arrival at the [CONDITION(S)] center as ,d+[DATE] and ,d+[DATE]. The facility failed to monitor CR #3's [CONDITION(S)] site to ensure [CONDITION(S)] catheter and failed to assess site on [DATE] in order to identify change in catheter status and signs of infections. On [DATE], the [CONDITION(S)] center found CR #3 upon arrival at the center, less than 10 minutes from the facility by car/ambulance, to have a dirty dressing with visibly dried blood and with the cuff of the sub- clavian catheter (hemodialysis catheter inserted into the chest wall) visible indicating a malfunction. The [CONDITION(S)] center could not perform [CONDITION(S)] and transferred CR #3 to the hospital where she was placed on hospice and later expired. Immediate Jeopardy was identified on [DATE]. While the IJ was lowered on [DATE] at 10:43 AM, the facility remained out of compliance at a scope of a pattern and severity of actual harm that is not immediate jeopardy as the facility requiring more time to monitor the Plan of removal for effectiveness. These failures placed facility residents receiving [CONDITION(S)] services at risk of harm including death. Findings include: CR #3 Record review of CR #3's face sheet revealed [AGE] year-old female resident was readmitted to the facility on [DATE] and effectively discharged on [DATE] at which time she was transferred to the hospital from her off-site [CONDITION(S)] center. Record review of CR #3's face sheet revealed the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . The review revealed CR #3 used sign language or written notes to communicate her needs. Record review of CR #3's physician current orders dated [DATE] revealed [MEDICATION(S)] patch weekly 0.1 mg/24 HR apply 1 patch transdermally one time every 7 day(s) for [CONDITION(S)] and remove per schedule. Record review of CR #3's physician orders with start date of [DATE], revealed [MEDICATION(S)] XL Tablet Extended Release 24-hour 60 MG ([MEDICATION(S)] ER Osmotic Release). (Give 1 tablet by mouth every 12 hours for [CONDITION(S)] Hold for SBP less than 110 and HR less than 60, Further review of Physician orders revealed no order to hold [MEDICATION(S)] at any time. Record review of CR #3 's [CONDITION(S)] orders dated [DATE] read, [CONDITION(S)]: Check [CONDITION(S)] site every shift; [CONDITION(S)]: May go to [CONDITION(S)] on MWF . [CONDITION(S)]: palpitate AV shunt-check for Bruit and Thrill every shift [CONDITION(S)]: Vital signs post [CONDITION(S)] .Vital signs post [CONDITION(S)]. However, CR #3 did not have an arm shunt but had hemodialysis chest catheter. Record review of CR #3 [CONDITION(S)] orders revealed physician orders to check her hemodialysis chest catheter it every shift. Record review of CR #3's care plan revealed a care-plan for hypertension and administration of anti-hypertensive medications, obtain blood pressure readings per MD order and notify MD if abnormal. CR #3 was also care-planned for [CONDITION(S)] services. The care plan was last reviewed on [DATE]. Record review of CR #3's care plan for hypertension read, Focus. has hypertension ([CONDITION(S)]) r/t CHF Date initiated [DATE] Revision on ,d+[DATE] 2021 Goal .will remain free of complications related to hypertension through review date .Target Date [DATE] Interventions Give anti-hypertensive medications as ordered. Monitor for side effects such as [CONDITION(S)] (a form of low BP that occurs when standing up from sitting or lying down position) and increased heart rate ([CONDITION(S)]) and effectiveness .Monitor document/report PRN any s/s of malignant hypertension: headache, visual problems, confusion, orientation, lethargy, nausea and vomiting, irritability, [CONDITION(S)] activity, difficulty breathing (Dyspnea). Record review of CR #3's care plan for [CONDITION(S)] services read, Focus .needs [CONDITION(S)] r/t renal failure Date initiated [DATE] Revision on [DATE] Goal .will have no s/s of complications from [CONDITION(S)] through the review date. Interventions: Palpate AV shunt-check for Bruit and Thrill per MD's orders Date initiated: [DATE]. Revision on: [DATE] Encourage resident to go for the scheduled [CONDITION(S)] appointments. Resident receives [CONDITION(S)] ( .M-W-F 6am). Monitor labs and report to doctor as needed. Monitor VITAL SIGNS per MD's orders. Notify MD of significant abnormalities. Focus .needs [CONDITION(S)] r/t renal failure Date initiated: [DATE] Revision CR #3 was dialyzed on [DATE], [DATE] and on [DATE]. CR #3 refused [CONDITION(S)] on [DATE].[DATE]. (The section for Goal had no documentation.) The section for Interventions read, Monitor/document/report PRN any s/s of infection to access site: Redness, Swelling, warmth or drainage. Monitor/document/report PRN for s/s of renal insufficiency, changes in level of consciousness, changes in skin turgor, oral mucosa, changes in heart and lung sounds. Monitor/document/report PRN for s/s of the following: Bleeding, Hemorrhage, Bacteremia, Septic shock. Record review of CR #3's progress note dated [DATE] at 10:51 AM and written by a former DON read, in part: [DATE] .Received phone call from .outpatient [CONDITION(S)], reports going to send resident to hospital due to uncontrolled high blood pressure attempted to control with [MEDICATION(S)] unsuccessful ,d+[DATE]. Caller expressed being upset that the resident has high blood pressure most of the time . Record review of CR #3 nursing note dated [DATE] read, [DATE] 18:40 [6:50PM] Health Status Note Resident arrived back from the hospital. Blood pressure checked on arrival to facility and it was high ,d+[DATE], Scheduled medications administered BP check 1 hour and B/P went down to ,d+[DATE] . Record review of CR #3's hospital records dated [DATE] revealed she was admitted for hypertension post [CONDITION(S)]. On [DATE] at 11:21 AM CR #3's BP in ER was ,d+[DATE], pulse 76. On [DATE] at 2:22 PM, BP was ,d+[DATE] and CR #3 was discharged to the facility the same day. Record review of CR #3's hospital records dated on [DATE] at 8:46 AM CR #3 was admitted for [CONDITION(S)]. Per hospital records she was admitted due to positive Covid results and need for [CONDITION(S)]. Per records CR #3Patient stated she was unsure why she was there. Per records CR #3 was evaluated and did not meet criteria for emergent [CONDITION(S)] at the time. CR #3 was discharged to the facility on [DATE] at 1:16 PM the same day. Record review of the top portion of the document entitled, [CONDITION(S)] Communication Form Pre-[CONDITION(S)] Information dated [DATE] and completed by the facility, read shunt location status chest right Vital signs BP 108. There was no further blood pressure written on the form and it is unknow whether the reading was systolic or diastolic. The review revealed no documentation of any assessment of the catheter site having been assessed prior to being sent to the [CONDITION(S)] center. Record review of nursing notes for CR #3 revealed the schedule for CR #3's [CONDITION(S)] was changed to Tuesday, Thursday, Saturday once Covid was diagnosed on [DATE], as the [CONDITION(S)] center provides [CONDITION(S)] services to Covid positive residents on those days. Record review of Nursing note from the facility for CR #3 dated [DATE] read, [DATE] 08:26 Resident left the facility via .to hospital pending [CONDITION(S)]. Resident is Covid positive and asymptomatic in stable condition . Nursing notes further read, [DATE] 13:42 Resident was transferred post [CONDITION(S)] in stable condition . Record review of nursing notes for CR #3 revealed that the schedule for CR #3's [CONDITION(S)] was changed to Tuesday, Thursday, Saturday once Covid was diagnosed on [DATE], as the [CONDITION(S)] center provides [CONDITION(S)] services to Covid positive residents on those days. Record review of hospital records dated [DATE] revealed CR #3 did not receive [CONDITION(S)] at the hospital that date. The review read in part, .female with history of [CONDITION(S)] on [CONDITION(S)] Monday, Wednesday and Friday presents .due to positive Covid test and need for [CONDITION(S)]. Patient speaks through sign language source timing was appropriate was obtained. Patient stated she has no complaints and is unsure of why she is here. The review further revealed the hospital contacted the facility and learned the patient was sent to the hospital for [CONDITION(S)] because she was Covid positive. The review read, She does not meet the need for emergent [CONDITION(S)] at this time. She does not have an emergent condition that requires her to go to the hospital. Record review of Nursing note from the facility for CR #3 dated [DATE] read, [DATE] 08:26 Resident left the facility via .to hospital pending [CONDITION(S)]. Resident is Covid positive and asymptomatic in stable condition . Nursing notes further read, [DATE] 13:42 Resident was transferred post [CONDITION(S)] in stable condition . A telephone interview with LPN Z was attempted on [DATE] at 12:20 PM, LPN Z did not answer or return call prior to exit. Record review of Social Services Notes from the facility for CR #3 for [DATE] read, I was informed that the resident refused to go to [CONDITION(S)] today. I called the RP and asked her to speak to the resident to make sure she goes on Thursday. Record review of CR#3's clinical chart including CR #3's nursing notes and assessments revealed no documentation indicating CR #3's physician or Nurse Practitioner were called regrading transfer to the hospital on [DATE] or about the missed [CONDITION(S)] on [DATE]. Additionally, review of the entire clinical chart revealed no change of condition form was completed for [DATE]. In an interview on [DATE] at 10:19 AM the RDO said she could not find CR #3's [CONDITION(S)] Communication Sheets for [DATE] and [DATE]. Record review of CR #3's MAR/TAR dated [DATE] through [DATE] revealed weekly [MEDICATION(S)] patch was removed on [DATE] at 7:59 AM by LPN Manager and not replaced at 8:00 AM by LPN Manager. [MEDICATION(S)] XL 60 mg was due and not checked as administered on the following: [DATE] at 6:00 AM, [DATE] at 6:00 PM and [DATE] at 6:00 AM. Record review of CR #3's progress note revealed an order administration note written by LPN Manager with the effective date [DATE] at 3:09 PM. It read: [MEDICATION(S)] Patch Weekly 0.1 mg/24 hour, apply 1 patch transdermally one time a day every 7 days for [CONDITION(S)] and remove per schedule. Awaiting delivery . Record review of CR #3's Blood Pressure Summary revealed on [DATE] at 5:35 PM the BP was ,d+[DATE], on [DATE] at 6:51 AM the BP was ,d+[DATE]. There were no other BP results recorded after [DATE] at 6:51 AM. Record review of CR #3's progress note revealed on [DATE] at 9:14 PM, LPN Z wrote a comprehensive skilled nursing note including vital signs: BP ,d+[DATE], pulse 76, RR 18, Temp 97.6, O2 97% and pain level of ,d+[DATE] (hurts a little bit) of abdomen. Review of clinical records revealed there were no notes regarding any communication with out-patient [CONDITION(S)] unit for the elevated BPs during [CONDITION(S)] on [DATE]. Record review of CR #3's [CONDITION(S)] treatment log dated [DATE] revealed, treatment initiated at 9:38 AM. Pre-treatment BP was ,d+[DATE], pulse 70. [MEDICATION(S)] 0.2 mg was given orally at 10:05 AM. Treatment was terminated early per NP at 12:16 PM due to high BP. Post treatment BP was ,d+[DATE]. [CONDITION(S)] notes further revealed CR #3 stated the nursing home did not give her BP medication. Post treatment data collection & assessment revealed NP was aware of patient BP, instructed [CONDITION(S)] to communicate with nursing home to give BP medication. Nursing home phone lines down. Verbal communication sent via EMS. Record review of CR#3's [CONDITION(S)] Communication Form Pre-[CONDITION(S)] Information dated [DATE] and completed by the facility, read shunt location status chest right Vital signs BP 108. There was no further blood pressure written on the form and it is unknow whether the reading was systolic or diastolic. The review revealed no documentation of any assessment of the catheter site having been assessed prior to being sent to the [CONDITION(S)] center. The section of the form completed by the [CONDITION(S)] center entitled, [CONDITION(S)] Center Information, read, Patient CVC bloody upon arrival cuff or catheter visible sent to hospital. Record review of CR#3's transportation log sheets for [DATE] revealed transportation was on-site at the facility at 6:51 AM and arrived at [CONDITION(S)] at 7:15 AM. The narrative notes read in part: .patient was transferred to EMS stretcher, placed on a semi-fowler position, covered with blanket and pillow to her back due to pain to lower back and trunk . Vitals were (no times were noted) ,d+[DATE] and ,d+[DATE]. When [CONDITION(S)] called for transport to return, they were still on site at 7:15 AM. Vital signs were (no times were noted) ,d+[DATE] and ,d+[DATE]. CR #3 was alert and oriented x 2. A head-to-toe assessment was done. CR #3 was covered with blanket and pillow to her back due to pain to lower back and trunk. At 7:21 AM transportation arrived at the hospital. Interview on [DATE] at 9:50 AM the Transportation EMT said on [DATE], CR #3 was transported to [CONDITION(S)]. He was the attendant who monitored CR #3's BPs several times on the trip. (EMT did not say if he checked BP prior to leaving the facility. The transportation log sheet did not indicate the time BPs were checked). He said he notified [CONDITION(S)] of her elevated BPs upon arrival. He said he did not notice anything unusual about CR #3 that day other than elevated BPs. (BPs were documented on the transportation log sheet dated [DATE]) Interview on [DATE] at 12:50 PM the outpatient [CONDITION(S)] nurse stated CR #3 was a regular [CONDITION(S)] patient. CR #3's [CONDITION(S)] schedule was Monday, Wednesday and Friday. When CR #3 tested Covid positive she had to switch to Tuesday, Thursday, and Saturday, the Covid positive patient schedule. She dialyzed on [DATE], skipped Monday [DATE] (due to Covid status, was rescheduled for [DATE]), missed [DATE](CR #3 refused), dialyzed [DATE], facility was closed on Saturday [DATE], she dialyzed on Sunday [DATE]. On [DATE], upon arrival to [CONDITION(S)], CR #3's BP was elevated. The systolic BP was above 200. Since CR #3 did not get started on [CONDITION(S)], the [CONDITION(S)] machine did not record the BP result. The CVC was partially out of the chest and the inner CVC cuff was exposed. The dressing over the catheter exit site had old-dried blood. CR #3 was sent immediately to the Hospital via primary transport. The [CONDITION(S)] NP and nursing facility was notified. Record review of hospital records dated [DATE] for CR #3 read in part, Presentation Chief complaint R chest catheter malfunction. Stated complaint HYPERTENSION, [CONDITION(S)] CATHETER OUT The review also revealed CR #3 was diagnosed with [CONDITION(S)] and Covid pneumonia. The prognosis was shared with family and she was placed on hospice. Review of the document entitled, Progress and POC Follow-Up Notes Report dated [DATE] for CR #3 read in part, UPON ARRIVAL TO UNIT, CVC CUFF VISIBLE ALONG WITH OLD BLOODY DRAINAGE TO DRESSING. PATIENT SENT TO HOSPITAL VIA PRIMARY TRANSPORTATION, NP AND NURSING HOME NOTIFIED PER CHARGE NURSE Record review of a second document entitled, Progress and POC Follow-Up Notes also dated [DATE], read in part, .sub reason for admission stroke .Pt condition declining family decided to put patient in Hospice Services, per daughter. The Summary Review further revealed CR #3 passed away per family on [DATE]. On [DATE] at 12:20 PM, a telephone call was made to LPN Z. No call back was received by exit. In a telephone interview on [DATE] at 8:00 PM LPN Q stated she works night shift 7:00 PM to 7:00 AM and she did not know if she administered [MEDICATION(S)] to CR #3 on [DATE] at 6:00 AM. LPN Q stated she did not remember what time CR #3 was picked up by transportation on [DATE], it was early. Night shift is usually the ones who send the resident out. LPN Q said CR #3 might have had a [CONDITION(S)] access on the right chest and she could not remember what it looked like the morning of [DATE]. She said to get CR #3 ready for [CONDITION(S)] she wound get paperwork, get her snack, we do vital signs and weight. This is documented on communication paper and CR #3 brings it back then the information we get from [CONDITION(S)] nurse we document in PCC (electronic health records) and then paper gets filed. When asked what she meant when she wrote BP 108 on the [CONDITION(S)] Communication Sheet for CR #3 on [DATE], LPN Q said systolic over diastolic, this is how we write it. It should have two numbers. LPN Q said it was too long ago and did not remember what the BP was. In a telephone interview on [DATE] at 4:45PM CNA G stated he works worked 6:00 AM to 2:00 PM shift. CR #3 did a lot of ADLs herself and needed little help with dressing; she wore Pjs or gown at night. CNA G when asked what CR#3's [CONDITION(S)] access looked like stated he did not remember seeing CR #3's [CONDITION(S)] access on [DATE] day shift. CNA G said he could not comment on the status of the hemodialysis catheter. On the morning of [DATE], CNA G said CR #3 would have left for [CONDITION(S)] by the time he started his shift at 6:00 AM and would not have had the opportunity to assess the status of the hemodialysis catheter. In a telephone interview on [DATE] at 5:05PM, CNA T stated she said she did work with CR #3 [DATE] to [DATE] [DATE] to [DATE] on the night shift. She was in the covid unit. She recalls she helped CR #3 to the bathroom a lot; she went frequently that night and CNA T did notify her nurse of her concern. She did not remember which nurse. That night CR #3 complained of feeling cold, was weak, did not want to remove her clothes. She just wanted to be covered up. CNA T said she did not remember seeing her [CONDITION(S)] access. She thought she had an AV fistula; she did not recall seeing a [CONDITION(S)] catheter in her chest. She said CR #3 always left early in the mornings for [CONDITION(S)]. CNA T said before she was in covid unit, CR #3 would communicate and would want to brush her hair, brush her teeth and do more. When in covid unit she did not want to do any of that, and she was always cold. In an interview on [DATE] at 12:21 PM, LPN T stated she worked 7:00 AM to 7:00 PM shift. On [DATE], night shift sent CR #3 out to [CONDITION(S)] before she started her shift. Interview on [DATE] at 12:50 PM the outpatient [CONDITION(S)] nurse stated CR #3 was a regular [CONDITION(S)] patient. CR #3's [CONDITION(S)] schedule was Monday, Wednesday and Friday. When CR #3 tested Covid positive she had to switch to Tuesday, Thursday, and Saturday Covid positive patient schedule. She dialyzed on [DATE], skipped [DATE], missed [DATE], dialyzed [DATE], facility was closed on Saturday [DATE], she dialyzed on Sunday [DATE]. On [DATE], upon arrival to [CONDITION(S)], CR #3's BP was elevated. The systolic BP was above 200. Since CR #3 did not get started on [CONDITION(S)], the [CONDITION(S)] machine did not record the BP result. The CVC was partially out of the chest and the inner CVC cuff was exposed. The dressing over the catheter exit site had old-dried blood. CR #3 was sent immediately to the Hospital via primary transport. The [CONDITION(S)] NP and nursing facility was notified. Interview on [DATE] at 9:50 AM the Transportation EMT said on [DATE], CR #3 was transported to [CONDITION(S)]. He was the attendant who monitored CR #3's BPs several times on the trip. He said he notified [CONDITION(S)] of her elevated BPs. He said he did not notice anything unusual about CR #3 that day other than elevated BPs. In a telephone interview on [DATE] at 1:45 PM, the MD said it was possible he was notified of CR #3's missed [CONDITION(S)] treatment on [DATE]. If he was notified, he said he would first ask for the reason why. He said the risks of not dialyzing would be fluid overload, electrolyte changes and possible death. In a telephone interview on [DATE] at 2:00 PM, the NP said she did not recall if she was notified that CR #3 went to theER on [DATE]. The only time she can recall being notified was when CR #3 went toER on [DATE]. She did not remember if she was notified of CR #3 missing [CONDITION(S)] on [DATE]. She said if [CONDITION(S)] was missed the MD/NP should always be notified. She would first find out why the resident refused and would instruct the nurses to monitor BPs. The risks of missing [CONDITION(S)] treatments would be fluid overload and it could be a life threatening. In an interview on [DATE] at 1:00 PM, the LPN Manager stated she ordered CR #3's [MEDICATION(S)] patch from the pharmacy on [DATE]. She said the computer was connected to pharmacy and this is how the order was placed. She said she passed it on to the oncoming nurse. She said it would have shown up on the 24-hour report (for nurses to see that it was ordered) had she clicked the 24-hour report box in the computer, but she did not do this. She said the risks of not getting [MEDICATION(S)] would be problems with BP. She gave CR #3 [MEDICATION(S)] XL on [DATE] at 6:00 PM per MAR. She said she did check CR #3's BP, but it did not pop up on vitals taken. She said it depends on how orders are entered in the system. If the add button is not selected, then special tasks such as check BP with each administration will not appear as a prompt. She said if she didn't get the [MEDICATION(S)] patch, she would call the MD to get instructions. LPN Manager did not say why she did not do call the MD when CR #3 did not receive the [MEDICATION(S)] patch. In an interview on [DATE] at 10:00 AM, LPN U stated regarding CR #3's [MEDICATION(S)] patch, she did not remember receiving report about [MEDICATION(S)] patch and it had not arrived yet on [DATE] for CR #3. She was not aware the [MEDICATION(S)] patch was ordered. Normally if a medication was not there, we would contact the pharmacy then notify MD. It would be the nurse's responsibility to get the medication here and pass on the information. In an interview on [DATE] at 1:59 PM the ADON stated CR #3 did not receive [MEDICATION(S)] on [DATE] at 6:00 AM and does not know why it was not given as there were no records. She said on [DATE] at 6:00 PM and [DATE] at 6:00 AM, the [MEDICATION(S)] doses were not given and does not know why they were not given. The ADON said if there was an administration note regarding [MEDICATION(S)] when it was due, the note would populate in the Progress notes. The ADON said she did not find Administration notes for the [MEDICATION(S)] on those dates and times. In an interview on [DATE] at 10:19 AM the RDO said she could not find CR #3's [CONDITION(S)] Communication Sheets for [DATE] and [DATE]. In an interview on [DATE] at 12:50PM, the Interim DON who started on [DATE] stated if a medication was ordered it automatically goes to the pharmacy the system. She expects the nurses to make sure it is was received and f/u; check to see if it is was in the E-kit. I expect them to give each other report; also, they should write it in the 24-hour report. The 5 rights for medication administration included if a med was skipped for some reason. The medical practitioner was in charge of audits and would match with the MAR and will then run the report, also make sure nurses were caring out the orders. In an interview on [DATE] at 12:35 PM the ADON said she has been at the facility since [DATE]. She said if the nurse sends a resident to the ER, she expects they would complete a change in condition form, write a basic nurse note: SBAR format. Transfer out and make the notifications (MD, DON, RP). There will always be a doctor order. The nurse would present the information to the MD based on change of condition. BP results should be documented in system. When the medication is selected the system will ask for supplemental documentation. If BPs are not checked along with BP medication as ordered there would be standard risks and we shouldn't give if not within parameters. If BP meds ordered for hypertension was missed the resident can be in a crisis and heart issues or stroke issues. She said the nurses understand what the risks are. Typically, the DON reviews the orders listing report. It is always the nurse responsibility to make sure orders are followed. If there's an issue the nurse is to follow up, contact the pharmacy and check on delivery status. In an interview on [DATE] at 9:25 AM, the RDO said they did not have a policy and procedure for Resident Assessment. Record review of CR #3's [CONDITION(S)] treatment log dated [DATE] revealed, treatment initiated at 9:38 AM. Pre-treatment BP was ,d+[DATE], pulse 70. [MEDICATION(S)] 0.2 mg was given orally at 10:05 AM. Treatment was terminated early per NP at 12:16 PM due to high BP. Post treatment BP was ,d+[DATE]. [CONDITION(S)] notes revealed CR #3 stated the nursing home did not give her BP medication. Post treatment data collection & assessment revealed NP was aware of patient BP, instructed [CONDITION(S)] to communicate with nursing home to give BP medication. Nursing home phone lines down. Verbal communication sent via EMS. Record review of CR #3's progress notes revealed between [DATE] at 4:47 AM and [DATE] 1at 10:39 AM there were no administration notes regarding [MEDICATION(S)]. Record review of CR #3's MAR/TAR dated [DATE] through [DATE] revealed weekly [MEDICATION(S)] patch was removed on [DATE] at 7:59 AM by LPN Manager and not replaced at 8:00 AM by LPN Manager. [MEDICATION(S)] XL 60 mg was due and not checked as administered on the following: [DATE] at 6:00 AM, [DATE] at 6:00 PM and [DATE] at 6:00 AM. Record review of CR #3's progress note revealed an order administration note written by LPN Manager with the effective date [DATE] at 3:09 PM. It read: [MEDICATION(S)] Patch Weekly 0.1 mg/24 hour, apply 1 patch transdermally one time a day every 7 days for [CONDITION(S)] and remove per schedule. Awaiting delivery. Record review of CR #3's Blood Pressure Summary revealed on [DATE] at 5:35 PM the BP was ,d+[DATE], on [DATE] at 6:51 AM the BP was ,d+[DATE]. There were no other BP results recorded after [DATE] at 6:51 AM. Record review of CR #3's progress note revealed on [DATE] at 9:14 PM, LPN Z wrote a comprehensive skilled nursing note including vital signs: BP ,d+[DATE], pulse 76, RR 18, Temp 97.6, O2 97% and pain level of ,d+[DATE] (hurts a little bit) of abdomen. Review of clinical records revealed there were no notes regarding any communication with out-patient [CONDITION(S)] unit for the elevated BPs during [CONDITION(S)] on [DATE]. Record review of the transportation log sheets for [DATE] revealed transportation was on-site at the facility at 6:51 AM and arrived at [CONDITION(S)] at 7:15 AM. The Narrative notes read in part: .patient was transferred to EMS stretcher, placed on a semi-fowler position, covered with blanket and pillow to her back due to pain to lower back and trunk . Vitals were (no times were noted) ,d+[DATE] and ,d+[DATE]. When [CONDITION(S)] called for transport to return, they were still on site at 7:15 AM. Vital signs were (no times were noted) ,d+[DATE] and ,d+[DATE]. CR #3 was alert and oriented x 2. A head-to-toe assessment was done. CR #3 was covered with blanket and pillow to her back due to pain to lower back and trunk. At 7:21 AM transportation arrived at the hospital. Record review of CR #3's progress note written by the Registered Dietician on [DATE] at 4:06 PM read in part: .reply from renal RD. [DATE] labs .K 5.1 .Hgb 10. 1 L (low) .No concerns with labs at this time . Record review of CR #3's hospital records dated [DATE] revealed she was admitted for hypertension post [CONDITION(S)]. BP in ER was ,d+[DATE], pulse 76. CR #3 was discharged the same day. On [DATE] CR #3 was admitted for [CONDITION(S)]. Per hospital records she was admitted due to positive Covid results and need for [CONDITION(S)]. Patient stated she was unsure why she was there. Per records CR #3 was evaluated and did not meet criteria for emergent [CONDITION(S)] at the time. CR #3 was discharged the same day. Record review of the top portion of the document entitled, [CONDITION(S)] Communication Form Pre-[CONDITION(S)] Information dated [DATE] and completed by the facility, read shunt location status chest right Vital signs BP 108. There was no further blood pressure written on the form and it is unknow whether the reading was systolic or diastolic. The review revealed no documentation of any assessment of the catheter site having been assessed prior to being sent to the [CONDITION(S)] center. The section of the form completed by the [CONDITION(S)] center entitled, [CONDITION(S)] Center Information, read, Patient CVC bloody upon arrival cuff or catheter visible sent to hospital. Review of the document entitled, Progress and POC Follow-Up Notes Report dated [DATE] for CR #3 read in part, UPON ARRIVAL TO UNIT, CVC CUFF VISIBLE ALONG WITH OLD BLOODY DRAINAGE TO DRESSING. PATIENT SENT TO HOSPITAL VIA PRIMARY TRANSPORTATION, NP AND NURSING HOME NOTIFIED PER CHARGE NURSE Record review of a second document entitled, Progress and POC Follow-Up Notes also dated [DATE], read in part, .sub reason for admission stroke .Pt condition declining family decided to put patient in Hospice Services, per daughter. The Summary Review further revealed CR #3 passed away per family on [DATE]. Record review of two facility in-service reports dated [DATE] and [DATE] titled [CONDITION(S)] Communication revealed topics included [CONDITION(S)] policy and procedures must be followed; proper communication; follow MD and Nephrologist orders; change of condition; vital signs; lab results. In-services were conducted by the NP Clinical Specialist as well as the DON at the time. The review revealed nursing staff signatures on sign in sheets. The review revealed a QAPI Committee meeting was conducted [DATE] specifically to address the [CONDITION(S)] IJ. Record review of hospital records dated [DATE] for CR #3 read in part, Presentation Chief complaint R chest catheter malfunction. Stated complaint HYPERTENSION, [CONDITION(S)] CATHETER OUT . The review also revealed CR #3 was diagnosed with [CONDITION(S)] and Covid pneumonia. The prognosis was shared with family and she was placed on hospice. Record review of the facility policy and procedure titled Hemodialysis, Copyright 2020 The Compliance Store, LLC and date implemented on [DATE] revealed i

Based on observations, interviews, and record reviews, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of two residents (CR #3 and Resident #1) reviewed for pharmacy services as evidenced by: The facility failed to ensure Resident #1's medications were separately administered via G-tube. The facility failed to ensure all of CR #3's medications were administered as ordered by the physician resulting in multiple omitted doses of two medications. This failure could place residents at risk of not receiving medications as ordered by their physicians and exacerbations of their medical conditions. Findings included: CR #3 Record review of CR #3s face sheet revealed the [AGE] year-old female resident was readmitted to the facility on [DATE] and effectively discharged on [DATE] at which time she was transferred to the hospital from her off-site [CONDITION(S)] center. The review revealed CR #3 had the following diagnoses: [CONDITION(S)], dependence on renal [CONDITION(S)], hypertensive heart disease with heart failure, congestive heart failure. Record review of CR #3's physician orders revealed the following orders: [MEDICATION(S)] patch weekly 0.1 mg/24 HR apply 1 patch trans-dermally one time every 7 day(s) for [CONDITION(S)] and remove per schedule. The [MEDICATION(S)] was ordered on 10/16/21 and was a current order. [MEDICATION(S)] XL Tablet Extended Release 24-hour 60 MG ([MEDICATION(S)] ER Osmotic Release. Give 1 tablet by mouth every 12 hours for [CONDITION(S)] Hold for SBP less than 110 and HR less than 60, order start date 11/25/21. There was no physician order to hold [MEDICATION(S)] at any time. Record review of CR #3's care plan for hypertension read, Focus has hypertension ([CONDITION(S)]) r/t CHF Date initiated 10/18/2021 Revision on 10/18 2021 Goal .will remain free of complications related to hypertension through review date .Target Date 01/16/2022 Interventions Give anti-hypertensive medications as ordered. Monitor for side effects such as [CONDITION(S)] and increased heart rate ([CONDITION(S)]) and effectiveness .Monitor document/report PRN any s/s of malignant hypertension: headache, visual problems, confusion, orientation, lethargy, nausea and vomiting, irritability, [CONDITION(S)] activity, difficulty breathing (Dyspnea) Date initiated: 10/18/2021. Review of CR #3's care plan for [CONDITION(S)] services read, Focus .needs [CONDITION(S)] r/t renal failure Date initiated 9/22/2021 Revision on 9/23/2021 Goal .will have no s/s of complications from [CONDITION(S)] through the review date. Interventions [CONDITION(S)]: Palpate AV shunt-check for Bruit and Thrill per MD's orders Encourage resident to go for the scheduled [CONDITION(S)] appointments. Resident receives [CONDITION(S)] ( .M-W-F 6am) Monitor labs and report to doctor as needed. Monitor VITAL SIGNS per MD's orders. Notify MD of significant abnormalities.Focus .needs [CONDITION(S)] r/t renal failure D CR #3 was dialyzed on 12/24/21, 12/30/21 and on 1/2/22. CR #3 refused [CONDITION(S)] on 12/28/21.09/23/2021 Interventions read, Monitor/document/report PRN any s/s of infection to access site: Redness, Swelling, warmth or drainage. Monitor/document/report PRN for s/s of renal insufficiency, changes in level of consciousness, changes in skin turgor, oral mucosa, changes in heart and lung sounds. Monitor/document/report PRN for s/s of the following: Bleeding, Hemorrhage, Bacteremia, Septic shock. Record review of CR #3's MAR/TAR dated 1/1/2022 through 1/31/2022 revealed weekly [MEDICATION(S)] patch was removed on 01/01/2022 at 7:59 AM by LPN Manager and was not replaced at 8:00 AM by LPN Manager. [MEDICATION(S)] XL 60 mg was due and not checked as administered on the following: 01/01/22 at 6:00 AM, 01/02/22 at 6:00 PM and 01/04/22 at 6:00 AM. Record review of CR #3's progress notes revealed between 01/01/22 4:47 AM and 01/04/22 10:39 AM there were no administration notes regarding [MEDICATION(S)]. Record review of CR #3's progress note revealed an order administration note written by LPN Manager with the effective date 01/01/2022 at 3:09 PM. It read: [MEDICATION(S)] Patch Weekly 0.1 mg/24 hour, apply 1 patch trans-dermally one time a day every 7 days for [CONDITION(S)] and remove per schedule. Awaiting delivery. In a telephone interview on 2/09/22 at 8:00 PM LPN Q stated she works night shift 7:00 PM to 7:00 AM and she did not know if she administered [MEDICATION(S)] to CR #3 on 01/04/21 at 6:00 AM. In an interview on 02/03/22 at 1:00 PM, the LPN Manager stated she ordered CR #3's [MEDICATION(S)] patch from the pharmacy on 01/01/22. She said the computer was connected to pharmacy. She said she passed it on to the on-coming nurse. It would have shown up on the 24-hour report had she clicked the 24-hour report box in the computer. She said the risks of not getting [MEDICATION(S)] would be problems with BP. She gave CR #3 [MEDICATION(S)] XL on 01/01/22 at 6:00 PM per MAR. She said if she didn't get the [MEDICATION(S)] patch, she would call the MD to get instructions. LPN Manager did not say why she did not do this. In an interview on 02/08/22 at 10:00 AM, LPN U stated regarding CR #3's [MEDICATION(S)] patch, she did not remember receiving report that [MEDICATION(S)] patch had not arrived yet on 01/01/22 for CR #3. Normally if medication was not there, they would contact the pharmacy then notify MD. It would be the nurse's responsibility to get the medication here and pass son the information. Record review of Pharmacy Delivery Manifest revealed on 12/25/21 at 3:19 PM, one [MEDICATION(S)] patch for CR #3 was delivered to the facility. In an interview on 02/08/22 at 11:20AM, the Pharmacist said the last time a [MEDICATION(S)] Patch for CR #3 was sent to the facility was on 12/25/21 and it was one patch. In an interview on 02/10/22 at 1:59 PM the ADON stated CR #3 did not receive [MEDICATION(S)] on 01/01/22 at 6:00 AM and does not know why it was not given as there were no records. On 01/02/22 at 6:00 PM and 01/04/22 at 6:00 AM, the [MEDICATION(S)] doses were not given and does not know why they were not given. The ADON said if there was an administration note regarding [MEDICATION(S)] when it was due, the note would populate in the Progress notes. The ADON said she did not find Administration notes for the [MEDICATION(S)] on those dates and times. In an interview on 02/08/22 at 12:50PM the Interim DON who started on 02/01/22 stated if a med was ordered it automatically goes to the pharmacy the system. She expects the nurses to make sure it was received and f/u; check to see if it is in the E-kit. She expected them to give each other report. Also, they should write it in the 24-hour report. The 5 rights for medication administration included if a med was skipped for some reason. The medical practitioner was in charge of audits and would match with the MAR and will then run the report, also make sure nurses were caring out the orders. In an interview on 02/10/22 at 12:35 PM the ADON said if BP medications ordered for hypertension was missed the resident can be in a crisis and heart issues or stroke issues. She said the nurses understand what the risks are. Typically, the DON reviews the orders listing report. It is always the nurse responsibility to make sure orders are followed. If there's an issue the nurse is to follow up, contact the pharmacy and check on delivery status. Resident #1 Record review of Resident #1's admission record revealed a [AGE] year-old-female admitted on [DATE] with diagnoses to include [CONDITION(S)] status, gastrostomy status, anxiety/depressive disorder, psychotic disorder, respiratory failure, and aphonia (inability to speak due to damage to larynx). Record review of Resident #1's admission MDS dated [DATE] revealed a BIMS score of 13 indicating she was cognitively intact. She required extensive assistance with two person assist for bed mobility. She was totally dependent on staff for intake of nourishment and toilet use. She required extensive assistance with one person assist for transfers, dressing and personal hygiene. The swallowing/nutritional status section of the MDS indicated she had a feeding tube while she was not a resident as well as while she was a resident. The special treatments section of the MDS indicated she required oxygen therapy, suctioning, [CONDITION(S)] care, invasive and non-invasive mechanical ventilator tube while she was not a resident as well as while she was a resident. Record review of Resident #1's care plan, last reviewed on 12/07/21 revealed care plans for requiring tube feedings r/t to difficulty swallowing; [CONDITION(S)] status and ventilator dependent r/t respiratory failure; ADL self-care deficit r/t confusion and limited mobility; communication deficit r/t aphonia. Record review of Resident #1's active physician orders as of 02/08/2022 revealed an order for the following: Loratadine 10 mg give 1 tablet one time a day for allergy symptoms; Famotidine 20 20 mg give 1 tablet via PEG-Tube two times a day for acid indigestion. [MEDICATION(S)] 1000 mg tablet via PEG-Tube two times a day for seizures: start date 07/16/21. [MEDICATION(S)] Solution 1000 mg/ml give 10 ml two times a day start date: 02/08/2021. [MEDICATION(S)] 10 mg tablet give 1 tablet via PEG-Tube two times a day for [CONDITION(S)]. [MEDICATION(S)] 60 mg tablet give 1 tablet via PEG-Tube 3 times a day for [CONDITION(S)]. [MEDICATION(S)] Sodium tablet 100 mg via PEG-Tube one time a day for constipation. [MEDICATION(S)] 30 mg/0.3 ml inject 30 mg subcutaneously one time a day for blood thinner. Record review of Resident #3's MAR/TAR for February 2022 revealed the following medications were administered on 02/08/2022 at 9:00 AM by LPN AA: Loratadine 10 mg tablet [MEDICATION(S)] Solution 1000 mg/ml give 10 ml, [MEDICATION(S)] 10 mg tablet, [MEDICATION(S)] 60 mg tablet, [MEDICATION(S)] Sodium tablet 100 mg [MEDICATION(S)] 30 mg/0.3ml injectable. Observation and interview on 02/08/22 at 8:45 AM, LPN AA prepare Resident #1's medications. LPN AA combined the tablets into one plastic pouch and crushed. She went to the sink and added 90 ml of warm water to drinking cup, added the crushed tablets and stirred. She paused the TF pump and disconnected tubing from PEG-Tube. Resident #1 was alert and sitting up in bed with the head of bed raised behind her. Towel was placed under PEG-Tube, LPN AA checked placement by injecting 20-30 cc of air via syringe, placed bell of stethoscope over abdomen near PEG listened with stethoscope; then aspirated; minimal formula was aspirated, and formula was pushed back into PEG-Tube. She attached syringe without plunger and poured 20-30 cc warm water. Water was not moving via gravity after unclamping the PEG-Tube. She then milked the tubing, gently pushed 20-30 cc air via syringe and instilled via gravity 20-30 cc of warm water. She poured dissolved meds into barrel of syringe and allowed to infuse via gravity. She flushed with 20-30cc water; administered the liquid [MEDICATION(S)] ([MEDICATION(S)]) then flushed with 30 cc water and reconnected TF restarting the TF pump. She Administered [MEDICATION(S)] injection to Resident #1's right abdomen. LPN AA said she had been doing this for [AGE] years and had always combined crushed tablets because she knows which medications should not be combined. She did not know what the facility's policy and procedure was for administration of medications via PEG-Tube. In an interview on 02/08/2022 at 11:00 AM, LPN AA checked Resident #1's order in the computer for [MEDICATION(S)] and said the liquid form was what was in the cart. She searched and said there was no [MEDICATION(S)] in tablet form for Resident #1. She said she would get the order changed from tablet to liquid form. An interview was not attempted with Resident #1 regarding the administration of the combined crushed medications via PEG-Tube in order to avoid unnecessary distress to the resident. Resident #1's diagnoses included anxiety, depressive and psychotic disorder. In an interview on 02/08/2022 at 12:50PM the Interim DON said most of the medications they do not mix them together and there should be flush in between the medicines even the liquid medications. She said that was done to make sure there was no interaction between medications and to make sure the resident gets the full dose. In an interview on 02/08/22 at 2:00 PM, the RDO said she heard about LPN AA mixing the medications and administering via PEG-Tube for Resident #1 and the [MEDICATION(S)] given was the wrong form (liquid vs tablet). The RDO shook her head when asked what should have occurred. RDO did not verbally answer the question. The RDO said the plan was to conduct Ad-Hoc QAPI on medication administration via PEG-Tube and to write a medication error report including for the liquid [MEDICATION(S)] and for follow up on orders. Record review of facility incident report for Resident #1 dated 02/08/22 at 3:38 PM and prepared by LPN AA read: Nursing Description: This writer administered [MEDICATION(S)] liquid that was not in the cart instead of [MEDICATION(S)] tablet that was on the EMAR. This writer also gave all the tablets crush together and staff was in-serviced. NP called and notified. Have orders to change tablet to liquid per PEG Tube. Resident #1's RP was notified. No injuries observed at time of incident. Record review of facility policy and procedure for Medication Administration via Enteral Tube dated 2021 read in part: It is the policy of this facility to ensure the safe and effective administration of medications via enteral feeding tubes by utilizing best practices. Policy Explanation and Compliance Guidelines: .6. Each medication will be administered separately, not combined or added to an enteral feeding formula . Record review of facility's policy and procedure for Medication Reordering, dated 2021 read in part: It is the policy of this facility to accurately and safely provide or obtain pharmaceutical services including the provision of routine and emergency medications and biologicals in a timely manner to meet the needs of each resident Policy Explanation and Compliance Guidelines: 1. The facility will utilize a systematic approach to provide or obtain routine and emergency medications and biologicals in order to meet the needs of each resident. 2. Acquisition of medications should be completed in a timely manner to ensure medications are administered in a timely manner. 3. Each time a nurse is administering medications and observes (6) or less doses left of one kind, that nurse will reorder the medication, time permitting 4. The facility will consider factors indicating errors in medication administration, including, but not limited to the following: a. Medication administration not in accordance with the prescriber's order. Examples include, but not limited to: i. Incorrect dose, rout of administration, dosage form, time of administration; ii. Medication omission; iii. Incorrect medication .6. Medication administration observations will be conducted periodically to evaluate facility medication administration practices. 7. To prevent medication errors and ensure safe medication administration, nurses should verify the following information: a. Right mediation, dose, route and time of administration . Record review of the facility's policy and procedure for Medications Errors, dated 2021 read in part: It is the policy of this facility to provide protection for the health, welfare, and rights of each resident by ensuring residents receive care and services safely in an environment free of significant medication errors. Definitions: Medication error means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order or accepted professional standards and principles which apply to professionals providing services Policy Explanation and Compliance Guidelines: 1. The facility shall ensure medications will be administered as follows: a. According to physician's orders. b. Per manufacturer's specifications regarding the preparation, and administration of the drug or biological. c. In accordance with accepted standards and principles which apply to professionals providing services 5. Medication timing errors will be determined by utilizing the facility's policy relating to dosing schedules. 6. Medication administration observations will be conducted periodically to evaluate facility medication administration practices 8. If a medication error occurs, the following procedure will be initiated: a. The nurse assesses and examines the resident's condition and notifies the physician or health care practitioner as soon as possible .

Based on observation , interview and record review, the facility failed to obtained laboratory services as ordered by the physician and report results in accordance with facility policy and procedures for notification for 3 of 3 residents (Resident #47, #296, #61) reviewed for notification of lab results. The facility failed to recheck Hgb level for Resident #47, #296 and #61 as ordered by the NP when previous Hgb lab values for all three [CONDITION(S)] residents were low/abnormal. Following Surveyors intervention, Resident #47, #296 and #61 were transported to the hospital for evaluation of their critical Hgb labs values which were confirmed to be low at the hospital. Resident #47, and #61 remained hospitalized until survey exit while #296 returned to the facility. An Immediate Jeopardy (IJ) was identified on 9/24/21. While the IJ was removed on 9/27/21, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern because the facility continued to train staff and monitor the effectiveness of the Plan of Removal. These deficient practices could place residents at risk of decline in health from not having their laboratories identified and addressed promptly. Resident #47 Review of Resident #47's MDS assessment, dated 08/12/21, reflected she was admitted to the facility on [DATE] readmitted , was a [AGE] year-old female, was severely cognitively impaired, and her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of progress note written NP A b y for Resident #47, dated 09/23/21, reflected the following, resident goes to [CONDITION(S)] Monday, Tuesday, Wednesday, Thursday, Friday in house [CONDITION(S)]. Record review of laboratory (Lab) results dated 9/8/21 indicated Resident #47's hemoglobin (Hgb) was 6.6 g /dl (normal range 12.9 -16.0 g/dl,) which was (critical), there was no documentation that the M.D/NP was notified. During an with Interview with the NP on 9/23/21 at 12:30 PM, she said she told the [CONDITION(S)] nurse ( RN AA ) and the DON about the critical lab and wanted it repeated before Resident #47 was dialyzed. There was were no documentation that [CONDITION(S)] was held, and lab was repeated from 9/9/21 till today (9/23/21) and Resident #47's Hgb was 5.5 m/dl, (Critical), and Resident #47 was transferred to hospital due to the critical labs. NP said she gave a verbal order on 9/9/21 for [CONDITION(S)] to be held and lab repeated. Interview with RN AA on 9/23/21 at 3:55 PM , she confirmed that Resident # 47 with low Hgb was were being dialyzed Monday through Friday. RN AA said the facility DON knew about the low Hgb and Resident #47's needed the Hgb repeated before being dialyzed. RN AA said she did not check for the lab before dialyzing Resident #47 on from 9/9/21, 9/10/21, 9/13/21, 9/14/21, 9/15/21, 9/16/21, 9/17/21, 9/20/21, 9/21/21, 9/22/21 and 9/23/21 (11 days). During an interview with the DON on 9/23/21 at 4:20 PM, regarding repeating critical Hgb of (6.6 mg/dl) for Resident #47 on 9/8/21. She DON said she was not aware of the lab order and RN AA did not bring it to her attention. Record review of a Resident #47's hospital ER assessment on 9/23/21 at 5:00 PM and lab for Resident #47 revealed the Hgb was 5.6 g/dl (LL) =( normal range12.0-16.0g/dl) and the HCT 18.2 (Hematocrit) (Low) ( range with 37-47%). Resident #47 was still in the hospital on 9/29/21. Resident #296 Record review of Resident # 296 Admission Record dated 09/24/21 revealed Resident #296 was [AGE] years-old and was admitted to the facility on [DATE]. Resident #296's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #296's Admission Minimum Data Set (MDS) assessment, dated 07/26/2021, revealed Resident #296 was severely cognitively impaired with a BIMS score of 0 and required extensive assistance from staff for bed mobility, and total dependence with dressing, toilet use, and personal hygiene. Observation on 09/21/21 at 10:10 AM, Resident #296's room the resident was out for [CONDITION(S)], feeding tube formula was on the table, canister on the bedside table had bloody secretions' that was suctioned from resident. Record review of Resident #296's physician orders revealed that Resident #296 had a [CONDITION(S)], feeding tube and was on [CONDITION(S)] 5 times per week. Further review of Resident #296's physician orders revealed order for medication of [MEDICATION(S)] 2.5mg daily via G- Tube. Record review of Resident #296's care plan dated 07/22/21 and was not revised with the resident medication [MEDICATION(S)] 2.5gm and the bleeding condition during suctioning. During an interview with the respiratory therapy director on 09/22/21 at 12:00 PM, he said that he had 12 staff under his supervision that work 12-hour shifts. He said that he was aware of Resident #296's bloody secretions and he notified the nurses but did not notify the physician. He said he does not know the cause of the bleeding but in most cases it's because of suctioning too much, not having enough humidity or positioning. He said that Resident #296 may need to have a scope to be able to know what was causing the bleeding and he had not been seen by a pulmonologist for the bleeding. He said that the resident had the episodes of bloody secretions during suctioning on and off since admission to the facility A record review of labs hematology collected on 09/07/21 and received on 09/08/21 results indicated the hemoglobin of 6.6 normal range was indicated as 13.7 -17.5. Another hematology collected on 09/09/21 and received on 09/09/21 results indicated hemoglobin of 7.8. Hematology collected on 09/21/21 results received on 09/23/21 hemoglobin results indicated 6.9. During an interview with RN [CONDITION(S)] nurse dialyze direct in-house [CONDITION(S)] on 9/23/21 at 9:01 PM, she said that they had 8 residents on the in -house [CONDITION(S)] and they had [CONDITION(S)] five times per week. She said that the residents they had [CONDITION(S)] five times a week because the [CONDITION(S)] machine they were using was a home [CONDITION(S)] machines that usually were used for stable patients who can walk and had less fluids. She said that [CONDITION(S)] communication sheet was facility's responsibility to fill the pre and the [CONDITION(S)] filled out the post [CONDITION(S)] portion and they have been instructed to leave them in the [CONDITION(S)] room and the unit manager picked them up. She said that she has not conducted any training with the nursing staff. She said that she would not recommend for residents that are not stable to use the [CONDITION(S)] machine that they had because it not for unstable patients. She said that when she observed something that is not normal in residents at [CONDITION(S)], she alerted the facility, the company nurse practitioner, and the [CONDITION(S)] nurse practitioner would notify the nephrologist. she reports she gave lab results for Resident #296 dated 9/8/21 with critical Hgb to ADON B and informed her verbally that lab for Hgb needed to be redrawn prior to next [CONDITION(S)] day. She said she never heard from the ADON B with the results, so they contained the next day to dialyze Residents #296. She said that the policy in the [CONDITION(S)] center is when the hemoglobin is less 7, they order a repeat lad and hold [CONDITION(S)] until they get the results. She said that she continued to [CONDITION(S)] for Resident #296 because she never heard back from ADON B and she never followed up with her to see if the results were received. She said that on 09/21/21 the [CONDITION(S)] nurse practitioner ordered hematology lab again and the results indicated that hemoglobin was 6.9 and the [CONDITION(S)] nurse practitioner recommended for Residents#296 to be sent out to the hospital. Interview with the nurse practitioner for the [CONDITION(S)] company on 9/23/21 at 10:31 AM, she said she saw the residents once per month, but the [CONDITION(S)] nurse would communicate with her via phone if there were any changes in residents from her last visit. she said that when hemoglobin levels drop below 7 their policy was to repeat the labs and if the results indicated low level, they recommended to send residents out to the hospital for transfusion. She said that when the RN [CONDITION(S)] nurse reported recommendation to the facility to repeat the lab the facility did not repeat the labs and or communicate back with [CONDITION(S)] that is why she ordered more lab on 09/21/21 for Resident #296 and the results on 09/23/21 were hemoglobin 6.9 and she recommended for Resident # 296 to be sent out to the hospital. Interview on 09/24/21 at 12:00 PM, the ADON said that the RN [CONDITION(S)] nurse communicated to her and if the unit manager is not available, she communicated with the charge nurses working on the halls. She said that when she got the information from the RN [CONDITION(S)] nurse, she gave the information to the charge nurses if it was not critical information. She said that when what they communicated to her by the RN [CONDITION(S)] nurse was critical, she would notify the physicians. She said that when the lab results were received on 09/08/21 they repeated the lab on 09/09/21 the results were still low but she did not communicate with [CONDITION(S)] RN to let her know about the results and she does not know if the floor nurse communicated the results. She said that the correct procedure was to report the results to [CONDITION(S)] nurse so that they knew what the repeat lab results were. Interview on 09/24/2021 at 12:15 PM, the DON she said that she reviews referrals but when they are [CONDITION(S)] the clinicals are sent to the [CONDITION(S)] company and the nephrologist will approve the clinicals. She said that they started in -house [CONDITION(S)] on 08/01/21 and the company approved the clinicals and notified the facility to admit the residents. She said the medication that residents receive at [CONDITION(S)] they have a communication sheet that they use to communicate with the [CONDITION(S)] center, but she had not followed up and she did not know if medications were administered in [CONDITION(S)]. She said that she did not know that the medication administered at [CONDITION(S)] was supposed to be on the resident medication profile or the care plan. She said that it was her responsibly to follow up with the nurses, unit managers and the [CONDITION(S)] nurse regarding the [CONDITION(S)] treatment and update. She said she was aware of the low hemoglobin for Resident #296, but she was not sure if the nurses repeated the labs and reported back to [CONDITION(S)]. She said she did not follow up with the nurses and the unit manages and moving forward she was going to put in place a new way to communicate to the [CONDITION(S)] staff and following up with the charge nurses and the unit managers. She said that she knew that the results received on 09/23/21 were low and Resident #296 was sent out to the hospital Resident #61 Record review, to include physician orders, laboratory reports and Minimum Data Set (MDS) revealed the facility admitted Resident #61 on 06/23/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed Resident #4 's BIMS score as 0, which indicated the resident was not able to be interviewed. A further review of the MDS revealed the facility assessed Resident #61 as needing [CONDITION(S)] five (5) out of five (5) days a week during the assessment period. A review of Resident #61's computerized physician orders (CPO) revealed no order for labs drawn on 09/07/2021 with reported Hemoglobin (Hgb)=4.6g/dL Normal range 11.2-15.7g/dL. A record review of the Medical Administration Record (MAR) dated 09/24/2021 revealed the [CONDITION(S)] facility gave [CONDITION(S)] on 09/08/2021, then resident sent to hospital on 09/09/2021. A review of Resident #61's computerized physician orders (CPO) dated 00/00/00 revealed the resident had orders for Complete Blood Count (CBC), Basic Metabolic Panel (BMP) and STAT CBC on 09/23/2021, no record of lab being obtained was noted on the chart. A review of the Minimum Data Set (MDS) record revealed on 9/9/21 eINTERACT in PointClick Care (PCC) shows Transfer form V4.1 for discharge to hospital. On 9/7/21 Resident #61 had a hemoglobin level of 6.9 and was sent out to the hospital on 9/21/21 with a hemoglobin level of 6.7 following surveyor intervention. The facility failed to follow physician order, requesting lab orders that were need based on resident's diagnostic and monitoring needs and processing test requisitions and arrange for tests due to low hemoglobin found by in facility [CONDITION(S)] laboratory results During an interview on 9/24/21 at 9:10 AM, the Administrator reported he and the DON are responsible for requesting and monitoring labs for residents that receive [CONDITION(S)] within facility [CONDITION(S)] center. [NAME] reports: in facility [CONDITION(S)] center has a different process and the in-facility [CONDITION(S)] center's lab company is Ascend Clinical, will draw routine labs but not sure of the process. [NAME] lab company comes when [NAME] calls for lab draws. [NAME] reports he does not know how critical labs are monitored and directed investigator to director of nurses. During an interview on 9/27/21 at11:45 AM, the [CONDITION(S)] RN with DCD, reported she gave lab dated 9/8/21 with critical Hgb for Resident #61 to LPN B (primary care nurse) and informed her verbally that lab for Hgb needed to be redrawn prior to next [CONDITION(S)] day. Per in house [CONDITION(S)] policy Hgb will be above 7 g/dL. [CONDITION(S)] RN produced document from her computer with lab results and that Hgb needed to be redrawn. During an interview on 9/27/21 at 12:30 PM, LPN B was asked if she received lab request from the [CONDITION(S)] RN, she was not able to remember ever receiving labs from the [CONDITION(S)] center or any verbal request for drawing Hgb lab. She reported she did not call the MD for any orders as she had not been notified of need. A review of the facility policy titled, Lab and Diagnostic Test Results-Clinical Protocol, last revised November 2018, revealed, The center is responsible for the timeliness of the services. The Director of Nursing (DON)/designee will be responsible for requesting lab orders when there is a need based on resident's diagnostic and monitoring needs and will process test requisitions and arrange for tests. The DON/designee will be responsible to notify the MD when a lab result is not received in a timely manner. The facility Administrator was informed that an Immediate Jeopardy (IJ) was identified on 9/24/21 at 6:25pm. IJ template was provided and plan of removal was requested. A Plan of Removal was accepted on 9/27/21 at 4:15pm after several revisions. The plan of removal included the following: Resident #296 is no longer in the facility. Resident #47 and # 61 is no longer in the facility. Residents #296's heir attending physicians were notified of the alleged deficiency on 9/24/21. There was no new order obtained. On 9/24/2021, the DON (director of nursing) completed an audit of all laboratory orders and most recent laboratory results of the eight (8) residents on hemodialysis. The audit was completed after the IJ was called. The results of the audit were documented on the QI tools titled, [CONDITION(S)] Communication Audit Tool. There was no concern identified. The audits were completed before midnight on 9/24/2021. Ad-Hoc QAPI meeting was held on 9/24/2021, with the Medical Director, NHA (Nursing Home Administrator), VP of Patient Services from [CONDITION(S)] company and DON to review the alleged deficiencies, policy and procedure, and the plan for removal of immediacy. The policy pertaining to hemodialysis was reviewed on 9/24/2021 by the DON, NHA (Nursing Home Administrator) and Medical Director. The policy includes, but not limited to compliance guidelines related to ongoing communication and collaboration of the [CONDITION(S)] unit staff and the nurses in the unit. As of 9/24/2021, a new protocol was developed by the QAPI team related to the [CONDITION(S)] communication. Starting on 9/25/2021, the facility will use a revised [CONDITION(S)] communication form. The licensed nurse will complete the portion related to: Additional Information such as Changes in condition, physician order changes, new labs since last visit. Before the return of the resident to the unit after [CONDITION(S)] treatment, the [CONDITION(S)] nurse will complete the portion of the [CONDITION(S)] communication related to: Additional Information - Changes in condition, medications administered, labs drawn, lab results, and new MD Orders/Recommendations. In addition, the facility and [CONDITION(S)] staff will also conduct a [CONDITION(S)] huddle meeting during scheduled [CONDITION(S)] treatments. The meeting minutes will documented in the [CONDITION(S)] Huddle Meeting Minutes form. The [CONDITION(S)] staff and facility clinical team will discuss items which will include but not limited to: i) changes in condition during [CONDITION(S)], ii) new physician order changes, iii) new labs orders and iv) any recommendations from the [CONDITION(S)] staff. The facility will follow the Policy for Change of Condition. The facility will contact the primary care physicians, the families and the nephrologists. These communications will take place after facility has been notified of changes from [CONDITION(S)]. Licensed staff will complete change of condition in the EMR system. Care plan nurse will update the care plan. Nursing staff will carry out care plans. The clinical management team and [CONDITION(S)] staff will be trained by the DON/designee on the above-mentioned policies and procedures and revisions, focusing on communication to ensure labs are done timely as ordered. The training will also include but not limited to: providing or obtaining laboratory services to meet the needs of its residents, the staff's responsibility to ensure quality and timeliness of laboratory services and carrying out lab orders. The training was initiated on 9/24/2021 and will be completed on 9/25/2021. Clinical management team/[CONDITION(S)] staff will not be allowed to work until they receive the training. The DON will monitor compliance by completing audit of three (3) [CONDITION(S)] residents per week for four (4) weeks. This was initiated on 9/25/2021. Any identified concern will be addressed immediately and if trends and patterns are identified, the facility will conduct an Ad-Hoc QAPI meeting to discuss if additional interventions are needed to ensure compliance. The Administrator will be responsible to ensure this plan is completed on 9/29/2021. The surveyors monitored the Plan to lower the Immediately Jeopardy as follows: Record review of the facility roster dated 9/28/21 revealed the DON completed an audit of all residents to verify new laboratory [CONDITION(S)] were identified and proper assessments were completed. The form revealed there was no findings of change in conditions not identified. Interview with facility Administrator on 09/28/21 at 4:00pm, the facility Administrator said the facility should have done a proper follow up with residents on in house [CONDITION(S)] with the [CONDITION(S)] company. He said a new form indicating what went on at [CONDITION(S)] had been developed and is being implemented. He said starting from 09/28/21, there will be a weekly meeting with the facility staff and the [CONDITION(S)] staff to discuss all resident's on inhouse [CONDITION(S)] and their progress. He said the IJ incident occurred due to lack of proper communication between the [CONDITION(S)] company and facility staff. He said all nursing personnel would be trained on assessing all resident' before and after [CONDITION(S)] that includes, weights, vital signs, [CONDITION(S)] shunt, and what medication was given pre and post [CONDITION(S)] as well as monitoring resident's intakes. Record review of facility monitoring tool started on 9/28/21 revealed the DON was monitoring what residents had a change in condition, laboratory services order and result of any critical labs what the change was and when it was noted, if the MD/NP was notified, if there was orders given and were they carried out and whether there was any concern identified with the procedure for the particular change in condition. Record review of facility monitoring tool started on 9/27/21 revealed DON was monitoring 24-hour reports and whether nursing staff were reporting and identifying change in conditions on the report and if nursing staff had communicated and followed up on changes on the next shift. The Administrator and DON were notified the IJ was removed on 9/27/21 at 4:15 PM. However, the facility remained out of compliance at a severity of level of actual harm that is not immediate jeopardy and a scope of pattern due to the facility needing more time to monitor the plan of correction effectiveness.

Based on observation, interview, and record review the facility failed to ensure residents who require [CONDITION(S)] receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 3 of 9 residents (Resident #297) reviewed for in house [CONDITION(S)]. The facility failed to have a system that ensured residents are assessed prior to admission to ensure [CONDITION(S)] offered at facility will meet their needs. The in-house [CONDITION(S)] machine was not capable of removing fluid from unstable [CONDITION(S)] for Resident #297 with end stage [CONDITION(S)]. The facility failed to establish an effective alternative way to dialyze Resident #297 when it was determined the in-house [CONDITION(S)] offered did not met the resident's [CONDITION(S)] needs. The facility failed to have systems in place where care provided to the residents through the [CONDITION(S)] contracted service was communicated to the facility and primary care physician to ensure continuation of care. The [CONDITION(S)] contractor did not follow physician's orders concerning obtaining labs, holding [CONDITION(S)] until lab results received and analyzed, notify the facility immediately when critical labs were reported. The facility failed to have a system in place to monitor the services provided by the in house contracted [CONDITION(S)] center. An Immediate Jeopardy (IJ) was identified on 9/25/21. While the IJ was removed on 9/27/21, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern because the facility continued to train staff and monitor the effectiveness of the Plan of Removal. This failure could place residents who received in house [CONDITION(S)] at risk for complications and not receiving proper care and treatment to meet their needs. Findings included: Resident #297 Record review of Resident #297's Admission Record dated 09/24/21 revealed she was a [AGE] year-old female admitted on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #297's Quarterly Minimum Data Set (MDS) assessment, dated 08/27/2021, revealed Resident #297 was severely cognitively impaired with a BIMS score of 0 and required total assistance from staff for bed mobility, transfers, locomotion, dressing, toilet use, and personal hygiene. During an interview on 09/21/21 at 10:21 AM, Resident #297's family member said she felt like the [CONDITION(S)] company was not doing a good job with Resident #297's [CONDITION(S)]. She said the resident had [CONDITION(S)](low blood pressure) when she went to [CONDITION(S)] her BP dropped and she was unable to complete [CONDITION(S)] and she felt like that had caused Resident #297to have a lot of fluids. She said that Resident #297 was on a medication to raise the blood pressure, but she did not know the name of the medication and the medication was PRN (As needed), but was changed to a scheduled dose. Resident #297's family member said she wanted the medication to be PRN as well so when Resident #297's blood pressure dropped; she can have the medication. She said she talked to the administrator and the DON and they said they were going to talk to the [CONDITION(S)] nurses. She said Resident #297 admitted with fluid to both arms, but it had gotten worse. She said she thought the [CONDITION(S)] nurses and the facility didn't care concerning Resident #297's [CONDITION(S)] and the fluids she had accumulated as a result of [CONDITION(S)] not pulling enough fluids off. During an observation on 09/21/21 at 10:30 AM, Resident #297 with [CONDITION(S)], ventilator, feeding tube and 4+ [CONDITION(S)] to bilateral (both arms) upper extremities. Record review of Resident #297's physician orders revealed she had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of nurse notes dated 08/08/21,08/23/21, 09/04/21,09/13/21 and 09/14/21 revealed Resident #297 had +3 [CONDITION(S)] and +4 documented on 07/23/21. Record review of Resident #297's care plan dated 00/00/00 revealed that the centered care was not addressing [MEDICATION(S)] 10mg (1) tablet via feeding tube every 8 hours for [CONDITION(S)] and the 3+ [CONDITION(S)]. Further review revealed Resident #297 needs [CONDITION(S)] related to end stage renal disease goal to have no sign and symptoms of complication from [CONDITION(S)], interventions to monitor input and output, monitor labs and report to physicians as needed. During an interview on 09/22/21 at 01:38 PM, the primary physician for Resident #297 said he was aware of the [CONDITION(S)] to the upper extremities and he ordered Dopplers last week not sure about the date. He said on 09/21/21 at night he received a call that Resident #297 was not doing well so they ordered to send her out for fluid overload. He said he was not sure why Resident #297 received [CONDITION(S)] 5 times per day it was the nephrologist that ordered it. He said that he was not sure if labs were ordered but his nurse practitioner will be able to answer the questions. During an interview on 09/22/21 at 03:07 PM, the NP said she was aware of Resident #297's [CONDITION(S)] and the difficulty with [CONDITION(S)]. She said she was notified and told that the [CONDITION(S)] machine did not pull fluids they only clean up creatinine. She said she found out about this on 09/20/21 when she saw Resident #297's [CONDITION(S)] had gotten worse and she went to the [CONDITION(S)] center and the [CONDITION(S)] nurse told her that the machine was not pulling the required fluid from Resident #297. The NP said that they would not take her to another [CONDITION(S)] centers because she was a ventilator resident. She said she talked to Resident #297's daughter about discharge to another facility after finding out about the machine, but the resident became critical and the night of 09/21/21 and was sent to the hospital for fluid overload. During an interview on 09/23/21 at 09:01 AM, RN [CONDITION(S)] nurse for dialyze direct in-house [CONDITION(S)], she said that they had 8 residents on the in -house [CONDITION(S)] and they had [CONDITION(S)] five times per week. She said the residents had [CONDITION(S)] five times a week because the [CONDITION(S)] machine they were using was a home [CONDITION(S)] machine that usually was used for stable patients who can walk and had less fluids, and that had been part of problem for Resident #297. She said Resident#297 was not stable, and the machines were meant for more stable patients. She said the machine pulled the fluids slowly and do not pull enough fluids from Resident #297 because of her unstable condition and somedays her blood pressure would drop, and they had to hold [CONDITION(S)]. She said she did not assess the resident before admission to the - in house [CONDITION(S)] the intake department for the company evaluated the residents for admissions. She said she reported to the NP , neurologist, and the DON that Resident #297 was not suitable for the [CONDITION(S)] machine and they had been failing to remove the required 5 liters of fluids they would only remove 1.5 liter and some days no fluid. She said the NP,, neurologist and the DON said they should continue to see if the machine would remove more fluids, but they did not suggest sending the resident to the hospital. She said the machine was not appropriate for the Resident#297 because of her unstable condition, she said the facility and [CONDITION(S)] company was accepting residents that are critical and with [CONDITION(S)], low blood pressure and they were not suitable for the in-house [CONDITION(S)] .She said that [CONDITION(S)] communication sheet was the facility's responsibility to fill the pre and [CONDITION(S)] filled out the post [CONDITION(S)] portion and they have been instructed to leave them in the [CONDITION(S)] room and the unit manager picked them up. She said that she had not conducted any training with the nursing staff. She said that she would not recommend for residents that are not stable to use the [CONDITION(S)] machine they had because it was not for unstable patients. She said that when she observed something that is not normal in residents at [CONDITION(S)], she alerted the facility, the company NP, and the [CONDITION(S)] NP would notify the nephrologist. During an interview on 09/23/21 at 09:36 AM, LVN [CONDITION(S)] nurse, with the [CONDITION(S)] company said she had been working for the [CONDITION(S)] center in the facility for three months but had 9 years' experience in [CONDITION(S)]. , She said Resident #297 was not stable enough and the [CONDITION(S)] center did not have the medications and the equipment required to pull the fluids, she said on multiple occasions she needed the nurses to notify the primary physician to send Resident #297 out but when she came back the next day the resident was still in the facility. She said that Resident #297 had fluid overload and they recommended that the facility call their physician to send her out. She said they were unable to pull a lot of fluids from Resident #297 because of the machines and the system they had in place. She said she had notified the nursing staff and the facility about Resident #297's fluids were not pulled out during [CONDITION(S)] and notified them also about the episodes of low blood pressure during [CONDITION(S)]. She said this problem had been going on about two months and she reported to the RN [CONDITION(S)] charge nurse who reported to the facility. During an interview on 09/23/21 at 10:00 AM, RN [CONDITION(S)] nurse, said Resident #297 was not getting enough fluids pulled out and the DON was notified. She said she was the one responsible to communicate with the facility when there was new recommendations from the [CONDITION(S)] NP or nephrologist and when the [CONDITION(S)] staff had information about residents that they needed the facility to be aware. During an interview on 09/23/21 at 10:31 AM, the NP for the [CONDITION(S)] company said she saw the residents once per month, but the [CONDITION(S)] nurse would communicate with her via phone if there were any changes in residents from her last visit. She said when hemoglobin levels drop below 7 their policy was to repeat the labs and if the results indicated low level, they recommended to send residents out to the hospital for transfusion. She said when the RN [CONDITION(S)] nurse reported recommendation to the facility to send the residents out, the facility did not send them out. She said that she knew that the [CONDITION(S)] machine pulled very little fluids and they were having a hard time pulling fluids from Resident#297 she needed to be sent back to the hospital. She said to be honest she does not know why Resident #297 was admitted to the facility because she was not stable and not appropriate for in- house [CONDITION(S)] machine at the facility. She said that the nephrologist was aware of the machine and the condition of Resident #297. She said that when she notified the physician about the machine and that it would only take out 2 liters or less instead of 5 liters because Resident# 297 was not stable, she said the physician said to try to pull whatever fluids they would pull and hold [CONDITION(S)] if the blood pressure dropped. During an interview on 09/24/21 at 12:00 PM, the ADON said the RN [CONDITION(S)] nurse communicated to her if the unit manager is not available, she communicated with the charge nurses working on the halls. She said that when she got the information from the RN [CONDITION(S)] nurse, she gave the information to the charge nurses if it was not critical information. She said that when information communicated to her by the RN [CONDITION(S)] nurse was critical, she would notify the physicians. The ADON said she talked Resident #297's daughter but did not remember the date, she said she was complaining that the [CONDITION(S)] center was not pulling out enough fluids. She said that she went to the room assessed the resident and she did not have a lot of fluid., she said she did not document her findings but she noticed that the resident had [CONDITION(S)] to the bilateral upper extremities and not the lower extremities. She said she did not notify the primary physician about Resident #297's concerns because the physician was aware of the [CONDITION(S)]. During an interview on 09/24/2021 at 12:15 PM, the DON said she reviews referrals but when they are [CONDITION(S)] the clinicals are sent to the [CONDITION(S)] company and the nephrologist will approve the clinicals. She said they started in -house [CONDITION(S)] on 08/01/21 and the company approved the clinicals and notified the facility to admit the residents. She said the medications that residents receive at [CONDITION(S)] they have a communication sheet they use to communicate with the [CONDITION(S)] center, but she had not followed up and she did not know if medications were administered in [CONDITION(S)]. She said that she did not know that the medication administered at [CONDITION(S)] was supposed to be on resident medication profile or care plan. She said that she was not aware that the [CONDITION(S)] machine was not pulling required fluid from Resident #297. She said the [CONDITION(S)] staff and daughter did not notify her about the machine not pulling enough fluids. She said that it was her responsibly to follow up with the nurses, unit manager and the [CONDITION(S)] nurse in regarding the [CONDITION(S)] treatment and update. She said she did not follow up with the nurses and the unit managers and moving forward she was going to put in place a new way to communicate to the [CONDITION(S)] staff and following up with the charge nurses and the unit manager. During an interview on 9/24/21 at 9:10 AM, the Administrator reported he and the DON are responsible for requesting and monitoring labs for residents that receive [CONDITION(S)] within facility [CONDITION(S)] center. [NAME] reports: in facility [CONDITION(S)] center has a different process and the in-facility [CONDITION(S)] center's lab company is Ascend Clinical, will draw routine labs but not sure of the process. [NAME] lab company comes when [NAME] calls for lab draws. [NAME] reports he does not know how critical labs are monitored and directed investigator to director of nurses. During an interview on 9/27/21 at11:45 AM, the [CONDITION(S)] RN with DCD, reported she gave lab dated 9/8/21 with critical Hgb for Resident #61 to LPN B (primary care nurse) and informed her verbally that lab for Hgb needed to be redrawn prior to next [CONDITION(S)] day. Per in house [CONDITION(S)] policy Hgb will be above 7 g/dL. [CONDITION(S)] RN produced document from her computer with lab results and that Hgb needed to be redrawn. During an interview on 9/27/21 at 12:30 PM, LPN B was asked if she received lab request from the [CONDITION(S)] RN, she was not able to remember ever receiving labs from the [CONDITION(S)] center or any verbal request for drawing Hgb lab. She reported she did not call the MD for any orders as she had not been notified of need. A review of the facility policy titled, Lab and Diagnostic Test Results-Clinical Protocol, last revised November 2018, revealed, The center is responsible for the timeliness of the services. The Director of Nursing (DON)/designee will be responsible for requesting lab orders when there is a need based on resident's diagnostic and monitoring needs and will process test requisitions and arrange for tests. The DON/designee will be responsible to notify the MD when a lab result is not received in a timely manner. Record review of the facility Renal [CONDITION(S)] Affiliation Agreement dated 6/1/21 . 1. Initiation of Services. A. The Long Term Care (LTC) facility shall notify the [CONDITION(S)] facility when a Resident requires Renal [CONDITION(S)] and submit information to the [CONDITION(S)] facility regarding the resident as requested by the [CONDITION(S)] facility. B. The [CONDITION(S)] Facility shall accept medically stable Residents into its home renal [CONDITION(S)] program, within the limit of its programs and facilities. Each such Resident accepted into the [CONDITION(S)] Facility's home hemodialysis program is referred to herein as a [CONDITION(S)] Resident, and collectively as, the [CONDITION(S)] Resident. The [CONDITION(S)] Facility reserves the right to refuse treatment to any Resident of the long term care facility that does not meet its admission criteria. At a minimum, in order for a Resident of the LTC facility to be accepted into the [CONDITION(S)] facility's home hemodialysis program, such resident must have a prescription for home hemodialysis written by a physician who has either temporary or permanent clinical privileges at the [CONDITION(S)] Facility . 8. Education. The LTC facility shall make staff available to receive education from [CONDITION(S)] Facility involved in caring for [CONDITION(S)] Residents in the following areas to assure the LTC facility staff's ability to perform interventions for [CONDITION(S)] Residents when necessary: A. Monitoring of fluid gain and loss, including assessment of weight, blood pressure, pulse, respirations and intake and output. B. Assessment of laboratory values such as: BUN, serum creatinine, sodium, potassium, calcium, magnesium, [MEDICATION(S)] levels, white blood count, hemoglobin and hematocrit. The facility Administrator was informed that an Immediate Jeopardy (IJ) was identified on 9/25/21 at 12:23 pm . IJ template was provided and plan of removal was requested. A Plan of Removal was submitted and was accepted on 9/27/21 at 4:15 PM after several revisions. The plan of removal included the following: Resident #296 is no longer in the facility. On 9/24/2021, the DON (director of nursing) completed an audit of all laboratory orders and most recent laboratory results of the eight (8) residents on hemodialysis. The audit was completed after the IJ was called. The results of the audit were documented on the QI tools titled, [CONDITION(S)] Communication Audit Tool. There was no concern identified. The audits were completed before midnight on 9/24/2021. Ad-Hoc QAPI meeting was held on 9/24/2021, with the Medical Director, NHA (Nursing Home Administrator), VP of Patient Services from [CONDITION(S)] company and DON to review the alleged deficiencies, policy and procedure, and the plan for removal of immediacy. Another Ad-Hoc QAPI meeting was held on 9/25/2021, with the Medical Director, NHA (Nursing Home Administrator), VP of Patient Services from [CONDITION(S)] company and DON to review the alleged deficiencies, policy and procedure, and the plan for removal of immediacy. Starting on 9/25/2021, the facility leadership (Administrator, DON and Unit managers) will have a weekly call to discuss the overall [CONDITION(S)] program with the contracted [CONDITION(S)] company and review the specific services provided for each resident who requires [CONDITION(S)] treatments, to ensure that each resident receives the services consistent with the professional standards of practice, comprehensive person-centered care plan and the residents' goals and preferences. Meetings will start the week of 27 Sept - 1 [DATE]. These meetings are in addition to the daily handoff with facility clinical staff. The discussion will include but not limited to alternate way to dialyze residents whose [CONDITION(S)] needs cannot be met by the in-house [CONDITION(S)] program. Any concern identified during the weekly call will be reported to the nephrologist and/or medical director for further discussion. The facility will continue to have the [CONDITION(S)] staff review referral for potential admissions. Dialyze Direct Intake Department will review patients to ensure they can meet their needs. No resident will be admitted for in-house [CONDITION(S)] without their approval. DON/designee will review clinical paperwork to ensure facility can meet their needs. The policy pertaining to hemodialysis was reviewed on 9/24/2021 by the DON, NHA (Nursing Home Administrator) and Medical Director. The policy includes, but not limited to compliance guidelines related to ongoing communication and collaboration of the [CONDITION(S)] unit staff and the nurses in the unit. The Administrator will be responsible to ensure this plan is completed on 9/28/2021. The surveyors monitored the Plan to lower the Immediately Jeopardy as follows: Record review of the facility roster dated 9/24/21 revealed the DON completed an audit of all residents to verify change in conditions were identified and proper assessments were completed. The form revealed there was no findings of change in conditions not identified. Record review of the facility's in - services dated 9/24/21 through 9/28/21 revealed facility nursing staff were in - serviced over procedure for change in condition. The DON (director of nursing) completed an audit of all laboratory orders and most recent laboratory results of the eight (8) residents on hemodialysis. The audit was completed after the IJ was called. The results of the audit were documented on the QI tools titled, [CONDITION(S)] Communication Audit Tool. There was no concern identified. The audits were completed before midnight on 9/28/2021. Interviews were conducted on 9/25/21 and 9/26/21 with weekend staff members that included LVN's, and RT's. On 9/25/21 starting at 1:42 PM, 2 morning shift (6am - 2pm) and 9/26/21 evening shift (2pm -10pm) LVN's were interviewed change in condition, obtaining laboratory test, documenting, reporting results to doctor of the eight (4) residents on in house hemodialysis. On 9/27/21 starting at 10:42 AM 2 day shift nurses (7am - 7pm) were interviewed and on 9/27/21 1 night shift (7pm - 7am) nurse was interviewed regarding what was considered a change in condition, obtaining laboratory test, documenting, reporting results to doctor of the residents. All staff members interviewed were able to voice knowledge over in - service areas and provided acceptable answers to interview questions. Interview with facility Administrator on 09/28/21 at 4:00pm, the facility Administrator said the facility should have done a proper follow up with residents on in house [CONDITION(S)] with the [CONDITION(S)] company. He said a new form indicating what went on at [CONDITION(S)] had been developed and is being implemented. He said starting from 09/28/21, there will be a weekly meeting with the facility staff and the [CONDITION(S)] staff to discuss all resident's on inhouse [CONDITION(S)] and their progress. He said the IJ incident occurred due to lack of proper communication between the [CONDITION(S)] company and facility staff. He said all nursing personnel would be trained on assessing all resident' before and after [CONDITION(S)] that includes, weights, vital signs, [CONDITION(S)] shunt, and what medication was given pre and post [CONDITION(S)] as well as monitoring resident's intakes. Record review of facility monitoring tool started on 9/28/21 revealed the DON was monitoring what residents had a change in condition, laboratory services order and result of any critical labs what the change was and when it was noted, if the MD/NP was notified, if there was orders given and were they carried out and whether there was any concern identified with the procedure for the particular change in condition. Record review of facility monitoring tool started on 9/27/21 revealed DON was monitoring 24-hour reports and whether nursing staff were reporting and identifying change in conditions on the report and if nursing staff had communicated and followed up on changes on the next shift. The Administrator and DON were notified the IJ was removed on 9/27/21 at 4:15 PM. However, the facility remained out of compliance at a severity of level of actual harm that is not immediate jeopardy and a scope of pattern due to the facility needing more time to monitor the plan of correction effectiveness.

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 2 of 11 residents (CR #1 and CR #2) reviewed for quality of care. The facility failed to timely identify CR #1's change in condition of repeated diarrhea overnight (10pm - 6am shift). The facility failed to timely assess, notify physician, and provide interventions to CR #1 who began to have complaints of not feeling well, an elevated heart rate, and constant diarrhea. The facility failed to transfer CR #1 to the hospital for 4 hours after she was identified to have rapid pulse and continuous diarrhea. CR #1's heart rate was in the 180's, she had a fever, and was still experiencing continuous diarrhea when she was eventually transferred to the hospital. CR #1 was admitted to the hospital and diagnosed with [CONDITION(S)] and dehydration, she remained in the hospital ICU (intensive care unit) to receive IV antibiotics for 17 days. The facility failed to have CR #2 transferred to [CONDITION(S)] center for 2 consecutive appointments (Friday and Monday) causing CR #2 to go 6 days without receiving hemodialysis. The facility failed to document and communicate to CR #2's physician he had gone 6 days without receiving [CONDITION(S)] which enabled the physician to make appropriate treatment decisions for CR #2 when he experienced a change in condition. The facility failed to monitor CR #2 for 5 hours after he had a change in condition of nausea, vomiting, low blood pressure and complaints of not feeling well on the 6th day of him not receiving [CONDITION(S)]. CR #2 was found unresponsive 6 hours after his change in condition, resident was pronounced deceased in the facility after resuscitation efforts were attempted. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern because the facility continued to train staff and monitor the effectiveness of the Plan of Removal. These failures could place residents at risk of not receiving timely care, health complications, serious illness or death. Findings included: CR #1 Record review of CR #1's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's admission MDS dated [DATE] revealed BIMS score of 0 indicating severe cognitive impairment. A staff assessment of mental status was not completed. Further review of the MDS revealed CR #1 was always continent of bowel and bladder and did not use an indwelling catheter. Record review of CR #1's baseline care plan dated [DATE] revealed resident did not use a foley catheter and was incontinent of bladder. Record review of CR #1's progress notes dated [DATE] at 6:09 PM revealed an admission note that read in part, .Resident has/uses a catheter, Foley #16 Resident had/used a catheter between a month and a week and reason/diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's progress notes dated [DATE] - [DATE] revealed 3 notes on [DATE], [DATE], and [DATE] that read in part, .continent of bladder, uses a foley catheter . Review of all other notes from [DATE] - [DATE] revealed no mention of foley catheter of foley catheter care. Record review of CR #1's progress notes dated [DATE] at 6:41 PM revealed, Resident c/o of burning upon urination. Afebrile, no complaints of pain. Foley bag intact, draining clear yellow urine. Readjust foley catheter and provided foley catheter care. Resident continue to complain of burning. Updated NP received order for UA and C&S lab. Record review of CR #1's progress notes dated [DATE] at 12:54 AM, revealed a skilled note indicating resident uses a foley catheter. There was no mention of foley catheter care being performed. Record review of CR #1's progress notes dated [DATE] at 4:10 AM revealed, Specimen for UA C&S obtained via catheter and picked up by lab. Record review of CR #1's UA results collected on [DATE] and resulted [DATE] revealed her WBC's were 50+ with a reference range of (negative 0 - 5) and bacteria was many with a reference range of (negative). Results indicated CR #1 had a urinary tract infection ([CONDITION(S)]). Record review of CR #1's urine culture collected [DATE] and resulted on [DATE] revealed urine had bacteria of Escherichia coli (E. Coli) isolated and [MEDICATION(S)] was susceptible. Record review of CR #1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's [DATE] MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Medication was administered on [DATE] and [DATE] at 8:00 AM. Record review of CR #1's progress notes dated [DATE] at 7:57 AM revealed, [MEDICATION(S)] Tablet 500 MG Give 500 mg via PEG-Tube one time a day for [CONDITION(S)] for 7 Days - on order. Record review of CR #1's progress notes dated [DATE] revealed no documentation of concerns or change in condition. Interview on [DATE] at 2:09 PM, CNA A said he worked the night of [DATE] from 10pm - 6am on [DATE] with CR #1. He said he remembered she kept hitting the call light that night to either be changed or was asking for the respiratory therapist (RT) because she was saying she could not breathe. CNA A said it was not out of the normal for CR #1 to have complaints of not being able to breathe and said that she's always had those complaints every time he worked with her due to her having a ventilator. CNA A said the RT checked CR #1 several times over night and he was not told of any issues with her breathing. CNA A said CR #1 seemed like she was fine all night, but he had to change her several times that night because she was having diarrhea. CNA A said he did not know how long she had the diarrhea going on, so he did not know if it was a new occurrence/change in condition. CNA A said he did not know if the night nurse knew about CR #1 having diarrhea and said he did not mention anything to her about it. CNA A said he left around 6 am on [DATE] and did not see the morning CNA before he left. CNA A said he did not recall CR #1 having a foley catheter and said CNA's did not do foley care. CNA A said the nurses usually do foley care for resident and CNA's just changed or emptied the foley bags. CNA A said CR #1 was able to communicate very well and would often talk to him when he cared for her. CNA A denied noticing any other changes in CR #1. Record review of CR #1's ventilator flow sheet dated [DATE] at 8:55 AM revealed RT A noted heart rate was 164. RT A also noted on the sheet, nurse medicated resident for anxiety and elevated heart rate. Record review of CR #1's ventilator flow sheet dated [DATE] at 10:30 AM revealed RT A noted heart rate was 140. Record review of CR #1's progress notes dated [DATE] at 11:00 AM revealed RT A noted, .RT called to resident's room. Bilateral breath sounds (BBS) decreased with crackles. Suctioned pale yellow secretions from [CONDITION(S)]. 02 sat. 100%, HR.143, RR.28. Nurse notified of resident's HR. Will continue to monitor resident . Record review of CR #1's ventilator flow sheet dated [DATE] at 11:50 AM revealed RT A noted heart rate was 171. RT A also noted on the sheet, RN notified. Treatment held for high heart rate. Record review of CR #1's progress notes dated [DATE] at 2:35 PM revealed RT A noted, .[MEDICATION(S)]-[MEDICATION(S)] Solution 0.,d+[DATE].5 (3) MG/3ML 1 vial via [CONDITION(S)] every 6 hours related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE Treatment held due to 171 HR., 02 sat. 100%, RR.27. Nurse notified. Resident taken to hospital by EMS. 12:20 . Interview on [DATE] at 6:08 PM, RT A said she came in for work at 6:00 am on [DATE]. RT A said she checked CR #1 when she first came in and she was fine, all her vitals were normal, and she had no complaints. RT A said around 8:30 am -- 9 am she checked CR #1 again and her heart rate was high. She said she performed suctioning and checked everything respiratory related and could not find an issue but her heart rate was still high in the 160's. RT A said she notified the nurse of CR #1's heart rate being high and how she was unable to get it down. RT A said she suggested to the nurse the issue with CR #1's heart rate was not respiratory related and requested the nurse provide the resident with any medications she may have. RT A said she told the nurse; CR #1 may have some anxiety issues causing the heart to go high and suggested she provide CR #1 with anxiety medication if she had any. RT A said she also thought maybe the resident could be having issues with pain and that would also cause her heart rate to be elevated and asked the nurse to provide her with any pain medications she had as well. The RT said she came back a little later to recheck CR #1 and her heart rate was still high. She said she went back and asked the nurse if she had medicated the resident and the nurse told her she had given CR #1 all of her medications. RT A said she did not see the nurse give CR #1 the medications, but she was not around to see if she had. RT A said she could not remember if it was the night nurse or morning nurse who she was talking to. She said she checked the heart rate again around 11:30 am for her respiratory treatment and the heart rate was still high and she had to hold the treatment. She said she went to talk to the nurse again about the heart rate being high and said the physician needed to be notified. She said the nurse called the physician and sent CR #1 out to the hospital. Interview on [DATE] at 4:26 PM, LVN A said she worked the night shift which was 7pm - 7am on [DATE] - [DATE]. LVN A said she did not recall CR #1 having any issues overnight but said she was anxious, so she provided some prn [MEDICATION(S)] and [MEDICATION(S)] to her around midnight. She said the resident slept the rest of the night with no issues. LVN A said she was not told CR #1 was having issues with diarrhea. LVN A said if she was aware, she would have checked if she had any prn medication for it and if not called the physician to get an order. LVN A said she had checked on CR #1 several times overnight and she had no complaints. LVN A said she took CR #1's temperature around 7pm on [DATE] when she came in and it was normal. LVN A said she last checked CR #1 around 6am when she went to check her blood sugar and gave her morning medications. LVN A said CR #1 was fine the last time she saw her. LVN A said she did remember RT A mentioning to her CR #1 heart rate was high and thought she was having some anxiety. She said she told RT A she had given CR #1 all her medications and had given her [MEDICATION(S)] as well. LVN A said she was already leaving for her shift when RT A had approached her and said it was around 9 am. LVN A said she did not assess CR #1 at that time because she was already leaving but said she stopped by CR #1's room on her way out and asked if she was okay, she said the resident mouthed to her she was okay. LVN A said the oncoming morning nurse (LVN B) was running late so she gave LVN C who was working on another hall her keys and did medication count with her. LVN A said she did not recall CR #1 having a foley catheter and said nurses performed catheter care and CNA's would empty the catheter bags. Record review of LVN A's employee time card dated [DATE] revealed she clocked out of work at 9:07AM. Record review of CR #1's [DATE] MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's [DATE] MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's [DATE] MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's [DATE] MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .,d+[DATE] MG/15ML Give 15 ml via G-Tube every 6 hours as needed for PAIN was last administered on [DATE]. Further review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's [DATE] MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's [DATE] MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] >101.5 was last administered on [DATE]. Further review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's [DATE] MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] ([MEDICATION(S)]) Give 1 tablet via G-Tube every 8 hours as needed for Anxiety was last administered on [DATE] at 3:37 AM and [DATE] at 2:48 PM. Further review of MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's [DATE] MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] #1 on [DATE] by LVN A. Interview on [DATE] at 12:08 PM, CR #'1s family member said she was visiting CR #1 on [DATE]. The family member said she got to the facility around 10:00 AM and right away saw CR #1 did not look well. She said she went to hug CR #1 and she felt hot and she asked her how she was feeling. The family member said CR #1 said she was not feeling well and had been telling the staff, but they were not doing anything. The family member said RT A came into the room to check on CR #1 and herself and CR #1 told the RT she was not feeling well. The family said the RT kept telling her and CR #1 that her O2 saturations were fine and she was stable so there was nothing else she could do. The family member said CR #1 was getting frustrated the RT kept telling her nothing was wrong. The family member also said when she came in CR #1 was having uncontrollable diarrhea and said she was never like that. She said CR #1 could not stop defecating and said the CNA would come in to change her and before they could finish changing her, she was going while they were changing her. The family member said the CNA who came in to change CR #1 saw she did not look good and said he would tell the nurse. She said a little while later a nurse did come into the room to check CR #1 and rushed her out of the room. The family member said the nurse eventually came out of the room and said they were sending CR #1 to the hospital because they could not get her heart rate down and it was in the 170's. She said the nurse told her she did not know what hospital CR #1 was going to yet. The family member said a nurse had not been into the room while she was there to assess CR #1 before the occurrence of the nurse coming in and asking her to step out. The family member said she went outside to her car and called CR #1's RP to tell them what was going on and during that time the ambulance arrived and loaded up CR #1. She said from there she followed the ambulance to the hospital. The family member said it was around 1:00PM when CR #1 was transferred to the hospital. Interview on [DATE] at 2:04 PM, CNA B said he did not remember what hours he was working on [DATE] but said he remembered he had just started his shift when someone asked him to change CR #1. He said he went into CR #1's room and right away saw she did not look well. He said she looked, more out of it than usual. He said he asked CR #1 how she was, and she said she was not feeling well. CNA B said she was also having real bad diarrhea. He said he changed CR #1 about 5 or 6 times back to back. CNA B said he went told the nurse (LVN B) about CR #1 having diarrhea and not looking well. CNA B said he did see LVN B go check on CR #1 after he told her. CNA B said he recalled an RT coming into the room and reassuring CR #1 she was going to be okay and he was doing the same when he would go into the room to change her. CNA B said he did not recall CR #1 having a foley catheter and said CNA's did foley care for residents and they emptied the catheter bags. Record review of CNA B's employee timecard dated [DATE] revealed he clocked in for work at 8:41 AM. Interview on [DATE] at 2:42 PM, LVN B said she worked the morning of [DATE] and said she was running late that morning. LVN B said her shift usually started at 7 AM but she did not get on the floor until about 10:00 AM. She said she was not on the floor for long when CNA B and RT A approached her saying CR #1 was not doing good. LVN B said RT A told her, she (RT A) and LVN A had been working on CR #1 because she had an elevated heart rate and they were not able to get it down. She said RT A told her the heart rate was 164, 171, 176 and now her stomach and head were hurting. She said CNA B also came and told her CR #1 was having constant diarrhea and looked real sick. LVN B said she went in CR #1's room to assess her and right away saw she looked very ill. She said CR #1 was usually very alert and talkative through gestures, but she was not doing any of that when she went into the room. LVN B said there was a family member visiting and she asked her to step out of the room and she did. She said she went to check CR #1's vitals but was not able obtain vital signs. She said she checked her temperature and it first read 98.3, she said she uncovered the resident to try and let her cool off. LVN B said she waited a minute or two and rechecked CR #1's temperature and it was over 101. She said the DON had told everyone to not transfer a resident out to hospital without consulting her due to billing issues. LVN B said she first tried calling the on - call nurse manager, who did not answer. She said she then called the DON several times and she did not answer. LVN B said she also called the NP who did not answer and physician who did not answer either. LVN B said she decided to use her nursing judgment to go ahead and transfer CR #1 to the hospital. LVN B said she gathered the paperwork for her hospital transfer which took a while because the printer was at the front of the facility. She said once she gathered CR #1's documentation she called 911 and they were there within 3 minutes. LVN B said at the time of transfer she recalled CR #1's heart rate being 186. She said CR #1 was still awake and was not unresponsive when she left the facility. LVN B said while CR #1 was already being transferred out the NP had called back and agreed CR #1 should be sent to the hospital. LVN B said another nurse (LVN C) tried calling the DON again after CR #1 was out the building and she picked up. LVN B said she talked to the DON and told her she had to send CR #1 out because she had an elevated heart rate they could not get down and she the DON asked her if she knew what A - fib was ([CONDITION(S)] is an irregular, often rapid heart rate that commonly causes poor blood flow) and told her the resident had A - fib so she would have issues with her heart rate and was not a reason to transfer her to hospital. LVN B said she was upset the DON asked her something like that and did not like that she did not support her decision to transfer CR #1 to the hospital. LVN B said she quit her job at the facility that same day. LVN B said it was her understanding from RT A that CR #1's heart rate issues were going on before she got there and LVN A was aware. LVN B said she did not see LVN A when she came in for her shift because she was late and LVN A had already left, so she did not get a verbal shift report. LVN B said she did not know what LVN A had done about CR #1's heart rate because RT A just reported her and the nurse had been working on getting it down. LVN B said she had not administered any morning medications to CR #1 because she had just gotten on the floor when she was told about her not feeling well. LVN B said CR #1's RP did come up the facility later that evening to get CR #1's communication board and told her CR #1 had coded when she got to the hospital but they were able to revive her and she was in ICU. LVN B added she did not recall CR #1 having a foley catheter and said nurses performed catheter care and the CNA's would just empty the foley bags. Record review of LVN B's employee timecard dated [DATE] revealed she clocked in at 9:00 AM. Record review of CR #1's hospital transfer form dated [DATE] at 1:00 PM completed by LVN B revealed CR #1 was being transferred to the hospital for .elevated temperature 101.6, elevated heart rate of 186, pulse 106, constant diarrhea, uncontrollable tremors . Resident vitals signs were also noted to be BP ,d+[DATE], HR 106, RR 27, Temperature 101.6, O2 sat 100%. Interview on [DATE] at 10:00 AM, CR #1's RP said CR #1 admitted to the facility with a catheter and had it in place until she was admitted to the hospital on [DATE] and still had it in the hospital. CR #1's RP said she was not told CR #1 had a [CONDITION(S)] or was being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . They were able to revive CR #1 and she was in the ICU. The RP said they had to insert a PICC line for CR #1 to receive antibiotics. The RP said CR #1 was diagnosed with a [CONDITION(S)], dehydration, and was septic with 3 different types of bacteria. The RP said the doctor said she could have got infection from the foley catheter not being cleaned properly or from her wound not being cleaned properly. The RP said the bacteria's found were E. Coli, staphylococci, and Acinetobacter. Interview on [DATE] at 4:00 PM, Physician A said he was called the afternoon of the 17th and he was told about CR #1 having elevated heart rate and them deciding to send her out to hospital. Physician A said he was not told about CR #1 having diarrhea until he was told she was being transferred to hospital. The physician said they made the right call to transfer CR #1 to hospital given how high her heart rate was. Physician A said CR #1 did not have a history of diarrhea, so her developing diarrhea would be something new for her. He said CR #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . He said he had not talked to the family regarding CR #1's [CONDITION(S)] diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He said the NP gave the order for the [MEDICATION(S)] and said sometimes she did communicate with the families regarding changes. Interview on [DATE] at 2:34 PM, the NP said CR #1 had chronic [CONDITION(S)] and was intubated in [DATE]. She said she came to the facility on a vent and respiratory was trying to ween her off, but the resident could not tolerate it and said she was too anxious and had anxiety with being awake on a vent. The NP said she was called on [DATE] about CR #1's heart rate being high and said she thinks the residents increased anxiety had a lot to do with her heart rate being high. The NP said she agreed with them transferring CR #1 to the hospital because with all she had going on it was best to get it checked out. The NP said she did see CR #1 the previous day on [DATE] and the resident was fine, she was looking and feeling well and had no issues with heart rate. Interview on [DATE] at 4:45 PM, the DON said she did not tell staff not to transfer residents to the hospital without speaking to her first. The DON said the nurses should notify the physicians before transferring a resident to the hospital but did not need to wait to for a response from the physicians in order to transfer a resident. The DON said in a situation where nurses are unable to reach the physician or NP they should call the Medical Director. The DON said her expectations were for the nurses to use their nursing judgement on when a resident should be transferred to the hospital if they are unable to reach someone. The DON said she expected the CNA's to notify the nurse on duty if they notice a change in condition in the resident such as diarrhea. The DON said the nurse should then assess the resident and provide any PRN medications if there were some available, if not, the nurse should call the physician to get an order. The staff should monitor the resident to see if diarrhea subsides and if not, notify the physician again of the change in condition continuing. The DON said she knew CR #1 had a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON said the nurse should have assessed CR #1 when she was informed of issues with heart rate. The DON said the nurse should have administered CR #1 morning medications and monitored CR #1 to see if the heart rate went down. The DON said if the heart rate continued to rise or remain high after an hour of medication administration, the nurse should have notified physician and transferred the resident to the hospital. The DON said it was her understanding LVN B had administered CR #1's morning medications and had waited to see if the medications would bring down the heart rate because LVN B had marked the medications were administered on CR #1's MAR. The DON said from RT A's vent sheet of CR #1, it looked like the heart rate did go down a little to 140 after she thought LVN A had administered her morning medications but agreed 140 was still high. The DON said she did not know why 4 hours had passed before the resident was transferred to the hospital from the time of identified elevated heart rate and agreed 4 hours was too long to wait. Record review of CR #1's [DATE] MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] Tablet 500 MCG ([MEDICATION(S)]) Give 1 tablet via G-Tube one time a day for [CONDITION(S)] [MEDICATION(S)] Tablet 40 MG ([MEDICATION(S)]) Give 1 tablet via G-Tube one time a day for Congestive Heart Failure [MEDICATION(S)] Crys ER 20 MEQ Tablet extended release Give 20 mEq via G-Tube one time a day for Diuretic Therapy [MEDICATION(S)] Tablet 10 MG Give 3 tablet via G-Tube one time a day for [CONDITION(S)] Give 3 tablets=30mg [MEDICATION(S)] Packet Give 4 gram via G-Tube two times a day for Peripheral Arterial Disease [MEDICATION(S)] Tablet 0.5 MG Give 1 tablet via G-Tube two times a day for Anxiety [MEDICATION(S)] Sulfate LiquidGive 5 ml via G-Tube two times a day for [CONDITION(S)] [MEDICATION(S)] Tablet 50 MG Give 1 tablet via G-Tube two times a day for Hypertension [MEDICATION(S)] Tablet 400 MG ([MEDICATION(S)] HCl) Give 1 tablet via G-Tube two times a day for [CONDITION(S)] [MEDICATION(S)] HCl Tablet 60 MG Give 1 tablet via G-Tube three times a day for Hypertension Further review of CR #1's [DATE] MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] Sulfate Liquid Give 5 ml via G-Tube two times a day for [CONDITION(S)] at 5:0 0PM [MEDICATION(S)] Tablet 50 MG Give 1 tablet via G-Tube two times a day for Hypertension at 5:00 PM [MEDICATION(S)] Tablet 400 MG ([MEDICATION(S)] HCl) Give 1 tablet via G-Tube two times a day for [CONDITION(S)] at 5:00 PM [MEDICATION(S)] HCl Tablet 60 MG Give 1 tablet via G-Tube three times a day for Hypertension at 1:00PM. CR #2 Record review of CR #2's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #2's baseline care plan dated [DATE] revealed CR #2 received [CONDITION(S)]. Record review of CR #2's hospital discharge summary dated [DATE] revealed he had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . CR #2 was also noted to have a central line: internal jugular, right [CONDITION(S)] tunneled and a gastric tube/abdomen drain. CR #2's history and physical revealed in part, .history of metastatic [CONDITION(S)] with metastases to the liver, [CONDITION(S)] on hemodialysis, chronic [CONDITION(S)], abdominal ascites with now a peritoneal drain, recent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of CR #2's progress notes dated [DATE] at 8:42 PM revealed in part, 0 bp in left arm due to left upper arm fistula, non-working. Right non-tunneled [MEDICATION(S)] access, abdomen round and soft right lower quad abdomen dressing clean/dry/intact, resident receiving Plurex draining Monday Wednesday and Friday . Record review of CR #2's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #2's progress notes dated [DATE] at 6:30 AM revealed in part, . Resident has diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #2's progress notes dated [DATE] at 12:05 PM revealed, Transportation arrived at the facility to transport the patient to [CONDITION(S)] via stretcher. The patient left the facility in a stable condition, with no acute sign of distress or discomfort noted. Record review of CR #2's [CONDITION(S)] communication record dated [DATE] revealed he received [CONDITION(S)] Monday, Wednesday, and Friday at an offsite [CONDITION(S)] center and went to [CONDITION(S)] and returned on [DATE] with no concerns. Record review of CR #2's [CONDITION(S)] center patient note dated [DATE] at 3:59 PM revealed in part, .New patient started today. BP was stable at the beginning of treatment but started dropping as treatment begun . BP improved but started dropping again. Patient requested to get off the machine early per CN. CN states patient not feeling well. Doctor notified, okay to terminate treatment . Record review of CR #2's progress notes dated [DATE] at 8:30 PM revealed in part, .Resident returned from [CONDITION(S)] at 5:30 pm. Upon arrival, resident is alert and awake, no distress. Vital signs within safe range . Record review of CR #2's 2020 December MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #2's 2020 Decem

Based on interview and record review, the facility failed to ensure resident who entered the facility with an indwelling urinary catheter, received appropriate care and services to prevent urinary tract infections to the extent possible for one of 11 residents (CR #1) reviewed for incontinence. The facility failed to identify CR #1's indwelling urinary foley catheter on her MDS assessment, baseline care plan, and physician orders. The facility failed to have orders and interventions in place for CR #1's foley catheter to prevent [CONDITION(S)] infections. Facility staff who cared for CR #1 were not aware of her foley catheter status and failed to monitor or provide care to CR #1's foley catheter and she was diagnosed with a [CONDITION(S)] which she was hospitalized for 3 days later. These failures placed residents at risk for repeated urinary tract infections complications and decline in health. Findings include: Record review of CR #1's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's admission MDS dated [DATE] revealed BIMS score of 0 indicating severe cognitive impairment. A staff assessment of mental status was not completed. Further review of the MDS revealed CR #1 was always continent of bowel and bladder and did not use an indwelling catheter. Record review of CR #1's baseline care plan dated [DATE] revealed resident did not use a foley catheter and was incontinent of bladder. Record review of CR #1's progress notes dated [DATE] at 6:09 PM revealed an admission note that read in part, .Resident has/uses a catheter, Foley #16 Resident had/used a catheter between a month and a week and reason/diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's progress notes dated [DATE] - [DATE] revealed 3 notes on [DATE], [DATE], and [DATE] that read in part, .continent of bladder, uses a foley catheter . Review of all other notes from [DATE] - [DATE] revealed no mention of foley catheter [NAME] foley catheter care. Record review of CR #1's progress notes dated [DATE] at 6:41 PM revealed, Resident c/o of burning upon urination. Afebrile, no complaints of pain. Foley bag intact, draining clear yellow urine. Readjust foley catheter and provided foley catheter care. Resident continue to complain of burning. Updated NP received order for UA and C&S lab. Record review of CR #1's progress notes dated [DATE] at 12:54 AM revealed a skilled note indication resident uses a foley catheter. There was no mention of foley catheter care being performed. Record review of CR #1's progress notes dated [DATE] at 4:10 AM revealed, Specimen for UA C&S obtained via catheter and picked up by lab. Record review of CR #1's UA results collected on [DATE] and resulted [DATE] revealed her WBC's were 50+ with a reference range of (negative 0 - 5) and bacteria was many with a reference range of (negative). Results indicated CR #1 had a urinary tract infection ([CONDITION(S)]). Record review of CR #1's urine culture collected [DATE] and resulted on [DATE] revealed urine had bacteria of Escherichia coli (E. Coli) isolated and [MEDICATION(S)] was susceptible. Record review of CR #1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's [DATE] MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Medication was administered on [DATE] and [DATE] at 8:00 AM. Record review of CR #1's progress notes dated [DATE] at 7:57 AM revealed, [MEDICATION(S)] Tablet 500 MG Give 500 mg via PEG-Tube one time a day for [CONDITION(S)] for 7 Days - on order. Record review of CR #1's hospital transfer form dated [DATE] at 1:00 PM completed by LVN B revealed CR #1 was being transferred to the hospital for .elevated temperature 101.6, elevated heart rate of 186, pulse 106, constant diarrhea, uncontrollable tremors . Resident vital signs were also noted to be BP ,d+[DATE], HR 106, RR 27, Temperature 101.6, O2 sat 100%. Interview on [DATE] at 2:04 PM, CNA B said he did not remember what hours he was working on [DATE] but said he remembered he had just started his shift when someone asked him to change CR #1. He said he went into CR #1's room and right away saw she did not look well. CNA B said he had worked with CR #1 before, so he knew how she usually was and looked. CNA B said he did not recall CR #1 having a foley catheter and said CNA's completed catheter care and emptied to catheter bags for residents. Interview on [DATE] at 2:42 PM, LVN B said she worked the morning of [DATE] with CR #1. LVN B said she had worked with CR #1 before and said she did not recall CR #1 having a foley catheter. LVN B said the nurses completed foley catheter care for the residents and the CNA's emptied the bags. LVN B said residents had orders to complete foley catheter care. Interview on [DATE] at 2:09 PM, CNA A said he worked the night of [DATE] from 10pm - 6am on [DATE] with CR #1. He said he had worked with CR #1 several times before, so he was familiar with her. He said CR #1 could communicate and they would often talk when he came to change her. CNA A said he did not recall CR #1 having a foley catheter and said CNA's did not do foley care but said they would empty the catheter bags. Interview on [DATE] at 2:45 PM, LVN C said she did not recall entering the order for CR #1's [MEDICATION(S)]. LVN C denied working with CR #1 very often and said she think may have entered the order because she was helping with training a new nurse (LVN D) who was assigned to CR #1 that day. LVN C said she did not remember putting in the order and denied calling CR #1's RP to notify them of the [CONDITION(S)] diagnoses. LVN C said she did not recall if CR #1 had a foley catheter and said to check with LVN D if she notified the family of [CONDITION(S)] or knew if she had a foley catheter. Interview on [DATE] at 3:17 PM, LVN D said she was still in orientation on [DATE] and her and LVN C were working together. She had worked with CR #1 one other time before [DATE] and said CR #1 was calm and talkative in a pleasant way. LVN D said she saw CR #1 again on [DATE] and she did not recognize her at first and seemed very anxious. LVN D said she recalled checking CR #1's chart and saw an order had just been put in for [MEDICATION(S)] due to her having a [CONDITION(S)] and the LVN thought that would explain the behavior change she observed. LVN D said she had not talked to the family about the [CONDITION(S)] diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN D said she did not remember CR #1 having a foley catheter but said she was not sure. Interview on [DATE] at 5:00 PM, the MDS Coordinator said she recalled going to assess CR #1 when she admitted and noticed she had a foley catheter and there wasn't an order in the system for her to have one. She said she notified the DON about her not having orders and was not sure what happened after that. She said she could not code the foley catheter in the MDS if there wasn't an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Interview on [DATE] at 4:26 PM, LVN A said she worked the night shift which was 7pm - 7am on [DATE] - [DATE]. LVN A said she did not recall CR #1 having any issues overnight but said she was anxious, so she provided some prn [MEDICATION(S)] and [MEDICATION(S)] to her around midnight. She said the resident slept the rest of the night with no issues. LVN A said she did not recall CR #1 having a foley catheter. LVN B said nurses complete foley catheter care for residents. Interview on [DATE] at 10:00 AM, CR #1's RP said CR #1 admitted to the facility with a catheter and had it in place until she was admitted to the hospital on [DATE] and still had it in the hospital. CR #1's RP said she was not told CR #1 had a [CONDITION(S)] or was being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . They were able to revive CR #1 and she was in the ICU. The RP said they had to insert a PICC line for CR #1 to receive antibiotics. The RP said CR #1 was diagnosed with a [CONDITION(S)], dehydration, and was septic with 3 different types of bacteria. The RP said the doctor said she could have got infection from the foley catheter not being cleaned properly or from her wound not being cleaned properly. The RP said the bacteria's found were E. Coli, staphylococci, and Acinetobacter. Interview on [DATE] at 12:45PM, the DON said the facility should put in orders for foley, foley care, monitoring of the foley and to also change bag PRN. The DON said when CR #1 admitted the unit manager was responsible for putting the orders in for foley catheter. The DON said they should either identify the resident has a foley catheter while doing the initial assessment or they'll have discharge orders from the hospital indicating the resident has a foley catheter but either way CR #1's foley catheter should have been identified and order should have been entered for it. The DON said the CNA's were responsible for emptying foley bags and completing foley catheter care. The DON said the nurses were responsible for making sure the CNA's completed the foley care and checking it off on the MAR. The DON said foley care should be completed every shift and PRN. The DON said the CNA's should be able to see who had a foley when they complete incontinent care, but the nurses should also be informing them of residents on the unit who have foley catheters. The DON said she believes there was a breakdown in communication and that's how CR #1 foley catheter went without orders and proper treatment. Record review of the facility Catheter Care, Urinary policy (Revised [DATE]) revealed in part, . The purpose of this procedure is to prevent catheter - associated urinary tract infections. Preperation. 1. Review the resident's care plan to assess for any special needs of the resident . The following information should be recorded in the resident's medical record: 1. Date and time the catheter care was given. 2. The name and title of the individual(s) giving the catheter care. 3. All assessment data obtained when giving catheter care. 4. Character of urine such as color, clarity, and odor. 5. Any problems noted at the catheter - urethral junction during perineal care such as drainage, redness, bleeding, irritation, crusting, or pain. 6. Any problems or complaints made by resident related to the procedure. 7. How the resident tolerated the procedure. 8. If the resident refused the procedure, the reason(s) why and the intervention taken. 9. Signature and title of the person recording the data .

Based on observation, interview and record review, the facility failed to provide the necessary treatment and services, based on the comprehensive assessment and consistent with professional standards of practice to prevent development and worsening of pressure ulcers for 5 of 12 residents (Resident #1, #2, #3, #4, and #5) reviewed for pressure ulcers. Resident #1's physician orders [REDACTED]. The facility failed to have a system in place to prevent, promptly assess to identify , treat, monitor and document progress of pressure ulcers in the facility or promote healing of pressure ulcers resulting in 5 (#1, #2, #3, #4, and #5) resident's pressure ulcers developing and/or worsening. The facility failed to timely develop person centered care plan and implement care plan for Resident's #1, #2, #3, #4, and #5 pressure ulcer and risks of developing new ones. The facility failed to ensure Resident #2 who admitted with three stage 4 pressure ulcers (sacral, left ischium, right ischium) did not have wound assessments completed for over 2 months and wound assessments that were previously completed by the facility did not correctly document the dept of her wounds. Resident #2 was not timely repositioned in her chair to prevent pain and worsening of pressure ulcers. These failures resulted in an immediate jeopardy on 9/4/20. While the IJ was removed on 9/10/20 the facility remained out of compliance at a scope of pattern and severity of actual harm due to the facility requiring more time to monitor the plan of removal for effectiveness. These failures affected 5 residents and placed residents with wounds and/or pressure ulcers at risk of wound development, wound deterioration, a decline in health, possible hospitalization , and infection. Findings include: Resident #1 Record review of Resident #1's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #1's admission assessment dated [DATE] revealed resident had no open wounds and he was at moderate risk for skin breakdown. Record review of Resident #1's significant change MDS dated [DATE] revealed he had moderate cognitive impairment based on staff assessment. Resident was totally dependent on staff for his activities of daily life and was incontinent of bowel and bladder. Resident #1 was at risk for developing pressure ulcers and had one unhealed stage 3 pressure ulcer. MDS only noted pressure ulcer/injury care as treatments provided. Options of pressure reducing devices, turning/repositioning program, or nutrition/hydration interventions were not selected on the MDS. Record review of Resident #1's care plan initiated on 3/5/20 and revised on 8/20/20 revealed Resident was at risk for skin breakdown related to incontinence, impaired bed mobility, and alteration in nutrition . He has wound to the left hip, stage 3 (not added until 8/20/20). Interventions listed were: Monitor for incontinent episode every 2 hours (revised 8/29/20), assess skin weekly and record findings (3/5/20), assist with repositioning as needed (3/5/20), using padding between pressure areas (3/5/20), give medications per orders(3/5/20), monitor for skin breakdown . report to doctor and RP (3/5/20), provide pressure relieving and positioning devices as needed (3/5/20), Turn and reposition every 2 hours and as needed (added 8/20/20), and wound treatment daily as ordered (added 8/20/20). Record review of Resident #1's care plan initiated on 5/15/20 revealed resident had contractures and was at risk for skin breakdown, the interventions included: provide pressure reducing devices on bed and chair (5/15/20), monitor for increased pain/stiffness - provide medications and treatments - assess for relief (5/15/20), assist with repositioning every 2 hours using positioning devices to maintain proper body alignment - provide for comfort measures as needed (5/15/20), Keep contracted areas clean and dry, provide progressive range of motion - do not force contracted areas (5/15/20), OT and PT to evaluate and treat PRN as his status warrants (not added until 8/29/20). Care plan did not mention individualized interventions for residents' body deformities and/or use of specialized wheel chair/amount of time spent in chair that were identified as the cause of his left hip pressure ulcer. Observation on 9/2/20 at 1:25PM, Resident #1 was lying in bed resting with head of bed elevated 30 degrees, lying on his back. Resident was smiling and able to make eye contact but unable to communicate with surveyors. Resident was able to move his head, but bilateral upper and lower extremities were contracted and residents' body (hip area) curved to the left. Observation on 9/10/20 at 10:40AM, Resident #1 wound was observed to be a stage 3 and was pinkish in color, had slight/clear discharge, and adipose tissue was visualized. Record review of Resident #1's Braden Scale (scale used to help health professionals, especially nurses, assess a patient's risk of developing a pressure ulcer) dated 2/29/20 revealed a score of 10 - high risk. Record review of Resident #1's Weekly skin assessments dated 2/29/20 revealed he had red area from a previous surgical site on his left trochanter (hip). Record review of Resident #1's Braden scale dated 3/7/20 signed by the ADON revealed a score of 15 - Low Risk. The assessments questions answered revealed he had no impairment of sensory perception (has no sensory deficit which would limit ability to feel or voice pain or discomfort), he was occasionally moist, his nutrition was adequate (on a tube feeding regimen which probably meets most of his nutritional needs), and friction/sheer were a potential problem for him (moves feebly or requires minimum assistance . maintains relatively good position in chair or bed most of the time but occasionally slides down). Record review of Resident #1's weekly skin assessments dated 3/7/20 - 3/13/20 revealed his skin was intact. Record review of Resident #1's Braden Scale dated 3/14/20 signed by the ADON revealed a score of 15 - Low Risk with no changes in previous answers. Record review of Resident #1's assessments on 9/2/20 revealed there was no Braden scales completed after 3/14/20 and no corrections were made on previous Braden scales. Interview on 9/9/20 at 10:23AM, the ADON said she had completed Resident #1's Braden scales on 3/7/20 and 3/14/20. She said the resident was not a low risk and said he was high risk. The ADON said there was a system error that happened where she could not change what was in the assessment. Further record review of all sampled residents revealed no additional system errors were identified by the ADON resulting in accurate Braden scales. Record review of Resident #1's weekly skin assessments dated 3/20/20 - 4/10/20 revealed his skin was intact. Further review of weekly skin assessments revealed there were no skin assessments completed between 4/10/20 - 5/5/20 (3 weeks). Interview on 9/3/20 at 3:00PM, the DON said the previous wound care nurse (LVN #3) was responsible for completing the weekly skin assessments and in her absence the weekly skin assessments were assigned to the floor nurses. LVN #3 no longer worked at the facility and the DON could not speak on why Resident #1's weekly skin assessments were not completed for 3 weeks as she was not working in the facility as the DON during that time (4/10/20 - 5/5/20). The DON said to her knowledge Resident #1 developed his pressure ulcer because of his body shape and his hip pressed up against the wheel chair. The DON said the wheel chair needed to be reevaluated and for now the resident should not be up in his wheel chair for long periods of time and be repositioned every 2 hours. Record review of Resident #1's weekly skin assessment dated [DATE] signed by LVN #2 revealed the resident's skin was intact/unbroken and noted there were no NEW skin issues not identified last week. Further review of the weekly skin assessment noted Resident #1 had a pressure ulcer wound open area from pressure to his left trochanter (hip). Record review of Resident #1's progress notes dated 5/5/20 at 11:12PM, LVN #2 noted there was, a pressure area on his left hip minimal amount of exudate observed, no signs of pain or discomfort, no signs of infection noted, T 98.0, 66, 20, 123/67, wound care team to follow up in AM. Record review of Resident #1's clinical record revealed there were no assessments of left hip wound (measurements, staging, signs of infection, etc.) or physician orders [REDACTED]. Phone interview on 9/10/20 at 2:14PM, LVN #2 said she was the one who found Resident #1's wound to his hip on 5/5/20. She said she did an SBAR and entered a progress note about it. (SBAR was not previously in records, SBAR noted to appear in assessments as in progress on 9/10/20). LVN #2 said she contacted the physician and he gave order for a wound consult. She was asked if he gave treatment or dressing orders for the wound and she replied, He gave orders for wound consult. LVN #2 said the wound was open when she saw it and said previously the area was just reddened. She said the wound was draining a little blood when she saw it on 5/5/20. LVN #2 said the wound care team was supposed to take over from there with treatment and documentation of wound. Record review of Resident #1's weekly skin assessments dated 5/13/20 signed by LVN #3 revealed the resident's skin was NOT intact and he had a pressure ulcer to left trochanter (hip) . open area pink wound bed blood tinged drainage. Record review of Resident #1's pressure wound care sheet dated 5/13/20 signed by LVN #3 revealed the wound was initially identified on 5/13/20. Further review of the assessment revealed in part, .Site: Left trochanter (hip), Type: Pressure, Length: 1.9cm, Width: 1.1cm, Depth: 0.1, Stage: III . Interventions: air mattress overlay, wheel chair cushion, positioning device/pillows . Comments: Resident alert non-verbal has open area to left hip wound bed red 1.9 x 1.1 x 0.1, 40% slough 60% granulation area cleaned and treatment applied Doctor here to see resident will continue to treat and monitor for any changes . Record review of Resident #1's physician order [REDACTED]. Order was discontinued on 8/25/20. Review of Resident #1's TAR revealed order was followed. Record review of Resident #1's clinical record revealed no weekly skin assessments or facility wound assessments were completed after 5/13/20 through his discharge to the hospital on [DATE] (Hospital visit not related to issues with wound). Interview on 9/3/20 at 3:00PM, the DON said she did not know why the assessments weren't completed for Resident #1 in the electronic record and said the previous wound care nurse was completing the assessments, but she did not know where she was documenting them. The previous wound care nurse (LVN #3) left middle of July. Record review of Resident #1's physician order [REDACTED]. Plus, hydration Enteral Feeding: Administer Ensure per G-button via Bolus. 1 can plus 90cc of water in the morning, evening and at bedtime. Order was discontinued on 9/2/20. Record review of Resident #1's physician order [REDACTED]. Set water flush @_35_ml/hr of water to run concurrently with enteral feeding from 11pm to 5am daily. Order was discontinued on 9/2/20. Record review of Resident #1's progress notes dated 5/28/20 at 3:04PM by Dietician revealed in part, .Resident continues on Enteral Nutrition of Ensure formula at the request of family per nursing. PO (by mouth) diet of Pureed with 25 - 50% noted. Skin: Stage 3 wound per skin assessment. Nutrition Diagnosis: [REDACTED]. Recommend: Vitamin C 500mg daily, 2. ZnSo4 (220mg) daily x 21days, 3. Discontinue ensure supplement if family agrees, 4. Consider Ensure Plus to replace current order (new regime will provide addition protein that is needed). Will follow up with nursing as to the change . Interview on 9/2/20 at 2:00PM, the Dietician said the family was very particular about what they wanted to give the resident. The Dietician said the family insisted Resident #1 get Ensure but she felt the consistency was not good for him and did not provide enough nutrients, so she recommended on 5/28/20 they use Ensure Plus because the resident needed more protein along with other vitamins. The recommendations were followed by the facility. The Dietician said that she does take into consideration residents skin integrity with her recommendations as Nutrition has a vital role in skin integrity and wound healing. Record review of Resident #1 physician order [REDACTED]. continuous enteral feeding. Formula: Ensure Plus Rate:50 ml/hr to run currently with H2O at 35 ml/hr. Turn feeding Off at 6AM and On at 10PM. Order was discontinued on 7/19/20. Record review of Residents #1's clinical record revealed he transferred to the hospital on [DATE] for projectile vomiting. Record review of Resident #1's progress notes dated 7/18/20 at 8:44PM, revealed he was readmitted to the facility from the hospital. Record review of Resident #1 physician order [REDACTED].@ 35cc/hour from 10PM to 6AM at bedtime for Nutritional Intake. Order was discontinued on 9/2/20. Record review of Resident #1 physician order [REDACTED]. Order was discontinued on 9/2/20. Record review of Resident #1 physician order [REDACTED]. Order was discontinued on 9/2/20. Record review of Resident #1 physician order [REDACTED].#4 revealed, every night shift for nutritional supplement. continuous enteral feeding. Formula: Ensure Plus Rate: 100ml/hr x6 hours (11pm-5am) to run currently with H2O at 35ml/hr. Order was discontinued on 9/2/20. Record review of Resident #1 physician order [REDACTED].#4 revealed, Additional Fluid needs 90ml water 6x per day. Order was discontinued on 9/2/20. Record review of Residents #1's progress notes dated 7/19/20 at 5:42AM by LVN #4 revealed in part, .peg tube intact and patent, continuous nightly feeding of Ensure Plus 100ml/hr from 11PM to 6AM. Resident tolerated well . Record review of Residents #1's progress notes dated 7/20/20 at 5:37AM by LVN #4 revealed in part, .peg tube intact and patent, continuous nightly feeding of Ensure Plus 100ml/hr from 11PM to 6AM. Resident tolerated well . Record review of Residents #1's progress notes dated 7/21/20 at 4:42AM by LVN #4 revealed in part, .peg tube intact and patent, continuous nightly feeding of Ensure Plus 100ml/hr from 11PM to 6AM. Resident tolerated well . Phone interview on 9/10/20 at 1:25PM, LVN #4 said she cannot remember putting in feed orders of 100ML/HR for Resident #1 on 7/19/20 but said if there was a new order sent from the hospital she would always check with the doctor first to see if he wanted to implement order before putting it into the system. She said if the system shows she entered the order than it was what the doctor said he wanted. LVN #4 said she did not know there was a previous feed order of 50ML/HR in the system. She said they're supposed to discontinue the old order if doctor wants to implement new order. She said she works PRN and had not worked at the facility in a while, so she was not aware of two orders remaining in the system for Resident #1. Phone interview on 9/10/20 at 2:14PM, LVN #2 said when Resident #1 was initially admitted to the facility back in February the family was wanting the resident to receive more feeding, but it was decided that he would only receive 50ML/HR. She said since then the resident has always received 50ML/HR from 11PM - 5AM up until last night when she came to work and saw that he had different [DEVICE] orders. LVN #2 said she was not aware she had signed off on MAR the resident was receiving 100ML/HR. Record review of Resident #1's progress notes dated 7/26/20 at 5:40AM by LVN #4 revealed in part, .started with Hospice on 7/25/20 . Record review of Resident #1's physician orders [REDACTED].Diet: Ensure Plus 100ml/hr x 6 hours. Run with H2O at 35ml/hr. Pureed diet 3 x day . Record review of Resident #1's progress notes dated 7/28/20 at 7:17AM revealed in part, .resident out to hospital for follow up appointment with doctor . Record review of Resident #1's After Visit Summary from follow up appointment dated 7/28/20 revealed in part, .wound instruction - Resident #1 has a wound on his left hip. Needs to be well take care of or he can end up with a bone infection. Please apply MediGel Honey and apply sacral [MEDICATION NAME] border to the wound at least every 3 days. This is likely painful, after wound care please make sure the wound is not pressing up on anything; you can also put a gel pillow against it to cushion . Nutrition is the most important thing in wound care. Resident #1's feed should go as follows: Ensure plus - 1 can three times a day then at 100cc/hour from 11pm to 5am. Please also give oral diet/foods. He needs 90ml water flush 6 x/day to prevent constipation and GERD/gastritis and UTI's . Record review of Resident #1's progress notes dated 7/30/20 at 10:37AM by Dietician revealed in part, .Resident readmitted to the facility with previous Enteral and by mouth diet . Will discuss with nursing multiple Enteral orders for clarification. Resident continues to be at nutrition, fluid deficit, weight loss and further skin breakdown due to his medical condition . Interview on 9/2/20 at 2:00PM, the Dietician was asked about her note where she noted on 7/30/20 that orders needed to be clarified. The Dietician said she had saw two orders in the system and said she may have mentioned it to the ADON. The Dietician said she could not remember what the response was or what was decided. The Dietician was told about the orders from Hospice and the hospital to increase Resident #1's feeding rate to 100ML/HR and the Dietician said she was not aware of those orders. The Dietician suggested that the family may have declined to order to increase the feeding. Interview on 9/2/20 at 1:40PM, Resident #1's RP said he was not sure what Resident #1's current feeding orders were but said he know they had increased his [DEVICE] feeding when he went back to the facility from the hospital. He said the doctor at the hospital (doctor who wrote physician order [REDACTED].#1 more feeding to help with his wound healing. The RP said he knows it was provided to the facility and assumed that's what the resident had been receiving. The RP said in the past they had made request for Resident #1 to receive certain types of formula, but he had not told the facility he did not want Resident #1's feeding increased to 100ML/HR after it was ordered from the hospital doctor. Record review of Resident #1's clinical record revealed Resident #1 had several contradicting/overlapping orders for nutrition entered on 7/18/20 and 7/19/20 as reviewed above and mentioned in Dietician progress note on 7/30/20. Further review of the record revealed no clarification orders or notes were entered. Record review of Resident #1's MAR/TAR for July 2020, August 2020, and September 2020 revealed nursing staff checked off that all contradicting/overlapping nutritional orders were administered. Interview on 9/2/20 at 2:16PM, RN #1 said he was the nurse working with Resident #1 and it was his first day working the new shift of 7AM - 7PM and he previously worked the 6AM - 2PM shift. He said Resident #1 received bolus feedings of Ensure 3 times a day and he also received 50ML Ensure plus with 35ML/HR of H2O continuous feeding at night. He added with the Bolus feedings three times a day the resident also received 90ml of water with each feeding. RN #1 said when he comes in on his shift the continues feeding through [DEVICE] should be finished. Interview on 9/2/20 at 2:20PM, the ADON said Resident #1 received 50ML/HR of Ensure Plus with 35cc/hr of water that was given to him at night. He also received ensure bolus three times a day. Interview on 9/2/20 at 3:00PM, ADON #2 was asked what Resident #1 was receiving for Nutrition because there were multiple feeding orders on the physician orders [REDACTED].#2 said Resident #1 had been receiving 50ML/HR feeding and 35ML/HR water overnight and Bolus feedings three times a day at 9am, 2pm, and 5pm. ADON #2 reviewed the multiple orders on surveyor computer and said that the she would contact the physician to clarify the orders and said she was unaware the order of 100ML/HR was on the MAR and said the nursing staff should contact the Physician to clarify the order when there's duplicate orders. She verified that both orders for 50ml/HR and 100ml/HR were both on the MAR being checked off by nursing staff that they were administered for over 2 months and did not know why it hadn't been noticed. Interview and record review on 9/3/20 at 3:45PM, The DON was asked about how nobody noticed the duplicate feeding orders in the system for Resident #1. She said she did not know and would be in-servicing the nursing staff on looking at what they're administering and checking off on the MAR/TAR. The DON said she did not recall the Dietician mentioning anything to her about their needing to be clarification of the orders. The DON was then asked why the facility staff were following the order of 50ML/HR when there were two orders to increase to 100ML/HR. The DON was shown orders from Resident #1 hospital visit and from hospice to increase to 100 ML/HR. The DON asked where surveyor found the orders and was told they were found in Resident #1's hard chart. The DON said she had never seen the orders before and was unaware of the orders. She said they have a lot of new staff who may have filed the orders away in his chart without telling anyone. She said Resident #1 was being reassessed by the Dietician and doctor to determine best feeding orders for the resident as the resident's nutrition was important to his wound healing and skin integrity. Record review of Facility provided surgical consult reports from wound doctor for Resident #1 revealed: 7/27/20 - Left hip pressure injury/ulcer, Stage 3, length 2.2 cm, width 2.2cm, depth 0.2cm 8/7/20 - Left hip pressure injury/ulcer, Stage 3, length 3.0 cm, width 2.5cm, depth 0.2cm 8/14/20 - Left hip pressure injury/ulcer, Stage 3, length 3.6 cm, width 2.2cm, depth 0.2cm 8/21/20 - Left hip pressure injury/ulcer, Stage 3, length 4.4 cm, width 3.4cm, depth 0.3cm Further review of consults revealed wound doctor noted in part, .The pressure against the hip wound continues to be from his wheelchair complicated by his spinal deformity . Record review of Resident #1's weekly skin assessment dated [DATE] and 8/18/20 revealed he had a left hip wound with treatment in progress (First weekly skin assessments completed since 5/13/20, no other weekly skin assessments completed after 8/18/20 and/or before surveyor intervention on 9/2/20). Interview on 9/3/20 at 12:28PM, Social Worker at hospital said Resident #1 had an appointment to refill his [MEDICATION NAME] pump at the hospital on [DATE] and the hospital Nurse Practitioner (NP) happened to see Resident #1 wound on his hip and had concerns. The social worker said the NP felt the wound looked bad and decided to call the hospital's plastic surgery team to look at his wound. She said the hospital plastic surgery team gave new treatment orders for the wound and orders for him to have a surgical consult. Record review of Resident #1's progress notes dated 8/24/20 at 6:37PM, revealed in part, .Resident went to his [MEDICATION NAME] pump appointment and returned with a new order for dressing change . Resident needs a wound care appointment to be scheduled . Record review of Resident #1's physician orders [REDACTED]. Order was discontinued 8/28/20. Record review of Resident #1's physician orders [REDACTED]. Order was discontinued 8/28/20. Record review of Resident #1's physician orders [REDACTED]. Order was discontinued 9/4/20. Record review of Resident #1's physician orders [REDACTED]. Order was discontinued 9/1/20. Record review of Resident #1's physician orders [REDACTED]. Pat dry apply [MEDICATION NAME] to wound bed only cover with dry dressing every day shift for wound care. Order was discontinued 9/4/20. Record review of Resident #1's Pressure Wound Care Sheet dated 9/4/20 revealed in part, .Initial date wound was identified: 5/13/20 .Site: Left Trochanter (hip), Type: pressure, Length: 4.4cm, Width: 3.5cm, Depth: 2cm, Stage: Unstageable . (First facility wound assessment completed since wound developed on 5/13/20) Resident #2 Record review of Resident #2's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #2's quarterly MDS dated [DATE] revealed a BIMS score of 9 out of 15 indicating she had moderate cognitive impairment. MDS further revealed resident required extensive assistance of 2 people for bed mobility and had 3 stage 4 pressure ulcers. Further review of the MDS revealed she had a pressure reducing device for bed and received pressure ulcer/injury care. Record review of Resident #2's care plan initiated on 1/14/19 and revised on 3/4/20 revealed she was at had pressure wound stage 4 to right ischium, left ischium, and sacrum that were at risk of infection, pain and not healing. Interventions were air mattress, offloading. Medication as ordered for wound healing and pain management, provide treatment as ordered. Observe wound when changing dressing for signs and symptoms of healing or complications or if wound shows no improvement in 2 weeks notify doctor. RD to review quarterly, refer to wound care nurse as indicated. Weekly treatment documentation to include measurements of each area of skin breakdown's width, length, depth, type of tissue and exudate. Record review of Resident #2 assessments revealed her last completed Pressure Wound Care Sheet was on 6/23/20. Record review of recent completed Pressure Wound Care sheets revealed wounds were identified on 9/25/19 and measurement revealed: 5/13/20 - Site: sacrum, Type: pressure, Length: 5.2cm, Width: 2.9cm, Depth: 0.9, Stage: IV Site: left ischium, Type: pressure, Length: 4.1cm, Width: 3.2cm, Depth: 0.5 Stage: IV Site: right ischium, Type: pressure, Length: 6.7cm, Width: 6.2cm, Depth: 0.6 Stage: IV 5/22/20 - Site: sacrum, Type: pressure, Length: 5.4cm, Width: 2.8cm, Depth: 0.9 Stage: IV Site: left ischium, Type: pressure, Length: 3.5cm, Width: 2.9cm, Depth: 0.6 Stage: IV Site: right ischium, Type: pressure, Length: 5.2cm, Width: 4.8cm, Depth: 0.6 Stage: IV 6/6/20 - Site: sacrum, Type: pressure, Length: 5.2cm, Width: 2.9cm, Depth: 0.9 Stage: IV Site: left ischium, Type: pressure, Length: 3.7cm, Width: 2.8cm, Depth: 0.6 Stage: IV Site: right ischium, Type: pressure, Length: 5.2cm, Width: 4.5cm, Depth: 0.7 Stage: IV 6/23/20 - Site: sacrum, Type: pressure, Length: 5.2cm, Width: 3.5cm, Depth: (nothing entered) Stage: IV Site: left ischium, Type: pressure, Length: 3.1cm, Width: 2.2cm, Depth: (nothing entered) Stage: IV Site: right ischium, Type: pressure, Length: 5.4cm, Width: 4.2cm, Depth: (nothing entered) Stage: IV (On 6/23/20 assessment, the measurements for depth were left blank) Observation on 9/3/20 at 11:15AM revealed call light was on in room [ROOM NUMBER] (Resident #2's room). There was one nurse on the hallways at her medication cart and two CNA's. One CNA was in another resident room and the other CNA was observed coming out of a resident's room and walked past the room with the call light on and proceeded to go down the hallway. Surveyor observed hallway for 25 minutes and call light remained on with several staff members passing the room with call light on. At 11:40AM, CNA #1 was observed walking into room [ROOM NUMBER] and coming right back out with the call light now off. Observation and Interview on 9/3/20 at 11:40AM, surveyor went to Resident #2's room once CNA #1 left out and observed Resident #2 sleeping in her chair. Surveyor knocked on the door twice and the resident awakened and told surveyor to come in. Surveyor asked Resident #2 if she had her call light on and did the CNA get her what she needed. Resident #2 said she had dozed off and said she did not see anyone come into the room and didn't realize her call light wasn't on anymore. She said she had been waiting for someone to come pull her up in her chair and said she needed to be moved off her wounds. Resident #2 put her call light back on and CNA #1 immediately came back into the room and asked the resident what she needed. The resident said she had been waiting for someone to come in, so she could tell them she needed to be pulled up in her chair. The CNA told the resident, remember I just came in and told you I needed to get someone to help me. Resident #2 said she did not recall that happening. CNA #1 went out into the hallway and asked the wound care nurse to come assist her with repositioning Resident #2. Surveyor asked CNA #1 if she had answered Resident #2 call light earlier and she said yes, I just went in there and told her I'd be back after I found someone to help. Interview on 9/5/20 at 12:26PM, Resident #2 said she just this morning she had to wait 45 minutes to an hour just for her light to be answered so she could ask them to reposition her and then still had to wait some more after she asked. She said the wound care was okay and they do it regularly, but they take a long time to come and reposition

Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one of 12 residents (CR#1) reviewed for quality of care, in that : The facility failed to develop and implement a care plan that addressed CR#1's behaviors that affected others and himself. The facility failed to document the progress of CR#1's behavior and failed to train nursing staff on how to care for resident with frequent mood changes and behaviors that affected others and himself. The facility failed to implement CR#1's ordered psych consult for 6 months and failed to consult CR#1's physician when CR #1 continuously expressed he wanted to die, refusing care, yelling, cursing at staff members, and attempted to pull out his [MEDICAL CONDITION] . The facility failed to update CR#1's care plan after he attempted to pull out his [MEDICAL CONDITION]. The facility staff did not attempt to use a [MEDICAL CONDITION] to open CR#[MEDICAL CONDITION] CR#1 was unresponsive with [MEDICAL CONDITION]. CR #1 was transported to the hospital where he passed away. An immediate jeopardy and SQC was identified on [DATE]. While the IJ was lowered on [DATE] , the facility remained out of compliance at a scope of isolated and a severity of actual harm is not immediate due to facility requiring more time to monitor the plan of removal for effectiveness. These failures affected one former resident and placed other resident in the facility at risk of not being provided with appropriate and timely care needed prevent decline in health. Findings included: CR#1 Record review of CR #1 face sheet revealed a 41year old admitted to the facility on [DATE] and again on [DATE] with the following diagnoses; end stage [MEDICAL CONDITIONS], voice and resonance disorders, communication deficit, dysphagia, muscle weakness, [MEDICAL CONDITION], hypoxic ischemic [MEDICAL CONDITION], type 2 diabetes mellitus, with unspecified diabetic retinopathy- [MEDICAL CONDITIONS], hypertension, functional quadriplegic, dependence on [MEDICAL TREATMENT], and gastrostomy. Record review of CR # 1 MDS assessment dated [DATE] revealed that CR #1 had a BIMS score of 9, indicating cognitive moderately impaired. Review of CR#1 range of motion revealed that CR#1 had impairment on both sides of extremities upper and lower. Further record review revealed that CR # 1 was totally dependent on staff for activities of daily living and always incontinent of bowel and bladder. The MDS indicated the resident had no mood changes or behaviors and requires oxygen therapy and [MEDICAL CONDITION] care. The MDS also indicted the resident received [MEDICAL TREATMENT] . Record review of CR #1 comprehensive care plan dated [DATE] revealed that resident was being care planned for depression with an intervention to provide psych consults per order with social worker to notify Senior Psych care. Further record review revealed that CR#1 was also being care planned for behavioral problems (spitting at staff, yelling at staff, making false accusations, refusing accu-checks, refusing [MEDICAL TREATMENT], and non-compliance with diet despite education on the pros and cons and complying with ordered diet. Further review of above care plan revealed CR#1 had a [MEDICAL CONDITION] related to [MEDICAL CONDITION] and impaired breathing mechanic. Goal indicated the resident will have clear and equal breath sound bilaterally through the review date . Interventions included: observe /document for restlessness, agitation, confusion, increased heart rate and low heart rate. Observe /document level of consciousness, mental status and Lethargy as needed. Observe document respiratory rate , depth and quality . check and document every shift as ordered. Provide good oral care daily and as needed. Provide means of communication and procedural information reassure that help is available immediately . Reassure resident to decrease anxiety. Suction as necessary . Record review of CR #1's physician order [REDACTED]. [MEDICAL TREATMENT] - may go on Monday, Wednesday and Friday one time a day related to dependence on [MEDICAL TREATMENT] Record review of CR #1's physician orders [REDACTED]. Record review of facility's fax cover sheet for consult for Senior Psych Care dated [DATE] revealed CR #1 may be seen and treated by a Psychiatrist. This consult was faxed by ADON-B who no longer was working at the NF. Record review of CR#1's record revealed no further follow up for Psych consult faxed to Senior Psych Care. Record review of CR#1's Physician order [REDACTED]. Further review revealed an order on [DATE] for [MEDICATION NAME] 20mg (milligram) one tablet by mouth one time a day for depression. Record review of CR#1's Medication Administration Record [REDACTED]. Further review did not reveal any documentation of mood changes and behaviors monitoring for the medication [MEDICATION NAME]. Record review of CR#1's Treatment Administration Record for the months of (MONTH) and (MONTH) 2019 revealed no documentation indicating CR#1's behaviors were monitored. Record review of Social Worker notes on [DATE] at 12:30p.m. revealed in part: .Nursing staff requested S.W. to speak with CR #1 due to his verbal derogatory language towards staff. Resident is hostile and easily agitated. He displays confusion and delusional in conversation. Nursing staff reported difficulty in caring for resident due to his hostile nature. Resident gives conflicting information within same conversation. Resident stated he has been good for 2 weeks and has not cursed anyone out. S.W. counseled resident on acceptable behavior, language and, expectations in an effort to assist with his behavior. The RP was called. The S.W. was unable to leave a message on RP's voice-mail . Record review of Nurses notes dated [DATE] at 7:39 p.m. by LVN-D revealed in part: .When CR#1 was told again there were no hamburgers he then stated he wanted another dinner tray, resident was informed there was not anymore of the dinner portions that's when the resident said he did not get his lunch due to being at [MEDICAL TREATMENT] and that he was promised by the dietary manager that he could continue to eat whatever he wanted until he was full. CR#1 was offered another sandwich but he refused and started to raise his voice at the nurse. Then again started to scream obscenities and saying he was told he could have whatever he wanted .the nurse continued again attempted to reason with resident offering him what was available but CR#1 continued to refuse and curse and was finally escorted to his room by the CNA while he continued to scream obscenities down the hall . Record review of Nurses notes late entry dated [DATE] at 2:54 p.m. by the DON read in part: .Spoke to CR#1 this morning about his desire to go on Hospice . CR#1 said he had spoken to Hospice company while in the hospital that he could go to their inpatient unit .The DON told CR#1 that he would most likely not qualify for inpatient hospice but could become hospice while in the NF and that inpatient hospice was for patients actively dying. CR#1 said if he refused [MEDICAL TREATMENT], he knew he will die faster .The DON told CR#1 that she would notify hospice to review his medical records for appropriate placement regarding Hospice . The DON contacted and spoke with hospice who said they would review CR#1 records for appropriate placement and would contact the DON, CR#1 and his family member . Record review of CR#1's record revealed no further follow up for Psych consult faxed to Senior Psych Care on [DATE]. Record review of Nurses notes dated [DATE] at 4:05 a.m. by LVN-F revealed in part: .CR#1 was upset with the CNA that was changing him telling her to get the F out of his room. At that point the second CNA ask if she could change CR#1 and CR#1 said yes, she could .CR#1 was cleaned up and given water .at that point CR#1 was still agitated, and started to pull at his trach, CNA was able to calm him down. In a little CR#1 started to holler to call the DON and was calling respiratory to assist him. Respiratory came in and checked CR#1 out for proper placement [MEDICAL CONDITION].the DON was contacted for CR#1. The nurse, CNA, and respiratory was in CR#1 room while CR#1 was speaking to DON. Respiratory then re-checked [MEDICAL CONDITION] and gave breathing treatment. CR#1 is resting at this time .will continue to monitor for further behaviors . Record review of Social Worker note on [DATE] at 3:15 p.m. revealed in part: .SW met with CR#1 regarding morning breakfast and not going to [MEDICAL TREATMENT] .Resident was encouraged by nursing staff to calm down and that angered him even more . Resident was loud, hostile, demanding, and confused. His demeanor is narcissistic based on his gang related lifestyle (resident stated) prior to him getting ill. SW reminded him that his behavior continuously to be at odds with staff and other resident to the point that residents are writing grievances. CR#1 was not willing to listen to reason or compromise. The longer you talk with CR#1 the more the story changes. SW ended the conversation . Record review of the NF 24- hour Summary dated [DATE] at 5:58 a.m. regarding CR#1 revealed in part: .CR#1 yelling and screaming obscenities toward CNA staff .CNA's provided incontinent care and repositioning, and met CR#1 requests, nurse unsuccessful with redirection of CR#1 . Record review of Nursing Notes dated [DATE] at 5:48 a.m. by LVN-Z revealed in part: .CR#1 remains stable this shift with no distress or behaviors this shift. CR#1 left for [MEDICAL TREATMENT] with paper work via stretcher (Priority EMS) and attendants x 2, CR#1 was assisted with feeding of 2 (two) sandwiches and fruit juice per request .CR#1 left in stable condition, alert and oriented x 4, B/P=,[DATE], HR=90, RR=18, Temp=98.1, BS=132, SPO2=98% . Record review of Nurses notes dated [DATE] at 10:03a.m. by LVN-A revealed in part: .CR#1 continues to continues to yell at staff in hallway loudly .nurse enters CR#1 room and talked to CR#1, CR#1 yelled out I'm tired, I want to go on Hospice and die, CR#1 family member was at bedside quietly pointed fingers on her lips .nurse attempted to calm CR#1 down at bedside, CR#1 room door stayed opened, nurse knocked and entered through out shift . Record review of CR # 1 Nurses notes on [DATE] at 6:18 p.m. by LVN-A revealed in part: .CR#1 noted lying in bed with eyes closed unresponsive to any tactile stimuli and sternal rub.[MEDICAL CONDITION] lying next to resident on resident chest. CPR initiated AED in use, message given to continue CPR, Nursing team and respiratory team at CR#1 bedside .nurse called 911, nursing staff and rehab staff continue with CPR . Record review of CR #1 Respiratory notes on [DATE] at 6:50p.m. by RT-A revealed in part: .at 8:13 p.m. called to CR#1 room for code blue myself and RT-B. Arrived to room with CR#1 unconscious and not breathing, checked left carotid pulse no pulse started CPR with chest compression. CR#[MEDICAL CONDITION] out [MEDICAL CONDITION] still in place .with initial 2 minute chest compressions and chest compressions relieved by nurse, I attempted to [MEDICAL CONDITION], unsuccessful, CR#1 trachea was closed with surface tissue bleeding, covered trachea with gauze and tape. RT-B BMV 100% oxygen resident with slight chest rise .continued with CPR assisted with attaching AED leads, AED was turned on and working properly .no shock advised continue CPR .6:25p.m. EMS arrived on scene and assumed CR#1 emergency care. I continued with BMV with EMS on compressions. EMS attempted [NAME] ET tube (The [NAME] ET tube airway consists of a curved tube with ventilation apertures located between 2 inflatable cuffs. A single valve/pilot balloon is used to inflate both cuffs. The [NAME] airway is intended for airway management in patients over 4 feet tall for controlled or spontaneous ventilations.) intubation which was unsuccessful, signs patient stomach contents presented upon removal of [NAME] ET tube, continued with BMV with EMS assistance, CR#1 was moved to stretcher. EMS assumed all care of CR#1. CR#1 transported to outside facility . Record review of CR#1 Nurses notes by LVN-A on [DATE] at 8:11 p.m. revealed in part: .Officer reported to supervisor and charge nurse CR#1 expired . Interview on [DATE] at 10:40 a.m., the Administrator said she got a call from the DON on [DATE] while CR#1's family member was at the NF when CR#1 had been cursing at the staff. The Administrator said the DON had shared with her that CR#1 said on [DATE] that day he was going to die and had requested what he wanted for his last meal. The Administrator said CR #1 had went to the hospital not sure for what and while there had requested to go on hospice . The Hospital had reached out to the NF of CR#1 wishes. The Administrator said she wanted to first speak with CR#1 family member to ensure that everyone was in agreement. The Administrator said she spoke with CR#1 family member who was against it but said she needed to speak with CR#1 first to see if that is what he really wanted to do before making a final decision. The Administrator said when CR#1 returned back to the NF, he was not on Hospice care and said he wanted to go to an inpatient Hospice because of what was told to him in the hospital. Interview on [DATE] at 11:02 a.m. with the DON said she had been working at the NF since (MONTH) 24, 2019. The DON said she received a call from the NF on [DATE] and spoke to one of the nurses telling her that CR#1 was unresponsive and EMS 911 had been called. The DON said she received the call at approximately 6 p.m. The DON said the staff member that called her was one of the Unit Managers who had also been called by the NF. The DON said CR#1 was never placed on Hospice care because he did not meet the criteria for inpatient Hospice. The DON said on [DATE] when CR#1 returned from [MEDICAL TREATMENT], he mentioned again about hospice care to the staff (weekend supervisor) who told CR#1she would have to get an order for [REDACTED].#1 had expressed feelings of suicide she would have immediately call the doctor for psych services and place CR#1 on one to one monitoring. Interview on [DATE] at 12:20 p.m. with CNA-1 said she was working the 2p-10p shift on [DATE] and was CR#1 CN[NAME] CNA-1 said when she came on shift, she done rounds with the previous CNA and CR#1 was sleeping in bed at the time which was around 1:45p.m. or 2p.m. CNA-1 said the morning CNA had reported that CR#1 had been having behaviors on the morning shift yelling and saying he wanted to die. CNA-1 said CR#1 always said that as well as speaking about going on Hospice would he would become angry. CNA-1 said on [DATE] she checked on CR#1 at 4p.m. or after making her rounds and the medication aide was coming out of his room and guessed the medication aide had given CR#1 his medication. CNA-1 said shortly after that, dinner trays were on the unit to be given to the residents. CNA-1 said when she took CR#1 his dinner tray he said he did not want to eat at the time. CNA-1 said she told CR#1 that she would leave his tray in the room in case she wanted to eat later and CR#1 said okay. CNA-1 said she left CR#1 room and reported to CR#1 nurse that he had refused his dinner tray at that time and nurse said okay she was about to go in and check CR#1's blood sugar and at that time it was around 5p.m. CNA-1 said she went back to pick up the resident dinner trays from their rooms around 5:45 p.m. or so. A guy approached the nurse station and identified himself as CR#1's family member and said to CNA-2 that CR#1 was acting strange not responding. CNA-2 went to CR#1 room and returned telling CNA-1 she thought CR#1 had passed away. CNA-1 said she immediately got the nurse and they went to CR#1 room. CR#1's family member was standing at the bedside. CR#1's mouth was open, and his eyes were closed. The nurse checked CR#1's pulse. CNA-1 said she immediately called a code blue. CNA-1 said EMS 911 and the DON was called by the supervisor. CNA-1 said CR#1 was paralyzed but was able to move one of his hands. The RT was trying to reinsert [MEDICAL CONDITION] was unable to [MEDICAL CONDITION] the way in. CPR was still being performed until EMS arrived. Interview on [DATE] at 1:10 p.m. with Family Member #1 said CR#1 never shared that he wanted to harm himself or die but did express that he wanted to go on hospice . Family Member #1 said she told CR#1 that she did not want him to go on Hospice . Interview on [DATE] at 1:20 p.m. with Family Member #2 said he came to visit the NF on [DATE] around 5:45 pm or 6pm. Family Member #2 said when he entered the room the lights and T.V. were off normally but the T.V. was on at the time. Family Member #2 said he thought CR#1 was asleep and when he tried to wake CR#1 he did not respond. Family Member #2 said CR#1 eyes were closed and his mouth was open. CR#[MEDICAL CONDITION] out laying on the right side of his neck area. Family Member #2 said he went and got staff. Family member #2 said the police had also come to the NF. Further interview with Family Member #2 said CR#1 never expressed to him that he wanted to commit suicide but that he wanted to die all the time especially when he got in his depressed mode and wanted family to come and see him. Family Member #2 said he spoke to Family Member #1 on [DATE] after everything had transpired. Family Member #1 had shared that CR#1 wanted to go on hospice but told CR#1 she did not want him to go on hospice . Interview on [DATE] at 2:15 p.m. with the Director of Respiratory said he had looked for the progress notes for the RT-B on [DATE] on the 6a-6p shift regarding CR#1 but could not find any of RT-B progress notes for that day. The Director said it was the NF policy to document twice in the respiratory progress notes with one being the charges of treatment provided as well as a note about the resident care and condition. The Director said that was a tough one to explain. The Director said RT-B worked 12 hour shifts most of the time 6a-6p. Interview on [DATE] at 2:27p.m. with CNA-2 said after dinner she saw CR#1 family member enter CR#1 room and came out of the room saying CR#1 was not responding. CNA-2 said she went to the room and found CR#[MEDICAL CONDITION] out with dry blood on it laying to the left side of his chest. CNA-2 said CR#1 never expressed to her he wanted to harm himself but that he wanted to die all the time. CNA-2 said the last time CR#1 said he wanted to die was approximately 2 weeks prior and CR#1 mother was present in room. CNA-2 said she never reported this to anyone because CR#1 had said it often and thought it was in the nurses notes therefore they knew about it. CNA-2 said if it was a new behavior that CR#1 was expressing, she would have reported it to the DON. CNA-2 said when she reported that CR#1 was not responding to the nurse, she did not go back into the room. CNA-2 said in the past she had provided care for CR#1 and resident had to be fed but could hold a cup. CNA-2 could not remember which hand. Interview on [DATE] at 2:50p.m. with LVN-A said she was CR#1 nurse on [DATE]. LVN-A said she reported to work before 6am and saw CR#1 being taken to [MEDICAL TREATMENT] and appeared stable. LVN-A said she got report from the night nurse and there were no issues reported. LVN-A said CR#1 returned to the NF from [MEDICAL TREATMENT] on the 6a-2p shift around 9 or 9:30 a.m. LVN-A said she worked a double shift on [DATE] but normally work 6a-2p shift. LVN-A said she heard CR#1 screaming, he wanted to die, he wanted to go on hospice . LVN-A said when he went to CR#1 room the family member was present and signal to her by placing her hand on her own lip LVN-A to be quiet. CR#1 wanted to observe CR#1 behavior for herself. LVN-A said she spoke with CR#1 letting him know she was there for him. LVN-A said she continued to check on CR#1 but did not know what time CR#1's family member left the NF. Further interview with LVN-A said around 4 p.m. closer to dinner time on [DATE] she checked CR#1 blood sugar which did not require any insulin coverage at the time. CR#1 did not want to eat. LVN-A said she did not observe any problems and CR#[MEDICAL CONDITION] intact. LVN-A said she took a lunch for approximately 45 minutes then returned proceeding to provide care for another resident that was needing her help when approached by CNA-1 saying she was needed stat (right away) to CR#1 room. LVN- A said CR#1 was in a semi-fowler position with head leaning downward, eyes closed, and mouth open. LVN-A said she checked CR#1 pulse and there was no pulse. LVN-A said she immediately started CPR and did not notice that CR#[MEDICAL CONDITION] out until RT (could not remember their name) said CR#[MEDICAL CONDITION] out and began to try and re-insert the trach. LVN-A said herself along with other staff members kept performing CPR until EMS arrived. Record review of CR#1's records revealed no documentation indicating the resident was sent to hospital for psych evaluation or for saying he wanted to die. Interview on [DATE] at 3:22 p.m., RT-B said he worked on [DATE] from 6a-6p. RT-B said he worked at the NF on an as needed basis but often time worked full time hours. RT-B said the care he provided for CR#1 on day consisted of checking CR#1 vital signs, oxygen saturation,[MEDICAL CONDITION] consisted of cleaning [MEDICAL CONDITION] peroxide came inside [MEDICAL CONDITION] kit along with suctioning CR#1 on an as needed basis. RT-B said the reason he did not document his care provided for CR#1 was because there was no incident or changes in CR#1 condition. RT-B said he was not sure about the NF policy on documentation regarding the respiratory department. RT-B said he had provided care to approximately 6 (six) other residents with trachs prior to administer care to CR#1 on his last spot check for the shift which was around 4 p.m. or so. RT-B said at time CR#1 was resting in bed with no distress and [MEDICAL CONDITION] intact. RT-B said CR#1 never expressed to him verbally he wanted to die, do harm to himself, or go on Hospice. RT-B said CR#1 would curse at staff sometimes. Interview on [DATE] at 3:40 p.m. with RT-A said he worked the evening shift 6p-6a on a as needed basis. RT-A said he had not checked on CR#1 and went to CR#1 room when he heard a code was being called. RT-A said when he arrived to CR#1's room, CR#1 was unresponsive with no pulse. CR#[MEDICAL CONDITION] dislodged. CPR was started. When this surveyor proceeded to ask RT-A more questions he refused saying everything he did was in his documentation and to asked surveyor to review his documentation. Attempts were made to interview Harris County Police Department unit # 45E20 for case # ,[DATE] on [DATE] at 4:00 pm was but was unsuccessful. A message was left with dispatcher with a call back for deputy in charge of this case. No calls were returned. Interview on [DATE] at 4:20 p.m., the Administrator said the NF sent psych referral over to Senior Psych Care Services on [DATE]. The Administrator said she spoke with a staff member at Senior Psych Care Services on [DATE] who shared with her CR#1 was never seen and had to find out why. The Administrator said the NF previous S.W. who left the NF in (MONTH) of 2019 should have followed up on the referral. The Administrator said the referral was just left in limbo. The Administrator said the new S.W. was not aware of the referral but when the DON spoke to CR#1 family member about Hospice care services after returning from the hospital, the family member wanted CR#1 to have a psych evaluation. The DON spoke to the S.W. who told the DON that CR#1 was already on psych services. The Administrator said she did not realize until [DATE] after calling the psych facility CR#1 was never evaluated. The Administrator said the S.W. would come to the morning meetings, nursing meetings as well as QAPI discussing all residents with behaviors including CR#1. The S.W. would go to CR#1 room and talk with him. The Administrator said the types of behaviors CR#1 was showing warranted a psych referral. Record review of CR#1's records revealed no documentation indicating the resident was sent to hospital for psych evaluation or for saying he wanted to die. Interview on [DATE] at 9:30a.m. with the Administrator said she guessed it would have been herself that supervised the S.W. ensuring the S.W. was carrying out her job duties since there was no one in the Corporate Office was overseeing the S.W. Interview on [DATE] at 9:40 a.m. with the Physical Therapy Coordinator said he never worked with CR#1 but knew he was blind. The Physical Therapy Director said the staff would assist CR#1 up in the wheelchair. CR#1 would often yell out loud cursing at the staff and asking to speak to his family member. Interview on [DATE] at 9:50 a.m., the Director of Respiratory said he had crossed trained on the nurses [MEDICAL CONDITION] and administering nebulizer treatments only. The Director said it was the RT's that [MEDICAL CONDITION] such as caring for the trach. The Director said she had spoken to RT-B informing him that he should have documented something in the progress notes even if there were no changes in CR#1 condition such as: no distress,[MEDICAL CONDITION] and what care was provided. The Director said CR#1 required the fundamentals [MEDICAL CONDITION] such as changing out [MEDICAL CONDITION] or simply cleaning the trach. The Director said if a resident had heavy secretions the [MEDICAL CONDITION] needed to be changed at least every other day but CR#1 was did not have heavy secretions and therefore did not needed to be suction frequently just as needed. The Director said CR#1 had a strong cough reflex that is why he did not completely understand why [MEDICAL CONDITION] there. The Director said one would have to speak the Physician. The Director said CR#[MEDICAL CONDITION] was a #6 Shiley. The Director said when [MEDICAL CONDITION] dislodged one can down size to a smaller size if they feel comfortable in doing so or just seal [MEDICAL CONDITION] off with a bandage well and use the ambu bag to get air to the resident. The Director said sometimes when [MEDICAL CONDITION] dislodged the opening can start to spasm therefore making it a challenge to insert [MEDICAL CONDITION]. The Director said it is not as easy it sounds and from his understanding that is what the RT done. The Director said CR#1 never pulled out [MEDICAL CONDITION] went to the hospital for pulling out his trach. Attempted interview was made on [DATE] at 10:35 a.m. with the Harris County Police Deputy who was not available. This surveyor left message for a return call, but call was not returned. Interview on [DATE] at 11:30 a.m. with RN-A said she started working at the NF in (MONTH) 2019 on a PRN basis. RN-A she had taken care of CR#1 and it was typical for CR#1 to curse at staff and yell out. RN-A said if this was a new behavior for CR#1 she would have notified the Physician, DON, RP, S.W., nurse manager, and document the behaviors. RN-A said she was told by other staff members that was how CR#1 behaves. RN-A said she thought CR#1 behaviors had already been addressed. Interview on [DATE] at 11:45 a.m. with LVN-C said she did not work at the NF on [DATE] only worked Monday-Friday from 9a-5p. LVN-C said she received a call from LVN-A that CR#1 had coded. LVN-C said she had been working at the NF approximately a month. LVN-C said she observed CR#1 of being very sweet to very demanding cursing at the staff and sometimes refusing care. LVN-C said she would intervene CR#1 behaviors by, talking with him, informing the DON of his behaviors, and just giving CR#1 what he wanted like extra food and a shower. LVN-C said she never called the physician but did instruct the unit nurse to call the physician regarding CR#1 behaviors. LVN-C said she did follow up with the unit nurse who said she notified the physician. LVN-C said she never saw any new orders addressing CR#1 behaviors. LVN-C said as a charge nurse she should have followed up. Further interview with LVN-C said the NF should have had CR#1 on Psych services. CR#1 medications could have been adjusted along with providing CR#1 with maybe counselor to speak with him. CR#1 may would have benefited in being sent out to a behavior hospital for further treatment. LVN-C said if an order is received for psych services the following should be done; print the order, give to the S.W., and behavioral monitoring is put in place. Interview on [DATE] at 12:25 p.m. with S.W. said there was never an order for [REDACTED]. said she started working at the NF in the middle of (MONTH) 2019. In the morning meetings they just talked about CR#1 behaviors. The S.W. said often CR#1 reflected back on his past life saying he had a good life. S.W. said the staff did report to her CR#1 used derogatory language. The S.W. said she did not know about a psych evaluation for CR#1 until the Administrator told her on [DATE]. Interview with the DON on [DATE] at 12:45 p.m. said she never reached out the doctor to get a psych referral for CR#1 and nor did she view CR#1 medical records to see if there was ever order for a psych evaluation. The DON said she looked back, she should have asked more questions regarding CR#1 behaviors and checked to see if there was an order for [REDACTED].#1 there but she refused him due to his behaviors. The DON said the nursing staff was not doing behavior and monitoring on CR#1 on the TAR (treatment administration record) just documented in their nursing notes but not consistently. Further interview with the DON said she started a 100% audit for any residents on psychoactive medications on [DATE] looking a behaviors and side effects for each medication and if they were being documented on TAR each shift. The DON said she also initiated an in-service on [DATE] what to do if a resident started expressing they want to die, signs of suicidal thoughts, a list of resource Psych hospital, and notifying the Administrator, DON, RP, Physician, and S.W. The DON said the managers were also in-serviced the steps that should be taken regarding behaviors and psych referrals. The DON said she did not do a written investigation regarding CR#[MEDICAL CONDITION] just talked with the staff. The DON said she felt bad and it was sad. Interview on [DATE] at 4:00 pm with LVN-B said she had read in his chart somewhere that CR#1 had a history of [REDACTED]. LVN-B said she never called the doctor regarding a psych evaluation for CR#1 behaviors because she saw in CR#1 records there was an order for [REDACTED].

Based on interview and record review, the facility failed to ensure a resident received and the facility provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for one resident of 12 (CR#1) residents reviewed for behavioral health services. The facility failed to coordinate behavioral health services for CR#1 who exhibited aggressive behaviors towards others. The facility failed to consult CR#1's physician when CR #1 continuously expressed that he wanted to die, refusing care, yelling, cursing at staff members, and attempted to dislodge [MEDICAL CONDITION]. The facility failed to have goals and intervention that addressed CR#1's aggressive behaviors. The facility failed to have a system that resident who had order for psych consult was implemented and treated. The facility failed to monitor CR#1's behavior of attempting to pull out his [MEDICAL CONDITION]. CR #1 was found unresponsive with [MEDICAL CONDITION] dislodged which resulted to his death. These failures resulted in an Immediate Jeopardy identified on [DATE]. While the IJ was lowered on [DATE] the facility remained out of compliance at a scope of isolated and a severity of actual harm that is not immediate jeopardy due to facility requiring more time to monitor the plan of removal for effectiveness. These failures affected one resident and placed residents living in the facility at risk of not receiving behavioral health services and decline in quality of life. Findings included: CR #1 Record review of CR #1 face sheet revealed a 41year old admitted to the facility on [DATE] and again on [DATE] with the following Diagnoses: [REDACTED]. Record review of CR # 1 MDS assessment dated [DATE] revealed that CR #1 had a BIMS score of 9, indicating cognitive moderately impaired. Review of CR#1 range of motion revealed that CR#1 had impairment on both sides of extremities upper and lower. Further record review revealed that CR # 1 was totally dependent on staff for activities of daily living and always incontinent of bowel and bladder. The MDS indicated the resident had no mood changes or behaviors and requires oxygen therapy and [MEDICAL CONDITION] care. The MDS also indicted the resident received [MEDICAL TREATMENT] . Record review of CR #1's physician orders dated [DATE] and [DATE] revealed an order for [REDACTED]. Record review of CR #1's physician order dated [DATE] revealed order [MEDICAL CONDITION] every shift [MEDICAL CONDITION] and as needed. [MEDICAL TREATMENT] - may go on Monday, Wednesday and Friday one time a day related to dependence on [MEDICAL TREATMENT]. Record review of CR #1's comprehensive care plan dated [DATE] revealed he had a care plan for depression with an intervention to provide psych consults per order with social worker to notify Senior Psych care. CR #1's also had a care plan for behavioral problems defined as spitting at staff, yelling at staff, making false accusations, refusing accu-checks, refusing [MEDICAL TREATMENT], and non-compliance with diet despite education on the pros and cons and complying with ordered diet. Further review of above care plan revealed CR#1 had a [MEDICAL CONDITION] related to [MEDICAL CONDITION] and impaired breathing mechanic. Goal indicated the resident will have clear and equal breath sound bilaterally through the review date . Interventions included: observe /document for restlessness, agitation, confusion, increased heart rate and low heart rate. Observe /document level of consciousness, mental status and Lethargy as needed. Observe document respiratory rate , depth and quality . check and document every shift as ordered. Provide good oral care dial and as needed. Provide means of communication and procedural information reassure that help is available immediately . Reassure resident to decrease anxiety. Suction as necessary . Record review of NF fax cover sheet for consult for Senior Psych Care dated [DATE] that CR #1 may be seen and treated by a Psychiatrist. This consult was faxed by ADON-B who no longer was working at the NF. Record review of CR#1's physician order revealed an order on [DATE] for [MEDICATION NAME] tablet 1 mg (milligram) by mouth every 6 hours as needed for anxiety until [DATE] and [MEDICATION NAME] 150 mg tablet by mouth at bedtime for depression. Further review revealed an order on [DATE] for [MEDICATION NAME] 20 mg (milligram) one tablet by mouth one time a day for depression. Record review of CR #1's Medication Administration Record [REDACTED]. There was no monitoring of his mood and behaviors related to the medication [MEDICATION NAME]. Record review of CR#1's Treatment Administration Record for the months of (MONTH) and (MONTH) 2019 revealed no documentation indicating CR#1's behaviors were monitored. Record review of Social Worker notes on [DATE] at 12:30p.m. revealed in part: .Nursing staff requested S.W. to speak with CR #1 due to his verbal derogatory language towards staff. Resident is hostile and easily agitated. He displays confusion and delusional in conversation. Nursing staff reported difficulty in caring for resident due to his hostile nature. Resident gives conflicting information within same conversation. Resident stated he has been good for 2 weeks and has not cursed anyone out. S.W. counseled resident on acceptable behavior, language and, expectations in an effort to assist with his behavior. The RP was called. The S.W. was unable to leave a message on RP's voice-mail . Record review of Nurses notes dated [DATE] at 7:39 p.m. by LVN-D revealed in part: .When CR#1 was told again there were no hamburgers he then stated he wanted another dinner tray, resident was informed there was not anymore of the dinner portions that's when the resident said he did not get his lunch due to being at [MEDICAL TREATMENT] and that he was promised by the dietary manager that he could continue to eat whatever he wanted until he was full. CR#1 was offered another sandwich but he refused and started to raise his voice at the nurse. Then again started to scream obscenities and saying he was told he could have whatever he wanted .the nurse continued again attempted to reason with resident offering him what was available but CR#1 continued to refuse and curse and was finally escorted to his room by the CNA while he continued to scream obscenities down the hall . Record review of Nurses notes late entry dated [DATE] at 2:54 p.m. by the DON read in part: .Spoke to CR#1 this morning about his desire to go on Hospice . CR#1 said he had spoken to Hospice company while in the hospital that he could go to their inpatient unit .The DON told CR#1 that he would most likely not qualify for inpatient hospice but could become hospice while in the NF and that inpatient hospice was for patients actively dying. CR#1 said if he refused [MEDICAL TREATMENT], he knew he will die faster .The DON told CR#1 that she would notify hospice to review his medical records for appropriate placement regarding Hospice . The DON contacted and spoke with hospice who said they would review CR#1 records for appropriate placement and would contact the DON, CR#1 and his family member . Record review of Nurses notes dated [DATE] at 4:05 a.m. by LVN-F revealed in part: .CR#1 was upset with the CNA that was changing him telling her to get the F out of his room. At that point the second CNA ask if she could change CR#1 and CR#1 said yes, she could .CR#1 was cleaned up and given water .at that point CR#1 was still agitated, and started to pull at his trach, CNA was able to calm him down. In a little CR#1 started to holler to call the DON and was calling respiratory to assist him. Respiratory came in and checked CR#1 out for proper placement [MEDICAL CONDITION].the DON was contacted for CR#1. The nurse, CNA, and respiratory was in CR#1 room while CR#1 was speaking to DON. Respiratory then re-checked [MEDICAL CONDITION] and gave breathing treatment. CR#1 is resting at this time .will continue to monitor for further behaviors . Record review of Social Worker note on [DATE] at 3:15 p.m. revealed in part: .SW met with CR#1 regarding morning breakfast and not going to [MEDICAL TREATMENT] .Resident was encouraged by nursing staff to calm down and that angered him even more . Resident was loud, hostile, demanding, and confused. His demeanor is narcissistic based on his gang related lifestyle (resident stated) prior to him getting ill. SW reminded him that his behavior continuously to be at odds with staff and other resident to the point that residents are writing grievances. CR#1 was not willing to listen to reason or compromise. The longer you talk with CR#1 the more the story changes. SW ended the conversation . Record review of the NF 24- hour Summary dated [DATE] at 5:58 a.m. regarding CR#1 revealed in part: .CR#1 yelling and screaming obscenities toward CNA staff .CNA's provided incontinent care and repositioning, and met CR#1 requests, nurse unsuccessful with redirection of CR#1 . Record review of Nursing Notes dated [DATE] at 5:48 a.m. by LVN-Z revealed in part: .CR#1 remains stable this shift with no distress or behaviors this shift. CR#1 left for [MEDICAL TREATMENT] with paper work via stretcher (Priority EMS) and attendants x 2, CR#1 was assisted with feeding of 2 (two) sandwiches and fruit juice per request .CR#1 left in stable condition, alert and oriented x 4, B/P=,[DATE], HR=90, RR=18, Temp=98.1, BS=132, SPO2=98% . Record review of Nurses notes dated [DATE] at 10:03a.m. by LVN-A revealed in part: .CR#1 continues to continues to yell at staff in hallway loudly .nurse enters CR#1 room and talked to CR#1, CR#1 yelled out I'm tired, I want to go on Hospice and die, CR#1 family member was at bedside quietly pointed fingers on her lips .nurse attempted to calm CR#1 down at bedside, CR#1 room door stayed opened, nurse knocked and entered through out shift . Record review of CR # 1 Nurses notes on [DATE] at 6:18 p.m. by LVN-A revealed in part: .CR#1 noted lying in bed with eyes closed unresponsive to any tactile stimuli and sternal rub.[MEDICAL CONDITION] lying next to resident on resident chest. CPR initiated AED in use, message given to continue CPR, Nursing team and respiratory team at CR#1 bedside .nurse called 911, nursing staff and rehab staff continue with CPR . Record review of CR #1's Nursing documentation by LVN-A on [DATE] at 8:11 p.m. revealed in part: .Officer reported to supervisor and charge nurse CR #1 expired . Interview on [DATE] at 10:40 a.m., the Administrator said she got a call from the DON on [DATE] while CR#1's family member was at the NF when CR#1 had been cursing at the staff. The Administrator said the DON had shared with her that CR#1 said on [DATE] that day he was going to die and had requested what he wanted for his last meal. The Administrator said CR #1 had went to the hospital not sure for what and while there had requested to go on hospice . The Hospital had reached out to the NF of CR#1 wishes. The Administrator said she wanted to first speak with CR#1 family member to ensure that everyone was in agreement. The Administrator said she spoke with CR#1 family member who was against it but said she needed to speak with CR#1 first to see if that is what he really wanted to do before making a final decision. The Administrator said when CR#1 returned back to the NF, he was not on Hospice care and said he wanted to go to an inpatient Hospice because of what was told to him in the hospital. The Administrator said after speaking with staff about finding CR#1 unresponsive, she did not think that she needed to do any in-service or investigation of her own simply because of what she was told by the staff. The Administrator said she was just told that CR#1 was sent to the hospital because he was unresponsive and later passed away. Interview on [DATE] at 11:02 a.m. with the DON said she had been working at the NF since (MONTH) 24, 2019. The DON said she received a call from the NF on [DATE] and spoke to one of the nurses telling her that CR#1 was unresponsive and EMS 911 had been called. The DON said she received the call at approximately 6 p.m. The DON said the staff member that called her was one of the Unit Managers who had also been called by the NF. The DON said CR#1 was never placed on Hospice care because he did not meet the criteria for inpatient Hospice . The DON said later CR#1 had to return to the hospital for continuous vomiting and when he returned to the NF the second time he did not mentioned anymore to her about Hospice . The DON said on [DATE] when CR#1 returned from [MEDICAL TREATMENT], he mentioned again about hospice care to the staff (weekend supervisor) who told CR#1she would have to get an order for [REDACTED].#1 had expressed feelings of suicide she would have immediately call the doctor for psych services and place CR#1 on one to one monitoring. The DON said she did not do a written investigation regarding CR#1 just a verbal nor did she do in-service with the staff on behavior and monitoring after CR#1 was found unresponsive on [DATE]. Interview on [DATE] at 11:50 a.m. with the Social Worker said spoke with CR#1 all the time. CR#1 would always refer to his previous life style before becoming ill. The S. W. said CR#1 never expressed to her that he wanted to harm himself but had refused going to [MEDICAL TREATMENT] due to his teeth not being brushed or not receiving his medications. The S.W. said CR#1 did have periods of anger and irritated along with outburst. The S. W. said at one time she did mentioned to resident if he wanted to go on hospice and he refused asking her if she was crazy? The S. W. said when a referral is order she get the order for a certain service and follow through with the referral. The S. W. said if a family inquire about a certain service she would let the nursing staff know. The S.W. said if a resident said a certain day was going to be his or her last and made a request for what they wanted to eat, she would inquire more to see if they were planning to harm themselves and if so, would sent the resident out for an evaluation. The resident would also be placed on one to one for monitoring. Interview on [DATE] at 12:20 p.m. with CNA-1 said she was working the 2p-10p shift on [DATE] and was CR#1 CN[NAME] CNA-1 said when she came on shift, she done rounds with the previous CNA and CR#1 was sleeping in bed at the time which was around 1:45p.m. or 2p.m. CNA-1 said the morning CNA had reported that CR#1 had been having behaviors on the morning shift yelling and saying he wanted to die. CNA-1 said CR#1 always said that as well as speaking about going on Hospice would he would become angry. CNA-1 said on [DATE] she checked on CR#1 at 4p.m. or after making her rounds and the medication aide was coming out of his room and guessed the medication aide had given CR#1 his medication. CNA-1 said shortly after that, dinner trays were on the unit to be given to the residents. CNA-1 said when she took CR#1 his dinner tray he said he did not want to eat at the time. CNA-1 said she told CR#1 that she would leave his tray in the room in case she wanted to eat later and CR#1 said okay. CNA-1 said she left CR#1 room and reported to CR#1 nurse that he had refused his dinner tray at that time and nurse said okay she was about to go in and check CR#1 blood sugar and at that time it was around 5p.m. CNA-1 said she went back to pick up the resident dinner trays from their rooms around 5:45 p.m. or so. A guy approached the nurse station and identified himself as CR#1's family member and said to CNA-2 that CR#1 was acting strange not responding. CNA-2 went to CR#1 room and returned telling CNA-1 she thought CR#1 had passed away. CNA-1 said she immediately got the nurse and they went to CR#1 room. CR#1's family member was standing at the bedside. CR#1 mouth was open, and his eyes were closed. The nurse checked CR#1 pulse. CNA-1 said she immediately called a code blue. CNA-1 said EMS 911 and the DON was called by the supervisor. CNA-1 said CR#1 was paralyzed but was able to move one of his hands. The RT was trying to reinsert [MEDICAL CONDITION] was unable to [MEDICAL CONDITION] the way in. CPR was still being performed until EMS arrived. Interview on [DATE] at 1:10 p.m. with Family Member #1 said CR#1 never shared that he wanted to harm himself or die but did express that he wanted to go on hospice . Family Member #1 said she told CR#1 that she did not want him to go on hospice . Interview on [DATE] at 1:20 p.m. with Family Member #2 said he came to visit the NF on [DATE] around 5:45 pm or 6pm. Family Member #2 said when he entered the room the lights and T.V. were off normally but the T.V. was on at the time. Family Member #2 said he thought CR#1 was asleep and when he tried to wake CR#1 he did not respond. Family Member #2 said CR#1 eyes were closed and his mouth was open. CR#[MEDICAL CONDITION] out laying on the right side of his neck area. Family Member #2 said he went and got staff. Family member #2 said the police had also come to the NF. Further interview with Family Member #2 said CR#1 never expressed to him that he wanted to commit suicide but that he wanted to die all the time especially when he got in his depressed mode and wanted family to come and see him. Family Member #2 said he spoke to Family Member #1 on [DATE] after everything had transpired. Family Member #1 had shared that CR#1 wanted to go on hospice but told CR#1 she did not want him to go on hospice . Interview on [DATE] at 2:05 p.m. with the Administrator said the police never came to the NF regarding CR#1. The Administrator said the only thing that was shared with her was that CR#1 was sent to the hospital. Interview on [DATE] at 2:27 p.m., CNA-2 said after dinner she saw CR #1's family member entered CR #1's room and came out of the room saying CR #1 was not responding. CNA-2 said she went to the room and found CR #1'[MEDICAL CONDITION] out with dry blood on it laying to the left side of his chest. CNA-2 said CR #1 never expressed to her he wanted to harm himself but that he wanted to die all the time. CNA-2 said the last time CR #1 said he wanted to die was approximately 2 weeks prior and CR #1 family member was present in room. CNA-2 said she never reported this to anyone because CR #1 had said it often and thought it was in the nursing documentation therefore they knew about it. CNA-2 said if it was a new behavior that CR #1 was expressing, she would have reported it to the DON. CNA-2 said when she reported to the nurse that CR #1 was not responding, she did not go back into the room. CNA-2 said in the past she had provided care for CR #1 and resident had to be fed but could hold a cup could not remember which hand. Interview on [DATE] at 2:50 p.m., LVN-A said she was CR #1's nurse on [DATE]. LVN-A said she reported to work before 6 a.m. and saw CR #1 being taken to [MEDICAL TREATMENT] and he appeared stable. LVN-A said she got report from the night nurse and there were no issues reported. LVN-A said CR #1 returned to the NF from [MEDICAL TREATMENT] on the 6a-2p shift around 9 or 9:30 a.m. LVN-A said she pulled a double shift on [DATE] normally work 6a-2p shift. LVN-A said she heard screaming, CR #1 was screaming he wanted to die, he wanted to go on Hospice. LVN-A said when he went to CR #1 room the family member was present and signal to her by placing her hand on her own lips LVN-A to be quiet. LVN-A said she spoke with CR #1 letting him know she was there for him. LVN-A said she continued to check on CR #1 but did not know what time CR #1 family member had left the NF. Further interview with LVN-A said around 4 p.m. closer to dinner time on [DATE] she checked CR #1's blood sugar which did not require any insulin coverage at the time. CR #1 did not want to eat. LVN-A said she did not observe any problems and CR #1'[MEDICAL CONDITION] intact. LVN-A said she took a lunch for approximately 45 minutes then returned proceeding to provide care for another resident that was needing her help when approached by CNA-1 saying she was needed stat (right away) to CR #1's room. LVA-A said CR #1 was in a semi-fowler position with head leaning downward, eyes closed, and mouth open. LVN-A said she checked CR #1's pulse and there was no pulse. LVN-A said she immediately started CPR and did not notice that CR #1'[MEDICAL CONDITION] out until RT (could not remember their name) said CR #1'[MEDICAL CONDITION] out and began to try and re-insert the trach. LVN-A said herself along with other staff members kept performing CPR until EMS arrived. LVN-A said CR #1 was sent out numerous times saying he wanted to die. Record review of CR#1's records revealed no documentation indicating the resident was sent to hospital for psych evaluation or for saying he wanted to die. Attempts were made to interview Harris County Police Department unit # 45E20 for case # ,[DATE] on [DATE] at 4:00 pm was but was unsuccessful. A message was left with dispatcher with a call back for deputy in charge of this case. No calls were returned. Interview on [DATE] at 4:20 p.m., the Administrator said the NF sent psych referral over to Senior Psych Care Services on [DATE]. The Administrator said she spoke with a staff member at Senior Psych Care Services on [DATE] who shared with her CR#1 was never seen and had to find out why. The Administrator said the NF previous S.W. who left the NF in (MONTH) of 2019 should have followed up on the referral. The Administrator said the referral was just left in limbo. The Administrator said the new S.W. was not aware of the referral but when the DON spoke to CR# 1's family member about hospice care services after returning from the hospital, the family member wanted CR#1 to have a psych evaluation. The DON went to speak with the S.W. who was now working in the NF. The S.W. told the DON that CR#1 was already on psych services. The Administrator said she did not realize until [DATE] after calling the psych facility CR#1 was never evaluated. The Administrator said that was why she was so upset because the previous S.W. would come to the morning meetings, nursing meetings as well as QAPI where she discussed all residents with behaviors including CR#1. The S.W. would go to CR#1 room and talk with him. The Administrator said the types of behaviors CR#1 was showing warranted a psych referral. Interview on [DATE] at 9:30a.m. with the Administrator said she guessed it would have been herself that supervised the S.W. ensuring the S.W. was carrying out her job duties since there was no one in the Corporate Office was overseeing the S.W. Interview on [DATE] at 9:40 a.m. with the Physical Therapy Coordinator/Director said he never worked with CR#1 but knew he was blind. The Physical Therapy Coordinator/Director said the staff would assist CR#1 up in the wheelchair. CR#1 would often yell out loud cursing at the staff and asking to speak to his family member . Attempted interview was made on [DATE] at 10:35 a.m. with the Harris County Police Deputy who was not available. This surveyor left message for a rerun call, but call was not retuned. Interview on [DATE] at 11:30 a.m. with RN-A said she started working at the NF in (MONTH) 2019 on a PRN basis. RN-A she had taken care of CR#1 and it was typical for CR#1 to curse at staff and yell out. RN-A said if this was a new behavior for CR#1 she would have notified the physician, DON, RP, S.W., nurse manager, and document the behaviors. RN-A said she was told by other staff members that was how CR#1 behaved. RN-A said she thought CR#1 behaviors had already been addressed. Interview on [DATE] at 11:45 a.m. with LVN-C said she did not work at the NF on [DATE] only worked Monday-Friday from 9a-5p. LVN-C said she received a call from LVN-A that CR#1 had coded. LVN-C said she had been working at the NF approximately a month. LVN-C said she observed CR#1 of being very sweet to very demanding cursing at the staff and sometimes refusing care. LVN-C said she would intervene CR#1 behaviors by, talking with him, informing the DON of his behaviors, and just giving CR#1 what he wanted like extra food and a shower. LVN-C said she never called the physician but did instruct the unit nurse to call the physician regarding CR#1 behaviors. LVN-C said she did follow up with the unit nurse who said she notified the physician. LVN-C said she never saw any new orders addressing CR#1 behaviors. LVN-C said as a charge nurse she should have followed up. Further interview with LVN-C said the NF should have had CR#1 on Psych services. CR#1 medications could have been adjusted along with providing CR#1 with maybe counselor to speak with him. CR#1 may would have benefited in being sent out to a behavior hospital for further treatment. LVN-C said if an order is received for psych services the following should be done; print the order, give to the S.W., and behavioral monitoring is put in place. Interview on [DATE] at 12:25 p.m. with S.W. said there was never an order for [REDACTED]. said she started working at the NF in the middle of (MONTH) 2019. In the morning meetings they just talked about CR#1 behaviors. The S.W. said often CR#1 reflected back on his past life saying he had a good life. S.W. said the staff did report to her CR#1 used derogatory language. The S.W. said she did not know about a psych evaluation for CR#1 until the Administrator told her on [DATE]. Interview with the DON on [DATE] at 12:45 p.m. said she never reached out the doctor to get a psych referral for CR#1 and nor did she view CR#1 medical records to see if there was ever order for a psych evaluation. The DON said she looked back, she should have asked more questions regarding CR#1 behaviors and checked to see if there was an order for [REDACTED].#1 there but she refused him due to his behaviors. The DON said the nursing staff was not doing behavior and monitoring on CR#1 on the TAR (treatment administration record) just documented in their nursing notes but not consistently. Interview with the Administrator on [DATE] at 3:15 p.m. said she did not do a formal investigation regarding CR#1 death incident because of the way it was presented to her . Interview on [DATE] at 4:00 pm with LVN-B said she had read in his chart somewhere that CR#1 had a history of [REDACTED]. LVN-B said she never called the doctor regarding a psych evaluation for CR#1 behaviors because she saw in CR#1 records there was an order for [REDACTED]. Interview on [DATE] at 2:43 pm., with Occupational Therapist said she did here CR#1 express verbally that he wanted to die. OT said she documented the behavior and notified the nursing staff. OT said CR#1 behaviors were discussed in the morning meetings with the other staff members. Interview on [DATE] at 4:30 p.m. with the DON said she resigned as DON at the NF on [DATE] because she did not have adequate support from Corporate Office to be successful in her job in caring for the residents. The DON said the nursing staff did not also know how to go in the system to document residents receiving psych medications to monitor for behaviors and any side effects. The DON said this should be done daily on each shift. The DON said she educated the staff on [DATE]. The DON said she had received a call from the S.W. at home saying when she had asked her to speak with CR#1 she thought the DON just wanted her to just go and talk with CR#1. Record review of the facility policy titled Behavioral Assessment, Intervention and Monitoring revised (MONTH) (YEAR) revealed in part: .The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress, and potential safety risk to the resident, and develop a plan of care accordingly. Safety strategies will be implemented immediately if necessary to protect the resident and others from harm . The Administrator, ADON and Business Office Manager were notified on [DATE] at 3:20 pm of the IJ, IT, and SQC identified due to the above failures and a Plan of removal was requested. The POR was received and after 3 revisions it was accepted on [DATE]. Interview on [DATE] at 1:00 pm, the Administrator said she thought the Immediate Jeopardy came about because the facility's lack of policies, procedures, and training provided to staff on how to identify the resident who need referrals and ensure referrals are initiated and treatment is received. She said there was no training provided to the staff regarding the matter prior to calling the IJ and SQC .The Administrator said the facility was now in-servicing the staff. Plan of Removal of Immediate Jeopardy [DATE] at 3:20 pm read in part . Once residents are identified with irregular psychosocial behaviors the Administrator/ADON/Social Worker will coordinate a plan best fits patient needs - example 1x1 monitoring, additional activities, suggestion of medication management and will communicate with patient's physician and psychological services. These residents will by identified by specific shift to shift reporting, supervisory communication via PCC and/or notification from Social Services with daily follow up All residents have the potential to be affected by these deficiencies Revision of the Behavioral Monitoring Process (Freedom from Abuse, Neglect and Exploration/ Quality of Care/ Behavioral Health Services) Review of All residents who have psychological and behavior needs reviewed an care planned, during audit we identified 1 other resident is in need services hadn't been seen. We immediately faxed over the referral and the resident has been placed in queue to be seen by the Psychology Dept : Assistant Director of Nursing, Social Worker, MDS Coordinator and Administrator completed [DATE] Texas Institute for Clinically Complex Care (Ti3C) incorporates a resident centered approach on caring for our patients. Upon each new patient they are accomplice with an admission packet includes their H&P, MAR, labs, etc. all this is entered PCC. At daily stand up and stand down the IDT team reviews and discuss patients' medical conditions, PCC includes corrective actions and follow up . All facility physicians were contacted to obtain a psychological evaluation on all their patients via verbal order for assessment to rule out harm; binder located in Social Worker office : ADON/ Social Services Completed [DATE] A Binder is placed at All nursing station of all residents are on psychological services with the NP & MD information to be updated bi-weekly for any admits/discharges: Social Services <br

Based on interview, observation, and record review the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 12 residents (Resident #4) reviewed for accident hazards, in that: Resident # 4 fell from a mechanical lift to the floor, fracturing her back. This failure affected one resident, placing her at risk for further trauma, pain, and hospitalization . Findings included: Resident #4 Record review of Resident #4's face sheet revealed she was [AGE] years old who was admitted to the Nursing facility on 01/28/2016 and 08/14/19. Her [DIAGNOSES REDACTED]. Record review of Resident #4's MDS assessment dated [DATE] revealed a BIMS score of 12 indicating she had moderately impaired cognitive skills. She required extensive assistance with activities of daily living for 2 (two) persons assist with bed mobility, transfers, personal hygiene, and toileting. Resident #4 had functional limitation in range of motion to one side upper and lower extremities and required the mobile device of a wheelchair. Resident #4 was always incontinent of bowel and bladder. Record review of Resident #4's comprehensive care plan dated 02/19/19 revealed that she had a care plan indicating she required a mechanical (Hoyer) lift for transfers. Resident #4 had a care plan dated 12/04/18 and revised on 08/15/19 addressing her risk for falls related to poor balance, unsteady gait, muscle weakness, and lack of coordination. Resident #4 had a care plan dated 07/22/19 indicating she had an actual fall with no injury and another actual fall on 08/09/19 which resulted in a fracture. The interventions included 2-person Hoyer lift transfers. Record review of Resident #4's weight taken on 08/08/19 revealed a weight of 251.1pounds. Observation on 08/22/19 at 1:10 p.m. of the Hoyer lift machine revealed that Resident #4 had fallen from being brought from the broken storage room. The Hoyer lift had a sign on machine indicating out of use, with last inspection date of 07/19/19. There was a sticker on machine reading up to 300 pounds. The legs on the machine were un-even. The leg on the left side was not even with the right leg. Record review of Resident #4's Nursing Progress Notes dated 07/22/19 revealed in part: .9:11 p.m. RN-C was notified by shower tech that Resident # 4 was on the floor. When RN-C went into room, Resident #4 was on the floor. Resident #4 was alert and oriented times 3. The other nurse and two CNAs were with Resident #4. Resident #4's bed was in lowest position. One of the CNAs said she was in the room with Resident #4 using the Hoyer lift to put Resident #4 back to bed. The Hoyer lift tilted, and the CNA reported she slowly eased Resident #4 to the floor. Resident #4 denied hitting her head and denied of pain. Resident #4 said she would notify staff if she was in pain. No new bruises noted. Resident #4's RP was notified along with the Nurse Practitioner. The DON was present . Interview on 08/15/19 at 2:05 p.m. with the DON, she said she did not do an investigation when Resident #4 fell the first time from the Hoyer lift on 07/22/19. The DON said she just in-serviced the staff. Record review did not reveal an investigation was conducted following Resident #4's first falls from a Hoyer lift . Record review of Resident #4's Nursing Progress Notes dated 08/09/19 revealed in part: .at 9:45 a.m. documented by RN-B Resident was transferred with Hoyer lift from bed to wheelchair, Resident #4 slid on floor. RN-B assessed all Resident #4 body for injuries, no apparent injuries. Resident #4 denied pain at this time. In the afternoon Resident #4 complained of her back. RN-B gave Tylenol 325 mg (milligrams) 1 (one) tablet by mouth, stat order for X-ray all spine. RN-B communicated to X-ray department, neuro check in progress note every shift time 72 hours [DIAGNOSES REDACTED]. Record review of Resident #4's Nursing Progress Notes dated 08/09/19 revealed in part: .9:45 a.m. documented by ADON that investigation conducted about Resident #4's fall on 08/09/19. Due to investigation details it, was found that the Resident #4 was being transferred from the bed to wheelchair using Hoyer lift that resulted in a fall. Resident #4 was immediately assessed with [REDACTED].#4 was able to move all extremities. Resident #4 denied hitting head, complaining of slight discomfort to back. PRN pain medication offered at this time, but Resident #4 declined. Resident #4 assisted into Hoyer and into wheelchair. The MD (Medical Doctor) and the RP was notified. Neuro checks initiated, will continue to monitor. Advised Resident #4 to alert staff to any increase in pain. Resident #4 verbalized understanding. Further Record review of Resident #4's Nursing Progress Notes on 08/09/19 revealed in part: .5:30 p.m. documented by RN-C Resident #4 complaining of severe back pain and abdominal pain. Resident #4 face grimacing. Aspercreme applied to Resident #4's low back, b/p-180/107, HR-85, RR-18, and temp-97.9. Radiology tech came to perform back x-ray. Radiology tech said Resident #4 was too large at 251 pounds for a Mobile x-ray and the image on the x-ray would not be clear and therefore suggested that Resident #4 needed to go the hospital. The NP was called, no answer, left message. The DON was notified along with Resident #4 family member. Resident #4 was transported to Hospital . Record review of Physician order [REDACTED]. Record review of Resident #4's Hospital Record dated 08/09/19 revealed that Resident #4 told hospital staff that she had a fall at Skilled Nursing Facility about 2 weeks previously; no further work up at that time. Computed [NAME]ography (CT) Scan was done on 08/09/19 indication: Chronic back pain, fall with an impression of a nondisplaced left lateral sacral fracture. Interview on 08/15/19 at 2:05 p.m., the DON said Resident #4 was being transferred by 2 (two) CNAs from the bed to the wheelchair and the Hoyer lift machine tilted and Resident #4's upper body hit the floor. The 2 CNAs lowered the rest of Resident #4's body down to the floor. Resident #4 was assessed by the nurse and denied pain. The DON said, later, Resident #4 started to complain of pain to her abdomen and back. The DON said Resident #4 already had chronic back pain. The nurse gave her something for pain when Resident #4 complained of pain. The DON said the MD was called and orders were given to get a stat X-ray. Resident #4 had to be sent out to the hospital for an accurate X-ray because she weighed too much for the mobile X-ray equipment. Further interview with the DON said an in-service was started on Hoyer lift transfer when the NF found out that Resident #4 had a fracture. The DON said the Physical Therapy Department started a more formal in-service with the Nursing staff 2 days ago, she believed. The DON said when she first started working at the NF she learned that the state came to the NF regarding Resident #4's fall so she began in-servicing the staff on Hoyer lifts and transfers. The DON said prior to Resident #4's fall on 08/09/19 was her second fall from the Hoyer lift during transfers. Resident #4's fall in (MONTH) 2019 was due to a CNA transferring Resident #4 by herself. The DON said that CNA was terminated immediately. Resident did not verbalize pain with the first fall when the nurse assessed her. The DON said the NP was notified and gave orders to do labs. Interview on 08/20/19 at 1:20 p.m., CNA #3 said she was the CNA assigned to Resident #4 when resident fell during an Hoyer lift transfer on 08/09/19. CNA #3 said she got Resident #4 dressed while in bed and placed the Hoyer sling underneath Resident #4 before she went to get assistance with the transfer. CNA #3 said she got CNA #4 to assist her with the transfer. Further interview with CNA #3 said both she and CNA #4 attached the Hoyer sling to the Hoyer machine. CNA #3 said she was the one operating the machine and CNA #4 was guiding Resident #4 legs. CNA #3 said as she began to turn the machine and out of nowhere, the Hoyer lift machine tilt backwards. The Hoyer lift machine hit CNA #4 legs. Resident #4 fell backwards hitting the floor still strapped in the Hoyer lift sling. CNA #3 said she did not know what happened because it happened so fast. CNA #3 said the nurse was called to the room. Resident #4 was not complaining of any pain at the time of the incident and said she was fine. The nurse assessed Resident #4. CNA #3 said a new Hoyer lift machine was brought in Resident #4 room to lift resident off the of the floor and back in her bed. CNA #3 said Resident #4 was left in bed for the remainder of her the shift. Interview on 08/20/19 at 1:40 p.m., CNA #4 said she was called to Resident #4 room to assist with Hoyer lift transfer because Hoyer lift transferred had to be done with 2 people. CNA #4 said Resident #4 was in bed when she entered the room with the Hoyer sling already underneath her. CNA #4 said she assisted CNA #3 with attaching the Hoyer sling to the Hoyer machine. CNA #4 said she was standing at the foot of Resident #4 guiding her legs when CNA #3 began lift resident off the bed. When transferring Resident #4 in the Hoyer lift from the bed to the wheelchair, the Hoyer machine began to tilt with resident going backward. Resident #4 went down of the floor still in the Hoyer sling. The nurse was called to the room. Resident was assessed by the nurse and said she was okay and denied pain. CNA #4 said she left the room because other staff members had come to the room. Interview on 08/20/19 at 2:15 p.m., RN-B said she was the nurse on duty when Resident #4 fell to floor in the Hoyer sling on 08/09/19. RN-B said both CNA's #3 and #4 both communicated with her that they were going to get Resident #4 up with the Hoyer lift and she said okay. RN-B said CNA #3 came out of the room informing her that Resident #4 had fallen. RN-B said when she entered Resident #4 room, she saw resident on the floor on her back still in the Hoyer sling and the Hoyer machine was on the floor on its side. RN-B said she assessed Resident #4 who denied pain at that present time. RN-B said after assessing Resident #4, she got another Hoyer lift machine to assist in getting resident off the floor to her bed with the assistance of 5 (five) other staff members. RN-B said the MD was called and she received orders to do an X-ray of the spine. RN-B said she gave report to the oncoming nurse and went home. RN-B said her last in-service with Hoyer lift transfers was a week ago with the Physical Therapy Department. RN-B said she had received in-service with Hoyer lift transfer prior but could not remember the date. Interview on 08/20/19 at 3:05 p.m., RN-C said she worked the 2p-10-p shift. RN-C said she received report from RN-B on 08/09/19. RN-C said she had received in report that Resident #4 had fallen, and that X-ray had been called. RN-C said she assessed Resident #4 who had begun to complain of abdominal pain and back pain. RN-C said Resident #4 said it may have been something she had eaten. RN-C said when X-ray came, they were unable to get the X-ray due to Resident #4 size and therefore had to send resident to the hospital. Observation on 08/20/19 at 4:25 p.m. of Resident #4 in bed wearing gown with call light in reach. Resident T.V. was on in room. Interview was conducted with Resident #4 on 08/20/19 at 4:25 p.m. Resident # 4 who was alert and oriented. Resident #4 said she had fallen when staff members CNAs #3 and #4 using the Hoyer lift to transfer her. Resident said when staff members were transferring her, she fell backwards on the floor. Interview on 08/21/19 at 10:00 a.m., the Physical Therapist Coordinator said he had done in-service with the Nursing staff on 08/13/19 on the maintenance of the Hoyer lift and preparing residents for Hoyer lift transfer. Interview on 08/21/19 at 11:15 a.m., the Administrator said when Resident #4 fell the first time from the Hoyer lift on 07/22/19 she did not conduct an investigation because the CNA was doing the transfer by herself. The CNA had reported that she did not have time to go and get help and therefore was terminated. The Administrator said when Resident #4 fell a second time from the Hoyer lift during transfer on 08/09/19, she could not understand why the Hoyer lift machine would tilt. The Administrator said the Maintenance Director looked at the machine and discovered one of the legs on the machine on the left side was turned inward and was tagged not to be used. The Administrator said it was the Maintenance Department and the Physical Therapy Department that inspected the equipment to ensure the equipment was safe to use but more so the Maintenance Department. The Administrator said Maintenance Department check the Hoyer lift machines and other resident care equipment was checked monthly. The Administrator said no resident care equipment such as the Hoyer lift machine had been reported to her as broken. The Administrator said the Maintenance Department have their own log of their monthly checks for resident care equipment. Interview on 08/21/19 at 11:50 a.m., the Maintenance Director said he made rounds every day checking the communication log on each Nursing unit twice a day looking at things that need to be address. The Maintenance Director said he believed the problem with the Hoyer lift was brought to his attention after Resident #4 had her second fall. The Maintenance Director said it was the discovered that the Hoyer lift that one of the legs of the Hoyer lift machine was not opening properly. The Director said the Hoyer lift machine was tagged not to be used and taken out of rotation and then placed in the broken equipment room for repair. The Director said the staff did not all the time communicate in the communication log book kept on the nurse station but instead, called him in the hallway and he informed the or shared in the morning meetings. He said that the staff needed to write it in the communication log, but informal communication kept happening. The Director said there was no communication in the log book of a Hoyer lift not working properly. Record review of the Maintenance communication log on each unit (Hall-100 and Hall-300) did not reveal communication of broken Hoyer lift. Interview on 08/21/19 at 1:10 p.m., CNA #5 said when she reported to work on 07/22/19, Resident #4 was sitting up in her wheelchair in her room and had requested to go back to bed because she had soiled her brief. CNA #5 said she could not find anyone to assist her and Resident #4 kept calling to be place back in bed so that her brief could be changed. CNA #5 said she attempted by herself to transfer Resident #4 back to bed using the Hoyer lift. CNA #4 said she place Resident #4 in the Hoyer sling and proceeded to lift resident out of wheelchair to transfer to the bed and the Hoyer lift machine stopped. CNA #5 said she left Resident #4's room to go and get another battery to place in the machine. CNA #5 said the machine began to move again then the battery popped out of the machine causing the machine to stop abruptly making her loose her balance. CNA #5 said she fell on the floor. CNA #5 said Resident #4 was still in the Hoyer lift sling, never hitting the floor. CNA #5 said it was she who fell on the floor. CNA #5 said she began to scream for help. Resident #4 was eased down on the floor. CNA #5 said she tried to tell the DON that something was wrong with the Hoyer lift machine and explained to the DON what had occurred, but the DON fired her. CNA #5 said she told the DON that the Hoyer lift machine was not good. CNA #5 said she found out later that Resident #4 had fallen again with the same Hoyer lift. CNA #5 said she could not remember the person's name who called and told her. Interview on 08/21/19 at 2:05 p.m. with RN-C said the first fall incident regarding Resident #4 on 07/22/19. She was in another resident's room and was called to Resident #4 room to find resident on floor with the Hoyer lift over to the side of Resident #4. CNA #5 was present along with another staff member could not remember her name for certain. RN-C said she assessed Resident #4 who denied pain. RN-C said shortly after, the DON came to Resident #4 room. CNA #5 begin to explain to the DON what had happened telling the DON that during transfer of Resident #4 the Hoyer lift stopped and think that CNA #5 told the DON that she eased Resident #4 down to the floor. Interview on 08/21/19 at 2:15 p.m., Resident #4 said during her first fall in the Hoyer lift machine she never hit the floor, but the staff eased her down to the floor. Resident #4 said during the second incident with the Hoyer lift she hit the floor like Bam! Interview on 08/21/19 at 9:37 a.m., the Administrator said there were 3 (three) Hoyer lifts on Hall- 300 and 1 Hoyer lift on Hall-100. Interview on 08/22/19 at 10:20 a.m., CNA #6 said if equipment was broken or appeared to be broken, she would place the equipment in the storage room and notify the charge nurse and the ADON. CNA #6 said she would also tag the equipment and communicate in the log book for the Maintenance department. CNA #6 said she had received training with Hoyer lift transfers. Interview on 08/22/19 at 10:50 a.m., the Maintenance Director said he did a visual check on the Hoyer lift machines each month. The Director said he raised and lowered the machine making sure the legs were working properly. The Maintenance Director said he could not provide a copy of his maintenance log record for the Hoyer lift machine. Interview on 08/22/19 at 11:20 a.m., CNA #7 said whenever a Hoyer lift was not functioning properly, he would put it back in the storage room and get another one. CNA #7 said he had never been in-serviced on how to store broken resident care equipment. Observation was made on 08/22/19 at 11:50 a.m. of Hoyer lift machines in use at the NF with last inspection date reading 08/19. Interview on 08/22/19 at 1:00 p.m., the Administrator said the Maintenance Director did not give her a log of his monthly inspections of resident care equipment. He told her verbally or sent an e-mail. The Administrator said she had not sent out any Hoyer lifts to be repaired. Record review of the Nursing facility policy on Maintenance Service revised (MONTH) 2009 revealed in part: .The Maintenance Department is responsible for maintain the buildings, grounds, and equipment in a safe and operable manner at all times .A copy of the maintenance schedule shall be provided to each department director so that appropriate scheduling can be made without interruption of services to residents .Records shall be maintained in the Maintenance Director office. Record review of Hoyer Lift Manufacture Guide revealed in part: .always check the legs of the lift open and close satisfactorily .Warning! Do not use the lift while charging is taking place

Based on observation , interview, and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one of seven residents (Resident #1) reviewed for quality of care, in that; Resident #1 sustained a fall on 12/4/18 and verbalized right leg and hip pain, the facility only obtained X-ray of Resident#1's right hip and not the right leg . Resident #1 was diagnosed with [REDACTED]. The facility failed to properly assess and intervene when Resident #1 continued to complain of pain to left leg. Resident #1 was diagnosed with [REDACTED]. These failures affected one resident and placed her at risk of neglect and injury. Findings include: Intake # 6/TX 213 Intake # 3/TX 710 Resident #1 Record review of Resident #1's face sheet revealed an [AGE] year-old female, initially admitted to the facility on [DATE], and re-admitted on [DATE]. Resident's [DIAGNOSES REDACTED]. Record review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS score of six, indicating severely impaired cognition. The MDS revealed the resident was always incontinent of both bowel and bladder, required extensive assistance of two persons for bed mobility. She required total assistance of one person for dressing, total assistance of two staff for toilet use, and extensive assistance of one person for personal hygiene. Record review of Resident #1's significant change Minimum Data Set ((MDS) dated [DATE] revealed a BIMS score of three, indicating severely impaired cognition. The MDS revealed the resident was always incontinent of both bowel and bladder, required extensive assistance of two persons for bed mobility, dressing , toilet use and personal hygiene. Record review of Resident #1's care plan (Target date 3/31/19) revealed focus: Resident #1 has an ADL self-care performance deficit related to dementia. Interventions: Resident required extensive assist of two with bed mobility, toileting, transfers, dressing, and personal hygiene. Further review revealed: Focus: Resident #1 was risk for falls related to incontinence, vision/hearing. Interventions: Anticipate and meet the resident's needs. Further review revealed Resident #1 is risk for falls related to incontinence, vision/hearing problems. Had an actual fall on 12/4/18, no injury noted. Observation and interview with Resident #1 on 2/12/19 at 8:55 AM, resident was observed lying in bed, dressed in a gown, pillow propped under her legs, and groomed. Resident #1 expressed no concerns of pain. Resident #1 stated she had a fractured leg, but that she did not have a fall, and she did not know how the fracture happened. Record review of Resident #1's incident report dated 12/4/18 revealed: Incident description: while being cleaned and changed, resident was helping to turn and when left leg was moved to turn, resident fell out of bed on the left side. Immediate action taken: Resident was assessed for injuries. Able to move all extremities. Draw sheet placed underneath resident and four staff members lifted to bed. Re-assessed for further injuries. Has complained of right leg/hip pain. Taken to hospital: No. Injury report post incident: No injuries observed post incident. Interview with CNA #1 on 2/12/19 at 11:49 AM, CNA #1stated while she was making rounds, she went to Resident #1's room to change the resident, when turning the resident in the bed, the resident's left leg was over the right leg and the resident started to slide off the bed. CNA #1 stated resident was lowered to the floor, and the nurse was called to the room. The resident was assessed by the nurse, and the resident was placed back in the bed. CNA #1 further stated the resident complained of pain to the leg, and the resident received an x-ray right hip. CNA #1 stated resident was a one person assist prior to the incident, and after the incident the resident was changed to a two person assist. Record review of radiology report dated 12/4/18 revealed in part .conclusion: there is no radiographic evidence of acute disease in the right hip. If there is continued clinical concern, then cross-sectional imaging follow-up is recommended. There is [MEDICAL CONDITION] joint disease in the right hip. Bone demineralization is present . Interview with DON on 2/12/19 at 1:48 PM, the DON stated in interview with Resident #1 after the incident, the resident complained of pain to the hip, which was why only the hip X-ray was done . Record review of Resident #1's progress notes dated 12/4/18, revealed: stat order for X-ray of right hip was negative, no fracture, new order for venous doppler left leg, result no evidence of [MEDICAL CONDITION]. Record review of Resident #1's progress notes dated 12/4/18, revealed: Tylenol 325 MG give 2 tablets by mouth every 6 hours as needed for pain. Author: RN #3. Interview with RN #3 on 2/12/19 at 1:33 PM, RN #3 stated she did not see anything unusual about Resident #1, there was no swelling or bruises after the resident's fall. RN #3 further stated resident did not complain of any pain to the legs. RN #3 explained that Resident #1 was receiving Tylenol and [MEDICATION NAME] for headaches. Record review of Resident #1's progress notes dated 12/6/18, revealed: Tylenol 325 MG give 2 tablets by mouth every 6 hours as needed for pain. Record review of Resident #1's progress notes dated 12/6/18, revealed patient is in bed throughout 2-10 shift. Patient frequently complains of pain to left leg. Tylenol 650 mg given per doctor's order for pain. Author: RN #1. Interview with RN#1 on 2/12/19 at 2:27 PM, she stated she could not remember notifying the MD of Resident #1's complaint of pain. RN#1 stated she would normally either call the MD or use the communication log to inform the MD, but she could not recall if she did. Record review of Resident #1's progress notes dated 12/16/18 revealed [MEDICATION NAME] HCI Tablet 50 MG. Give 1 tablet by mouth every 4 hours as needed for pain. Resident complained of sharp pain radiating from her lower legs and rates pain level as 6 of 10. Will follow up. Author: RN #2. On 2/12/19 at 1:44PM, Surveyor attempted to reach RN #2 for a phone interview, but she did not return call. Interview with MD on 2/12/18 at 1:25 PM, the MD stated she was made aware of the resident's fall on 12/4/18 and was informed of the area in which the resident complained of pain, and an x-ray was ordered which showed no injury. The MD stated she could not off the top of her head recall being informed of resident expressing pain on 12/6 or 12/16. The MD also stated she has had several conversations with the resident after the fall and the resident did not express any pain. Record review of physician's progress notes revealed: Date of service: 12/5/18. Chief complaint: eval LLE, right hip, mood. Review of systems: musculoskeletal: History of acute left lower extremity pain. Today tells me at first no pain, then when I ask her again, at the end of exam she says she does have pain. However, during both episodes, patient without facial grimace or appearance of pain. Physical exam: musculoskeletal: no tenderness to palpitation bilateral hip area. Non-specific tenderness to palpitation BLE (Bilateral lower Extremity ), but specifically around knees. Date of service: 12/17/18. Chief complaint: poor appetite, [MEDICAL CONDITION]([MEDICAL CONDITION] ), dementia. Debility. treatment plan: [REDACTED]. Date of service: 12/20/18. Chief complaint: Evaluation status [REDACTED]. Review of systems: musculoskeletal: HX (history ) of left lower extremity pain. Physical exam: left lower extremity pain. Date of service: 12/27/2018. Chief complaint: poor appetite, FTT (Failure to thrive), UTI, Sacral wound. Review of systems: musculoskeletal: HX of left lower extremity pain. Physical exam: left lower extremity pain. Interview with DON on 2/12/19 at 1:48 PM, the DON stated he was not aware of Resident #1's complaints of pain on 12/6/18 and 12/16/18. Record review of Resident #1's progress notes dated 1/30/19 revealed in part .Resident stated she did not want to be placed back to bed or repositioned to a more comfortable position in wheel chair. Resident stated she has pain generally all over and was able to shift hips to reposition self in wheel chair without any signs or symptoms of pain. After further discussion by interdisciplinary team, it was determined to have X-ray of left hip and left knee area for further evaluation . Record review of radiology report dated 1/30/19 read in part .conclusion: Recent fracture involving left distal femur with modest displacement and mild callus formation . Surveyor requested the MD communication logs for 12/1/18 - 2/19/19, DON provided logs dated 1/11/19 - 2/15/19. Interview with DON on 2/19/19 at 10:38 AM, the DON stated the logs were unofficial documents, and not used officially or kept by the facility. The DON stated he was unable to locate the (MONTH) (YEAR) logs. Record review of communication logs revealed: Resident: Resident #1. Date of occurrence: 1/14/19. Concern: [MEDICATION NAME] 64.8 mg. Needs new script. Resident: Resident #1. Date of occurrence: 1/31/19. Concern: was transferred to hospital 12:05 AM. Returned to facility at 3:05 AM. Per hospital it is an old fracture (left leg) and there is periosteal inflammation and remodeling around site. Follow up with ortho surgeon in 3-5 days. Record review of emergency room visit dated 1/31/19 revealed: Chief complaint: according to nursing home, patient has deformity to left leg, no complaints of pain, last known fall, 12/4/18. Radiology results dated 1/31/19: Findings: There is a [MEDICAL CONDITION] femoral metaphysis with impaction and overlap of the components. However, for the most part, this fracture is chronic as there is remodeling and periosteal reaction surrounding the fracture site. An acute refracture is a possibility. Record review of Resident #1's X-ray result dated 2/7/19 revealed acute pain of left knee and other closed fractures of distal end of right femur. Subacute right femur fracture, chronic left femur fracture. Record review of the facility policy titled assisting the nurse in examining and assessing the resident dated (MONTH) 2010 revealed the purpose of this procedure is to assist the nurse in gathering information about the overall condition of the resident and his or her performance of activities of daily living . General guidelines- 3) While only licensed nurses can conduct a full assessment , non-licensed nurse obtain important information about the resident in their daily observations and interaction. 4) Accurately documenting and reporting your observations provided the interdisciplinary team with information that help tailor the care plan to the specific needs of the resident.

Based on observation , interview, and record review, the facility failed to ensure each resident was free from neglect for one of ten residents (CR #1) reviewed for neglect, in that; CR#1 who required two person's assistance for incontinent care was assisted by one CNA which resulted in a fall CR #1 was identified to have a swollen left knee by her family member and was not adequately screened for prompt intervention . CR #1 was diagnosed to have a fracture to the left femur. These failures affected one closed record who suffered a fracture and placed her at risk of abuse and decline in health from not having their needs identified and addressed promptly. Findings include: Intake # 6 Intake # 4 CR #1 Record review of CR #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 CR #1's quarterly Minimum Data Set ((MDS) dated [DATE] revealed a BIMS score of 4, indicating severe cognitive impairment. Further review revealed CR #1 required extensive assist of two staff for bed mobility, transfers, toilet use and was always incontinent of bowel and bladder . Record review of CR #1's care plan (Target date 12/20/18) revealed in part .Focus: CR #1 has an ADL self-care performance deficit related to stroke as evidenced by resident is dependent on staff for ADL's. Resident requires total assist of two for transfers. Resident required total assist of two for toileting. Resident requires extensive assist of two for bed mobility. Resident requires total assist of one for eating . Further review revealed .CR #1 has impaired cognitive function and impaired thought processes related to long term memory loss, short term memory loss . Further review revealed .CR #1 is high risk for falls related to paralysis . Further review revealed . CR #1 had a fall with no injuries related to poor balance, muscle weakness, and impaired mobility . Record review of CR #1's incident report dated 10/13/18 revealed in part .Incident description: nurse called to patient's room [ROOM NUMBER] B at about 5:00 AM. Nurse noted patient lying on the floor. Writer asked what the resident was doing at the time of fall. CNA stated I am turning patient to do patient care then she slide out of the bed. No signs or symptoms of distress noted. Nurse immediately assessed the resident, no visible injuries noted. Positive ROM assessed. Resident immediately removed from the floor . Author was LVN #2. Record review of CR #1's progress notes revealed in part .nurse called to patient's room [ROOM NUMBER] B at about 5:00 AM. Nurse noted patient lying on the floor. Writer asked what the resident was doing at the time of fall. CNA stated I am turning patient to do patient care then she slide out of the bed. No signs or symptoms of distress noted. Nurse immediately assessed the resident, no visible injuries noted. Positive ROM assessed. Resident immediately removed from the floor . Author was LVN #2. Interview with LVN #2 on 1/24/19 at 2:28 PM, LVN #2 stated on the day of the incident(10/13/18) , she was making rounds when CNA #1 called her and said CR #1 slid out of the bed. LVN stated she went to the room, assessed the resident, and the resident was fine. LVN further stated the mechanical lift was used to place the resident back in bed. LVN stated she did not know who was in the room when the incident occurred, she only remembered being called by CNA #1 who stated the resident was on the floor. Interview with CNA #1 on 1/24/19 at 2:46 PM, CNA #1 stated on the day of the incident, she was making her last rounds and went into CR #1's room and found the resident soiled, so she started to change the resident. CNA #1 stated when she rolled the resident over to the side, the resident started to slip, so she ran over to the other side of the bed and caught the resident and lowered the resident to the floor. CNA #1 stated usually two staff tend to CR #1, but when she was getting ready to change CR #1, CNA #2 who was in the room with her walked out of the room, leaving her to finish changing the resident by herself. CNA #1 stated CR#1 said she was sorry, and that she knew she only slipped off the bed. CNA #1 stated she proceeded to call the nurse to the room. Surveyor attempted to interview CNA #2 on 1/24/19 at 3:30pm, but CNA did not respond to phone calls. Interview with DON on 1/24/18 at 3:08 PM, DON stated he could not answer why CNA #1 went into CR #1's room alone to provide care. DON explained that there were yellow dots on residents' doors which alerts the staff of the type of care the residents need, and the facility also has a P[NAME] (point of care tracking system) in place which staff can utilize for information on resident care. DON further stated staff also had start of shift meetings (huddles), so the staff can learn the type of care the resident needs, so he did not know why the CNA went in the room alone. Record review of facility's incident/accident log dated 11/9/18 - 1/23/19 revealed no additional incidents with CR #1. Record review of CR #1's progress notes dated 10/2/18 - 1/22/19 revealed only one incident on 10/13/18. Record review of CR#1's records revealed no documentation regarding her swollen left knee or a change in her condition prior to the family member bringing it to the facility staff's attention. Record review of CR #1's hospital record revealed the following: History and Physical/Admission Notes: admitted : 1/22/19 Chief complaint: Patient was sent from nursing home. Patient has bilateral chronic [MEDICAL CONDITION], was sent to orthopedic specialist's office and since family could not afford copay, so patient was sent toER on family request for further evaluation and treatment. History of present illness: CR #1 is a [AGE] year-old African American female with a history of [MEDICAL CONDITION], stroke, chronic bedbound, [MEDICAL CONDITION]; was sent to ER for further evaluation of leg injury. Assessment and plan: 1. Bilateral impacted femoral condyle fracture, probably chronic. Consult ortho, probably neurosurgery. Surgical intervention at present. Emergency/Urgent Care: admitted : 1/22/19 History of Present Illness: The patient presents with left knee injury. The onset was five weeks ago. The course/duration of symptoms is constant and worsening. Type of injury: fall. Location: left knee. The character of symptoms is swelling. The degree at onset was minimal. The degree at present is moderate. The exacerbating factor is none. The location where the incident occurred was at a nursing home. Risk factors consists of hypertension and immobility. [AGE] year-old female with a past medical history of [REDACTED]. Family member explains that patient's leg began to swell after a fall in her nursing home in (MONTH) (YEAR) . She received a doppler to test for [MEDICAL CONDITION] which was negative but received no other testing. Yesterday patient received an x-ray per family request and it showed a fracture. Review of systems: left knee swelling. Radiology results dated 1/22/19: Pelvis 1 view: impression: 2. Chronic changes are present involving the left hip. Left femur 2 views: Findings: Bilateral impacted femoral condyle fractures are present, likely chronic. Report: left knee 4 views: Findings: A comminuted impacted [MEDICAL CONDITION] femur, with the femoral shaft impacted 7 CM into the intercondylar aspect of the knee. Observation of CR #1 at the hospital on [DATE] at 12:20 PM, CR #1 observed lying in bed, asleep, Family Member sitting at bedside. Resident groomed and dressed appropriately. Further observation revealed a brace to CR #1's left leg. Surveyor attempted to interview CR #1, but CR#1 did not awaken. Interview with CR #1's Family Member on 1/24/19 at 12:20 PM, Family Member stated on 10/13/18 around 6AM she received a phone call from facility stating CR #1 had a fall. Family Member stated that she sent a text message to the ADON asking about the incident, and ADON informed her that she was aware of the incident and would look into it. Family Member further stated facility staff informed her that CR #1 fell out of the bed while being changed, but that she was fine. ADON later informed her that a head to toe assessment was completed, and nothing was found, and the facility would continue to monitor the resident. Family Member further stated she also spoke to the facility's DON and inquired if the resident needed to go to the hospital to be x-rayed, but the DON said no, because CR #1 was not complaining of any pain and seemed fine. Family Member further stated that the DON also acknowledged that it was one person changing the resident when the incident occurred. Family Member explained that on 12/3/18, she began to notice swelling to the resident's left knee, which she mentioned to the ADON, and a doppler was completed, which revealed no [MEDICAL CONDITION], but still no x-ray was done. Family Member stated facility expressed that they thought that the swelling was caused by problems with the resident's blood because she was being seen by a hematologist. Family Member stated on 1/21/19 around 9AM, she received a phone call from the ADON stating the CR #1's physician requested an x-ray of the knee, and when the results came in, it was found that the resident had a fracture, and that the resident needed to be seen by an orthopedic physician. Record review of photographic evidence dated 12/3/18 revealed CR #1's left knee was significantly swollen. Attempt was made on 1/24/19 at 12:48pm to interview CR#1's physician without success, phone calls made to the doctor's office were not return. Attempt to interview CNA #3 (who was CR#1's regular CNA) via phone on 1/24/18 at 3:29pm was made regarding observation of swelling to resident's left leg, but CNA did not return call. Interview with ADON on 1/24/19 at 2:52 PM, ADON stated on the day of the incident (10/13/18), she received a call from the facility informing her that during care, CR #1 was being changed by CNA#1when she started to slide off the low air mattress. The CNA guided the resident to the floor and called the nurse. The resident was assessed with [REDACTED].#1 needed two staff to assist. ADON further explained that CR #1 had no other incidents after 10/13/18, until she received a phone call from the resident's Family Member on 12/4/18 and informed her of swelling to the left knee. ADON stated in interview with LVN#1 , she was informed that CR #1 had a history of [REDACTED]. ADON further stated the NP and MD assessed the resident. Around the holidays, the swelling returned, and the facility reached out to the resident's Hematologist to see if the swelling was related to resident's blood count. An x-ray was requested which showed a chronic fracture. Interview with DON on 1/24/18 at 3:08 PM, DON stated when CR #1's x-ray results came in, he was notified that the fracture was chronic. DON explained that the injury was not reported to HHSC because the facility did not have the determination of the age of the fracture, and the facility did not know what happened. DON explained that he also reviewed CR #1's history which revealed CR #1 had a history of [REDACTED].#1 had an appointment with the hematologist to see why the resident had extremely high red blood cell count, and thought maybe the resident had some kind of auto immune response in addition to the swelling of the knee. DON stated he did not connect the fall on 10/13/18 to the fracture because it had been a long period without any complaints. Interview with administrator on 1/24/19 at 3:35 PM, administrator stated she was made aware of CR #1's incident, she was informed that the resident was sliding out of the bed, and that her left leg hit the floor. Administrator stated she inquired if there was any pain, and was informed that the physician was contacted, and that a pain assessment was completed, and there was no pain. Administrator further stated that more recently CR #1's Family Member complained of swelling to CR #1's leg. An x-ray was completed which showed a chronic fracture. Administrator stated she was the abuse coordinator, but that she did not report the resident's fracture to HHSC because per the corporate office and the DON, the facility needed to see what the results would be from CR #1's orthopedic appointment. Interview with RN #1 on 1/24/19 at 3:39 PM, RN #1 stated she worked with the CR #1 but that she did not notice the swelling to the left knee until the resident's family member pointed it out. RN #1 explained that she believed she informed the DON or ADON, and also wrote it in the physician's book. RN #1 stated CR #1 had chronic pain in the joints and even before the incident the resident would reposition her legs, and also taking [MEDICATION NAME] and biofreeze, therefore she did not think it was out of the norm. Record review of facility's policy titled Abuse and Neglect - Clinical protocol (revised (MONTH) 2013) revealed in part .Treatment/Management: 1. The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. 2. The management and staff with the support of the physicians, will address situations of suspected or identified abuse and report them in a timely manner to appropriate agencies, consistent with applicable laws and regulations.

Based on observation , interview and record review, the facility failed to ensure alleged violations involving neglect including injuries of unknown source were thoroughly investigated and results of investigations reported to the State Survey Agency, within 5 working days of the incident for one of 10 residents (CR#1) reviewed for abuse and neglect. The facility failed to thoroughly investigate CR#1's [MEDICAL CONDITION] femur injury of unknown source This failure affected one closed record who suffered a fracture and placed her at risk of abuse and decline in health from not having their needs identified and addressed promptly. Findings include: Intake # 6 Intake # 4 CR #1 Record review of CR #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 CR #1's quarterly Minimum Data Set ((MDS) dated [DATE] revealed a BIMS score of 4, indicating severe cognitive impairment. Further review revealed CR #1 required extensive assist of two staff for bed mobility, transfers, toilet use and was always incontinent of bowel and bladder . Record review of CR #1's care plan (Target date 12/20/18) revealed in part .Focus: CR #1 has an ADL self-care performance deficit related to stroke as evidenced by resident is dependent on staff for ADL's. Resident requires total assist of two for transfers. Resident required total assist of two for toileting. Resident requires extensive assist of two for bed mobility. Resident requires total assist of one for eating . Further review revealed .CR #1 has impaired cognitive function and impaired thought processes related to long term memory loss, short term memory loss . Further review revealed .CR #1 is high risk for falls related to paralysis . Further review revealed . CR #1 had a fall with no injuries related to poor balance, muscle weakness, and impaired mobility . Record review of CR #1's incident report dated 10/13/18 revealed in part .Incident description: nurse called to patient's room [ROOM NUMBER] B at about 5:00 AM. Nurse noted patient lying on the floor. Writer asked what the resident was doing at the time of fall. CNA stated I am turning patient to do patient care then she slide out of the bed. No signs or symptoms of distress noted. Nurse immediately assessed the resident, no visible injuries noted. Positive ROM assessed. Resident immediately removed from the floor . Author was LVN #2. Record review of CR #1's progress notes revealed in part .nurse called to patient's room [ROOM NUMBER] B at about 5:00 AM. Nurse noted patient lying on the floor. Writer asked what the resident was doing at the time of fall. CNA stated I am turning patient to do patient care then she slide out of the bed. No signs or symptoms of distress noted. Nurse immediately assessed the resident, no visible injuries noted. Positive ROM assessed. Resident immediately removed from the floor . Author was LVN #2. Interview with LVN #2 on 1/24/19 at 2:28 PM, LVN #2 stated on the day of the incident(10/13/18) , she was making rounds when CNA #1 called her and said CR #1 slid out of the bed. LVN stated she went to the room, assessed the resident, and the resident was fine. LVN further stated the mechanical lift was used to place the resident back in bed. LVN stated she did not know who was in the room when the incident occurred, she only remembered being called by CNA #1 who stated the resident was on the floor. Interview with CNA #1 on 1/24/19 at 2:46 PM, CNA #1 stated on the day of the incident, she was making her last rounds and went into CR #1's room and found the resident soiled, so she started to change the resident. CNA #1 stated when she rolled the resident over to the side, the resident started to slip, so she ran over to the other side of the bed and caught the resident and lowered the resident to the floor. CNA #1 stated usually two staff tend to CR #1, but when she was getting ready to change CR #1, CNA #2 who was in the room with her walked out of the room, leaving her to finish changing the resident by herself. CNA #1 stated CR#1 said she was sorry, and that she knew she only slipped off the bed. CNA #1 stated she proceeded to call the nurse to the room. Surveyor attempted to interview CNA #2 on 1/24/19 at 3:30pm, but CNA did not respond to phone calls. Interview with DON on 1/24/18 at 3:08 PM, DON stated he could not answer why CNA #1 went into CR #1's room alone to provide care. DON explained that there were yellow dots on residents' doors which alerts the staff of the type of care the residents need, and the facility also has a P[NAME] (point of care tracking system) in place which staff can utilize for information on resident care. DON further stated staff also had start of shift meetings (huddles), so the staff can learn the type of care the resident needs, so he did not know why the CNA went in the room alone. Record review of facility's incident/accident log dated 11/9/18 - 1/23/19 revealed no additional incidents with CR #1. Record review of CR #1's progress notes dated 10/2/18 - 1/22/19 revealed only one incident on 10/13/18. Record review of CR#1's records revealed no documentation regarding her swollen left knee or a change in her condition prior to the family member bringing it to the facility staff's attention. Record review of CR #1's hospital record revealed the following: History and Physical/Admission Notes: admitted : 1/22/19 Chief complaint: Patient was sent from nursing home. Patient has bilateral chronic [MEDICAL CONDITION], was sent to orthopedic specialist's office and since family could not afford copay, so patient was sent toER on family request for further evaluation and treatment. History of present illness: CR #1 is a [AGE] year-old African American female with a history of [MEDICAL CONDITION], stroke, chronic bedbound, [MEDICAL CONDITION]; was sent to ER for further evaluation of leg injury. Assessment and plan: 1. Bilateral impacted femoral condyle fracture, probably chronic. Consult ortho, probably neurosurgery. Surgical intervention at present. Emergency/Urgent Care: admitted : 1/22/19 History of Present Illness: The patient presents with left knee injury. The onset was five weeks ago. The course/duration of symptoms is constant and worsening. Type of injury: fall. Location: left knee. The character of symptoms is swelling. The degree at onset was minimal. The degree at present is moderate. The exacerbating factor is none. The location where the incident occurred was at a nursing home. Risk factors consists of hypertension and immobility. [AGE] year-old female with a past medical history of [REDACTED]. Family member explains that patient's leg began to swell after a fall in her nursing home in (MONTH) (YEAR) . She received a doppler to test for [MEDICAL CONDITION] which was negative but received no other testing. Yesterday patient received an x-ray per family request and it showed a fracture. Review of systems: left knee swelling. Radiology results dated 1/22/19: Pelvis 1 view: impression: 2. Chronic changes are present involving the left hip. Left femur 2 views: Findings: Bilateral impacted femoral condyle fractures are present, likely chronic. Report: left knee 4 views: Findings: A comminuted impacted [MEDICAL CONDITION] femur, with the femoral shaft impacted 7 CM into the intercondylar aspect of the knee. Observation of CR #1 at the hospital on [DATE] at 12:20 PM, CR #1 observed lying in bed, asleep, Family Member sitting at bedside. Resident groomed and dressed appropriately. Further observation revealed a brace to CR #1's left leg. Surveyor attempted to interview CR #1, but CR#1 did not awaken. Interview with CR #1's Family Member on 1/24/19 at 12:20 PM, Family Member stated on 10/13/18 around 6AM she received a phone call from facility stating CR #1 had a fall. Family Member stated that she sent a text message to the ADON asking about the incident, and ADON informed her that she was aware of the incident and would look into it. Family Member further stated facility staff informed her that CR #1 fell out of the bed while being changed, but that she was fine. ADON later informed her that a head to toe assessment was completed, and nothing was found, and the facility would continue to monitor the resident. Family Member further stated she also spoke to the facility's DON and inquired if the resident needed to go to the hospital to be x-rayed, but the DON said no, because CR #1 was not complaining of any pain and seemed fine. Family Member further stated that the DON also acknowledged that it was one person changing the resident when the incident occurred. Family Member explained that on 12/3/18, she began to notice swelling to the resident's left knee, which she mentioned to the ADON, and a doppler was completed, which revealed no [MEDICAL CONDITION], but still no x-ray was done. Family Member stated facility expressed that they thought that the swelling was caused by problems with the resident's blood because she was being seen by a hematologist. Family Member stated on 1/21/19 around 9AM, she received a phone call from the ADON stating the CR #1's physician requested an x-ray of the knee, and when the results came in, it was found that the resident had a fracture, and that the resident needed to be seen by an orthopedic physician. Record review of photographic evidence dated 12/3/18 revealed CR #1's left knee was significantly swollen. Attempt was made on 1/24/19 at 12:48pm to interview CR#1's physician without success, phone calls made to the doctor's office were not return. Attempt to interview CNA #3 (who was CR#1's regular CNA) via phone on 1/24/18 at 3:29pm was made regarding observation of swelling to resident's left leg, but CNA did not return call. Interview with ADON on 1/24/19 at 2:52 PM, ADON stated on the day of the incident (10/13/18), she received a call from the facility informing her that during care, CR #1 was being changed by CNA#1when she started to slide off the low air mattress. The CNA guided the resident to the floor and called the nurse. The resident was assessed with [REDACTED].#1 needed two staff to assist. ADON further explained that CR #1 had no other incidents after 10/13/18, until she received a phone call from the resident's Family Member on 12/4/18 and informed her of swelling to the left knee. ADON stated in interview with LVN#1 , she was informed that CR #1 had a history of [REDACTED]. ADON further stated the NP and MD assessed the resident. Around the holidays, the swelling returned, and the facility reached out to the resident's Hematologist to see if the swelling was related to resident's blood count. An x-ray was requested which showed a chronic fracture. Interview with DON on 1/24/18 at 3:08 PM, DON stated when CR #1's x-ray results came in, he was notified that the fracture was chronic. DON explained that the injury was not reported to HHSC because the facility did not have the determination of the age of the fracture, and the facility did not know what happened. DON explained that he also reviewed CR #1's history which revealed CR #1 had a history of [REDACTED].#1 had an appointment with the hematologist to see why the resident had extremely high red blood cell count, and thought maybe the resident had some kind of auto immune response in addition to the swelling of the knee. The DON stated he did not connect the fall on 10/13/18 to the fracture because it had been a long period without any complaints. Interview with administrator on 1/24/19 at 3:35 PM, administrator stated she was made aware of CR #1's incident, she was informed that the resident was sliding out of the bed, and that her left leg hit the floor. Administrator stated she inquired if there was any pain, and was informed that the physician was contacted, and that a pain assessment was completed, and there was no pain. Administrator further stated that more recently CR #1's Family Member complained of swelling to CR #1's leg. An x-ray was completed which showed a chronic fracture. Administrator stated she was the abuse coordinator, but that she did not investigate and report the resident's fracture to HHSC because per the corporate office and the DON, the facility needed to see what the results would be from CR #1's orthopedic appointment. Interview with RN #1 on 1/24/19 at 3:39 PM, RN #1 stated she worked with the CR #1 but that she did not notice the swelling to the left knee until the resident's family member pointed it out. RN #1 explained that she believed she informed the DON or ADON, and also wrote it in the physician's book. RN #1 stated CR #1 had chronic pain in the joints and even before the incident the resident would reposition her legs, and also taking [MEDICATION NAME] and biofreeze, therefore she did not think it was out of the norm. Record review of facility's policy titled Abuse and Neglect - Clinical protocol (revised (MONTH) 2013) revealed in part .Treatment/Management: 1. The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. 2. The management and staff with the support of the physicians, will address situations of suspected or identified abuse and report them in a timely manner to appropriate agencies, consistent with applicable laws and regulations. Record review of facility's policy titled reporting abuse to state agencies and other entities /individuals dated (MONTH) 2009 read in part . all suspected violation and all substantiated incidents of abuse will be immediately reported to appropriate state agencies and other entities or individuals as may be required by law. Should a suspected violation or substantiated incident or mistreatment , neglect, injuries of an unknown source or abuse be reported , the facility administrator or his designee will promptly notify the following person of such incident; The state licensing /certification agency responsible for surveying /licensing the facility, the resident's representative etc. The administrator will provide the appropriate agencies with a written report of the findings of the investigation within 5 working days of occurrence of the incident .

Based on observation, interview, and record review , the facility failed to ensure comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and time frames to meet residents' mental and psychosocial needs was implemented for one of ten residents (CR #1) reviewed for comprehensive care plans, in that: CR#1 who required two person's assistance for incontinent care and bed mobility was not provided care as outlined in her care plan. One CNA provided incontinent care to CR#1 which resulted in a fall. CR #1 was identified to have a swollen left knee by her family member and was diagnosed to have a fracture to the left femur. These failures affected one closed record and placed her at risk of harm and diminished quality of life . Findings include: Intake # 6 Intake # 4 CR #1 Record review of CR #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 CR #1's quarterly Minimum Data Set ((MDS) dated [DATE] revealed a BIMS score of 4, indicating severe cognitive impairment. Further review revealed CR #1 required extensive assist of two staff for bed mobility, transfers, toilet use and was always incontinent of bowel and bladder . Record review of CR #1's care plan (Target date 12/20/18) revealed in part .Focus: CR #1 has an ADL self-care performance deficit related to stroke as evidenced by resident is dependent on staff for ADL's. Resident requires total assist of two for transfers. Resident required total assist of two for toileting. Resident requires extensive assist of two for bed mobility. Resident requires total assist of one for eating . The care plan revealed .CR #1 has impaired cognitive function and impaired thought processes related to long term memory loss, short term memory loss .CR #1 is high risk for falls related to paralysis . CR #1 had a fall with no injuries related to poor balance, muscle weakness, and impaired mobility . Further review of the care plan revealed .CR #1 has bowel and bladder incontinence related to impaired mobility and poor diet. Intervention: Provide pericare after each incontinent episode . Record review of CR #1's incident report dated 10/13/18 revealed in part .Incident description: nurse called to patient's room [ROOM NUMBER] B at about 5:00 AM. Nurse noted patient lying on the floor. Writer asked what the resident was doing at the time of fall. CNA stated I am turning patient to do patient care then she slide out of the bed. No signs or symptoms of distress noted. Nurse immediately assessed the resident, no visible injuries noted. Positive ROM assessed. Resident immediately removed from the floor . Author was LVN #2. Record review of CR #1's progress notes revealed in part .nurse called to patient's room [ROOM NUMBER] B at about 5:00 AM. Nurse noted patient lying on the floor. Writer asked what the resident was doing at the time of fall. CNA stated I am turning patient to do patient care then she slide out of the bed. No signs or symptoms of distress noted. Nurse immediately assessed the resident, no visible injuries noted. Positive ROM assessed. Resident immediately removed from the floor . Author was LVN #2. Interview with LVN #2 on 1/24/19 at 2:28 PM, LVN #2 stated on the day of the incident(10/13/18) , she was making rounds when CNA #1 called her and said CR #1 slid out of the bed. LVN stated she went to the room, assessed the resident, and the resident was fine. LVN further stated the mechanical lift was used to place the resident back in bed. LVN stated she did not know who was in the room when the incident occurred, she only remembered being called by CNA #1 who stated the resident was on the floor. Interview with CNA #1 on 1/24/19 at 2:46 PM, CNA #1 stated on the day of the incident, she was making her last rounds and went into CR #1's room and found the resident soiled, so she started to change the resident. CNA #1 stated when she rolled the resident over to the side, the resident started to slip, so she ran over to the other side of the bed and caught the resident and lowered the resident to the floor. CNA #1 stated usually two staff tend to CR #1, but when she was getting ready to change CR #1, CNA #2 who was in the room with her walked out of the room, leaving her to finish changing the resident by herself. CNA #1 stated CR#1 said she was sorry, and that she knew she only slipped off the bed. CNA #1 stated she proceeded to call the nurse to the room. Surveyor attempted to interview CNA #2 on 1/24/19 at 3:30pm, but CNA did not respond to phone calls. Interview with DON on 1/24/18 at 3:08 PM, DON stated he could not answer why CNA #1 went into CR #1's room alone to provide care. DON explained that there were yellow dots on residents' doors which alerts the staff of the type of care the residents need, and the facility also has a P[NAME] (point of care tracking system) in place which staff can utilize for information on resident care. DON further stated staff also had start of shift meetings (huddles), so the staff can learn the type of care the resident needs, so he did not know why the CNA went in the room alone. Record review of facility's incident/accident log dated 11/9/18 - 1/23/19 revealed no additional incidents with CR #1. Record review of CR #1's progress notes dated 10/2/18 - 1/22/19 revealed only one incident on 10/13/18. Record review of CR#1's records revealed no documentation regarding her swollen left knee or a change in her condition prior to the family member bringing it to the facility staff's attention. Record review of CR #1's hospital record revealed the following: History and Physical/Admission Notes: admitted : 1/22/19 Chief complaint: Patient was sent from nursing home. Patient has bilateral chronic [MEDICAL CONDITION], was sent to orthopedic specialist's office and since family could not afford copay, so patient was sent toER on family request for further evaluation and treatment. History of present illness: CR #1 is a [AGE] year-old African American female with a history of [MEDICAL CONDITION], stroke, chronic bedbound, [MEDICAL CONDITION]; was sent to ER for further evaluation of leg injury. Assessment and plan: 1. Bilateral impacted femoral condyle fracture, probably chronic. Consult ortho, probably neurosurgery. Surgical intervention at present. Emergency/Urgent Care: admitted : 1/22/19 History of Present Illness: The patient presents with left knee injury. The onset was five weeks ago. The course/duration of symptoms is constant and worsening. Type of injury: fall. Location: left knee. The character of symptoms is swelling. The degree at onset was minimal. The degree at present is moderate. The exacerbating factor is none. The location where the incident occurred was at a nursing home. Risk factors consists of hypertension and immobility. [AGE] year-old female with a past medical history of [REDACTED]. Family member explains that patient's leg began to swell after a fall in her nursing home in (MONTH) (YEAR) . She received a doppler to test for [MEDICAL CONDITION] which was negative but received no other testing. Yesterday patient received an x-ray per family request and it showed a fracture. Review of systems: left knee swelling. Radiology results dated 1/22/19: Pelvis 1 view: impression: 2. Chronic changes are present involving the left hip. Left femur 2 views: Findings: Bilateral impacted femoral condyle fractures are present, likely chronic. Report: left knee 4 views: Findings: A comminuted impacted [MEDICAL CONDITION] femur, with the femoral shaft impacted 7 CM into the intercondylar aspect of the knee. Observation of CR #1 at the hospital on [DATE] at 12:20 PM, CR #1 observed lying in bed, asleep, Family Member sitting at bedside. Resident groomed and dressed appropriately. Further observation revealed a brace to CR #1's left leg. Surveyor attempted to interview CR #1, but CR#1 did not awaken. Interview with CR #1's Family Member on 1/24/19 at 12:20 PM, Family Member stated on 10/13/18 around 6AM she received a phone call from facility stating CR #1 had a fall. Family Member stated that she sent a text message to the ADON asking about the incident, and ADON informed her that she was aware of the incident and would look into it. Family Member further stated facility staff informed her that CR #1 fell out of the bed while being changed, but that she was fine. ADON later informed her that a head to toe assessment was completed, and nothing was found, and the facility would continue to monitor the resident. Family Member further stated she also spoke to the facility's DON and inquired if the resident needed to go to the hospital to be x-rayed, but the DON said no, because CR #1 was not complaining of any pain and seemed fine. Family Member further stated that the DON also acknowledged that it was one person changing the resident when the incident occurred. Family Member explained that on 12/3/18, she began to notice swelling to the resident's left knee, which she mentioned to the ADON, and a doppler was completed, which revealed no [MEDICAL CONDITION], but still no x-ray was done. Family Member stated facility expressed that they thought that the swelling was caused by problems with the resident's blood because she was being seen by a hematologist. Family Member stated on 1/21/19 around 9AM, she received a phone call from the ADON stating the CR #1's physician requested an x-ray of the knee, and when the results came in, it was found that the resident had a fracture, and that the resident needed to be seen by an orthopedic physician. Record review of photographic evidence dated 12/3/18 revealed CR #1's left knee was significantly swollen. Attempt was made on 1/24/19 at 12:48pm to interview CR#1's physician without success, phone calls made to the doctor's office were not return. Attempt to interview CNA #3 (who was CR#1's regular CNA) via phone on 1/24/18 at 3:29pm was made regarding observation of swelling to resident's left leg, but CNA did not return call. Interview with ADON on 1/24/19 at 2:52 PM, ADON stated on the day of the incident (10/13/18), she received a call from the facility informing her that during care, CR #1 was being changed by CNA#1when she started to slide off the low air mattress. The CNA guided the resident to the floor and called the nurse. The resident was assessed with [REDACTED].#1 needed two staff to assist. ADON further explained that CR #1 had no other incidents after 10/13/18, until she received a phone call from the resident's Family Member on 12/4/18 and informed her of swelling to the left knee. ADON stated in interview with LVN#1 , she was informed that CR #1 had a history of [REDACTED]. ADON further stated the NP and MD assessed the resident. Around the holidays, the swelling returned, and the facility reached out to the resident's Hematologist to see if the swelling was related to resident's blood count. An x-ray was requested which showed a chronic fracture. Interview with DON on 1/24/18 at 3:08 PM, DON stated when CR #1's x-ray results came in, he was notified that the fracture was chronic. DON explained that the injury was not reported to HHSC because the facility did not have the determination of the age of the fracture, and the facility did not know what happened. DON explained that he also reviewed CR #1's history which revealed CR #1 had a history of [REDACTED].#1 had an appointment with the hematologist to see why the resident had extremely high red blood cell count, and thought maybe the resident had some kind of auto immune response in addition to the swelling of the knee. The DON stated he did not connect the fall on 10/13/18 to the fracture because it had been a long period without any complaints. Interview with administrator on 1/24/19 at 3:35 PM, administrator stated she was made aware of CR #1's incident, she was informed that the resident was sliding out of the bed, and that her left leg hit the floor. Administrator stated she inquired if there was any pain, and was informed that the physician was contacted, and that a pain assessment was completed, and there was no pain. Administrator further stated that more recently CR #1's Family Member complained of swelling to CR #1's leg. An x-ray was completed which showed a chronic fracture. Administrator stated she was the abuse coordinator, but that she did not investigate and report the resident's fracture to HHSC because per the corporate office and the DON, the facility needed to see what the results would be from CR #1's orthopedic appointment. Interview with RN #1 on 1/24/19 at 3:39 PM, RN #1 stated she worked with the CR #1 but that she did not notice the swelling to the left knee until the resident's family member pointed it out. RN #1 explained that she believed she informed the DON or ADON, and also wrote it in the physician's book. RN #1 stated CR #1 had chronic pain in the joints and even before the incident the resident would reposition her legs, and also taking [MEDICATION NAME] and biofreeze, therefore she did not think it was out of the norm. Record review of the facility policy titled Resident Participation - Assessment/Care Plans (Revised (MONTH) (YEAR)) did not address following care plans. Record review of the facility policy titled Prevention and Screening - Clinical Protocol (Revised (MONTH) 2012) revealed in part .Assessment and Recognition: 1.a. Primary prevention is aimed at reducing the incidence of a disease or condition by preventing its onset; for example, immunizations, injury prevention, medication adjustments to prevent adverse drug reactions, fall prevention measures .

Based on observation, interview and record review, the facility failed to ensure that a resident who entered the facility without pressure ulcers did not develop pressure ulcers unless the resident's clinical condition demonstrated they were unavoidable, for one of four residents (Resident #1) reviewed for pressure ulcers. - The facility failed to prevent Resident #1 from developing multiple stage II pressure sores to his bilateral buttocks. -The facility failed to accurately or consistently assess Resident #1 ' s skin after previous stage II pressure sores on the resident's buttocks had healed. The facility also failed to develop a care plan to treat the actual pressure sore. These failures affected one resident and placed all 16 residents with pressure ulcers at risk for developing new pressure ulcers and a decline in existing pressure ulcers due to the delayed discovery and treatment. Findings included: Record review of Resident #1 ' s admission face sheet revealed he was [AGE] years old. He was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 was readmitted on [DATE] which was not listed on the resident ' s admission face sheet. Resident #1 was transferred to a local hospital on [DATE] for urinary tract infection [MEDICAL CONDITION]. Record review of Resident #1 ' s electronic Admission Braden Scale for Predicting Pressure Sore Risk dated and signed 05/17/2016 revealed in part a score of 11 indicating high risk. Further record review revealed the resident ' s skin was warm and dry and no pressure wounds were identified on the resident ' s buttocks. Continued review of the residents clinical record did not reveal a recent Braden Scale Assessment. Record review of Resident #1 ' s electronic care plans dated 09/06/2016 revealed in part the focus area Resident #1 has potential for impairment to skin integrity related to bed mobility. The care plan revealed the goal Resident #1 will maintain or develop clean and intact skin. Continued review of the care plan did not reveal updated or recent interventions to prevent pressure ulcers. The care plan revealed no care plan for actual pressure ulcers. Record review of Resident #1 November 2016 electronic consolidated physician orders revealed the following physician's order in part: Ensure wound care dressing is intact every shift for right buttock wound. Order dated 11/04/2016. Continued review of Resident #1's consolidated order did not reveal an order for [REDACTED]. Record review of Resident #1 ' s electronic Treatment Administration Record (TAR) dated 11/01/2016-11/30/2016 revealed the following treatment order dated 10/30/2016: Vitamin A+D Ointment, Apply to buttocks topically every shift for redness to buttocks. Continued review of the resident's TAR revealed it was initialed as applied from 11/01/2016 to 11/28/2016 every shift. Record review of Resident #1 ' s electronic TAR dated November 2016 revealed the following treatment order dated 11/01/2016: Cleanse the right buttocks with normal saline, pat dry, then cover with a dry dressing daily until healed and as needed. The TAR was initialed daily to indicate it was completed on 11/01/2016 to 11/13/2016. Record review of Resident #1 ' s electronic TAR dated 11/01/2016-11/30/2016 revealed the following treatment order dated 11/13/16: Cleanse the right buttocks with normal saline, pat dry, apply house cream barrier once daily until healed. The TAR was initialed to indicate it was completed on 11/14/2016, 11/15/2016, 11/16/2016, and 11/17/2016. Continued review of the TAR revealed there were no initials after 11/17/2016. Record review of Resident #1 ' s electronic head to toe skin check form dated 11/15/2016 revealed healing right buttock stage II pressure wound onset dated 10/31/16. The form revealed the pressure wound was acquired at facility. Continued review of the skin assessment form indicated the pressure area was healed. Record review of Resident #1 ' s Wound Care Specialist Evaluation dated 11/15/2016 revealed in part: chief complaint Patient has a wound on their buttocks. Resident presented with a stage II pressure wound of the right buttocks of at last two weeks duration. Continued review of the wound specialist form revealed stage II pressure wound of the right buttock resolved on 11/15/2016. Record review of Resident #1 ' s electronic head to toe skin check form dated 11/21/2016 revealed no pressure areas. Record review of Resident #1 ' s clinical record did not reveal a head to toe skin check form after the 11/21/16 assessment. Record review of Resident #1 ' s electronic quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident was sometimes understood and sometime understood others. The resident ' s Brief Interview for Mental Status (BIMS) was not scored and his cognitive skills for daily decision making was moderately impaired. Continued review of the resident MDS revealed he required extensive assistance from two staff for bed mobility, transfer and dressing. The resident required extensive assistant from one staff for toilet use and personal hygiene. Resident #1 had limitation in range of motion to his bilateral upper and lower extremities. The MDS did not reveal the presence of pressure wounds. However, the MDS did reveal the resident was identified as being at risk of developing pressure ulcers. Record review of Resident #1 ' s local hospital record revealed he arrived at the local hospital 11/29/2016 at 6:02am. Continued review of the resident ' s hospital record revealed a picture dated 11/29/2016 at 3:35pm of bilateral buttock open wounds. Observation on 11/30/16 at 6:05am of Resident #1 ' s room in the facility revealed his name at the door entrance. Continued review revealed the resident ' s belongings at the bedside. The resident ' s bed linens were removed and revealed he did not have an air mattress in place. In an observation and interview on 11/30/2016 at 2:26pm revealed Resident #1 in a local hospital in contact isolation on an air mattress. The resident was nonverbal but he opened his eyes when spoken too. The resident had oxygen to his [MEDICAL CONDITION] (trach) [MEDICAL CONDITION]. There was a normal saline intravenous infusing on a pump. The resident was positioned on his right side with a pillow under the left side of his back. Continued observation at this time revealed the resident had multiple open wounds to his bilateral buttocks with small areas of drainage. In an interview at this time the hospital RN stated Resident #1 was diagnosed and being treated for [REDACTED]. In an interview on 12/1/2016 at 7:30am ADON A stated a Braden scale was completed on admission and on those with pressure wounds. ADON A continued and stated she would need to review the policy because she was not sure how often it was to be done she believed weekly or quarterly. In an interview on 12/1/2016 at 8:04am Treatment Nurse A stated she did the treatment on the 100 hall. Treatment Nurse A stated she started to work on the unit on 11/25/16. As the interview continued she stated she never assessed Resident #1 ' s skin nor did any wound care for him. In an interview on 12/1/2016 at 9:10am DON stated she believed the Braden Scale was done during admission, weekly for four weeks, quarterly, annual and significant changes to skin. The DON stated she would need to review the policy to be sure. As the interview continued the DON stated the nurse ' s on the units did weekly skin assessment unless the resident has a wound then the treatment nurse will do it. She stated the use of an air mattress was based on the score from the Braden scale but they try to look at factors that increase the risk of developing a pressure wound such as immobility. In an interview on 12/1/2016 at 9:30am Unit Manager A stated after reviewing Resident #1 ' s electronic records there should have been a head to toe skin check form completed on 11/28/16 that was the next assessment due to be done but there was not one in the record. In an interview on 12/1/2016 at approximately 3:30pm the DON stated she believed the other treatment nurse did the skin assessment but she did not have a computer access so she completed a paper form. The DON continued and stated the treatment nurse was returning to the facility to help look for it. Record review of Resident #1 ' s clinical record did not reveal any Weekly Pressure Ulcer Record No record of Resident #1's head to toe skin assessment form dated 11/28/16 was provided prior to exit. Record review of the facility policy titled Skin Management Revision dated August 2012 revealed . 1. Upon admission, all residents are assessed for skin integrity by completing a head to toe physical assessment of skin condition and completing the Braden Scale-For Predicting Pressure Sore Risk. 2. Following Admission, Braden Scale-For Predicting Pressure Sore Risk will be completed weekly for 3 additional weeks . 3. Appropriate preventive surfaces of beds, wheelchairs, will be implemented on all residents identified at risk (score of 18 or less on the Braden Scale-For Predicting Pressure Sore Risk), and the interventions documented on the care plan . CMS for 672 revealed the facility had 17 residents in the facility currently with pressure ulcers and 9 pressure ulcers present on admission.

Based on observation, interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest, practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care for 2 of 14 residents (CR #10 and Resident #11) reviewed for diabetes. - The facility failed to assess, monitor and consult with the physician when CR #10 and Resident #11's blood glucose levels were above the parameters of 401 mg/dL. - The facility failed to monitor CR #10 and Resident #11's blood glucose and administer insulin as ordered. - The facility failed to have a method to accurately document on the Medication Administration Record the amount of insulin that was administered to residents. - CR #10 requested to be sent to the hospital and he was admitted to the intensive care unit with a blood glucose of 978 mg/dL and was diagnosed with [REDACTED]. An Immediate Jeopardy (IJ) was identified on 10/20/16. While the IJ was lowered on 10/21/2016, the facility remained out of compliance at a severity of Actual harm that is not Immediate Jeopardy and a scope of pattern. The facility remained out of compliance because they had not yet monitored their plan for effectiveness. These failures affected one former resident and one current resident at the facility and had the potential to affect the other 29 residents at the facility who receive finger stick blood sugar checks and could result in a deterioration in their condition and possible admission to the hospital. Findings included: Intake # 8 CR #10 Record review of the medical record face sheet revealed CR #10 was admitted on [DATE]. [DIAGNOSES REDACTED]. He was [AGE] years old. CR #10 went to the hospital on [DATE] at his request. Record review of CR # 10's admission MDS assessment with 09/11/2016 ARD date revealed that his short and long term memory were intact. CR #10 required total assistance of two staff support for bed mobility, dressing and bathing. He required one person assistance for toilet use and extensive assistance of two staff support for personal hygiene. CR #10 was always incontinent of bowel and had an indwelling catheter. Further record review revealed that MDS assessment did not have CR#10 with an active [DIAGNOSES REDACTED]. Record review of CR #10's Plan of Care initiated 9/20/2016 revealed no information that CR #10 had [DIAGNOSES REDACTED]. Further record review revealed no interventions to monitor for signs and symptoms of hyper/[DIAGNOSES REDACTED] (high or low blood sugar levels). (High blood glucose: Frequent urination, Increased thirst, Shortness of breath, weak and tired, Breath that smells fruity, abdominal pain, Nausea and vomiting and Very dry mouth. Low blood glucose: Confusion, dizziness, feeling shaky, hunger, headaches, irritability, pounding heart; racing pulse. <http://www.diabetes.org>.) Record review of CR #10's consolidated MD orders for October 2016 revealed orders in part; -dated 9/18/2016 Accuchecks before meals and bedtime. Record review of CR #10's MD Order dated 10/13/2016 at 10:23 a.m. revealed order in part; -HumaLOG Solution 100 Unit/ml (Insulin [MEDICATION NAME] (Human) (fast acting insulin) Inject as per sliding scale: If 200 - 250 = 2 units (Give [MEDICATION NAME] if BS <70); 251- 300 mg/dl = 4 units 301- 350 mg/dl = 6 units 351- 400 mg/dl = 8 units 401 - 450 mg/dl = 10 units. Call MD if blood sugar is over 400 mg/dl Subcutaneously before meals and at bedtime for diabetes mellitus type 2. Record review of CR #10's Medication Administration Record (MAR) dated October 2016 revealed the following: HumaLOG Solution 100 Unit/ml (Insulin [MEDICATION NAME] (Human) Inject as per sliding scale: If 200 - 250 = 2 units (Give [MEDICATION NAME] if BS <70); 251- 300 mg/dl = 4 units 301- 350 mg/dl = 6 units 351- 400 mg/dl = 8 units 401 - 450 mg/dl = 10 units. Call MD if blood sugar is over 400 mg/dl Subcutaneously before meals and at bedtime for diabetes mellitus type 2. Record review of CR #10's October 2016 MAR revealed in part; -10/15/2016 at 06:30 a.m. Blood glucose reading = 498 mg/dl signed by LVN J. Further record review revealed no information of how many units of insulin were administered to CR #10. Continued record review revealed no information that the MD was notified of abnormal high blood glucose reading as ordered or any assessments for sign and symptoms of [MEDICAL CONDITION]. -10/15/2016 at 11:30 a.m. Blood glucose reading = 355 mg/dl. Further record review revealed no information of how many units of insulin were administered to CR #10. -10/15/2016 at 4:30 p.m. and 9:00 p.m. revealed that MAR had no blood glucose readings. (by RN H) Record review of CR #10's progress/nurses notes dated 10/15/2016 revealed no information of blood glucose readings at 4:30 p.m. or 9:00 p.m. and no information that any insulin was administered. Further record review revealed no assessments for sign and symptoms of hyper/[DIAGNOSES REDACTED]. -10/16/2016 at 06:30 a.m. MAR indicated a blood glucose reading = 600 mg/dl signed by LVN J. Further record review revealed no information of how many units of insulin were administered to CR #10. -10/16/2016 at 11:30 a.m. MAR indicated a blood glucose reading = 498 mg/dl signed by LVN J. Further record review revealed no information of how many units of insulin were administered to CR #10. Continued record review of the progress/nurses notes dated 10/16/2016 revealed no information that the MD was notified of abnormal high blood glucose reading as ordered or any assessments for sign and symptoms of [MEDICAL CONDITION]. -10/16/2016 at 4:30 p.m. and 9:00 p.m. revealed that MAR had no blood glucose readings. (by RN E) Record review of CR #10's progress/nurses notes dated 10/16/2016 revealed no information of blood glucose readings at 4:30 p.m. or 9:00 p.m. and no information that any insulin was administered. Further record review revealed no assessments for sign and symptoms of hyper/[DIAGNOSES REDACTED]. Continued record review of CR #10's October MAR revealed in part; -10/17/2016 at 6:30 a.m. Blood glucose reading = 400 mg/dl. -10/17/2016 at 11:30 a.m. Blood glucose reading = 392 mg/dl. -10/17/2016 at 4:30 p.m. Blood glucose reading = 368 mg/dl. -10/17/2016 at 9030 p.m. Blood glucose reading = 390 mg/dl. Further record review revealed no information of how many units of insulin were administered to CR #10 on 10/17/2016. -10/18/2016 at 6:30 a.m. and 11:30 a.m. revealed that MAR had no blood glucose readings. Record review of CR #10's progress/nurses notes dated 10/18/2016 revealed no information of blood glucose readings at 6:30 a.m. or 11:30 a.m. and no information that any insulin was administered. Further record review revealed no assessments for sign and symptoms of hyper/[DIAGNOSES REDACTED]. Further review of CR #10's progress/nurses notes dated 10/19/2016 at 12:53 a.m. revealed in part; Nursing Note. CR #10 was transferred to the hospital on his own request after the blood sugar read to be above normal range, he refused to be manage as he refused his blood sugar level to be rechecked after 10 units of Humalog insulin was administered subcutaneously according to sliding scale. Nurse Practitioner was notified and was picked up by the ambulance at 4:30 p.m. (10/18/2016) . Record review of CR #10's Emergency Department report dated 10/18/2016 at 5:59 p.m. revealed in part; Date and time of arrival: 10/18/2016 at 4:36 p.m. Time seen: immediately upon arrival. Chief complaint: High blood sugar. History of Present illness: CR #10 presents with [MEDICAL CONDITION] (high blood glucose). CR #10 is a [AGE] year old male with a recent medical history of [REDACTED]. CR#10 with glucose more than 500 on glucometer at nursing home. CR #10 is complaining of polydipsia (excess thirst), polyuria (frequent urination), polyphagia (excessive hunger), nausea and abdominal pain. Medical Decision Making: Diabetic Ketoacidosis, [MEDICAL CONDITION] . Laboratory results: -Sodium 122 mmol/L critical Reference range 135 and 145 milliequivalents per liter. -Potassium 5.8 mmol/L high Reference range 3.5 - 5.0 milliEquivalents per liter. -Glucose 978 mg/dL critical Reference range 70 to 100 mg/dL. Procedure: Critical care. Critical condition addressed for impending deterioration include: metabolic. Associated risk factors: metabolic changes, dehydration and acidosis. -Interventions: hemodynamic management, IV insulin, fluids . -Admitting Diagnoses: [REDACTED]. Disposition: Admit to Intensive Care Unit Record review of UTMB.edu/Diabetic ketoacidosis revealed in part .Diabetic ketoacidosis is an endocrine emergency. It is a metabolic state characterized by deficiency of insulin and excess of [MEDICATION NAME]. Dilutional [MEDICAL CONDITION] (low Sodium) occurs because of shift of water from the intracellular to the extracellular compartment secondary to [MEDICAL CONDITION]. Ketosis and acidosis elevate the serum potassium level by causing a shift of potassium from the intracellular to the extracellular fluid Observation and interview on 10/19/2016 at 12:30 p.m. revealed CR #10 was at a local hospital ICU unit (Intensive Care Unit). Further observation revealed that he was lying in an air mattress on his side facing the door. In continued observation, CR #10 was noted to have a Foley catheter that had approx. 500 cc of light yellow colored urine on the collection drainage bag. In an interview with CR #10 on 10/19/2016 at 12:45 p.m., he stated that he had high blood glucose levels on 10/18/2016 and that he felt very sick. He further said that on 10/18/2016 the nurse at the facility did not take his blood glucose levels during the morning and that he later felt very sick and called at the nurse who finally checked his blood glucose level. He then said that the blood glucose levels were very high . CR #10 continued saying that at that time, he knew that the facility staff was not really helping him and that he was in trouble and requested to be transferred to the hospital. CR #10 then said that upon arrival to the emergency room his blood glucose was almost a thousand. CR #10 further said that nurses at the facility would frequently miss taking his blood glucose and that on 10/18/2016 was not the first time that staff had missed his taking his blood glucose levels and then said I don't want to go back to that place. I feel that my life is in danger. In an interview on 10/19/2016 at 1:30 p.m. with the Hospital RN, she stated that CR#10 was a direct admit to the hospital Intensive Care Unit on 10/18/2016 and further said CR#10 came with blood glucose levels of 978 and was diagnosed with [REDACTED].#10 had orders for insulin IV drip and we are currently monitoring his blood glucose every 4 hours, his blood glucose now is 129 and the MD had discontinued the IV insulin drip and we will follow the sliding scale for insulin administration. In an interview on 10/19/2016 at 3:35 p.m. with RN E, she stated that CR#10 had orders to check his blood glucose before meals and before going to sleep and that the staff was supposed to call the MD if blood glucose levels were above 400. She then said that nurses were supposed to write on the progress/nurses notes anytime they notify the MD with any information of new orders. When asked if CR #10 had his blood glucose monitored on 10/18/2016 during the 6 to 2 p.m. shift, RN E stated as she reviewed CR #10's MAR and progress/nurses notes you would know what happened if it was documented but I don't see any documentation. Probably it was an agency nurse who worked that day. Further interview on 10/19/2016 at 3:40 p.m. with RN E at that time, she stated that she worked with CR #10 on 10/16/2016 during the 2 to 10 p.m. shift. When asked regarding the blood glucose levels of CR #10 on 10/16/2016 at 4:30 p.m. and 9:00 p.m. RN E stated It is not documented. I think that CR #10 refused his insulin. I believed his blood glucose was 300. When asked if the MD was made aware that CR #10 had refused his insulin, RN E stated I did not call the MD. When asked at what time was CR #10's blood glucose 300, the RN E stated I think was at 9:00 p.m. When asked if CR #10's blood glucose was checked at 4:30 p.m. and if CR #10 had any sign or symptoms of hypo/[MEDICAL CONDITION], RN E did not respond and said as she looked at CR #10's MAR I can't believe I did not write it down. Continued interview on 10/19/2016 at 3:47 p.m. with RN E, when asked where in the MAR staff documented the units of insulin administered to residents, RN E states the MAR has no place to document the units of insulin. In an interview on 10/19/2016 at 4:13 p.m. with the DON and the Wound Care Nurse, the Wound Care Nurse stated that CR #10 was readmitted to the facility with a pressure sore. DON further said that she remembered CR#10 having a [MEDICATION NAME] that he frequently used. Wound Care Nurse further said that she was present when CR #10 was sent to the hospital on [DATE] and then said CR#10's blood glucose was fine but he thought that his blood sugar was off and he kept saying that something was wrong. The charge nurse took his blood glucose levels and were fine and even showed to him the readings but kept insisting to go to the hospital and he called 911. At that time the DON stated that CR #10 was non-compliant and would frequently refuse to let the nurses do his blood glucose or have his insulin administered as ordered. Record review of CR #10's plan of care revealed no information that CR #10 refused to let staff monitor his blood glucose levels or that he refused his insulin or any medications as ordered by the MD. Record review of CR #10's progress/nurses notes dated 10/15/2016, 10/16/1016 and 10/18/2016 revealed no information that CR #10 refused to let staff monitor his blood glucose levels or had his insulin or any medications administered as ordered by the MD. In an interview on 10/20/2016 at 10:50 a.m. with LVN J, she stated that worked with CR #10's 10/15/2016 and 10/16/2016 during the 6 to 2 p.m. shift. LVN J then said that she remembered that CR #10's blood glucose was high and that she remembered calling a doctor. She further said that she did not remember which day or at what time she called the MD. LVN J also did not remember the name of the MD and further said I remember that I wrote the order in a telephone order sheet, but I did not do nursing notes or input the information on the computer because I was busy. When asked to find the telephone order sheet at CR #10's chart, LVN J immediately said No, it's not going to be there. I think the telephone order sheet is at the nursing station. At that time surveyor and LVN J went to the nursing station. Further observation and interview on 10/20/2016 at 11:06 a.m. with LVN J, she stated as she flipped thru binders and papers at the nurses' station I don't know where it could be. It's not here. It's not on the MD book either. We are supposed to transcribe the telephone orders into the computer system and then write the orders on the MAR. I was really busy. When asked if she called the MD on both days 10/15/2016 and 10/16/2016, LVN J stated No, I only called one day but I don't remember when. Further interview at that time, when asked LVN J, how could she tell how much insulin she had administered to CR #10 on 10/15/2016 and 10/16/2016, LVN J stated There is no way to know. That's what I am saying and I don't remember details. I know, if you don't document it, it was not done. I was busy. I got the order, flipped the paper over and continued doing what I was doing. I was really busy . Continued interview with LVN J, she stated If the blood glucose are high, you give the sliding scale insulin as ordered but the order said that you still have to call the MD and then said When you are by yourself, how do you do it and that's why we are in the situation we are now. In an interview on 10/21/2016 at 11:00 a.m with the Director of Staff Development, RN J, she stated that she was going to have the charge nurse assigned to CR #10 on 10/18/2016 during the 6 to 2 p.m. shift contact the surveyor. Surveyor did not receive a call from the nurse upon exit of the facility. In an interview on 10/20/2016 at 2:45 p.m. with the DON and the Administrator, when asked about how nursing documented the units of insulin given to the residents on the MAR, the DON stated that the MAR's on the 100 hallway did not have the space for nurses to write down the insulin administered. She then said that the Unit Manager M from the 100 station probably did not print them correctly and that she was going to have Unit Manager N teach Unit Manager M how to print the MAR's correctly. In an interview on 10/20/2016 at 3:03 p.m. with the DON and the Administrator, the DON stated we saw holes after surveyor gave us back CR#10's MAR's. I have talked to the nurses about it. The Unit Managers review the MAR's periodically. I was not aware that nurses were not calling the MD when blood glucose levels were above parameters. In an interview on 10/20/2016 at 3:26 p.m. with CR #10's MD, the MD stated that CR #10 went to the hospital on [DATE] due to high blood glucose levels. MD then said that she was aware that the nurses spoke with the Nurse Practitioner on 10/18/2016 and notified of his high blood glucose readings. She further said that CR #10 had history of running high blood glucose levels. When asked if she was made aware on 10/15/2016 and 10/16/2016 regarding CR #10's blood glucose were high above the parameters, the MD looked at her cell phone and said that she was going to look to see if there were any calls on those days from the facility. Further interview with the MD on 10/20/2016 at 4:05 p.m., she stated that she could only confirmed that the facility called regarding CR #10 on 10/13/2016 and 10/18/2016 when CR #10 at the time he went to the hospital. MD then said If I can confirm other calls for any other days, I will let you know. MD did not get back to surveyor prior to exit from the facility. In an interview on 10/21/2016 at 3:00 p.m. with RN H, she stated that she worked with CR #10 on 10/15/2016 during the 2 to 10 p.m. shift and said that she remembered taking the blood glucose levels for CR #10 at around 9:00 p.m. but that she missed documenting the results. RN H then said CR#10 usually runs either high or really low. She continued saying that she remembered giving insulin to CR #10 on 10/15/2016 but she did not write it down and further said we are supposed to document on the MAR. It just skipped my memory. I was going to write it down. I think I gave 2 units of insulin. I did not document the information. RN H verified that the current MAR's did not have a place to document insulin administration. Resident #11 Record review of Resident #11's face sheet (undated) revealed that she was a [AGE] year old female who was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #11's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 13, indicating no cognitive impairment, with an active [DIAGNOSES REDACTED]. Record review of Resident #11's physician's orders [REDACTED]. Record review of Resident #11's Medication Administration Record (MAR) dated October 2016 revealed that she was on [MEDICATION NAME] Insulin- 100 unit/ml. Give subcutaneous before meals and at bedtime if blood glucose: 0 - 150 mg/dl = 0 units 151- 200 mg/dl = 2 units 201- 250 mg/dl = 4 units 251- 300 mg/dl = 6 units 301- 350 mg/dl = 8 units 351- 400 mg/dl = 10 units 401 mg/dl + = 14 units and Call MD Further review of Resident #11's October 2016 MAR revealed that her blood glucose result on 10/13/16 at 4:30 p.m. was 440 mg/dl, she received 14 units of [MEDICATION NAME]. Record review of Resident # 11's progress notes dated 10/13/16 revealed that the physician was not called for the abnormal high blood glucose reading. In an interview on 10/20/16 at 1:50 p.m. with the Unit Manager , LVN M, she confirmed that Resident #11's physician was not called for her elevated blood glucose and did not receive an assessment. She states an SBAR (Situation Background Assessment Recommendation) or 24 hour report are done , and those reports go to her. She further stated that the 24 hour report for Resident #11 did not discuss Resident # 11's elevated blood glucose and no SBAR was filled out. In an interview on 10/20/16 at 3:12 p.m. with the DON, she stated the unit managers check the MARS periodically. She further stated that she was not aware of the physician not being called when residents have blood glucose above the set parameters, and that the nurses are supposed to put it on the 24 report. A telephone call on 10/20/16 at 4 p.m. to RN E, who was the nurse identified on duty, who did not call the physician, was unanswered and RN E did not return the Surveyors call as requested. Review of the facility's policy, Diabetic Management dated April 2005 and revised June 2008, read in part Assessment: -Blood glucose orders should include parameters to follow and when to notify the physician. Routine Care: -Blood glucose measurements are taken per the physician order. -Results outside of ordered parameters are communicated to the physician immediately. Documentation: For acute complications, the clinical record should include the following information: - notification of physician and any new orders -resident's signs and symptoms -results of blood testing -interventions initiated -resident's response to treatment -notification of responsible party. The facility Administrator and DON were notified on 10/20/16 at 3:12 PM that an IJ situation had been identified due to above failures. The Plan of Removal was submitted by the Administrator on 10/21/16. After several revisions, the final Plan of Removal was accepted on 10/21/16 at 2:26 PM. Plan of Removal All residents with Accucheck orders have been audited on October 20, 2016. The results of the audit were reviewed by the Medical Director on October 20, 2016. Medical Director made appropriate changes to orders on October 20, 2016. In-services and return demonstration on diabetic management was initiated on October 20, 2016 to all licensed nurses. This will be completed by October 21, 2016. Monitoring of diabetic management system began October 20, 2016 at 4:30 p.m. The facility QA Committee has met for an ad hoc meeting to review and approve these plans. The QA Committee will review progress on the plan and make recommendations for changes as needed. The surveyor monitored the current plan of removal as follows: In an interview on 10/21/2016 at 1:13 p.m. with the DON, she stated that all the MAR's from the 100 hallway had been reprinted with space for nursing to document the insulin administered to the residents. She further said that all nurses had been trained for diabetic management and that the pharmacist had been involved in the training. DON further said that she was new in the facility and that policies for diabetic management should had been in place. DON then said that the nurses should had been trained from school regarding medication administration and properly document care provided and MD notification. Further interview with the DON at that time, when asked how did she think this incident of IJ came about, the DON stated nurses not properly following through. I have already talked to the nurses regarding MD notification and follow up. I don't see the paper trails. For nurses, if you don't documented, you did not do it. I was not aware of those holes, especially for insulin and blood glucose monitoring, CR #10's MD, who is the Medical Director, was here 10/19/2016 and we discussed about those holes and we included the supervisors and talked about it. I just need to keep re-enforcing it. Record review and observation on 10/21/2016 at 3:10 p.m. revealed that the MAR ' s of residents requiring Accuchecks (blood glucose monitoring) had the space for nurses to document the insulin administered. In an interview on 10/21/2016 at 1:55 p.m. with LVN J, she stated that she had been trained on Diabetic management, protocol for notification of the MD and the family, accurate documentation, obtaining and transcribing MD orders and recognizing sign and symptoms of hyper/[DIAGNOSES REDACTED]. In an interview on 10/21/2016 at 2:10 p.m. with LVN D, she stated that she had been trained on Diabetic management, protocol for notification of the MD and the family, accurate documentation, obtaining and transcribing MD orders and recognizing sign and symptoms of hyper/[DIAGNOSES REDACTED]. In an interview on 10/21/2016 at 2:15 p.m. with RN A, she stated that she had been trained on assessments, MD notification, Diabetic management, protocol for notification of the MD and the family, accurate documentation, obtaining and transcribing MD orders and recognizing sign and symptoms of hyper/[DIAGNOSES REDACTED]. In an interview on 10/21/2016 at 2:30 p.m. with LVN K, she stated that she had been trained on MD notification related to changes in condition, family notification and follow up with documentation in nursing/progress notes including appropriate follow up of MD orders. She then said that training included Diabetic management, protocol for notification of the MD and the family, accurate documentation, obtaining and transcribing MD orders and recognizing sign and symptoms of hyper/[DIAGNOSES REDACTED]. In an interview on 10/21/2016 at 2:40 p.m. with LVN A, she stated that she had been trained on Diabetic management, protocol for notification of the MD and the family, accurate documentation, obtaining and transcribing MD orders and recognizing sign and symptoms of hyper/[DIAGNOSES REDACTED]. She then said that training included notification and follow up with documentation in nursing/progress notes including appropriate follow up of MD orders. In an interview on 10/21/2016 at 2:49 p.m. with RN D, she stated that she had been trained on Diabetic management, protocol for notification of the MD and the family, accurate documentation, obtaining and transcribing MD orders and recognizing sign and symptoms of hyper/[DIAGNOSES REDACTED]. In an interview on 10/21/2016 at 3:00 p.m. with RN H, she stated that she had been trained on Diabetic management, protocol for notification of the MD and the family, accurate documentation, obtaining and transcribing MD orders and recognizing sign and symptoms of hyper/[DIAGNOSES REDACTED]. Observations on 10/21/2016 at 4:20 p.m. revealed that staff was answering call lights timely. The residents appeared clean and appropriately dressed. Sample residents were turned on their sides. No lingering odors noted on hallways. Record review of facility In-service Training Attendance record dated 10/19/2016 revealed that licensed nursing staff were educated regarding diabetic management. Staff was provided with the policy and procedures for diabetic management dated April 2005 and policy and procedure for medication administration dated April 2005. Training included assessment for sign and symptoms of hyper/[DIAGNOSES REDACTED] including complications and documentation of insulin administered on the MAR, reporting to the MD and documenting information on the 24 hour report for follow up by oncoming nurse. Attached to the in-service were the attending staff signatures. Further record review of facility In-service Training Attendance record dated 10/20/2016 revealed that nursing staff were educated regarding MD notification if blood glucose is outside parameters and glucometer use. Attached to the in-service were the attending staff signatures. Continued record review of facility In-service Training Attendance record dated 10/21/2016 revealed that nursing staff were educated regarding insulin administration, storage of insulin and storage of insulin. Attached to the in-service were the attending staff signatures. On 10/21/16 at 4:26 PM, the Administrator was informed the IJ was lowered. However, the facility remained out of compliance at a severity level of actual harm that is not an IJ with a scope identified as a pattern due to the facility administration and staff requiring time to train all staff and monitor their plan of removal. The DON stated that there were 30 residents at the facility who required Accuchecks (blood sugar monitoring).

Based on observation, interview and record review, the facility failed to implement its written policy and procedures that prohibit neglect for four of fourteen residents (Resident #5, #6, #11 and CR#10) reviewed for neglect. -The facility staff failed to provide timely incontinent care to Resident #5 and she was found with brief heavily saturated with urine and she had developed multiple facility acquired stage II pressure sores to her right and left buttocks that were not identified by the staff. -The facility failed to prevent the development and worsening of facility acquired pressure ulcers for Resident #5 who was identified as Very High Risk to develop pressure sores. Resident # 5 developed four facility acquired Stage 2 pressure sores identified to her left and right buttocks. -The facility failed to provide preventative pressure sore measures to Resident #6 who had a facility acquired stage 4 pressure sore on her left buttocks. Resident #6 was observed lying on her back for more than 2 hours and was not turned/repositioned. -The facility failed to prevent the worsening of a pressure sore for CR #10 who had a Stage 2 pressure sore to his sacrum that worsened to a Stage 3 within two days of being readmitted to the facility. - The facility failed to care plan CR #10's Stage 2 pressure sore when he was readmitted to the facility on [DATE] with the wound. - The facility failed to assess, monitor and consult with the physician when CR #10 and Resident #11's blood glucose levels were above the parameters of 401 mg/dL. - The facility failed to monitor CR #10 and Resident #11's blood glucose and administer insulin as ordered. - The facility failed to have a method to accurately document on the Medication Administration Record [REDACTED]. - CR #10 requested to be sent to the hospital and he was admitted to the intensive care unit with a blood glucose of 978 mg/dL and was diagnosed with [REDACTED]. An Immediate Jeopardy (IJ) was identified on 10/17/2016 and 10/20/16. While the IJ was lowered on 10/21/2016, the facility remained out of compliance at a severity of Actual harm that is not Immediate Jeopardy and a scope of pattern. The facility remained out of compliance because they had not yet monitored their plan for effectiveness. These failures affected three residents and one former resident and placed the remaining 12 residents with pressure sores and 29 residents receiving Accuchecks in the facility at risk of not receiving adequate assessments and care, delayed treatment, pain, decline in their health condition well-being and hospitalization . Findings Include: Intake # 1, 1 and 8 Resident # 5 Record review of the medical record face sheet revealed Resident # 5 was admitted on [DATE]. [DIAGNOSES REDACTED]. She was [AGE] years old. Record review of Resident #5's Plan of Care initiated 3/21/2016 revealed in part: -Focus: Resident #5 has potential skin issues related to potential breakdown. Resident #5 has bladder incontinence related to disease process. -Goal: Resident #5's skin will remain intact and Resident #5 will remain free from skin breakdown due to incontinence and brief use. -Interventions: Notify MD of changes in wound or emerging wounds and Clean peri-area with each incontinence episode . Record review of Resident #5's Braden Scale for Predicting Pressure Sore Risk revealed in part; - 5/27/2016 revealed a score of 12 indicating High Risk to develop pressure sores. - 8/16/2016 revealed a score of 8 indicating Very High Risk to develop pressure sores. Further record review revealed that Resident #5's plan of care was not updated with interventions to prevent pressure sores. Record review of Resident # 5's quarterly MDS assessment with 08/17/2016 ARD date revealed that she was not interviewed for Cognitive Skills for Daily Decision Making. Resident #5 had short and long term memory problem and her cognitive skills for daily decision making were moderately impaired. She required total assistance of two staff support for all her activities of daily living. Resident #5 was always incontinent of bowel and bladder. The skin condition section of the assessment revealed she had no pressure sores and she was at risk of developing pressure ulcers. Observation on 10/16/2016 at 11:55 p.m. revealed that Resident #5 was in bed on her back with the head of the bed elevated at 45 degrees. Further observation revealed that Resident #5's room had a strong urine odor to the outside hallway of her room. Resident #5's eyes were closed. Observation and interview on 10/17/2016 at 12:20 a.m. during incontinent care to Resident #5 revealed that MA C and C.N.A. P stated that Resident #5 has some skin irritations. Further observation and interview at that time revealed Resident #5's front perineal area was reddened and as Resident #5 was turned to her side, her buttocks areas were noted with open areas on each of her buttocks. Resident #5 moaned on and off while MA C and C.N.A. P were wiping her front perineal area and buttocks. Continued observation revealed that resident #5 had her brief heavily saturated with urine, her brief was brownish in color and had several spots of bright and dark blood on the buttocks area. MA C then said brief is heavily soiled , MA C proceeded to remove the brief from underneath Resident #5. Further observation revealed that Resident #5's underneath pad had also a large circular brownish/yellowish wet area with several spots of bright red blood and dark red blood on the buttocks area where Resident #5 was lying. Interview at that time, C.N.A. P stated that Resident #5 would usually scream during incontinent care and then said especially since last week that she had these open areas. Further observation at that time revealed that Resident #5 had 3 open wounds to her left buttocks (left mid buttocks approx 2.5 x 4.0 cm., left lower buttocks had 2 wounds approx 3.0 x 2.0 and 2.0 x 2.0 c.m.) and one open wound to the right lower buttocks (approx 3.0 x 2.0 c.m.). Open wounds had wound base reddened and were bleeding. Surrounding site of the wounds were macerated. At that time, surveyor asked C.N.A. P to call the charge nurse. In an interview and observation on 10/17/2016 at 12:36 a.m. with RN D, she stated as she looked at Resident #5's buttocks areas Resident #5 already has treatment for [REDACTED]. RN D then stepped out of the room. Continued observation and interview on 10/17/2016 at 12:40 a.m. after incontinent care, C.N.A. P grabbed a 30 cc cup that was at Resident #5's bedside that had a clear colored ointment and another 30 cc cup that had a white powder, that was next to the cup that had the clear ointment. C.N.A. P stated we are going to put the powder and the cream on the sores. The nurses left these medications for Resident #5 . When asked what was the name of the cream and the powder that were on the 30 cc cup containers, C.N.A. P stated I don't know. MA C then said I think is [MEDICATION NAME], let me put the powder on her buttocks. C.N.A. P then said I will put the cream on the front. C.N.A. P continued saying Resident #5 is going to scream. Observation at that time revealed that as C.N.A. P rubbed the clear ointment to the front perineal area, Resident #5 moaned. MA C then sprinkled the powder to Resident #5's buttocks area covering the open wounds. Continued observation at that time revealed that Resident #5 was positioned on her back after incontinent care with the head of the bed elevated at 45 degrees. In an interview on 10/17/2016 at 12:45 a.m. with RN D, when asked for last skin assessment and orders for Resident #5, RN D stated as she read Resident #5's skin assessment, There is documentation that Resident #5 had a rash only. RN D further said that she was aware of the open wounds of Resident #5's buttocks and that she believed that the wounds had been assessed already last week and that when she saw the orders for [MEDICATION NAME] and [MEDICATION NAME] powder that she thought that the MD was aware of the open wounds. RN D continued saying that she did not leave the ointment and the powder at Resident #5's bedside, that probably was the PM shift nurse (LVN A). Record review of Resident #5's phone orders dated 10/12/2016 revealed in part: . -Wound care doctor to evaluate and treat as indicated, -[MEDICATION NAME] Ointment 2% (antibiotic). Apply to bilateral buttock topically one time a day for wounds. Clean area with Normal Saline, pat dry, apply [MEDICATION NAME] to bilateral buttocks wound, cover with non stick dressing until areas healed. -[MEDICATION NAME] powder apply to groin topically two times a day for moisture In a phone interview on 10/19/2016 at 9:33 a.m. with LVN A, she stated that she was the charge nurse on 10/16/2016 during the 2 to 10 shift for Resident #5 and further said Resident #5 had wounds to her buttocks and she had orders for [MEDICATION NAME] ointment. I never give the ointment to the C.N.A.'s. When asked if she had left a clear ointment and a white powder at the bedside of Resident #5, LVN A stated No, I did not do it. I don't know who did it. I did the treatment myself. Record review of Resident #5's Skin - Head to toe skin check dated 10/11/2016 signed by RN F revealed in part; New abrasions. Site: Left buttocks. Type: Rash . In an interview on 10/18/2016 at 1:40 p.m. with RN F, she stated that C.N.A. C reported to her since 10/11/2016 that Resident #5 had a rash. RN F further said that she went and assessed Resident #5's buttocks area at that moment and that she saw wounds to Resident #5's right and left buttocks, She said that the wounds looked red and were approx 10 x 1 c.m. RN F then said that she wrote the information on the book for the MD to review it whenever the MD would come to the facility. When asked if she wrote rash on Resident #5's assessment dated [DATE], RN F stated I probably wrote rash on the assessment form before going and evaluating Resident #5. In an interview on 10/17/2016 at 1:03 a.m. with RN D, she stated that she was aware since last week that Resident #5 had open wounds to her buttocks and that she did not measured or assessed the areas because there were orders already and further said we usually measure any new wounds and call the MD, but I wasn't sure with Resident 5's wounds. In an interview on 10/17/2016 at 1:09 a.m. with the DON and the Administrator, the DON stated that incontinent care was supposed to be done every 2 hours and that she had already seeing the pad that was removed from underneath Resident #5's and that the brief had been already put on the trash outside. DON said that she saw the wet pad with patches of blood. Further interview with the DON at that time, when asked if she was aware of Resident #5's open wounds to right and left buttocks, the DON stated It's so many residents. I am still trying to learn. I am new. I had been in this facility for a month only. Continued interview with the DON and the Staff Development Manager, RN J on 10/17/2016 at 1:15 a.m. RN J stated that she had called the Wound Care Nurse on the phone and that the Wound Care Nurse had said that on the skin assessment dated [DATE] Resident #5's skin was intact and that on the assessment dated [DATE] the nurses had identified a rash to Resident #5's left buttocks. RN J further said that the wound care nurse had not assessed Resident #5's skin because the wound care nurse only takes care of the pressure sores in the facility and that the nurses take care of other skin problems. RN J then said we always thought that Resident #5 had only a rash. Nurses are supposed to go and assess the residents when the aides report any skin problems, then they would get orders from the MD. Surveyor at that time, made DON and Staff Development Manager aware that Resident #5 had 3 open bleeding wounds to her left buttocks and one to her right buttocks. DON then said we will do 100% skin assessments tonight. Further interview with the DON on 10/17/2016 at 1:28 a.m., the DON stated that C.N.A.'s were not supposed to apply any prescription medication creams or ointments including powder medications to residents and that medications were not supposed to be left at the bedside either and further said we will do in-service now. Nurses are supposed to apply those medications only and not leave medications for C.N.A.'s to apply at the bedside. In an interview on 10/17/2016 at 10:15 a.m. with Staff Development Manager, RN J, she stated that she assessed Resident #5's open wounds and that Resident #5 had 3 open areas on her left buttocks and that she saw the wound base pink and further said the 3 wounds to the left buttocks were macerated open areas. Staff Development Manager, RN J further said that the right ishium open area was pink wound base and dry. Staff Development Manager, RN J handled to surveyor Resident #5's skin assessments done by facility. Record review of Resident #5's Skin - Head to toe skin check dated 10/17/2016 and signed by Staff Development Manager, RN J revealed in part . Describe new or existing other issues: Resident #5 noted with three open ulcers to left buttock and one open ulcer to right gluteal fold. -Site 32) Left buttock open ulcer. 2.5 x 4.0 c.m. (LxW) Stage 2. -Site 32) Left buttock open ulcer. 2.0 x 2.0 c.m. (LxW) Stage 2. -Site 32) Left buttock open ulcer. 1.5 x 3.0 c.m. (LxW) Stage 2. -Site 55) Right gluteal fold open ulcer. 1.2 x 3.0 c.m. (LxW) Stage 2. Further description of skin issues: Surrounding skin appears macerated, no bleeding noted . Observation and interview on 10/17/2016 at 10:35 a.m. revealed Resident #5 was on her back with the head of the bed elevated at 45 degrees. C.N.A. C and C.N.A. K were inside room of Resident #5, C.N.A. C stated that they had just finished providing incontinent care to Resident #5. When asked if they saw any dressing to Resident #5's buttocks, C.N.A. C stated Resident #5 had wounds to her buttocks and still did not have any dressings on them. Resident #5 had open areas to her right and left buttocks since last week, but I reported to Unit Manager N since last Friday (10/14/2016). C.N.A. C further said that when aides report any skin condition to the nurses, they would do it verbally only, that they are not required to complete any paper form. C.N.A. C continued saying that since the beginning of October 2016, she had been reporting to different nurses that Resident #5 had skin redness and breakdown on her buttocks and that finally on 10/14/2016, she made the report to Unit Manager N. C.N.A. C then said that Resident #5 spends most of the time in bed. Observation on 10/17/2016 at 11:10 a.m. revealed that the Wound Care Nurse was inside Resident #5's room and said to surveyor I just did the wound care now because I had to change wound care orders. RN J got orders earlier but I had to change orders. In an interview on 10/17/2016 at 11:15 a.m. with Staff Development Manager, RN J, she stated that she got wound care orders for Resident #5's open wounds on her buttocks since 8:00 a.m Record review of Resident #5's telephone orders dated 10/17/2016 written by Staff Development Manager, RN J revealed in part: -Santyl collagen (wound [MEDICATION NAME] ointment) to bilateral buttocks wounds daily and cover with clean 4x4 dressing. -Vitamin C 500 mg via peg tube daily -Zinc Sulfate 220 mg via peg tube daily -Wound care to evaluate and treat Further record review of telephone orders revealed orders dated 10/17/2016 at 11:00 a.m. in part .- Discontinue previous wound care orders. -Apply Calcium alginate (seaweed dressing for moist wounds) to left upper buttocks area, cover with 4x4 after cleanse with normal saline daily. -Cleanse left buttock area with normal saline, Apply Zinc Oxide to open areas daily and as needed. -Cleanse right ishium (buttocks) wound with normal saline. Pat dry. Apply Zinc Oxide to open area daily and as needed. -Air mattress . In an interview on 10/17/2016 at 11:35 a.m. with the DON, Administrator, who was the abuse coordinator and Staff Development Manager, RN J, when asked about the delayed in wound care to Resident #5 since 1:15 a.m. that surveyor made them aware of Resident #5's open wounds to her buttocks and wounds were not protected until 11:10 a.m., the DON stated we were trying to investigate, we were in the process of investigating, but it takes time. We were pulling the scheduled. Continued interview at that time, the Staff Development Manager, RN J then said Santyl (wound [MEDICATION NAME] ointment) needed to be ordered. Then the order was discontinued and Calcium Alginate (seaweed dressing for moist wounds) was ordered. Staff Development Manager, RN J further said that the wound care MD was going to see Resident #5 on 10/18/2016. Further interview at that time, the Administrator stated that the facility had on-call MD that could had been called for wound care orders for Resident #5 when surveyor made the facility aware of the open areas of Resident #5 at 1:15 a.m. In an interview on 10/17/2016 at 11:55 a.m. with the Wound Care Nurse, she stated today was my first time looking at Resident #5's wounds. Wound Care Nurse then said that on 10/13/2016, C.N.A. C asked her for something more than Zinc ointment for Resident #5's open areas but that C.N.A. C did not specify that Resident #5 had wounds and that she told the C.N.A. to report the condition to the charge nurse because she only takes care of pressure sores. When asked if she went to assessed Resident #5 after C.N.A. C reported open areas, the Wound Care Nurse said I did not go and see Resident #5. I only asked her to tell the charge nurse and C.N.A. C said that she had already reported to the charge nurse. So I went and continued with my work. Wound Care Nurse said that she had been doing wound care in the facility for 1 year and that she had been certified for wound care and that as an LVN she was able to stage wounds because she had been certified for wound care. Further interview at that time, Wound Care Nurse stated that the left medial buttocks open area appeared like an unstageable wound because it got thick necrotic tissue on 50% of the wound base and that the left and right lower buttocks wounds were also unstageable wounds because of the necrotic tissue on the wound base. Wound Care Nurse continued saying that the wound on the left medial buttocks was pressure for being on that side for long periods of time. Wound Care Nurse further said that the pressure sores on the lower buttocks were due to pressure from the brief because the briefs were too small and the tightness of the brief was putting pressure to the area and by Resident #5 lying on her back. Continued interview with the Wound Care Nurse on 10/17/2016 at 12:10 p.m., when asked if she was made aware that Resident #5 had wound care orders as of 8:00 a.m. The Wound Care Nurse stated Staff Development Manager, RN J told me at around 9:00 a.m. of the wound orders for Resident #5 but I had to do the wound dressings for station 1 first then I came to station 3 and that's when I saw you (surveyor) coming out of Resident #5's room. Wound Care Nurse stated that she had not updated the care plan for Resident #5 because she had been busy. In an interview on 10/17/2016 at 12:15 p.m. with Unit Manager N, he stated that he was made aware on 10/14/2016 of Resident #5's skin condition and that he went to see the resident and that he saw a skin tear on the left buttocks area that was approx 3x5 inches and that he checked the orders and that he saw orders for [MEDICATION NAME] ointment. When asked if he wrote a skin assessment for Resident #5 when he went to assess her left buttocks, Unit Manager N stated No, I did not do wound assessments because it was documented that a skin assessment was recently done. When asked if he reviewed the skin assessment that was recently completed, the Unit Manager N stated No, I did not review the assessment. I thought that the open area had been already identified so I did not think I needed to further call the MD or re-do an assessment. In an interview on 10/17/2016 at 12:46 p.m. the DON stated that Resident #5 was getting an air mattress. In an interview on 10/18/2016 at 1:45 p.m. with RN F, she stated that whenever staff reports any skin condition, they were supposed to go and assess the area, then enter the assessment on the computer. RN F said that MD needed to be notified at that time and orders need to be carried out as soon as possible. RN F continued saying that she remembered that the day she placed the notification on the MD book regarding the open areas to Resident #5's buttocks, that she believed she saw other notifications on the MD book written by other nurses regarding the skin condition of Resident #5. In a phone interview on 10/19/2016 at 9:21 a.m. with C.N.A. D, he stated that he was the C.N.A. for Resident #5 on 10/16/2016 for the 2 to 10 p.m. shift. C.N.A.'s D further said that he first saw Resident #5 at around 2 p.m. on 10/16/2016 and did incontinent care to her. C.N.A. D then said that he saw wounds to Resident #5's right and left buttocks and then said the nurses know about the wounds, they would give us the ointment to put on Resident #5's wounds and further said I believed the diaper was too tight and then she would just lay on her back, then the wounds would bleed, the wounds were bleeding, they were not healing. When asked when was the last time he provided incontinent care to Resident #5 on 10/16/2016 before the end of his shift, C.N.A. D stated Resident #5 was not wet on my last round. I get off at 10:00 p.m. and she was supposed to be checked every 2 hours and we are supposed to turn her every 2 hours as well. Further interview at that time, C.N.A. D stated that he turned and repositioned Resident #5 to her side at 9:00 p.m during the last round and that Resident #5 was dry. When asked if he was aware that Resident #5 was found with her brief heavily soiled on 10/16/2016 at midnight, C.N.A. D stated Resident #5 is heavy wetter. Resident #6 Record review of the medical record face sheet revealed Resident # 6 was admitted on [DATE]. [DIAGNOSES REDACTED]. She was [AGE] years old. Record review of Resident #6's Plan of Care initiated 12/07/2015 and last reviewed 9/7/2016 revealed in part: -Problem: Resident #6 has pressure ulcer to left ischium (sitting bone) related to sensory perception, moisture/incontinence, decreased activity, impaired mobility and friction and shear problem. -Goal: Pressure ulcer will show signs of healing process as evidence by decrease in depth, width and length by at least 2 c.m. -Approach: Turn and reposition while in bed and chair frequently for comfort and pressure reduction. Other: pillows/wedge, limited to 60 minutes up in wheel chair . Record review of Resident #6's Braden Scale for Predicting Pressure Sore Risk dated 9/06/2016 revealed a score of 15 indicating at Risk to develop pressure sores. Record review of Resident # 6's quarterly MDS assessment with 08/7/2016 ARD date revealed that she was cognitively intact with a BIMS score of 13 out of a total possible of 15. Resident #6 required extensive assistance of two staff support for bed mobility, dressing and total dependent on staff for transfers, toilet use and bathing. Resident #6 had an external catheter and an ostomy including [MEDICATION NAME], [MEDICAL CONDITION] and [MEDICAL CONDITION]. The skin condition section of the assessment revealed she had one stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling) that measured 3.0 x 2.3 x 1.0 c.m. (LWD). Record review of Resident #6's Skin - weekly pressure ulcer record dated 10/11/2016 revealed in part: . Site: Left ischium. Pressure sore. Measure: 4.5 x 3.2 x 0.8 c.m. (LWD) Stage: 4. Date of onset 12/07/2015 Record review of hand-written pressure ulcer list dated 10/17/2016 revealed that Resident #6's pressure sore to her left ischium was In-house acquired as of 12/7/2015. Record review of Resident #6's MD orders dated 10/12/2016 revealed orders in part; -Clean left hip wound with normal saline, pat dry, apply silver alginate to wound. Cover with 4x4 dressing then dry dressing every day and as needed one time a day for wound care. Observation on 10/16/2016 at 11:15 p.m. revealed Resident #6 lying in bed on her back with the head of the bed elevated at 45 degrees. Observation and interview on 10/17/2016 at 12:20 p.m. revealed that Resident #6 was lying in bed on her back with her head elevated at approx 35 degrees. Resident #6 stated that she was up on her chair from 9:30 a.m. to 12:00 p.m. and that the C.N.A. had helped her to bed. Resident #6 further said facility staff do not turn me or reposition me. I lay on my back for hours. They are supposed to turn me but they don't do it. I have never refused to be turned or repositioned. I try to do it myself sometimes because is very uncomfortable to be on one side for long time but I can't do it. I am not strong enough to turn myself. Sometimes it is very painful to be on my back. I have a wedge that the staff are supposed to put on my side but it's over there on the chair. Even before I have the pressure sore on my left buttocks, they would never turn me. Interview at that time with Resident #6's visitor friend, she stated that she visited Resident #6 frequently and stays with her for long time and that she has never observed any staff turn or reposition Resident #6. Observation and interview on 10/17/2016 at 1:50 p.m. with Resident #6 revealed that she was still lying on her back with the head of the bed at 45 degrees. Resident #6 stated that still no staff had come to offer her to be turned or repositioned to her side. Resident #6 further said last night when you were here, I was on my back and stayed lying on my back the entire night. Sometimes I have to ask them to put the wedge on my back and they would do it. In an interview on 10/17/2016 at 2:00 p.m. with C.N.A. K, she stated that she worked 6 to 2 p.m. shift. She further said that Resident #6 required total assistance for all her activities of daily living and that was a hospice resident. She further said that Resident #6 had a pressure sore on her butt and that was on a turning and repositioning program and required turning every 2 hours. C.N.A. K then said that Resident #6 got up at around 9:30 a.m. on her chair until 12 p.m. and that the last time she repositioned Resident #6 was at 12 p.m. and then said Resident #6 is due to be turned and repositioned now. C.N.A. K then said that Resident #6 was alert and oriented. Further observation at that time revealed that C.N.A. K walked to the nursing station and did not come back. Observation and interview on 10/17/2016 at 2:50 p.m. revealed that Resident #6 was still on the same position on her back with the head of the bed elevated at 45 degrees. Resident #6 stated to surveyor still nobody has come to turn me. My buttocks and my back hurt. In an interview on 10/17/2016 at 3:03 p.m. with C.N.A. N, she stated that she was the PM shift aide for Resident #6 and that the morning C.N.A. had reported to her that Resident #6 was due to be turned and repositioned at 2:30 p.m. and that she had been busy. Observation and interview on 10/17/2016 at 3:05 p.m. with the Wound Care Nurse, she stated she was going to do wound care to Resident #6. Further observation revealed that Resident #6 was still lying on her back. Further observation at that time during wound care to Resident #6 revealed that Resident #6 had a circular open wound to her left lower buttocks approx 3 to 4 c.m. in diameter, wound base was red with approx 10% of yellow slough. Surrounding site of the wound was red and there was scant amount of brown drainage. Continued observation and interview after wound care treatment to Resident #6's left lower buttocks revealed that the Wound Care Nurse positioned Resident #6 to her back with the assistance of C.N.A. FF. At that time surveyor reported to Wound Care Nurse that Resident #6 had been on her back since 12 p.m. Wound Care Nurse then said She had?! and looked at Resident #6. Resident #6 stated yes. Wound Care Nurse immediately assisted Resident #6 to her side by placing a wedge to her left side. In an interview on 10/17/2016 at 3:25 p.m. with the Wound Care Nurse, she stated that nurses were supposed to supervise that C.N.A.'s would turn and reposition residents and then said I have the entire building. When I come in the morning I try to see everyone. Sometimes I call the C.N.A.'s. Last time I saw Resident #6 was earlier and she was up on her chair and I did not know what time she was assisted to bed. Resident #6 was supposed to be turn and reposition off her back. CR #10 Record review of the medical record face sheet revealed CR #10 was admitted on [DATE]. [DIAGNOSES REDACTED]. He was [AGE] years old. CR #10 went to the hospital on [DATE] at his request. Record review of CR # 10's admission MDS assessment with 09/11/2016 ARD date revealed that his short and long term memory were intact. CR #10 required total assistance of two staff support for bed mobility, dressing and bathing. He required one person assistance for toilet use and extensive assistance of two staff support for personal hygiene. CR #10 was always incontinent of bowel and had an indwelling catheter. The skin condition section of the assessment revealed he was at risk of developing pressure ulcers and did not have a pressure ulcer. Further record review revealed that MDS assessment did not have CR#10 with an active [DIAGNOSES REDACTED]. Record review of CR #10's Plan of Care initiated 9/20/2016 revealed in part: -Focus: CR #10 has potential impairment to skin integrity related to fragile skin. CR #10 has bladder incontinence related to impaired mobility. -Goal: Will remain free from skin breakdown. -Approach: Clean peri-area with each incontinence episode . Continued record review of CR #10's Plan of Care initiated 9/20/2016 revealed no information that CR #10 had [DIAGNOSES REDACTED]. Further record review revealed no interventions to monitor for sign and symptoms of hyper/[DIAGNOSES REDACTED] (high or low blood sugar levels). (High blood glucose: Frequent urination, Increased thirst, Shortness of breath, weak and tired, Breath that smells fruity, abdominal pain, Nausea and vomiting and Very dry mouth. Low blood glucose: Confusion, dizziness, feeling shaky, hunger, headaches, irritability, pounding heart; racing pulse. <http://www.diabetes.org>.) Record review of CR #10's Braden Scale for Predicting Pressure Sore Risk dated 10/09/2016 revealed a score of 11 indicating High Risk to develop pressure sores. Record review of CR #10's Skin - Head to toe skin check revealed in part; -10/9/2016 Re-admission. Site: Coccyx. Pressure sore. No measurements on assessment. Stage 2. -10/11/2016. Site: Sacrum. Pressure sore. 2.3x1.9x0.2.c.m. (LWD). Stage 3. -10/18/2016. Site:

Based on observation, interview and record review, the facility failed to implement their written policy and procedures that prohibit neglect for four of fourteen residents (Resident #5, #6, #11 and CR#10) reviewed for neglect. -The facility staff failed to provide timely incontinent care to Resident #5 and she was found with brief heavily saturated with urine and she had developed multiple facility acquired stage II pressure sores to her right and left buttocks that were not identified by the staff. -The facility failed to prevent the development and worsening of facility acquired pressure ulcers for Resident #5 who was identified as Very High Risk to develop pressure sores. Resident # 5 developed four facility acquired Stage 2 pressure sores identified to her left and right buttocks. -The facility failed to provide preventative pressure sore measures to Resident #6 who had a facility acquired stage 4 pressure sore on her left buttocks. Resident #6 was observed lying on her back for more than 2 hours and was not turned/repositioned. -The facility failed to prevent the worsening of a pressure sore for CR #10 who had a Stage 2 pressure sore to his sacrum that worsened to a Stage 3 within two days of being readmitted to the facility. - The facility failed to care plan CR #10's Stage 2 pressure sore when he was readmitted to the facility on [DATE] with the wound. - The facility failed to assess, monitor and consult with the physician when CR #10 and Resident #11's blood glucose levels were above the parameters of 401 mg/dL. - The facility failed to monitor CR #10 and Resident #11's blood glucose and administer insulin as ordered. - The facility failed to have a method to accurately document on the Medication Administration Record [REDACTED]. - CR #10 requested to be sent to the hospital and he was admitted to the intensive care unit with a blood glucose of 978 mg/dL and was diagnosed with [REDACTED]. An Immediate Jeopardy (IJ) was identified on 10/17/2016 and 10/20/16. While the IJ was lowered on 10/21/2016, the facility remained out of compliance at a severity of Actual harm that is not Immediate Jeopardy and a scope of pattern. The facility remained out of compliance because they had not yet monitored their plan for effectiveness. These failures affected three residents and one former resident and placed the remaining 12 residents with pressure sores and 29 residents receiving Accuchecks in the facility at risk of not receiving adequate assessments and care, delayed treatment, pain, decline in their health condition well-being and hospitalization . Findings Include: Intake # 1, 1 and 8 Record review of the facility policy on Abuse and Neglect Prohibition revised on June 2013 revealed in part Each resident has the right to be free from neglect. Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness .Prevention: 2.- Facility supervisors will immediately correct and intervene in identified situations in which neglect is at risk for occurring Resident # 5 Record review of the medical record face sheet revealed Resident # 5 was admitted on [DATE]. [DIAGNOSES REDACTED]. She was [AGE] years old. Record review of Resident #5's Plan of Care initiated 3/21/2016 revealed in part: -Focus: Resident #5 has potential skin issues related to potential breakdown. Resident #5 has bladder incontinence related to disease process. -Goal: Resident #5's skin will remain intact and Resident #5 will remain free from skin breakdown due to incontinence and brief use. -Interventions: Notify MD of changes in wound or emerging wounds and Clean peri-area with each incontinence episode . Record review of Resident #5's Braden Scale for Predicting Pressure Sore Risk revealed in part; - 5/27/2016 revealed a score of 12 indicating High Risk to develop pressure sores. - 8/16/2016 revealed a score of 8 indicating Very High Risk to develop pressure sores. Further record review revealed that Resident #5's plan of care was not updated with interventions to prevent pressure sores. Record review of Resident # 5's quarterly MDS assessment with 08/17/2016 ARD date revealed that she was not interviewed for Cognitive Skills for Daily Decision Making. Resident #5 had short and long term memory problem and her cognitive skills for daily decision making were moderately impaired. She required total assistance of two staff support for all her activities of daily living. Resident #5 was always incontinent of bowel and bladder. The skin condition section of the assessment revealed she had no pressure sores and she was at risk of developing pressure ulcers. Observation on 10/16/2016 at 11:55 p.m. revealed that Resident #5 was in bed on her back with the head of the bed elevated at 45 degrees. Further observation revealed that Resident #5's room had a strong urine odor to the outside hallway of her room. Resident #5's eyes were closed. Observation and interview on 10/17/2016 at 12:20 a.m. during incontinent care to Resident #5 revealed that MA C and C.N.A. P stated that Resident #5 has some skin irritations. Further observation and interview at that time revealed Resident #5's front perineal area was reddened and as Resident #5 was turned to her side, her buttocks areas were noted with open areas on each of her buttocks. Resident #5 moaned on and off while MA C and C.N.A. P were wiping her front perineal area and buttocks. Continued observation revealed that resident #5 had her brief heavily saturated with urine, her brief was brownish in color and had several spots of bright and dark blood on the buttocks area. MA C then said brief is heavily soiled , MA C proceeded to remove the brief from underneath Resident #5. Further observation revealed that Resident #5's underneath pad had also a large circular brownish/yellowish wet area with several spots of bright red blood and dark red blood on the buttocks area where Resident #5 was lying. Interview at that time, C.N.A. P stated that Resident #5 would usually scream during incontinent care and then said especially since last week that she had these open areas. Further observation at that time revealed that Resident #5 had 3 open wounds to her left buttocks (left mid buttocks approx 2.5 x 4.0 cm., left lower buttocks had 2 wounds approx 3.0 x 2.0 and 2.0 x 2.0 c.m.) and one open wound to the right lower buttocks (approx 3.0 x 2.0 c.m.). Open wounds had wound base reddened and were bleeding. Surrounding site of the wounds were macerated. At that time, surveyor asked C.N.A. P to call the charge nurse. In an interview and observation on 10/17/2016 at 12:36 a.m. with RN D, she stated as she looked at Resident #5's buttocks areas Resident #5 already has treatment for [REDACTED]. RN D then stepped out of the room. Continued observation and interview on 10/17/2016 at 12:40 a.m. after incontinent care, C.N.A. P grabbed a 30 cc cup that was at Resident #5's bedside that had a clear colored ointment and another 30 cc cup that had a white powder, that was next to the cup that had the clear ointment. C.N.A. P stated we are going to put the powder and the cream on the sores. The nurses left these medications for Resident #5 . When asked what was the name of the cream and the powder that were on the 30 cc cup containers, C.N.A. P stated I don't know. MA C then said I think is [MEDICATION NAME], let me put the powder on her buttocks. C.N.A. P then said I will put the cream on the front. C.N.A. P continued saying Resident #5 is going to scream. Observation at that time revealed that as C.N.A. P rubbed the clear ointment to the front perineal area, Resident #5 moaned. MA C then sprinkled the powder to Resident #5's buttocks area covering the open wounds. Continued observation at that time revealed that Resident #5 was positioned on her back after incontinent care with the head of the bed elevated at 45 degrees. In an interview on 10/17/2016 at 12:45 a.m. with RN D, when asked for last skin assessment and orders for Resident #5, RN D stated as she read Resident #5's skin assessment, There is documentation that Resident #5 had a rash only. RN D further said that she was aware of the open wounds of Resident #5's buttocks and that she believed that the wounds had been assessed already last week and that when she saw the orders for [MEDICATION NAME] and [MEDICATION NAME] powder that she thought that the MD was aware of the open wounds. RN D continued saying that she did not leave the ointment and the powder at Resident #5's bedside, that probably was the PM shift nurse (LVN A). Record review of Resident #5's phone orders dated 10/12/2016 revealed in part: . -Wound care doctor to evaluate and treat as indicated, -[MEDICATION NAME] Ointment 2% (antibiotic). Apply to bilateral buttock topically one time a day for wounds. Clean area with Normal Saline, pat dry, apply [MEDICATION NAME] to bilateral buttocks wound, cover with non stick dressing until areas healed. -[MEDICATION NAME] powder apply to groin topically two times a day for moisture In a phone interview on 10/19/2016 at 9:33 a.m. with LVN A, she stated that she was the charge nurse on 10/16/2016 during the 2 to 10 shift for Resident #5 and further said Resident #5 had wounds to her buttocks and she had orders for [MEDICATION NAME] ointment. I never give the ointment to the C.N.A.'s. When asked if she had left a clear ointment and a white powder at the bedside of Resident #5, LVN A stated No, I did not do it. I don't know who did it. I did the treatment myself. Record review of Resident #5's Skin - Head to toe skin check dated 10/11/2016 signed by RN F revealed in part; New abrasions. Site: Left buttocks. Type: Rash . In an interview on 10/18/2016 at 1:40 p.m. with RN F, she stated that C.N.A. C reported to her since 10/11/2016 that Resident #5 had a rash. RN F further said that she went and assessed Resident #5's buttocks area at that moment and that she saw wounds to Resident #5's right and left buttocks, She said that the wounds looked red and were approx 10 x 1 c.m. RN F then said that she wrote the information on the book for the MD to review it whenever the MD would come to the facility. When asked if she wrote rash on Resident #5's assessment dated [DATE], RN F stated I probably wrote rash on the assessment form before going and evaluating Resident #5. In an interview on 10/17/2016 at 1:03 a.m. with RN D, she stated that she was aware since last week that Resident #5 had open wounds to her buttocks and that she did not measured or assessed the areas because there were orders already and further said we usually measure any new wounds and call the MD, but I wasn't sure with Resident 5's wounds. In an interview on 10/17/2016 at 1:09 a.m. with the DON and the Administrator, the DON stated that incontinent care was supposed to be done every 2 hours and that she had already seeing the pad that was removed from underneath Resident #5's and that the brief had been already put on the trash outside. DON said that she saw the wet pad with patches of blood. Further interview with the DON at that time, when asked if she was aware of Resident #5's open wounds to right and left buttocks, the DON stated It's so many residents. I am still trying to learn. I am new. I had been in this facility for a month only. Continued interview with the DON and the Staff Development Manager, RN J on 10/17/2016 at 1:15 a.m. RN J stated that she had called the Wound Care Nurse on the phone and that the Wound Care Nurse had said that on the skin assessment dated [DATE] Resident #5's skin was intact and that on the assessment dated [DATE] the nurses had identified a rash to Resident #5's left buttocks. RN J further said that the wound care nurse had not assessed Resident #5's skin because the wound care nurse only takes care of the pressure sores in the facility and that the nurses take care of other skin problems. RN J then said we always thought that Resident #5 had only a rash. Nurses are supposed to go and assess the residents when the aides report any skin problems, then they would get orders from the MD. Surveyor at that time, made DON and Staff Development Manager aware that Resident #5 had 3 open bleeding wounds to her left buttocks and one to her right buttocks. DON then said we will do 100% skin assessments tonight. Further interview with the DON on 10/17/2016 at 1:28 a.m., the DON stated that C.N.A.'s were not supposed to apply any prescription medication creams or ointments including powder medications to residents and that medications were not supposed to be left at the bedside either and further said we will do in-service now. Nurses are supposed to apply those medications only and not leave medications for C.N.A.'s to apply at the bedside. In an interview on 10/17/2016 at 10:15 a.m. with Staff Development Manager, RN J, she stated that she assessed Resident #5's open wounds and that Resident #5 had 3 open areas on her left buttocks and that she saw the wound base pink and further said the 3 wounds to the left buttocks were macerated open areas. Staff Development Manager, RN J further said that the right ishium open area was pink wound base and dry. Staff Development Manager, RN J handled to surveyor Resident #5's skin assessments done by facility. Record review of Resident #5's Skin - Head to toe skin check dated 10/17/2016 and signed by Staff Development Manager, RN J revealed in part . Describe new or existing other issues: Resident #5 noted with three open ulcers to left buttock and one open ulcer to right gluteal fold. -Site 32) Left buttock open ulcer. 2.5 x 4.0 c.m. (LxW) Stage 2. -Site 32) Left buttock open ulcer. 2.0 x 2.0 c.m. (LxW) Stage 2. -Site 32) Left buttock open ulcer. 1.5 x 3.0 c.m. (LxW) Stage 2. -Site 55) Right gluteal fold open ulcer. 1.2 x 3.0 c.m. (LxW) Stage 2. Further description of skin issues: Surrounding skin appears macerated, no bleeding noted . Observation and interview on 10/17/2016 at 10:35 a.m. revealed Resident #5 was on her back with the head of the bed elevated at 45 degrees. C.N.A. C and C.N.A. K were inside room of Resident #5, C.N.A. C stated that they had just finished providing incontinent care to Resident #5. When asked if they saw any dressing to Resident #5's buttocks, C.N.A. C stated Resident #5 had wounds to her buttocks and still did not have any dressings on them. Resident #5 had open areas to her right and left buttocks since last week, but I reported to Unit Manager N since last Friday (10/14/2016). C.N.A. C further said that when aides report any skin condition to the nurses, they would do it verbally only, that they are not required to complete any paper form. C.N.A. C continued saying that since the beginning of October 2016, she had been reporting to different nurses that Resident #5 had skin redness and breakdown on her buttocks and that finally on 10/14/2016, she made the report to Unit Manager N. C.N.A. C then said that Resident #5 spends most of the time in bed. Observation on 10/17/2016 at 11:10 a.m. revealed that the Wound Care Nurse was inside Resident #5's room and said to surveyor I just did the wound care now because I had to change wound care orders. RN J got orders earlier but I had to change orders. In an interview on 10/17/2016 at 11:15 a.m. with Staff Development Manager, RN J, she stated that she got wound care orders for Resident #5's open wounds on her buttocks since 8:00 a.m Record review of Resident #5's telephone orders dated 10/17/2016 written by Staff Development Manager, RN J revealed in part: -Santyl collagen (wound [MEDICATION NAME] ointment) to bilateral buttocks wounds daily and cover with clean 4x4 dressing. -Vitamin C 500 mg via peg tube daily -Zinc Sulfate 220 mg via peg tube daily -Wound care to evaluate and treat Further record review of telephone orders revealed orders dated 10/17/2016 at 11:00 a.m. in part .- Discontinue previous wound care orders. -Apply Calcium alginate (seaweed dressing for moist wounds) to left upper buttocks area, cover with 4x4 after cleanse with normal saline daily. -Cleanse left buttock area with normal saline, Apply Zinc Oxide to open areas daily and as needed. -Cleanse right ishium (buttocks) wound with normal saline. Pat dry. Apply Zinc Oxide to open area daily and as needed. -Air mattress . In an interview on 10/17/2016 at 11:35 a.m. with the DON, Administrator, who was the abuse coordinator and Staff Development Manager, RN J, when asked about the delayed in wound care to Resident #5 since 1:15 a.m. that surveyor made them aware of Resident #5's open wounds to her buttocks and wounds were not protected until 11:10 a.m., the DON stated we were trying to investigate, we were in the process of investigating, but it takes time. We were pulling the scheduled. Continued interview at that time, the Staff Development Manager, RN J then said Santyl (wound [MEDICATION NAME] ointment) needed to be ordered. Then the order was discontinued and Calcium Alginate (seaweed dressing for moist wounds) was ordered. Staff Development Manager, RN J further said that the wound care MD was going to see Resident #5 on 10/18/2016. Further interview at that time, the Administrator stated that the facility had on-call MD that could had been called for wound care orders for Resident #5 when surveyor made the facility aware of the open areas of Resident #5 at 1:15 a.m. In an interview on 10/17/2016 at 11:55 a.m. with the Wound Care Nurse, she stated today was my first time looking at Resident #5's wounds. Wound Care Nurse then said that on 10/13/2016, C.N.A. C asked her for something more than Zinc ointment for Resident #5's open areas but that C.N.A. C did not specify that Resident #5 had wounds and that she told the C.N.A. to report the condition to the charge nurse because she only takes care of pressure sores. When asked if she went to assessed Resident #5 after C.N.A. C reported open areas, the Wound Care Nurse said I did not go and see Resident #5. I only asked her to tell the charge nurse and C.N.A. C said that she had already reported to the charge nurse. So I went and continued with my work. Wound Care Nurse said that she had been doing wound care in the facility for 1 year and that she had been certified for wound care and that as an LVN she was able to stage wounds because she had been certified for wound care. Further interview at that time, Wound Care Nurse stated that the left medial buttocks open area appeared like an unstageable wound because it got thick necrotic tissue on 50% of the wound base and that the left and right lower buttocks wounds were also unstageable wounds because of the necrotic tissue on the wound base. Wound Care Nurse continued saying that the wound on the left medial buttocks was pressure for being on that side for long periods of time. Wound Care Nurse further said that the pressure sores on the lower buttocks were due to pressure from the brief because the briefs were too small and the tightness of the brief was putting pressure to the area and by Resident #5 lying on her back. Continued interview with the Wound Care Nurse on 10/17/2016 at 12:10 p.m., when asked if she was made aware that Resident #5 had wound care orders as of 8:00 a.m. The Wound Care Nurse stated Staff Development Manager, RN J told me at around 9:00 a.m. of the wound orders for Resident #5 but I had to do the wound dressings for station 1 first then I came to station 3 and that's when I saw you (surveyor) coming out of Resident #5's room. Wound Care Nurse stated that she had not updated the care plan for Resident #5 because she had been busy. In an interview on 10/17/2016 at 12:15 p.m. with Unit Manager N, he stated that he was made aware on 10/14/2016 of Resident #5's skin condition and that he went to see the resident and that he saw a skin tear on the left buttocks area that was approx 3x5 inches and that he checked the orders and that he saw orders for [MEDICATION NAME] ointment. When asked if he wrote a skin assessment for Resident #5 when he went to assess her left buttocks, Unit Manager N stated No, I did not do wound assessments because it was documented that a skin assessment was recently done. When asked if he reviewed the skin assessment that was recently completed, the Unit Manager N stated No, I did not review the assessment. I thought that the open area had been already identified so I did not think I needed to further call the MD or re-do an assessment. In an interview on 10/17/2016 at 12:46 p.m. the DON stated that Resident #5 was getting an air mattress. In an interview on 10/18/2016 at 1:45 p.m. with RN F, she stated that whenever staff reports any skin condition, they were supposed to go and assess the area, then enter the assessment on the computer. RN F said that MD needed to be notified at that time and orders need to be carried out as soon as possible. RN F continued saying that she remembered that the day she placed the notification on the MD book regarding the open areas to Resident #5's buttocks, that she believed she saw other notifications on the MD book written by other nurses regarding the skin condition of Resident #5. In a phone interview on 10/19/2016 at 9:21 a.m. with C.N.A. D, he stated that he was the C.N.A. for Resident #5 on 10/16/2016 for the 2 to 10 p.m. shift. C.N.A.'s D further said that he first saw Resident #5 at around 2 p.m. on 10/16/2016 and did incontinent care to her. C.N.A. D then said that he saw wounds to Resident #5's right and left buttocks and then said the nurses know about the wounds, they would give us the ointment to put on Resident #5's wounds and further said I believed the diaper was too tight and then she would just lay on her back, then the wounds would bleed, the wounds were bleeding, they were not healing. When asked when was the last time he provided incontinent care to Resident #5 on 10/16/2016 before the end of his shift, C.N.A. D stated Resident #5 was not wet on my last round. I get off at 10:00 p.m. and she was supposed to be checked every 2 hours and we are supposed to turn her every 2 hours as well. Further interview at that time, C.N.A. D stated that he turned and repositioned Resident #5 to her side at 9:00 p.m during the last round and that Resident #5 was dry. When asked if he was aware that Resident #5 was found with her brief heavily soiled on 10/16/2016 at midnight, C.N.A. D stated Resident #5 is heavy wetter. Resident #6 Record review of the medical record face sheet revealed Resident # 6 was admitted on [DATE]. [DIAGNOSES REDACTED]. She was [AGE] years old. Record review of Resident #6's Plan of Care initiated 12/07/2015 and last reviewed 9/7/2016 revealed in part: -Problem: Resident #6 has pressure ulcer to left ischium (sitting bone) related to sensory perception, moisture/incontinence, decreased activity, impaired mobility and friction and shear problem. -Goal: Pressure ulcer will show signs of healing process as evidence by decrease in depth, width and length by at least 2 c.m. -Approach: Turn and reposition while in bed and chair frequently for comfort and pressure reduction. Other: pillows/wedge, limited to 60 minutes up in wheel chair . Record review of Resident #6's Braden Scale for Predicting Pressure Sore Risk dated 9/06/2016 revealed a score of 15 indicating at Risk to develop pressure sores. Record review of Resident # 6's quarterly MDS assessment with 08/7/2016 ARD date revealed that she was cognitively intact with a BIMS score of 13 out of a total possible of 15. Resident #6 required extensive assistance of two staff support for bed mobility, dressing and total dependent on staff for transfers, toilet use and bathing. Resident #6 had an external catheter and an ostomy including [MEDICATION NAME], [MEDICAL CONDITION] and [MEDICAL CONDITION]. The skin condition section of the assessment revealed she had one stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling) that measured 3.0 x 2.3 x 1.0 c.m. (LWD). Record review of Resident #6's Skin - weekly pressure ulcer record dated 10/11/2016 revealed in part: . Site: Left ischium. Pressure sore. Measure: 4.5 x 3.2 x 0.8 c.m. (LWD) Stage: 4. Date of onset 12/07/2015 Record review of hand-written pressure ulcer list dated 10/17/2016 revealed that Resident #6's pressure sore to her left ischium was In-house acquired as of 12/7/2015. Record review of Resident #6's MD orders dated 10/12/2016 revealed orders in part; -Clean left hip wound with normal saline, pat dry, apply silver alginate to wound. Cover with 4x4 dressing then dry dressing every day and as needed one time a day for wound care. Observation on 10/16/2016 at 11:15 p.m. revealed Resident #6 lying in bed on her back with the head of the bed elevated at 45 degrees. Observation and interview on 10/17/2016 at 12:20 p.m. revealed that Resident #6 was lying in bed on her back with her head elevated at approx 35 degrees. Resident #6 stated that she was up on her chair from 9:30 a.m. to 12:00 p.m. and that the C.N.A. had helped her to bed. Resident #6 further said facility staff do not turn me or reposition me. I lay on my back for hours. They are supposed to turn me but they don't do it. I have never refused to be turned or repositioned. I try to do it myself sometimes because is very uncomfortable to be on one side for long time but I can't do it. I am not strong enough to turn myself. Sometimes it is very painful to be on my back. I have a wedge that the staff are supposed to put on my side but it's over there on the chair. Even before I have the pressure sore on my left buttocks, they would never turn me. Interview at that time with Resident #6's visitor friend, she stated that she visited Resident #6 frequently and stays with her for long time and that she has never observed any staff turn or reposition Resident #6. Observation and interview on 10/17/2016 at 1:50 p.m. with Resident #6 revealed that she was still lying on her back with the head of the bed at 45 degrees. Resident #6 stated that still no staff had come to offer her to be turned or repositioned to her side. Resident #6 further said last night when you were here, I was on my back and stayed lying on my back the entire night. Sometimes I have to ask them to put the wedge on my back and they would do it. In an interview on 10/17/2016 at 2:00 p.m. with C.N.A. K, she stated that she worked 6 to 2 p.m. shift. She further said that Resident #6 required total assistance for all her activities of daily living and that was a hospice resident. She further said that Resident #6 had a pressure sore on her butt and that was on a turning and repositioning program and required turning every 2 hours. C.N.A. K then said that Resident #6 got up at around 9:30 a.m. on her chair until 12 p.m. and that the last time she repositioned Resident #6 was at 12 p.m. and then said Resident #6 is due to be turned and repositioned now. C.N.A. K then said that Resident #6 was alert and oriented. Further observation at that time revealed that C.N.A. K walked to the nursing station and did not come back. Observation and interview on 10/17/2016 at 2:50 p.m. revealed that Resident #6 was still on the same position on her back with the head of the bed elevated at 45 degrees. Resident #6 stated to surveyor still nobody has come to turn me. My buttocks and my back hurt. In an interview on 10/17/2016 at 3:03 p.m. with C.N.A. N, she stated that she was the PM shift aide for Resident #6 and that the morning C.N.A. had reported to her that Resident #6 was due to be turned and repositioned at 2:30 p.m. and that she had been busy. Observation and interview on 10/17/2016 at 3:05 p.m. with the Wound Care Nurse, she stated she was going to do wound care to Resident #6. Further observation revealed that Resident #6 was still lying on her back. Further observation at that time during wound care to Resident #6 revealed that Resident #6 had a circular open wound to her left lower buttocks approx 3 to 4 c.m. in diameter, wound base was red with approx 10% of yellow slough. Surrounding site of the wound was red and there was scant amount of brown drainage. Continued observation and interview after wound care treatment to Resident #6's left lower buttocks revealed that the Wound Care Nurse positioned Resident #6 to her back with the assistance of C.N.A. FF. At that time surveyor reported to Wound Care Nurse that Resident #6 had been on her back since 12 p.m. Wound Care Nurse then said She had?! and looked at Resident #6. Resident #6 stated yes. Wound Care Nurse immediately assisted Resident #6 to her side by placing a wedge to her left side. In an interview on 10/17/2016 at 3:25 p.m. with the Wound Care Nurse, she stated that nurses were supposed to supervise that C.N.A.'s would turn and reposition residents and then said I have the entire building. When I come in the morning I try to see everyone. Sometimes I call the C.N.A.'s. Last time I saw Resident #6 was earlier and she was up on her chair and I did not know what time she was assisted to bed. Resident #6 was supposed to be turn and reposition off her back. CR #10 Record review of the medical record face sheet revealed CR #10 was admitted on [DATE]. [DIAGNOSES REDACTED]. He was [AGE] years old. CR #10 went to the hospital on [DATE] at his request. Record review of CR # 10's admission MDS assessment with 09/11/2016 ARD date revealed that his short and long term memory were intact. CR #10 required total assistance of two staff support for bed mobility, dressing and bathing. He required one person assistance for toilet use and extensive assistance of two staff support for personal hygiene. CR #10 was always incontinent of bowel and had an indwelling catheter. The skin condition section of the assessment revealed he was at risk of developing pressure ulcers and did not have a pressure ulcer. Further record review revealed that MDS assessment did not have CR#10 with an active [DIAGNOSES REDACTED]. Record review of CR #10's Plan of Care initiated 9/20/2016 revealed in part: -Focus: CR #10 has potential impairment to skin integrity related to fragile skin. CR #10 has bladder incontinence related to impaired mobility. -Goal: Will remain free from skin breakdown. -Approach: Clean peri-area with each incontinence episode . Continued record review of CR #10's Plan of Care initiated 9/20/2016 revealed no information that CR #10 had [DIAGNOSES REDACTED]. Further record review revealed no interventions to monitor for sign and symptoms of hyper/[DIAGNOSES REDACTED] (high or low blood sugar levels). (High blood glucose: Frequent urination, Increased thirst, Shortness of breath, weak and tired, Breath that smells fruity, abdominal pain, Nausea and vomiting and Very dry mouth. Low blood glucose: Confusion, dizziness, feeling shaky, hunger, headaches, irritability, pounding heart; racing pulse. <http://www.diabetes.org>.) Record review of C

Based on observation, interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest, practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care for 2 of 14 residents (CR #10 and Resident #11) reviewed for diabetes. - The facility failed to assess, monitor and consult with the physician when CR #10 and Resident #11's blood glucose levels were above the parameters of 401 mg/dL. - The facility failed to monitor CR #10 and Resident #11's blood glucose and administer insulin as ordered. - The facility failed to have a method to accurately document on the Medication Administration Record the amount of insulin that was administered to residents. - CR #10 requested to be sent to the hospital and he was admitted to the intensive care unit with a blood glucose of 978 mg/dL and was diagnosed with [REDACTED]. An Immediate Jeopardy (IJ) was identified on 10/20/16. While the IJ was lowered on 10/21/2016, the facility remained out of compliance at a severity of Actual harm that is not Immediate Jeopardy and a scope of pattern. The facility remained out of compliance because they had not yet monitored their plan for effectiveness. These failures affected one former resident and one current resident at the facility and had the potential to affect the other 29 residents at the facility who receive finger stick blood sugar checks and could result in a deterioration in their condition and possible admission to the hospital. Findings included: Intake # 8 CR #10 Record review of the medical record face sheet revealed CR #10 was admitted on [DATE]. [DIAGNOSES REDACTED]. He was [AGE] years old. CR #10 went to the hospital on [DATE] at his request. Record review of CR # 10's admission MDS assessment with 09/11/2016 ARD date revealed that his short and long term memory were intact. CR #10 required total assistance of two staff support for bed mobility, dressing and bathing. He required one person assistance for toilet use and extensive assistance of two staff support for personal hygiene. CR #10 was always incontinent of bowel and had an indwelling catheter. Further record review revealed that MDS assessment did not have CR#10 with an active [DIAGNOSES REDACTED]. Record review of CR #10's Plan of Care initiated 9/20/2016 revealed no information that CR #10 had [DIAGNOSES REDACTED]. Further record review revealed no interventions to monitor for signs and symptoms of hyper/[DIAGNOSES REDACTED] (high or low blood sugar levels). (High blood glucose: Frequent urination, Increased thirst, Shortness of breath, weak and tired, Breath that smells fruity, abdominal pain, Nausea and vomiting and Very dry mouth. Low blood glucose: Confusion, dizziness, feeling shaky, hunger, headaches, irritability, pounding heart; racing pulse. <http://www.diabetes.org>.) Record review of CR #10's consolidated MD orders for October 2016 revealed orders in part; -dated 9/18/2016 Accuchecks before meals and bedtime. Record review of CR #10's MD Order dated 10/13/2016 at 10:23 a.m. revealed order in part; -HumaLOG Solution 100 Unit/ml (Insulin [MEDICATION NAME] (Human) (fast acting insulin) Inject as per sliding scale: If 200 - 250 = 2 units (Give [MEDICATION NAME] if BS <70); 251- 300 mg/dl = 4 units 301- 350 mg/dl = 6 units 351- 400 mg/dl = 8 units 401 - 450 mg/dl = 10 units. Call MD if blood sugar is over 400 mg/dl Subcutaneously before meals and at bedtime for diabetes mellitus type 2. Record review of CR #10's Medication Administration Record (MAR) dated October 2016 revealed the following: HumaLOG Solution 100 Unit/ml (Insulin [MEDICATION NAME] (Human) Inject as per sliding scale: If 200 - 250 = 2 units (Give [MEDICATION NAME] if BS <70); 251- 300 mg/dl = 4 units 301- 350 mg/dl = 6 units 351- 400 mg/dl = 8 units 401 - 450 mg/dl = 10 units. Call MD if blood sugar is over 400 mg/dl Subcutaneously before meals and at bedtime for diabetes mellitus type 2. Further record review of CR #10's October 2016 MAR revealed in part; -10/15/2016 at 06:30 a.m. Blood glucose reading = 498 mg/dl signed by LVN J. Further record review revealed no information of how many units of insulin were administered to CR #10. Continued record review revealed no information that the MD was notified of abnormal high blood glucose reading as ordered or any assessments for sign and symptoms of [MEDICAL CONDITION]. -10/15/2016 at 11:30 a.m. Blood glucose reading = 355 mg/dl. Further record review revealed no information of how many units of insulin were administered to CR #10. -10/15/2016 at 4:30 p.m. and 9:00 p.m. revealed that MAR had no blood glucose readings. (by RN H) Record review of CR #10's progress/nurses notes dated 10/15/2016 revealed no information of blood glucose readings at 4:30 p.m. or 9:00 p.m. and no information that any insulin was administered. Further record review revealed no assessments for sign and symptoms of hyper/[DIAGNOSES REDACTED]. -10/16/2016 at 06:30 a.m. MAR indicated a blood glucose reading = 600 mg/dl signed by LVN J. Further record review revealed no information of how many units of insulin were administered to CR #10. -10/16/2016 at 11:30 a.m. MAR indicated a blood glucose reading = 498 mg/dl signed by LVN J. Further record review revealed no information of how many units of insulin were administered to CR #10. Continued record review of the progress/nurses notes dated 10/16/2016 revealed no information that the MD was notified of abnormal high blood glucose reading as ordered or any assessments for sign and symptoms of [MEDICAL CONDITION]. -10/16/2016 at 4:30 p.m. and 9:00 p.m. revealed that MAR had no blood glucose readings. (by RN E) Record review of CR #10's progress/nurses notes dated 10/16/2016 revealed no information of blood glucose readings at 4:30 p.m. or 9:00 p.m. and no information that any insulin was administered. Further record review revealed no assessments for sign and symptoms of hyper/[DIAGNOSES REDACTED]. Continued record review of CR #10's October MAR revealed in part; -10/17/2016 at 6:30 a.m. Blood glucose reading = 400 mg/dl. -10/17/2016 at 11:30 a.m. Blood glucose reading = 392 mg/dl. -10/17/2016 at 4:30 p.m. Blood glucose reading = 368 mg/dl. -10/17/2016 at 9030 p.m. Blood glucose reading = 390 mg/dl. Further record review revealed no information of how many units of insulin were administered to CR #10 on 10/17/2016. -10/18/2016 at 6:30 a.m. and 11:30 a.m. revealed that MAR had no blood glucose readings. Record review of CR #10's progress/nurses notes dated 10/18/2016 revealed no information of blood glucose readings at 6:30 a.m. or 11:30 a.m. and no information that any insulin was administered. Further record review revealed no assessments for sign and symptoms of hyper/[DIAGNOSES REDACTED]. Further review of CR #10's progress/nurses notes dated 10/19/2016 at 12:53 a.m. revealed in part; Nursing Note. CR #10 was transferred to the hospital on his own request after the blood sugar read to be above normal range, he refused to be manage as he refused his blood sugar level to be rechecked after 10 units of Humalog insulin was administered subcutaneously according to sliding scale. Nurse Practitioner was notified and was picked up by the ambulance at 4:30 p.m. (10/18/2016) . Record review of CR #10's Emergency Department report dated 10/18/2016 at 5:59 p.m. revealed in part; Date and time of arrival: 10/18/2016 at 4:36 p.m. Time seen: immediately upon arrival. Chief complaint: High blood sugar. History of Present illness: CR #10 presents with [MEDICAL CONDITION] (high blood glucose). CR #10 is a [AGE] year old male with a recent medical history of [REDACTED]. CR#10 with glucose more than 500 on glucometer at nursing home. CR #10 is complaining of polydipsia (excess thirst), polyuria (frequent urination), polyphagia (excessive hunger), nausea and abdominal pain. Medical Decision Making: Diabetic Ketoacidosis, [MEDICAL CONDITION] . Laboratory results: -Sodium 122 mmol/L critical Reference range 135 and 145 milliequivalents per liter. -Potassium 5.8 mmol/L high Reference range 3.5 - 5.0 milliEquivalents per liter. -Glucose 978 mg/dL critical Reference range 70 to 100 mg/dL. Procedure: Critical care. Critical condition addressed for impending deterioration include: metabolic. Associated risk factors: metabolic changes, dehydration and acidosis. -Interventions: hemodynamic management, IV insulin, fluids . -Admitting Diagnoses: [REDACTED]. Disposition: Admit to Intensive Care Unit Record review of UTMB.edu/Diabetic ketoacidosis revealed in part .Diabetic ketoacidosis is an endocrine emergency. It is a metabolic state characterized by deficiency of insulin and excess of [MEDICATION NAME]. Dilutional [MEDICAL CONDITION] (low Sodium) occurs because of shift of water from the intracellular to the extracellular compartment secondary to [MEDICAL CONDITION]. Ketosis and acidosis elevate the serum potassium level by causing a shift of potassium from the intracellular to the extracellular fluid Observation and interview on 10/19/2016 at 12:30 p.m. revealed CR #10 was at a local hospital ICU unit (Intensive Care Unit). Further observation revealed that he was lying in an air mattress on his side facing the door. In continued observation, CR #10 was noted to have a Foley catheter that had approx. 500 cc of light yellow colored urine on the collection drainage bag. In an interview with CR #10 on 10/19/2016 at 12:45 p.m., he stated that he had high blood glucose levels on 10/18/2016 and that he felt very sick. He further said that on 10/18/2016 the nurse at the facility did not take his blood glucose levels during the morning and that he later felt very sick and called at the nurse who finally checked his blood glucose level. He then said that the blood glucose levels were very high . CR #10 continued saying that at that time, he knew that the facility staff was not really helping him and that he was in trouble and requested to be transferred to the hospital. CR #10 then said that upon arrival to the emergency room his blood glucose was almost a thousand. CR #10 further said that nurses at the facility would frequently miss taking his blood glucose and that on 10/18/2016 was not the first time that staff had missed his taking his blood glucose levels and then said I don't want to go back to that place. I feel that my life is in danger. In an interview on 10/19/2016 at 1:30 p.m. with the Hospital RN, she stated that CR#10 was a direct admit to the hospital Intensive Care Unit on 10/18/2016 and further said CR#10 came with blood glucose levels of 978 and was diagnosed with [REDACTED].#10 had orders for insulin IV drip and we are currently monitoring his blood glucose every 4 hours, his blood glucose now is 129 and the MD had discontinued the IV insulin drip and we will follow the sliding scale for insulin administration. In an interview on 10/19/2016 at 3:35 p.m. with RN E, she stated that CR#10 had orders to check his blood glucose before meals and before going to sleep and that the staff was supposed to call the MD if blood glucose levels were above 400. She then said that nurses were supposed to write on the progress/nurses notes anytime they notify the MD with any information of new orders. When asked if CR #10 had his blood glucose monitored on 10/18/2016 during the 6 to 2 p.m. shift, RN E stated as she reviewed CR #10's MAR and progress/nurses notes you would know what happened if it was documented but I don't see any documentation. Probably it was an agency nurse who worked that day. Further interview on 10/19/2016 at 3:40 p.m. with RN E at that time, she stated that she worked with CR #10 on 10/16/2016 during the 2 to 10 p.m. shift. When asked regarding the blood glucose levels of CR #10 on 10/16/2016 at 4:30 p.m. and 9:00 p.m. RN E stated It is not documented. I think that CR #10 refused his insulin. I believed his blood glucose was 300. When asked if the MD was made aware that CR #10 had refused his insulin, RN E stated I did not call the MD. When asked at what time was CR #10's blood glucose 300, the RN E stated I think was at 9:00 p.m. When asked if CR #10's blood glucose was checked at 4:30 p.m. and if CR #10 had any sign or symptoms of hypo/[MEDICAL CONDITION], RN E did not respond and said as she looked at CR #10's MAR I can't believe I did not write it down. Continued interview on 10/19/2016 at 3:47 p.m. with RN E, when asked where in the MAR staff documented the units of insulin administered to residents, RN E states the MAR has no place to document the units of insulin. In an interview on 10/19/2016 at 4:13 p.m. with the DON and the Wound Care Nurse, the Wound Care Nurse stated that CR #10 was readmitted to the facility with a pressure sore. DON further said that she remembered CR#10 having a [MEDICATION NAME] that he frequently used. Wound Care Nurse further said that she was present when CR #10 was sent to the hospital on [DATE] and then said CR#10's blood glucose was fine but he thought that his blood sugar was off and he kept saying that something was wrong. The charge nurse took his blood glucose levels and were fine and even showed to him the readings but kept insisting to go to the hospital and he called 911. At that time the DON stated that CR #10 was non-compliant and would frequently refuse to let the nurses do his blood glucose or have his insulin administered as ordered. Record review of CR #10's plan of care revealed no information that CR #10 refused to let staff monitor his blood glucose levels or that he refused his insulin or any medications as ordered by the MD. Record review of CR #10's progress/nurses notes dated 10/15/2016, 10/16/1016 and 10/18/2016 revealed no information that CR #10 refused to let staff monitor his blood glucose levels or had his insulin or any medications administered as ordered by the MD. In an interview on 10/20/2016 at 10:50 a.m. with LVN J, she stated that worked with CR #10's 10/15/2016 and 10/16/2016 during the 6 to 2 p.m. shift. LVN J then said that she remembered that CR #10 ' s blood glucose was high and that she remembered calling a doctor. She further said that she did not remember which day or at what time she called the MD. LVN J also did not remember the name of the MD and further said I remember that I wrote the order in a telephone order sheet, but I did not do nursing notes or input the information on the computer because I was busy. When asked to find the telephone order sheet at CR #10's chart, LVN J immediately said No, it's not going to be there. I think the telephone order sheet is at the nursing station. At that time surveyor and LVN J went to the nursing station. Further observation and interview on 10/20/2016 at 11:06 a.m. with LVN J, she stated as she flipped thru binders and papers at the nurses' station I don't know where it could be. It's not here. It's not on the MD book either. We are supposed to transcribe the telephone orders into the computer system and then write the orders on the MAR. I was really busy. When asked if she called the MD on both days 10/15/2016 and 10/16/2016, LVN J stated No, I only called one day but I don't remember when. Further interview at that time, when asked LVN J, how could she tell how much insulin she had administered to CR #10 on 10/15/2016 and 10/16/2016, LVN J stated There is no way to know. That's what I am saying and I don't remember details. I know, if you don't document it, it was not done. I was busy. I got the order, flipped the paper over and continued doing what I was doing. I was really busy . Continued interview with LVN J, she stated If the blood glucose are high, you give the sliding scale insulin as ordered but the order said that you still have to call the MD and then said When you are by yourself, how do you do it and that's why we are in the situation we are now. In an interview on 10/20/2016 at 2:45 p.m. with the DON and the Administrator, when asked about how nursing documented the units of insulin given to the residents on the MAR, the DON stated that the MAR's on the 100 hallway did not have the space for nurses to write down the insulin administered. She then said that the Unit Manager M from the 100 station probably did not print them correctly and that she was going to have Unit Manager N teach Unit Manager M how to print the MAR's correctly. In an interview on 10/20/2016 at 3:03 p.m. with the DON and the Administrator, the DON stated we saw holes after surveyor gave us back CR#10's MAR's. I have talked to the nurses about it. The Unit Managers review the MAR's periodically. I was not aware that nurses were not calling the MD when blood glucose levels were above parameters. In an interview on 10/20/2016 at 3:26 p.m. with CR #10's MD, the MD stated that CR #10 went to the hospital on [DATE] due to high blood glucose levels. MD then said that she was aware that the nurses spoke with the Nurse Practitioner on 10/18/2016 and notified of his high blood glucose readings. She further said that CR #10 had history of running high blood glucose levels. When asked if she was made aware on 10/15/2016 and 10/16/2016 regarding CR #10's blood glucose were high above the parameters, the MD looked at her cell phone and said that she was going to look to see if there were any calls on those days from the facility. Further interview with the MD on 10/20/2016 at 4:05 p.m., she stated that she could only confirmed that the facility called regarding CR #10 on 10/13/2016 and 10/18/2016 when CR #10 at the time he went to the hospital. MD then said If I can confirm other calls for any other days, I will let you know. MD did not get back to surveyor prior to exit from the facility. In an interview on 10/21/2016 at 11:00 a.m with the Director of Staff Development, RN J, she stated that she was going to have the charge nurse assigned to CR #10 on 10/18/2016 during the 6 to 2 p.m. shift contact the surveyor. Surveyor did not receive a call from the nurse upon exit of the facility. In an interview on 10/21/2016 at 3:00 p.m. with RN H, she stated that she worked with CR #10 on 10/15/2016 during the 2 to 10 p.m. shift and said that she remembered taking the blood glucose levels for CR #10 at around 9:00 p.m. but that she missed documenting the results. RN H then said CR#10 usually runs either high or really low. She continued saying that she remembered giving insulin to CR #10 on 10/15/2016 but she did not write it down and further said we are supposed to document on the MAR. It just skipped my memory. I was going to write it down. I think I gave 2 units of insulin. I did not document the information. RN H verified that the current MAR's did not have a place to document insulin administration. Resident #11 Record review of Resident #11's face sheet (undated) revealed that she was a [AGE] year old female who was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #11's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 13, indicating no cognitive impairment, with an active [DIAGNOSES REDACTED]. Record review of Resident #11's physician's orders [REDACTED]. Record review of Resident #11's Medication Administration Record (MAR) dated October 2016 revealed that she was on [MEDICATION NAME] Insulin- 100 unit/ml. Give subcutaneous before meals and at bedtime if blood glucose: 0 - 150 mg/dl = 0 units 151- 200 mg/dl = 2 units 201- 250 mg/dl = 4 units 251- 300 mg/dl = 6 units 301- 350 mg/dl = 8 units 351- 400 mg/dl = 10 units 401 mg/dl + = 14 units and Call MD Further review of Resident #11's October 2016 MAR revealed that her blood glucose result on 10/13/16 at 4:30 p.m. was 440 mg/dl, she received 14 units of [MEDICATION NAME]. Record review of Resident # 11's progress notes dated 10/13/16 revealed that the physician was not called for the abnormal high blood glucose reading. In an interview on 10/20/16 at 1:50 p.m. with the Unit Manager , LVN M, she confirmed that Resident #11's physician was not called for her elevated blood glucose and did not receive an assessment. She states an SBAR (Situation Background Assessment Recommendation) or 24 hour report are done , and those reports go to her. She further stated that the 24 hour report for Resident #11 did not discuss Resident # 11's elevated blood glucose and no SBAR was filled out. In an interview on 10/20/16 at 3:12 p.m. with the DON, she stated the unit managers check the MARS periodically. She further stated that she was not aware of the physician not being called when residents have blood glucose above the set parameters, and that the nurses are supposed to put it on the 24 report. A telephone call on 10/20/16 at 4 p.m. to RN E, who was the nurse identified on duty, who did not call the physician, was unanswered and RN E did not return the Surveyors call as requested. Review of the facility's policy, Diabetic Management dated April 2005 and revised June 2008, read in part Assessment: Blood glucose orders should include parameters to follow and when to notify the physician. Routine Care: -Blood glucose measurements are taken per the physician order. -Results outside of ordered parameters are communicated to the physician immediately. Documentation: For acute complications, the clinical record should include the following information: - notification of physician and any new orders -resident's signs and symptoms -results of blood testing -interventions initiated -resident's response to treatment -notification of responsible party. The facility Administrator and DON were notified on 10/20/16 at 3:12 PM that an IJ situation had been identified due to above failures. The Plan of Removal was submitted by the Administrator on 10/21/16. After several revisions, the final Plan of Removal was accepted on 10/21/16 at 2:26 PM. Plan of Removal All residents with Accucheck orders have been audited on October 20, 2016. The results of the audit were reviewed by the Medical Director on October 20, 2016. Medical Director made appropriate changes to orders on October 20, 2016. In-services and return demonstration on diabetic management was initiated on October 20, 2016 to all licensed nurses. This will be completed by October 21, 2016. Monitoring of diabetic management system began October 20, 2016 at 4:30 p.m. The facility QA Committee has met for an ad hoc meeting to review and approve these plans. The QA Committee will review progress on the plan and make recommendations for changes as needed. The surveyor monitored the current plan of removal as follows: Record review on 10/21/2016 at 3:10 p.m. revealed that the MAR ' s of residents requiring Accuchecks (blood glucose monitoring) had the space for nurses to document the insulin administered. In an interview on 10/21/2016 at 1:13 p.m. with the DON, she stated that all the MAR's from the 100 hallway had been reprinted with space for nursing to document the insulin administered to the residents. She further said that all nurses had been trained for diabetic management and that the pharmacist had been involved in the training. DON further said that she was new in the facility and that policies for diabetic management should have been in place. DON then said that the nurses should had been trained from school regarding medication administration and properly document care provided and MD notification. Further interview with the DON at that time, when asked how did she think this incident of IJ came about, the DON stated nurses not properly following through. I have already talked to the nurses regarding MD notification and follow up. I don't see the paper trails. For nurses, if you don't documented, you did not do it. I was not aware of those holes, especially for insulin and blood glucose monitoring, CR #10's MD, who is the Medical Director, was here 10/19/2016 and we discussed about those holes and we included the supervisors and talked about it. I just need to keep re-enforcing it. In an interview on 10/21/2016 at 1:55 p.m. with LVN J, she stated that she had been trained on Diabetic management, protocol for notification of the MD and the family, accurate documentation, obtaining and transcribing MD orders and recognizing sign and symptoms of hyper/[DIAGNOSES REDACTED]. In an interview on 10/21/2016 at 2:10 p.m. with LVN D, she stated that she had been trained on Diabetic management, protocol for notification of the MD and the family, accurate documentation, obtaining and transcribing MD orders and recognizing sign and symptoms of hyper/[DIAGNOSES REDACTED]. In an interview on 10/21/2016 at 2:15 p.m. with RN A, she stated that she had been trained on assessments, MD notification, Diabetic management, protocol for notification of the MD and the family, accurate documentation, obtaining and transcribing MD orders and recognizing sign and symptoms of hyper/[DIAGNOSES REDACTED]. In an interview on 10/21/2016 at 2:30 p.m. with LVN K, she stated that she had been trained on MD notification related to changes in condition, family notification and follow up with documentation in nursing/progress notes including appropriate follow up of MD orders. She then said that training included Diabetic management, protocol for notification of the MD and the family, accurate documentation, obtaining and transcribing MD orders and recognizing sign and symptoms of hyper/[DIAGNOSES REDACTED]. In an interview on 10/21/2016 at 2:40 p.m. with LVN A, she stated that she had been trained on Diabetic management, protocol for notification of the MD and the family, accurate documentation, obtaining and transcribing MD orders and recognizing sign and symptoms of hyper/[DIAGNOSES REDACTED]. She then said that training included notification and follow up with documentation in nursing/progress notes including appropriate follow up of MD orders. In an interview on 10/21/2016 at 2:49 p.m. with RN D, she stated that she had been trained on Diabetic management, protocol for notification of the MD and the family, accurate documentation, obtaining and transcribing MD orders and recognizing sign and symptoms of hyper/[DIAGNOSES REDACTED]. In an interview on 10/21/2016 at 3:00 p.m. with RN H, she stated that she had been trained on Diabetic management, protocol for notification of the MD and the family, accurate documentation, obtaining and transcribing MD orders and recognizing sign and symptoms of hyper/[DIAGNOSES REDACTED]. Record review of facility In-service Training Attendance record dated 10/19/2016 revealed that licensed nursing staff were educated regarding diabetic management. Staff was provided with the policy and procedures for diabetic management dated April 2005 and policy and procedure for medication administration dated April 2005. Training included assessment for sign and symptoms of hyper/[DIAGNOSES REDACTED] including complications and documentation of insulin administered on the MAR, reporting to the MD and documenting information on the 24 hour report for follow up by oncoming nurse. Attached to the in-service were the attending staff signatures. Further record review of facility In-service Training Attendance record dated 10/20/2016 revealed that nursing staff were educated regarding MD notification if blood glucose is outside parameters and glucometer use. Attached to the in-service were the attending staff signatures. Continued record review of facility In-service Training Attendance record dated 10/21/2016 revealed that nursing staff were educated regarding insulin administration, storage of insulin and storage of insulin. Attached to the in-service were the attending staff signatures. On 10/21/16 at 4:26 PM, the Administrator was informed the IJ was lowered. However, the facility remained out of compliance at a severity level of actual harm that is not an IJ with a scope identified as a pattern due to the facility administration and staff requiring time to train all staff and monitor their plan of removal. The DON stated that there were 30 residents at the facility who required Accuchecks (blood sugar monitoring).

Based on observation, interview, and record review, the facility failed to ensure that a resident who entered the facility without pressure sores did not develop pressure sores unless the individual's clinical condition demonstrated that they were unavoidable and failed to prevent the worsening of pressure ulcers and to promote the healing of pressure ulcers for 3 of 14 residents (Resident #5, 6, and CR#10) who were reviewed for pressure ulcer care and management. -The facility failed to prevent the development and worsening of facility acquired pressure ulcers for Resident #5 who was identified as Very High Risk to develop pressure sores. Resident # 5 developed four facility acquired Stage 2 pressure sores identified to her left and right buttocks. -The facility failed to provide preventative pressure sore measures to Resident #6 who had a facility acquired stage 4 pressure sore on her left buttock. Resident #6 was observed lying on her back for more than 2 hours and was not turned/repositioned. -The facility failed to prevent the worsening of a pressure sore for CR #10 who had a Stage 2 pressure sore to his sacrum that worsened to a Stage 3 within two days of being readmitted to the facility. - The facility failed to care plan CR #10's Stage 2 pressure sore when he was readmitted to the facility on [DATE] with the wound. An Immediate Jeopardy (IJ) was identified on 10/17/2016. While the IJ was lowered on 10/20/2016, the facility remained out of compliance at a severity of Actual harm that is not Immediate Jeopardy and a scope of pattern. The facility remained out of compliance because they had not yet monitored their plan for effectiveness. These failures affected two residents and one former resident and placed the 12 additional residents that were identified with pressure sores at risk for pain, development of additional pressure sores and worsening of current pressure sores. Findings Include: Intake #'s 1, 1 and 8 Resident # 5 Record review of the medical record face sheet revealed Resident # 5 was admitted on [DATE]. [DIAGNOSES REDACTED]. She was [AGE] years old. Record review of Resident #5's Plan of Care initiated 3/21/2016 revealed in part: -Focus: Resident #5 has potential skin issues related to potential breakdown. Resident #5 has bladder incontinence related to disease process. -Goal: Resident #5's skin will remain intact and Resident #5 will remain free from skin breakdown due to incontinence and brief use. -Interventions: Notify MD of changes in wound or emerging wounds and Clean peri-area with each incontinence episode . Record review of Resident #5's Braden Scale for Predicting Pressure Sore Risk revealed in part; - 5/27/2016 revealed a score of 12 indicating High Risk to develop pressure sores. - 8/16/2016 revealed a score of 8 indicating Very High Risk to develop pressure sores. Further record review revealed that Resident #5's plan of care was not updated with interventions to prevent pressure sores. Record review of Resident # 5's quarterly MDS assessment with 08/17/2016 ARD date revealed that she was not interviewed for Cognitive Skills for Daily Decision Making. Resident #5 had short and long term memory problem and her cognitive skills for daily decision making were moderately impaired. She required total assistance of two staff support for all her activities of daily living. Resident #5 was always incontinent of bowel and bladder. The skin condition section of the assessment revealed she had no pressure sores and she was at risk of developing pressure ulcers. Observation on 10/16/2016 at 11:55 p.m. revealed that Resident #5 was in bed on her back with the head of the bed elevated at 45 degrees. Further observation revealed that Resident #5's room had a strong urine odor to the outside hallway of her room. Resident #5's eyes were closed. Observation and interview on 10/17/2016 at 12:20 a.m. during incontinent care to Resident #5 revealed that MA C and C.N.A. P stated that Resident #5 has some skin irritations. Further observation and interview at that time revealed Resident #5's front perineal area was reddened and as Resident #5 was turned to her side, her buttocks areas were noted with open areas on each of her buttocks. Resident #5 moaned on and off while MA C and C.N.A. P were wiping her front perineal area and buttocks. Continued observation revealed that resident #5 had her brief heavily saturated with urine, her brief was brownish in color and had several spots of bright and dark blood on the buttocks area. MA C then said brief is heavily soiled , MA C proceeded to remove the brief from underneath Resident #5. Further observation revealed that Resident #5's underneath pad had also a large circular brownish/yellowish wet area with several spots of bright red blood and dark red blood on the buttocks area where Resident #5 was lying. Interview at that time, C.N.A. P stated that Resident #5 would usually scream during incontinent care and then said especially since last week that she had these open areas. Further observation at that time revealed that Resident #5 had 3 open wounds to her left buttocks (left mid buttocks approx 2.5 x 4.0 cm., left lower buttocks had 2 wounds approx 3.0 x 2.0 and 2.0 x 2.0 c.m.) and one open wound to the right lower buttocks (approx 3.0 x 2.0 c.m.). Open wounds had wound base reddened and were bleeding. Surrounding site of the wounds were macerated. At that time, surveyor asked C.N.A. P to call the charge nurse. In an interview and observation on 10/17/2016 at 12:36 a.m. with RN D, she stated as she looked at Resident #5's buttocks areas Resident #5 already has treatment for [REDACTED]. RN D then stepped out of the room. Continued observation and interview on 10/17/2016 at 12:40 a.m. after incontinent care, C.N.A. P grabbed a 30 cc cup that was at Resident #5's bedside that had a clear colored ointment and another 30 cc cup that had a white powder, that was next to the cup that had the clear ointment. C.N.A. P stated we are going to put the powder and the cream on the sores. The nurses left these medications for Resident #5 . When asked what was the name of the cream and the powder that were on the 30 cc cup containers, C.N.A. P stated I don't know. MA C then said I think is [MEDICATION NAME], let me put the powder on her buttocks. C.N.A. P then said I will put the cream on the front. C.N.A. P continued saying Resident #5 is going to scream. Observation at that time revealed that as C.N.A. P rubbed the clear ointment to the front perineal area, Resident #5 moaned. MA C then sprinkled the powder to Resident #5's buttocks area covering the open wounds. Continued observation at that time revealed that Resident #5 was positioned on her back after incontinent care with the head of the bed elevated at 45 degrees. In an interview on 10/17/2016 at 12:45 a.m. with RN D, when asked for last skin assessment and orders for Resident #5, RN D stated as she read Resident #5's skin assessment, There is documentation that Resident #5 had a rash only. RN D further said that she was aware of the open wounds of Resident #5's buttocks and that she believed that the wounds had been assessed already last week and that when she saw the orders for [MEDICATION NAME] and [MEDICATION NAME] powder that she thought that the MD was aware of the open wounds. RN D continued saying that she did not leave the ointment and the powder at Resident #5's bedside, that probably was the PM shift nurse (LVN A). Record review of Resident #5's phone orders dated 10/12/2016 revealed in part: . -Wound care doctor to evaluate and treat as indicated, -[MEDICATION NAME] Ointment 2% (antibiotic). Apply to bilateral buttock topically one time a day for wounds. Clean area with Normal Saline, pat dry, apply [MEDICATION NAME] to bilateral buttocks wound, cover with non stick dressing until areas healed. -[MEDICATION NAME] powder apply to groin topically two times a day for moisture In a phone interview on 10/19/2016 at 9:33 a.m. with LVN A, she stated that she was the charge nurse on 10/16/2016 during the 2 to 10 shift for Resident #5 and further said Resident #5 had wounds to her buttocks and she had orders for [MEDICATION NAME] ointment. I never give the ointment to the C.N.A.'s. When asked if she had left a clear ointment and a white powder at the bedside of Resident #5, LVN A stated No, I did not do it. I don't know who did it. I did the treatment myself. Record review of Resident #5's Skin - Head to toe skin check dated 10/11/2016 signed by RN F revealed in part; New abrasions. Site: Left buttocks. Type: Rash . In an interview on 10/18/2016 at 1:40 p.m. with RN F, she stated that C.N.A. C reported to her since 10/11/2016 that Resident #5 had a rash. RN F further said that she went and assessed Resident #5's buttocks area at that moment and that she saw wounds to Resident #5's right and left buttocks, She said that the wounds looked red and were approx 10 x 1 c.m. RN F then said that she wrote the information on the book for the MD to review it whenever the MD would come to the facility. When asked if she wrote rash on Resident #5's assessment dated [DATE], RN F stated I probably wrote rash on the assessment form before going and evaluating Resident #5. In an interview on 10/17/2016 at 1:03 a.m. with RN D, she stated that she was aware since last week that Resident #5 had open wounds to her buttocks and that she did not measured or assessed the areas because there were orders already and further said we usually measure any new wounds and call the MD, but I wasn't sure with Resident 5's wounds. In an interview on 10/17/2016 at 1:09 a.m. with the DON and the Administrator, the DON stated that incontinent care was supposed to be done every 2 hours and that she had already seeing the pad that was removed from underneath Resident #5's and that the brief had been already put on the trash outside. DON said that she saw the wet pad with patches of blood. Further interview with the DON at that time, when asked if she was aware of Resident #5's open wounds to right and left buttocks, the DON stated It's so many residents. I am still trying to learn. I am new. I had been in this facility for a month only. Continued interview with the DON and the Staff Development Manager, RN J on 10/17/2016 at 1:15 a.m. RN J stated that she had called the Wound Care Nurse on the phone and that the Wound Care Nurse had said that on the skin assessment dated [DATE] Resident #5's skin was intact and that on the assessment dated [DATE] the nurses had identified a rash to Resident #5's left buttocks. RN J further said that the wound care nurse had not assessed Resident #5's skin because the wound care nurse only takes care of the pressure sores in the facility and that the nurses take care of other skin problems. RN J then said we always thought that Resident #5 had only a rash. Nurses are supposed to go and assess the residents when the aides report any skin problems, then they would get orders from the MD. Surveyor at that time, made DON and Staff Development Manager aware that Resident #5 had 3 open bleeding wounds to her left buttocks and one to her right buttocks. DON then said we will do 100% skin assessments tonight. Further interview with the DON on 10/17/2016 at 1:28 a.m., the DON stated that C.N.A.'s were not supposed to apply any prescription medication creams or ointments including powder medications to residents and that medications were not supposed to be left at the bedside either and further said we will do in-service now. Nurses are supposed to apply those medications only and not leave medications for C.N.A.'s to apply at the bedside. In an interview on 10/17/2016 at 10:15 a.m. with Staff Development Manager, RN J, she stated that she assessed Resident #5's open wounds and that Resident #5 had 3 open areas on her left buttocks and that she saw the wound base pink and further said the 3 wounds to the left buttocks were macerated open areas. Staff Development Manager, RN J further said that the right ishium open area was pink wound base and dry. Staff Development Manager, RN J handled to surveyor Resident #5's skin assessments done by facility. Record review of Resident #5's Skin - Head to toe skin check dated 10/17/2016 and signed by Staff Development Manager, RN J revealed in part . Describe new or existing other issues: Resident #5 noted with three open ulcers to left buttock and one open ulcer to right gluteal fold. -Site 32) Left buttock open ulcer. 2.5 x 4.0 c.m. (LxW) Stage 2. -Site 32) Left buttock open ulcer. 2.0 x 2.0 c.m. (LxW) Stage 2. -Site 32) Left buttock open ulcer. 1.5 x 3.0 c.m. (LxW) Stage 2. -Site 55) Right gluteal fold open ulcer. 1.2 x 3.0 c.m. (LxW) Stage 2. Further description of skin issues: Surrounding skin appears macerated, no bleeding noted . Observation and interview on 10/17/2016 at 10:35 a.m. revealed Resident #5 was on her back with the head of the bed elevated at 45 degrees. C.N.A. C and C.N.A. K were inside room of Resident #5, C.N.A. C stated that they had just finished providing incontinent care to Resident #5. When asked if they saw any dressing to Resident #5's buttocks, C.N.A. C stated Resident #5 had wounds to her buttocks and still did not have any dressings on them. Resident #5 had open areas to her right and left buttocks since last week, but I reported to Unit Manager N since last Friday (10/14/2016). C.N.A. C further said that when aides report any skin condition to the nurses, they would do it verbally only, that they are not required to complete any paper form. C.N.A. C continued saying that since the beginning of October 2016, she had been reporting to different nurses that Resident #5 had skin redness and breakdown on her buttocks and that finally on 10/14/2016, she made the report to Unit Manager N. C.N.A. C then said that Resident #5 spends most of the time in bed. Observation on 10/17/2016 at 11:10 a.m. revealed that the Wound Care Nurse was inside Resident #5's room and said to surveyor I just did the wound care now because I had to change wound care orders. RN J got orders earlier but I had to change orders. In an interview on 10/17/2016 at 11:15 a.m. with Staff Development Manager, RN J, she stated that she got wound care orders for Resident #5's open wounds on her buttocks since 8:00 a.m Record review of Resident #5's telephone orders dated 10/17/2016 written by Staff Development Manager, RN J revealed in part: -Santyl collagen (wound [MEDICATION NAME] ointment) to bilateral buttocks wounds daily and cover with clean 4x4 dressing. -Vitamin C 500 mg via peg tube daily -Zinc Sulfate 220 mg via peg tube daily -Wound care to evaluate and treat Further record review of telephone orders revealed orders dated 10/17/2016 at 11:00 a.m. in part .- Discontinue previous wound care orders. -Apply Calcium alginate (seaweed dressing for moist wounds) to left upper buttocks area, cover with 4x4 after cleanse with normal saline daily. -Cleanse left buttock area with normal saline, Apply Zinc Oxide to open areas daily and as needed. -Cleanse right ishium (buttocks) wound with normal saline. Pat dry. Apply Zinc Oxide to open area daily and as needed. -Air mattress . In an interview on 10/17/2016 at 11:35 a.m. with the DON, Administrator. who was the abuse coordinator and Staff Development Manager, RN J, when asked about the delayed in wound care to Resident #5 since 1:15 a.m. that surveyor made them aware of Resident #5's open wounds to her buttocks and wounds were not protected until 11:10 a.m., the DON stated we were trying to investigate, we were in the process of investigating, but it takes time. We were pulling the scheduled. Continued interview at that time, the Staff Development Manager, RN J then said Santyl (wound [MEDICATION NAME] ointment) needed to be ordered. Then the order was discontinued and Calcium Alginate (seaweed dressing for moist wounds) was ordered. Staff Development Manager, RN J further said that the wound care MD was going to see Resident #5 on 10/18/2016. Further interview at that time, the Administrator stated that the facility had on-call MD that could had been called for wound care orders for Resident #5 when surveyor made the facility aware of the open areas of Resident #5 at 1:15 a.m. In an interview on 10/17/2016 at 11:55 a.m. with the Wound Care Nurse, she stated today was my first time looking at Resident #5's wounds. Wound Care Nurse then said that on 10/13/2016, C.N.A. C asked her for something more than Zinc ointment for Resident #5's open areas but that C.N.A. C did not specify that Resident #5 had wounds and that she told the C.N.A. to report the condition to the charge nurse because she only takes care of pressure sores. When asked if she went to assessed Resident #5 after C.N.A. C reported open areas, the Wound Care Nurse said I did not go and see Resident #5. I only asked her to tell the charge nurse and C.N.A. C said that she had already reported to the charge nurse. So I went and continued with my work. Wound Care Nurse said that she had been doing wound care in the facility for 1 year and that she had been certified for wound care and that as an LVN she was able to stage wounds because she had been certified for wound care. Further interview at that time, Wound Care Nurse stated that the left medial buttocks open area appeared like an unstageable wound because it got thick necrotic tissue on 50% of the wound base and that the left and right lower buttocks wounds were also unstageable wounds because of the necrotic tissue on the wound base. Wound Care Nurse continued saying that the wound on the left medial buttocks was pressure for being on that side for long periods of time. Wound Care Nurse further said that the pressure sores on the lower buttocks were due to pressure from the brief because the briefs were too small and the tightness of the brief was putting pressure to the area and by Resident #5 lying on her back. Continued interview with the Wound Care Nurse on 10/17/2016 at 12:10 p.m., when asked if she was made aware that Resident #5 had wound care orders as of 8:00 a.m. The Wound Care Nurse stated Staff Development Manager, RN J told me at around 9:00 a.m. of the wound orders for Resident #5 but I had to do the wound dressings for station 1 first then I came to station 3 and that's when I saw you (surveyor) coming out of Resident #5's room. Wound Care Nurse stated that she had not updated the care plan for Resident #5 because she had been busy. In an interview on 10/17/2016 at 12:15 p.m. with Unit Manager N, he stated that he was made aware on 10/14/2016 of Resident #5's skin condition and that he went to see the resident and that he saw a skin tear on the left buttocks area that was approx 3x5 inches and that he checked the orders and that he saw orders for [MEDICATION NAME] ointment. When asked if he wrote a skin assessment for Resident #5 when he went to assess her left buttocks, Unit Manager N stated No, I did not do wound assessments because it was documented that a skin assessment was recently done. When asked if he reviewed the skin assessment that was recently completed, the Unit Manager N stated No, I did not review the assessment. I thought that the open area had been already identified so I did not think I needed to further call the MD or re-do an assessment. In an interview on 10/17/2016 at 12:46 p.m. the DON stated that Resident #5 was getting an air mattress. In an interview on 10/18/2016 at 1:45 p.m. with RN F, she stated that whenever staff reports any skin condition, they were supposed to go and assess the area, then enter the assessment on the computer. RN F said that MD needed to be notified at that time and orders need to be carried out as soon as possible. RN F continued saying that she remembered that the day she placed the notification on the MD book regarding the open areas to Resident #5's buttocks, that she believed she saw other notifications on the MD book written by other nurses regarding the skin condition of Resident #5. In a phone interview on 10/19/2016 at 9:21 a.m. with C.N.A. D, he stated that he was the C.N.A. for Resident #5 on 10/16/2016 for the 2 to 10 p.m. shift. C.N.A.'s D further said that he first saw Resident #5 at around 2 p.m. on 10/16/2016 and did incontinent care to her. C.N.A. D then said that he saw wounds to Resident #5's right and left buttocks and then said the nurses know about the wounds, they would give us the ointment to put on Resident #5's wounds and further said I believed the diaper was too tight and then she would just lay on her back, then the wounds would bleed, the wounds were bleeding, they were not healing. When asked when was the last time he provided incontinent care to Resident #5 on 10/16/2016 before the end of his shift, C.N.A. D stated Resident #5 was not wet on my last round. I get off at 10:00 p.m. and she was supposed to be checked every 2 hours and we are supposed to turn her every 2 hours as well. Further interview at that time, C.N.A. D stated that he turned and repositioned Resident #5 to her side at 9:00 p.m during the last round and that Resident #5 was dry. When asked if he was aware that Resident #5 was found with her brief heavily soiled on 10/16/2016 at midnight, C.N.A. D stated Resident #5 is heavy wetter. Resident #6 Record review of the medical record face sheet revealed Resident # 6 was admitted on [DATE]. [DIAGNOSES REDACTED]. She was [AGE] years old. Record review of Resident #6's Plan of Care initiated 12/07/2015 and last reviewed 9/7/2016 revealed in part: -Problem: Resident #6 has pressure ulcer to left ischium (sitting bone) related to sensory perception, moisture/incontinence, decreased activity, impaired mobility and friction and shear problem. -Goal: Pressure ulcer will show signs of healing process as evidence by decrease in depth, width and length by at least 2 c.m. -Approach: Turn and reposition while in bed and chair frequently for comfort and pressure reduction. Other: pillows/wedge, limited to 60 minutes up in wheel chair . Record review of Resident #6's Braden Scale for Predicting Pressure Sore Risk dated 9/06/2016 revealed a score of 15 indicating at Risk to develop pressure sores. Record review of Resident # 6's quarterly MDS assessment with 08/7/2016 ARD date revealed that she was cognitively intact with a BIMS score of 13 out of a total possible of 15. Resident #6 required extensive assistance of two staff support for bed mobility, dressing and total dependent on staff for transfers, toilet use and bathing. Resident #6 had an external catheter and an ostomy including [MEDICATION NAME], [MEDICAL CONDITION] and [MEDICAL CONDITION]. The skin condition section of the assessment revealed she had one stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling) that measured 3.0 x 2.3 x 1.0 c.m. (LWD). Record review of Resident #6's Skin - weekly pressure ulcer record dated 10/11/2016 revealed in part: . Site: Left ischium. Pressure sore. Measure: 4.5 x 3.2 x 0.8 c.m. (LWD) Stage: 4. Date of onset 12/07/2015 Record review of hand-written pressure ulcer list dated 10/17/2016 revealed that Resident #6's pressure sore to her left ischium was In-house acquired as of 12/7/2015. Record review of Resident #6's MD orders dated 10/12/2016 revealed orders in part; -Clean left hip wound with normal saline, pat dry, apply siver alginate to wound. Cover with 4x4 dressing then dry dressing every day and as needed one time a day for wound care. Observation on 10/16/2016 at 11:15 p.m. revealed Resident #6 lying in bed on her back with the head of the bed elevated at 45 degrees. Observation and interview on 10/17/2016 at 12:20 p.m. revealed that Resident #6 was lying in bed on her back with her head elevated at approx 35 degrees. Resident #6 stated that she was up on her chair from 9:30 a.m. to 12:00 p.m. and that the C.N.A. had helped her to bed. Resident #6 further said facility staff do not turn me or reposition me. I lay on my back for hours. They are supposed to turn me but they don't do it. I have never refused to be turned or repositioned. I try to do it myself sometimes because is very uncomfortable to be on one side for long time but I can't do it. I am not strong enough to turn myself. Sometimes it is very painful to be on my back. I have a wedge that the staff are supposed to put on my side but it's over there on the chair. Even before I have the pressure sore on my left buttocks, they would never turn me. Interview at that time with Resident #6's visitor friend, she stated that she visited Resident #6 frequently and stays with her for long time and that she has never observed any staff turn or reposition Resident #6. Observation and interview on 10/17/2016 at 1:50 p.m. with Resident #6 revealed that she was still lying on her back with the head of the bed at 45 degrees. Resident #6 stated that still no staff had come to offer her to be turned or repositioned to her side. Resident #6 further said last night when you were here, I was on my back and stayed lying on my back the entire night. Sometimes I have to ask them to put the wedge on my back and they would do it. In an interview on 10/17/2016 at 2:00 p.m. with C.N.A. K, she stated that she worked 6 to 2 p.m. shift. She further said that Resident #6 required total assistance for all her activities of daily living and that was a hospice resident. She further said that Resident #6 had a pressure sore on her butt and that was on a turning and repositioning program and required turning every 2 hours. C.N.A. K then said that Resident #6 got up at around 9:30 a.m. on her chair until 12 p.m. and that the last time she repositioned Resident #6 was at 12 p.m. and then said Resident #6 is due to be turned and repositioned now. C.N.A. K then said that Resident #6 was alert and oriented. Further observation at that time revealed that C.N.A. K walked to the nursing station and did not come back. Observation and interview on 10/17/2016 at 2:50 p.m. revealed that Resident #6 was still on the same position on her back with the head of the bed elevated at 45 degrees. Resident #6 stated to surveyor still nobody has come to turn me. My buttocks and my back hurt. In an interview on 10/17/2016 at 3:03 p.m. with C.N.A. N, she stated that she was the PM shift aide for Resident #6 and that the morning C.N.A. had reported to her that Resident #6 was due to be turned and repositioned at 2:30 p.m. and that she had been busy. Observation and interview on 10/17/2016 at 3:05 p.m. with the Wound Care Nurse, she stated she was going to do wound care to Resident #6. Further observation revealed that Resident #6 was still lying on her back. Further observation at that time during wound care to Resident #6 revealed that Resident #6 had a circular open wound to her left lower buttocks approx 3 to 4 c.m. in diameter, wound base was red with approx 10% of yellow slough. Surrounding site of the wound was red and there was scant amount of brown drainage. Continued observation and interview after wound care treatment to Resident #6's left lower buttocks revealed that the Wound Care Nurse positioned Resident #6 to her back with the assistance of C.N.A. FF. At that time surveyor reported to Wound Care Nurse that Resident #6 had been on her back since 12 p.m. Wound Care Nurse then said She had?! and looked at Resident #6. Resident #6 stated yes. Wound Care Nurse immediately assisted Resident #6 to her side by placing a wedge to her left side. In an interview on 10/17/2016 at 3:25 p.m. with the Wound Care Nurse, she stated that nurses were supposed to supervise that C.N.A.'s would turn and reposition residents and then said I have the entire building. When I come in the morning I try to see everyone. Sometimes I call the C.N.A.'s. Last time I saw Resident #6 was earlier and she was up on her chair and I did not know what time she was assisted to bed. Resident #6 was supposed to be turn and reposition off her back. CR #10 Record review of the medical record face sheet revealed CR #10 was admitted on [DATE]. [DIAGNOSES REDACTED]. He was [AGE] years old. CR #10 went to the hospital on [DATE] at his request. Record review of CR # 10's admission MDS assessment with 09/11/2016 ARD date revealed that his short and long term memory were intact. CR #10 required total assistance of two staff support for bed mobility, dressing and bathing. He required one person assistance for toilet use and extensive assistance of two staff support for personal hygiene. CR #10 was always incontinent of bowel and had an indwelling catheter. The skin condition section of the assessment revealed he was at risk of developing pressure ulcers and did not have a pressure ulcer. Record review of CR #10's Plan of Care initiated 9/20/2016 revealed in part: -Focus: CR #10 has potential impairment to skin integrity related to fragile skin. CR #10 has bladder incontinence related to impaired mobility. -Goal: Will remain free from skin breakdown. -Approach: Clean peri-area with each incontinence episode . Record review of CR #10's Braden Scale for Predicting Pressure Sore Risk dated 10/09/2016 revealed a score of 11 indicating High Risk to develop pressure sores. Record review of CR #10's Skin - Head to toe skin check revealed in part; -10/9/2016 Re-admission. Site: Coccyx. Pressure sore. No measurements on assessment. Stage 2. -10/11/2016. Site: Sacrum. Pressure sore. 2.3x1.9x0.2.c.m. (LWD). Stage 3. -10/18/2016. Site: Sacrum. Pressure sore. 2.0x1.7x0.2 c.m. (LWD). Stage 3. Further record review revealed no care plan with interventions in place for CR#10's pressure sore to Sacrum. Record review of CR #10's MD orders dated 10/14/2016 revealed in part; -Clean sacrum wound with normal saline. Pat dry, apply calcium alginate. Cover with 4x4 then dry dressing every day and as needed. Record review of CR #10's progress/nurses notes dated 10/18/2016 at 4:25 p.m. revealed in part .Skin/Wound note This is a [AGE] year old black male was seen and evaluated today by wound care MD. CR#10 presented with a stage 3 wound to the sacrum with moderate serous exudate with no indications of pain . Observation and interview on 10/19/2016 at 12:30 p.m. revealed CR #10 was at a local hospital ICU unit (Intensive Care Unit). Further observation revealed that he was lying in an air mattress on his side facing the door. In continued observation, CR #10 was noted to have a Foley catheter that had approx. 500 cc of light yellow colored urine on the collection drainage bag. Further observation at that time revealed CR #10 with an open area to the sacrum approx 3.0 x 2.0 c.m. approx 50% of the wound base was yellow and the remaining of the wound base was red and surrounding site was red and macerated. Continued interview at that time, CR#10 stated Staff at the facility would not turn me or reposition me while I was in bed. I had to wait hours to have my brief changed and had to lay on my bowel movement for hours before they change my brief. My mother even got me a [MEDICATION NAME] to blow it for staff t

Based on observation, interview and record review, the Administration failed to oversee the facility in a manner that enabled it to use the facility's resources effectively to maintain the highest practicable physical well-being for three of fourteen residents (Resident #5, #6 and CR#10) reviewed for pressure sores, diabetes management and MD notification. -The Administrator, who was the abuse coordinator, failed to ensure the facility's policies and procedures were implemented for the prohibition of neglect. -The Administrator failed to develop a system of communication between the facility and the MD to notify skin changes in condition and abnormal blood glucose levels. --The Administrator failed to supervise and monitor the DON to ensure she carried out her responsibilities in the areas of assessment and monitoring of medical conditions, such as changes in skin condition, sign and symptoms of hypo/[MEDICAL CONDITION] including MD notifications. --The DON failed to train and monitor all nursing staff regarding changes in skin condition, blood glucose, thoroughly assess, and consult with physicians concerning changes in skin condition, abnormally high blood glucose readings and to monitor that staff follow the MD orders and complete their documentation. The DON failed to train all staff on prevention and treatment of [REDACTED]. -The DON failed to have a system in place for reviewing diabetics' medications administration record to assure residents were appropriate being monitored and recorded their blood glucose levels as ordered by the MD. An Immediate Jeopardy (IJ) was identified on 10/17/2016 and 10/20/16. While the IJ was lowered on 10/21/2016, the facility remained out of compliance at a severity of Actual harm that is not Immediate Jeopardy and a scope of pattern. The facility remained out of compliance because they had not yet monitored their plan for effectiveness. These failures affected two residents and one former resident and placed the remaining 12 residents with pressure sores and 30 residents receiving Accuchecks in the facility at risk of not receiving adequate assessments and care, delayed treatment, pain, decline in their health condition well-being and hospitalization . Findings Include: Intake # 1, 1 and 8 In an interview on 10/21/2016 at 3:30 p.m. with the Administrator, who was the abuse coordinator, he stated that he did not know about Resident #5 having any skin problems and further said I learned about it when you (surveyor) came and advanced from there. I believe there was a C.N.A. who notified the nurse and there was a failure to follow thru. Administrator continued saying that the facility staff had been trained on using an SBAR form for changes in condition including skin changes. He continued saying that the DON was new in the facility and that she was still being acclimated to the system. He then said that facility also had a Regional Nurse that monitors the nursing department, the morning meetings were the 24 hour report is reviewed and the he also made rounds in the facility. The Administrator then said that he was not made aware of Resident #5's skin wounds by anyone in the facility and that he did not remember any discussion regarding any wounds on the morning meetings. Administrator further said that he depended on the nurses and managers to follow facility policy and procedure for pressure sore prevention and that the facility Wound Care Nurse had been certified for wound care and was involved in training staff on pressure sores including the wound MD. Continued interview with the Administrator on 10/21/2016 at 3:45 p.m. he stated that there were policies and procedure in place and that supervisors were supposed to reviewed the MAR's and make sure the nurses were following thru with finger stick blood glucose, insulin administration, parameter notifications to the MD and documentation. Administrator then said that he believed something happened when the facility switched from the electronic MAR's to paper MAR's and then said I depend on my Regional Nurse to let me know if any problems. When asked how did he thing this incident of IJ came about, the Administrator stated staff left holes, did not notify the MD and there was a lack of documentation which was basic skills. The Nurse Practitioner comes once a day five times a week and he never notified me of any holes on the MAR's. I also have a pharmacy consultant that came this month already to destroy medications but I am not sure if she checked the MAR's or did any medication regimen review. The Regional Nurse did not report any problems either. Resident # 5 Record review of the medical record face sheet revealed Resident # 5 was admitted on [DATE]. [DIAGNOSES REDACTED]. She was [AGE] years old. Record review of Resident #5's Plan of Care initiated 3/21/2016 revealed in part: -Focus: Resident #5 has potential skin issues related to potential breakdown. Resident #5 has bladder incontinence related to disease process. -Goal: Resident #5's skin will remain intact and Resident #5 will remain free from skin breakdown due to incontinence and brief use. -Interventions: Notify MD of changes in wound or emerging wounds and Clean peri-area with each incontinence episode . Record review of Resident #5's Braden Scale for Predicting Pressure Sore Risk revealed in part; - 5/27/2016 revealed a score of 12 indicating High Risk to develop pressure sores. - 8/16/2016 revealed a score of 8 indicating Very High Risk to develop pressure sores. Further record review revealed that Resident #5's plan of care was not updated with interventions to prevent pressure sores. Record review of Resident # 5's quarterly MDS assessment with 08/17/2016 ARD date revealed that she was not interviewed for Cognitive Skills for Daily Decision Making. Resident #5 had short and long term memory problem and her cognitive skills for daily decision making were moderately impaired. She required total assistance of two staff support for all her activities of daily living. Resident #5 was always incontinent of bowel and bladder. The skin condition section of the assessment revealed she had no pressure sores and she was at risk of developing pressure ulcers. Observation on 10/16/2016 at 11:55 p.m. revealed that Resident #5 was in bed on her back with the head of the bed elevated at 45 degrees. Further observation revealed that Resident #5's room had a strong urine odor to the outside hallway of her room. Resident #5's eyes were closed. Observation and interview on 10/17/2016 at 12:20 a.m. during incontinent care to Resident #5 revealed that MA C and C.N.A. P stated that Resident #5 has some skin irritations. Further observation and interview at that time revealed Resident #5's front perineal area was reddened and as Resident #5 was turned to her side, her buttocks areas were noted with open areas on each of her buttocks. Resident #5 moaned on and off while MA C and C.N.A. P were wiping her front perineal area and buttocks. Continued observation revealed that resident #5 had her brief heavily saturated with urine, her brief was brownish in color and had several spots of bright and dark blood on the buttocks area. MA C then said brief is heavily soiled , MA C proceeded to remove the brief from underneath Resident #5. Further observation revealed that Resident #5's underneath pad had also a large circular brownish/yellowish wet area with several spots of bright red blood and dark red blood on the buttocks area where Resident #5 was lying. Interview at that time, C.N.A. P stated that Resident #5 would usually scream during incontinent care and then said especially since last week that she had these open areas. Further observation at that time revealed that Resident #5 had 3 open wounds to her left buttocks (left mid buttocks approx 2.5 x 4.0 cm., left lower buttocks had 2 wounds approx 3.0 x 2.0 and 2.0 x 2.0 c.m.) and one open wound to the right lower buttocks (approx 3.0 x 2.0 c.m.). Open wounds had wound base reddened and were bleeding. Surrounding site of the wounds were macerated. At that time, surveyor asked C.N.A. P to call the charge nurse. In an interview and observation on 10/17/2016 at 12:36 a.m. with RN D, she stated as she looked at Resident #5's buttocks areas Resident #5 already has treatment for [REDACTED]. RN D then stepped out of the room. Continued observation and interview on 10/17/2016 at 12:40 a.m. after incontinent care, C.N.A. P grabbed a 30 cc cup that was at Resident #5's bedside that had a clear colored ointment and another 30 cc cup that had a white powder, that was next to the cup that had the clear ointment. C.N.A. P stated we are going to put the powder and the cream on the sores. The nurses left these medications for Resident #5 . When asked what was the name of the cream and the powder that were on the 30 cc cup containers, C.N.A. P stated I don't know. MA C then said I think is [MEDICATION NAME], let me put the powder on her buttocks. C.N.A. P then said I will put the cream on the front. C.N.A. P continued saying Resident #5 is going to scream. Observation at that time revealed that as C.N.A. P rubbed the clear ointment to the front perineal area, Resident #5 moaned. MA C then sprinkled the powder to Resident #5's buttocks area covering the open wounds. Continued observation at that time revealed that Resident #5 was positioned on her back after incontinent care with the head of the bed elevated at 45 degrees. In an interview on 10/17/2016 at 12:45 a.m. with RN D, when asked for last skin assessment and orders for Resident #5, RN D stated as she read Resident #5's skin assessment, There is documentation that Resident #5 had a rash only. RN D further said that she was aware of the open wounds of Resident #5's buttocks and that she believed that the wounds had been assessed already last week and that when she saw the orders for [MEDICATION NAME] and [MEDICATION NAME] powder that she thought that the MD was aware of the open wounds. RN D continued saying that she did not leave the ointment and the powder at Resident #5's bedside, that probably was the PM shift nurse (LVN A). Record review of Resident #5's phone orders dated 10/12/2016 revealed in part: . -Wound care doctor to evaluate and treat as indicated, -[MEDICATION NAME] Ointment 2% (antibiotic). Apply to bilateral buttock topically one time a day for wounds. Clean area with Normal Saline, pat dry, apply [MEDICATION NAME] to bilateral buttocks wound, cover with non stick dressing until areas healed. -[MEDICATION NAME] powder apply to groin topically two times a day for moisture In a phone interview on 10/19/2016 at 9:33 a.m. with LVN A, she stated that she was the charge nurse on 10/16/2016 during the 2 to 10 shift for Resident #5 and further said Resident #5 had wounds to her buttocks and she had orders for [MEDICATION NAME] ointment. I never give the ointment to the C.N.A.'s. When asked if she had left a clear ointment and a white powder at the bedside of Resident #5, LVN A stated No, I did not do it. I don't know who did it. I did the treatment myself. Record review of Resident #5's Skin - Head to toe skin check dated 10/11/2016 signed by RN F revealed in part; New abrasions. Site: Left buttocks. Type: Rash . In an interview on 10/18/2016 at 1:40 p.m. with RN F, she stated that C.N.A. C reported to her since 10/11/2016 that Resident #5 had a rash. RN F further said that she went and assessed Resident #5's buttocks area at that moment and that she saw wounds to Resident #5's right and left buttocks, She said that the wounds looked red and were approx 10 x 1 c.m. RN F then said that she wrote the information on the book for the MD to review it whenever the MD would come to the facility. When asked if she wrote rash on Resident #5's assessment dated [DATE], RN F stated I probably wrote rash on the assessment form before going and evaluating Resident #5. In an interview on 10/17/2016 at 1:03 a.m. with RN D, she stated that she was aware since last week that Resident #5 had open wounds to her buttocks and that she did not measured or assessed the areas because there were orders already and further said we usually measure any new wounds and call the MD, but I wasn't sure with Resident 5's wounds. In an interview on 10/17/2016 at 1:09 a.m. with the DON and the Administrator, the DON stated that incontinent care was supposed to be done every 2 hours and that she had already seeing the pad that was removed from underneath Resident #5's and that the brief had been already put on the trash outside. DON said that she saw the wet pad with patches of blood. Further interview with the DON at that time, when asked if she was aware of Resident #5's open wounds to right and left buttocks, the DON stated It's so many residents. I am still trying to learn. I am new. I had been in this facility for a month only. Continued interview with the DON and the Staff Development Manager, RN J on 10/17/2016 at 1:15 a.m. RN J stated that she had called the Wound Care Nurse on the phone and that the Wound Care Nurse had said that on the skin assessment dated [DATE] Resident #5's skin was intact and that on the assessment dated [DATE] the nurses had identified a rash to Resident #5's left buttocks. RN J further said that the wound care nurse had not assessed Resident #5's skin because the wound care nurse only takes care of the pressure sores in the facility and that the nurses take care of other skin problems. RN J then said we always thought that Resident #5 had only a rash. Nurses are supposed to go and assess the residents when the aides report any skin problems, then they would get orders from the MD. Surveyor at that time, made DON and Staff Development Manager aware that Resident #5 had 3 open bleeding wounds to her left buttocks and one to her right buttocks. DON then said we will do 100% skin assessments tonight. Further interview with the DON on 10/17/2016 at 1:28 a.m., the DON stated that C.N.A.'s were not supposed to apply any prescription medication creams or ointments including powder medications to residents and that medications were not supposed to be left at the bedside either and further said we will do in-service now. Nurses are supposed to apply those medications only and not leave medications for C.N.A.'s to apply at the bedside. In an interview on 10/17/2016 at 10:15 a.m. with Staff Development Manager, RN J, she stated that she assessed Resident #5's open wounds and that Resident #5 had 3 open areas on her left buttocks and that she saw the wound base pink and further said the 3 wounds to the left buttocks were macerated open areas. Staff Development Manager, RN J further said that the right ishium open area was pink wound base and dry. Staff Development Manager, RN J handled to surveyor Resident #5's skin assessments done by facility. Record review of Resident #5's Skin - Head to toe skin check dated 10/17/2016 and signed by Staff Development Manager, RN J revealed in part . Describe new or existing other issues: Resident #5 noted with three open ulcers to left buttock and one open ulcer to right gluteal fold. -Site 32) Left buttock open ulcer. 2.5 x 4.0 c.m. (LxW) Stage 2. -Site 32) Left buttock open ulcer. 2.0 x 2.0 c.m. (LxW) Stage 2. -Site 32) Left buttock open ulcer. 1.5 x 3.0 c.m. (LxW) Stage 2. -Site 55) Right gluteal fold open ulcer. 1.2 x 3.0 c.m. (LxW) Stage 2. Further description of skin issues: Surrounding skin appears macerated, no bleeding noted . Observation and interview on 10/17/2016 at 10:35 a.m. revealed Resident #5 was on her back with the head of the bed elevated at 45 degrees. C.N.A. C and C.N.A. K were inside room of Resident #5, C.N.A. C stated that they had just finished providing incontinent care to Resident #5. When asked if they saw any dressing to Resident #5's buttocks, C.N.A. C stated Resident #5 had wounds to her buttocks and still did not have any dressings on them. Resident #5 had open areas to her right and left buttocks since last week, but I reported to Unit Manager N since last Friday (10/14/2016). C.N.A. C further said that when aides report any skin condition to the nurses, they would do it verbally only, that they are not required to complete any paper form. C.N.A. C continued saying that since the beginning of October 2016, she had been reporting to different nurses that Resident #5 had skin redness and breakdown on her buttocks and that finally on 10/14/2016, she made the report to Unit Manager N. C.N.A. C then said that Resident #5 spends most of the time in bed. Observation on 10/17/2016 at 11:10 a.m. revealed that the Wound Care Nurse was inside Resident #5's room and said to surveyor I just did the wound care now because I had to change wound care orders. RN J got orders earlier but I had to change orders. In an interview on 10/17/2016 at 11:15 a.m. with Staff Development Manager, RN J, she stated that she got wound care orders for Resident #5's open wounds on her buttocks since 8:00 a.m Record review of Resident #5's telephone orders dated 10/17/2016 written by Staff Development Manager, RN J revealed in part: -Santyl collagen (wound [MEDICATION NAME] ointment) to bilateral buttocks wounds daily and cover with clean 4x4 dressing. -Vitamin C 500 mg via peg tube daily -Zinc Sulfate 220 mg via peg tube daily -Wound care to evaluate and treat Further record review of telephone orders revealed orders dated 10/17/2016 at 11:00 a.m. in part .- Discontinue previous wound care orders. -Apply Calcium alginate (seaweed dressing for moist wounds) to left upper buttocks area, cover with 4x4 after cleanse with normal saline daily. -Cleanse left buttock area with normal saline, Apply Zinc Oxide to open areas daily and as needed. -Cleanse right ishium (buttocks) wound with normal saline. Pat dry. Apply Zinc Oxide to open area daily and as needed. -Air mattress . In an interview on 10/17/2016 at 11:35 a.m. with the DON, Administrator, who was the abuse coordinator and Staff Development Manager, RN J, when asked about the delayed in wound care to Resident #5 since 1:15 a.m. that surveyor made them aware of Resident #5's open wounds to her buttocks and wounds were not protected until 11:10 a.m., the DON stated we were trying to investigate, we were in the process of investigating, but it takes time. We were pulling the scheduled. Continued interview at that time, the Staff Development Manager, RN J then said Santyl (wound [MEDICATION NAME] ointment) needed to be ordered. Then the order was discontinued and Calcium Alginate (seaweed dressing for moist wounds) was ordered. Staff Development Manager, RN J further said that the wound care MD was going to see Resident #5 on 10/18/2016. Further interview at that time, the Administrator stated that the facility had on-call MD that could had been called for wound care orders for Resident #5 when surveyor made the facility aware of the open areas of Resident #5 at 1:15 a.m. In an interview on 10/17/2016 at 11:55 a.m. with the Wound Care Nurse, she stated today was my first time looking at Resident #5's wounds. Wound Care Nurse then said that on 10/13/2016, C.N.A. C asked her for something more than Zinc ointment for Resident #5's open areas but that C.N.A. C did not specify that Resident #5 had wounds and that she told the C.N.A. to report the condition to the charge nurse because she only takes care of pressure sores. When asked if she went to assessed Resident #5 after C.N.A. C reported open areas, the Wound Care Nurse said I did not go and see Resident #5. I only asked her to tell the charge nurse and C.N.A. C said that she had already reported to the charge nurse. So I went and continued with my work. Wound Care Nurse said that she had been doing wound care in the facility for 1 year and that she had been certified for wound care and that as an LVN she was able to stage wounds because she had been certified for wound care. Further interview at that time, Wound Care Nurse stated that the left medial buttocks open area appeared like an unstageable wound because it got thick necrotic tissue on 50% of the wound base and that the left and right lower buttocks wounds were also unstageable wounds because of the necrotic tissue on the wound base. Wound Care Nurse continued saying that the wound on the left medial buttocks was pressure for being on that side for long periods of time. Wound Care Nurse further said that the pressure sores on the lower buttocks were due to pressure from the brief because the briefs were too small and the tightness of the brief was putting pressure to the area and by Resident #5 lying on her back. Continued interview with the Wound Care Nurse on 10/17/2016 at 12:10 p.m., when asked if she was made aware that Resident #5 had wound care orders as of 8:00 a.m. The Wound Care Nurse stated Staff Development Manager, RN J told me at around 9:00 a.m. of the wound orders for Resident #5 but I had to do the wound dressings for station 1 first then I came to station 3 and that's when I saw you (surveyor) coming out of Resident #5's room. Wound Care Nurse stated that she had not updated the care plan for Resident #5 because she had been busy. In an interview on 10/17/2016 at 12:15 p.m. with Unit Manager N, he stated that he was made aware on 10/14/2016 of Resident #5's skin condition and that he went to see the resident and that he saw a skin tear on the left buttocks area that was approx 3x5 inches and that he checked the orders and that he saw orders for [MEDICATION NAME] ointment. When asked if he wrote a skin assessment for Resident #5 when he went to assess her left buttocks, Unit Manager N stated No, I did not do wound assessments because it was documented that a skin assessment was recently done. When asked if he reviewed the skin assessment that was recently completed, the Unit Manager N stated No, I did not review the assessment. I thought that the open area had been already identified so I did not think I needed to further call the MD or re-do an assessment. In an interview on 10/17/2016 at 12:46 p.m. the DON stated that Resident #5 was getting an air mattress. In an interview on 10/18/2016 at 1:45 p.m. with RN F, she stated that whenever staff reports any skin condition, they were supposed to go and assess the area, then enter the assessment on the computer. RN F said that MD needed to be notified at that time and orders need to be carried out as soon as possible. RN F continued saying that she remembered that the day she placed the notification on the MD book regarding the open areas to Resident #5's buttocks, that she believed she saw other notifications on the MD book written by other nurses regarding the skin condition of Resident #5. In a phone interview on 10/19/2016 at 9:21 a.m. with C.N.A. D, he stated that he was the C.N.A. for Resident #5 on 10/16/2016 for the 2 to 10 p.m. shift. C.N.A.'s D further said that he first saw Resident #5 at around 2 p.m. on 10/16/2016 and did incontinent care to her. C.N.A. D then said that he saw wounds to Resident #5's right and left buttocks and then said the nurses know about the wounds, they would give us the ointment to put on Resident #5's wounds and further said I believed the diaper was too tight and then she would just lay on her back, then the wounds would bleed, the wounds were bleeding, they were not healing. When asked when was the last time he provided incontinent care to Resident #5 on 10/16/2016 before the end of his shift, C.N.A. D stated Resident #5 was not wet on my last round. I get off at 10:00 p.m. and she was supposed to be checked every 2 hours and we are supposed to turn her every 2 hours as well. Further interview at that time, C.N.A. D stated that he turned and repositioned Resident #5 to her side at 9:00 p.m during the last round and that Resident #5 was dry. When asked if he was aware that Resident #5 was found with her brief heavily soiled on 10/16/2016 at midnight, C.N.A. D stated Resident #5 is heavy wetter. Resident #6 Record review of the medical record face sheet revealed Resident # 6 was admitted on [DATE]. [DIAGNOSES REDACTED]. She was [AGE] years old. Record review of Resident #6's Plan of Care initiated 12/07/2015 and last reviewed 9/7/2016 revealed in part: -Problem: Resident #6 has pressure ulcer to left ischium (sitting bone) related to sensory perception, moisture/incontinence, decreased activity, impaired mobility and friction and shear problem. -Goal: Pressure ulcer will show signs of healing process as evidence by decrease in depth, width and length by at least 2 c.m. -Approach: Turn and reposition while in bed and chair frequently for comfort and pressure reduction. Other: pillows/wedge, limited to 60 minutes up in wheel chair . Record review of Resident #6's Braden Scale for Predicting Pressure Sore Risk dated 9/06/2016 revealed a score of 15 indicating at Risk to develop pressure sores. Record review of Resident # 6's quarterly MDS assessment with 08/7/2016 ARD date revealed that she was cognitively intact with a BIMS score of 13 out of a total possible of 15. Resident #6 required extensive assistance of two staff support for bed mobility, dressing and total dependent on staff for transfers, toilet use and bathing. Resident #6 had an external catheter and an ostomy including [MEDICATION NAME], [MEDICAL CONDITION] and [MEDICAL CONDITION]. The skin condition section of the assessment revealed she had one stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling) that measured 3.0 x 2.3 x 1.0 c.m. (LWD). Record review of Resident #6's Skin - weekly pressure ulcer record dated 10/11/2016 revealed in part: . Site: Left ischium. Pressure sore. Measure: 4.5 x 3.2 x 0.8 c.m. (LWD) Stage: 4. Date of onset 12/07/2015 Record review of hand-written pressure ulcer list dated 10/17/2016 revealed that Resident #6's pressure sore to her left ischium was In-house acquired as of 12/7/2015. Record review of Resident #6's MD orders dated 10/12/2016 revealed orders in part; -Clean left hip wound with normal saline, pat dry, apply silver alginate to wound. Cover with 4x4 dressing then dry dressing every day and as needed one time a day for wound care. Observation on 10/16/2016 at 11:15 p.m. revealed Resident #6 lying in bed on her back with the head of the bed elevated at 45 degrees. Observation and interview on 10/17/2016 at 12:20 p.m. revealed that Resident #6 was lying in bed on her back with her head elevated at approx 35 degrees. Resident #6 stated that she was up on her chair from 9:30 a.m. to 12:00 p.m. and that the C.N.A. had helped her to bed. Resident #6 further said facility staff do not turn me or reposition me. I lay on my back for hours. They are supposed to turn me but they don't do it. I have never refused to be turned or repositioned. I try to do it myself sometimes because is very uncomfortable to be on one side for long time but I can't do it. I am not strong enough to turn myself. Sometimes it is very painful to be on my back. I have a wedge that the staff are supposed to put on my side but it's over there on the chair. Even before I have the pressure sore on my left buttocks, they would never turn me. Interview at that time with Resident #6's visitor friend, she stated that she visited Resident #6 frequently and stays with her for long time and that she has never observed any staff turn or reposition Resident #6. Observation and interview on 10/17/2016 at 1:50 p.m. with Resident #6 revealed that she was still lying on her back with the head of the bed at 45 degrees. Resident #6 stated that still no staff had come to offer her to be turned or repositioned to her side. Resident #6 further said last night when you were here, I was on my back and stayed lying on my back the entire night. Sometimes I have to ask them to put the wedge on my back and they would do it. In an interview on 10/17/2016 at 2:00 p.m. with C.N.A. K, she stated that she worked 6 to 2 p.m. shift. She further said that Resident #6 required total assistance for all her activities of daily living and that was a hospice resident. She further said that Resident #6 had a pressure sore on her butt and that was on a turning and repositioning program and required turning every 2 hours. C.N.A. K then said that Resident #6 got up at around 9:30 a.m. on her chair until 12 p.m. and that the last time she repositioned Resident #6 was at 12 p.m. and then said Resident #6 is due to be turned and repositioned now. C.N.A. K then said that Resident #6 was alert and oriented. Further observation at that time revealed that C.N.A. K walked to the nursing station and did not come back. Observation and interview on 10/17/2016 at 2:50 p.m. revealed that Resident #6 was still on the same position on her back with the head of the bed elevated at 45 degrees. Resident #6 stated to surveyor still nobody has come to turn me. My buttocks and my back hurt. In an interview on 10/17/2016 at 3:03 p.m. with C.N.A. N, she stated that she was the PM shift aide for Resident #6 and that the morning C.N.A. had reported to her that Resident #6 was due to be turned and repositioned at 2:30 p.m. and that she had been busy. Observation and interview on 10/17/2016 at 3:05 p.m. with the Wound Care Nurse, she stated she was going to do wound care to Resident #6. Further observation revealed that Resident #6 was still lying on her back. Further observation at that time during wound care to Resident #6 revealed that Resident #6 had a circular open wound to her left lower buttocks approx 3 to 4 c.m. in diameter, wound base was red with approx 10% of yellow slough. Surrounding site of the wound was red and there was scant amount of brown drainage. Continued observation and interview after wound care treatment to Resident #6's left lower buttocks revealed that the Wound Care Nurse positioned Resident #6 to her back with the assistance of C.N.A. FF. At that time surveyor reported to Wound Care Nurse that Resident #6 had been on her back since 12 p.m. Wound Care Nurse then said She had?! and looked at Resident #6. Resident #6 stated yes. Wound Care Nurse immediately assisted Resident #6 to her side by placing a wedge to her left side. In an interview on 10/17/2016 at 3:25 p.m. with the Wound Care Nurse, she stated that nurses were supposed to supervise that C.N.A.'s would turn and reposition residents and then said I have the entire building. When I come in the morning I try to see everyone. Sometimes I call the C.N.A.'s. Last time I saw Resident #6 was earlier and she was up on her chair and I did not know what time she was assisted to bed. Resident #6 was supposed to be turn and reposition off her back. CR #10 Record review of the medical record face sheet revealed CR #10 was admitted on [DATE]. [DIAGNOSES REDACTED]. He was [AGE] years old. CR #10 went to the hospital on [DATE] at his request. Record review of CR # 10's admission MDS assessment with 09/11/2016 ARD date revealed that his short and long term memory were intact. CR #10 required total assistance of two staff support for bed mobility, dressing

Based on observation, interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for one of fourteen residents (Resident #5) reviewed for ADL care. -The facility staff failed to provide timely incontinent care to Resident #5 and she was found with brief heavily saturated with urine and she had developed multiple facility acquired stage II pressure sores to her right and left buttocks that were not identified by the staff. This failure affected 1 resident and could place an additional 80 residents who were occasionally or frequently incontinent of bladder at risk for not receiving care and assistance when needed. Findings included: Intake # 1 and 1 Record review of the medical record face sheet revealed Resident # 5 was admitted on [DATE]. [DIAGNOSES REDACTED]. She was [AGE] years old. Record review of Resident #5's Plan of Care initiated 3/21/2016 revealed in part: -Focus: Resident #5 has potential skin issues related to potential breakdown. Resident #5 has bladder incontinence related to disease process. -Goal: Resident #5's skin will remain intact and Resident #5 will remain free from skin breakdown due to incontinence and brief use. -Interventions: Notify MD of changes in wound or emerging wounds and Clean peri-area with each incontinence episode . Record review of Resident #5's Braden Scale for Predicting Pressure Sore Risk revealed in part; - 5/27/2016 revealed a score of 12 indicating High Risk to develop pressure sores. - 8/16/2016 revealed a score of 8 indicating Very High Risk to develop pressure sores. Further record review revealed that Resident #5's plan of care was not updated with interventions to prevent pressure sores. Record review of Resident # 5's quarterly MDS assessment with 08/17/2016 ARD date revealed that she was not interviewed for Cognitive Skills for Daily Decision Making. Resident #5 had short and long term memory problem and her cognitive skills for daily decision making were moderately impaired. She required total assistance of two staff support for all her activities of daily living. Resident #5 was always incontinent of bowel and bladder. The skin condition section of the assessment revealed she had no pressure sores and she was at risk of developing pressure ulcers. Observation on 10/16/2016 at 11:55 p.m. revealed that Resident #5 was in bed on her back with the head of the bed elevated at 45 degrees. Further observation revealed that Resident #5's room had a strong urine odor to the outside hallway of her room. Resident #5's eyes were closed. Observation and interview on 10/17/2016 at 12:20 a.m. during incontinent care to Resident #5 revealed that MA C and C.N.A. P stated that Resident #5 has some skin irritations. Further observation and interview at that time revealed Resident #5's front perineal area was reddened and as Resident #5 was turned to her side, her buttocks areas were noted with open areas on each of her buttocks. Resident #5 moaned on and off while MA C and C.N.A. P were wiping her front perineal area and buttocks. Continued observation revealed that resident #5 had her brief heavily saturated with urine, her brief was brownish in color and had several spots of bright and dark blood on the buttocks area. MA C then said brief is heavily soiled , MA C proceeded to remove the brief from underneath Resident #5. Further observation revealed that Resident #5's underneath pad had also a large circular brownish/yellowish wet area with several spots of bright red blood and dark red blood on the buttocks area where Resident #5 was lying. Interview at that time, C.N.A. P stated that Resident #5 would usually scream during incontinent care and then said especially since last week that she had these open areas. Further observation at that time revealed that Resident #5 had 3 open wounds to her left buttocks (left mid buttocks approx 2.5 x 4.0 cm., left lower buttocks had 2 wounds approx 3.0 x 2.0 and 2.0 x 2.0 c.m.) and one open wound to the right lower buttocks (approx 3.0 x 2.0 c.m.). Open wounds had wound base reddened and were bleeding. Surrounding site of the wounds were macerated. At that time, surveyor asked C.N.A. P to call the charge nurse. In an interview and observation on 10/17/2016 at 12:36 a.m. with RN D, she stated as she looked at Resident #5's buttocks areas Resident #5 already has treatment for [REDACTED]. RN D then stepped out of the room. Continued observation and interview on 10/17/2016 at 12:40 a.m. after incontinent care, C.N.A. P grabbed a 30 cc cup that was at Resident #5's bedside that had a clear colored ointment and another 30 cc cup that had a white powder, that was next to the cup that had the clear ointment. C.N.A. P stated we are going to put the powder and the cream on the sores. The nurses left these medications for Resident #5 . When asked what was the name of the cream and the powder that were on the 30 cc cup containers, C.N.A. P stated I don't know. MA C then said I think is [MEDICATION NAME], let me put the powder on her buttocks. C.N.A. P then said I will put the cream on the front. C.N.A. P continued saying Resident #5 is going to scream. Observation at that time revealed that as C.N.A. P rubbed the clear ointment to the front perineal area, Resident #5 moaned. MA C then sprinkled the powder to Resident #5's buttocks area covering the open wounds. Continued observation at that time revealed that Resident #5 was positioned on her back after incontinent care with the head of the bed elevated at 45 degrees. In an interview on 10/17/2016 at 12:45 a.m. with RN D, when asked for last skin assessment and orders for Resident #5, RN D stated as she read Resident #5's skin assessment, There is documentation that Resident #5 had a rash only. RN D further said that she was aware of the open wounds of Resident #5's buttocks and that she believed that the wounds had been assessed already last week and that when she saw the orders for [MEDICATION NAME] and [MEDICATION NAME] powder that she thought that the MD was aware of the open wounds. RN D continued saying that she did not leave the ointment and the powder at Resident #5's bedside, that probably was the PM shift nurse (LVN A). Record review of Resident #5's phone orders dated 10/12/2016 revealed in part: . -Wound care doctor to evaluate and treat as indicated, -[MEDICATION NAME] Ointment 2% (antibiotic). Apply to bilateral buttock topically one time a day for wounds. Clean area with Normal Saline, pat dry, apply [MEDICATION NAME] to bilateral buttocks wound, cover with non stick dressing until areas healed. -[MEDICATION NAME] powder apply to groin topically two times a day for moisture In a phone interview on 10/19/2016 at 9:33 a.m. with LVN A, she stated that she was the charge nurse on 10/16/2016 during the 2 to 10 shift for Resident #5 and further said Resident #5 had wounds to her buttocks and she had orders for [MEDICATION NAME] ointment. I never give the ointment to the C.N.A.'s. When asked if she had left a clear ointment and a white powder at the bedside of Resident #5, LVN A stated No, I did not do it. I don't know who did it. I did the treatment myself. Record review of Resident #5's Skin - Head to toe skin check dated 10/11/2016 signed by RN F revealed in part; New abrasions. Site: Left buttocks. Type: Rash . In an interview on 10/18/2016 at 1:40 p.m. with RN F, she stated that C.N.A. C reported to her since 10/11/2016 that Resident #5 had a rash. RN F further said that she went and assessed Resident #5's buttocks area at that moment and that she saw wounds to Resident #5's right and left buttocks, She said that the wounds looked red and were approx 10 x 1 c.m. RN F then said that she wrote the information on the book for the MD to review it whenever the MD would come to the facility. When asked if she wrote rash on Resident #5's assessment dated [DATE], RN F stated I probably wrote rash on the assessment form before going and evaluating Resident #5. In an interview on 10/17/2016 at 1:03 a.m. with RN D, she stated that she was aware since last week that Resident #5 had open wounds to her buttocks and that she did not measured or assessed the areas because there were orders already and further said we usually measure any new wounds and call the MD, but I wasn't sure with Resident 5's wounds. In an interview on 10/17/2016 at 1:09 a.m. with the DON and the Administrator, the DON stated that incontinent care was supposed to be done every 2 hours and that she had already seeing the pad that was removed from underneath Resident #5's and that the brief had been already put on the trash outside. DON said that she saw the wet pad with patches of blood. Further interview with the DON at that time, when asked if she was aware of Resident #5's open wounds to right and left buttocks, the DON stated It's so many residents. I am still trying to learn. I am new. I had been in this facility for a month only. Continued interview with the DON and the Staff Development Manager, RN J on 10/17/2016 at 1:15 a.m. RN J stated that she had called the Wound Care Nurse on the phone and that the Wound Care Nurse had said that on the skin assessment dated [DATE] Resident #5's skin was intact and that on the assessment dated [DATE] the nurses had identified a rash to Resident #5's left buttocks. RN J further said that the wound care nurse had not assessed Resident #5's skin because the wound care nurse only takes care of the pressure sores in the facility and that the nurses take care of other skin problems. RN J then said we always thought that Resident #5 had only a rash. Nurses are supposed to go and assess the residents when the aides report any skin problems, then they would get orders from the MD. Surveyor at that time, made DON and Staff Development Manager aware that Resident #5 had 3 open bleeding wounds to her left buttocks and one to her right buttocks. DON then said we will do 100% skin assessments tonight. Further interview with the DON on 10/17/2016 at 1:28 a.m., the DON stated that C.N.A.'s were not supposed to apply any prescription medication creams or ointments including powder medications to residents and that medications were not supposed to be left at the bedside either and further said we will do in-service now. Nurses are supposed to apply those medications only and not leave medications for C.N.A.'s to apply at the bedside. In an interview on 10/17/2016 at 10:15 a.m. with Staff Development Manager, RN J, she stated that she assessed Resident #5's open wounds and that Resident #5 had 3 open areas on her left buttocks and that she saw the wound base pink and further said the 3 wounds to the left buttocks were macerated open areas. Staff Development Manager, RN J further said that the right ishium open area was pink wound base and dry. Staff Development Manager, RN J handled to surveyor Resident #5's skin assessments done by facility. Record review of Resident #5's Skin - Head to toe skin check dated 10/17/2016 and signed by Staff Development Manager, RN J revealed in part . Describe new or existing other issues: Resident #5 noted with three open ulcers to left buttock and one open ulcer to right gluteal fold. -Site 32) Left buttock open ulcer. 2.5 x 4.0 c.m. (LxW) Stage 2. -Site 32) Left buttock open ulcer. 2.0 x 2.0 c.m. (LxW) Stage 2. -Site 32) Left buttock open ulcer. 1.5 x 3.0 c.m. (LxW) Stage 2. -Site 55) Right gluteal fold open ulcer. 1.2 x 3.0 c.m. (LxW) Stage 2. Further description of skin issues: Surrounding skin appears macerated, no bleeding noted . Observation and interview on 10/17/2016 at 10:35 a.m. revealed Resident #5 was on her back with the head of the bed elevated at 45 degrees. C.N.A. C and C.N.A. K were inside room of Resident #5, C.N.A. C stated that they had just finished providing incontinent care to Resident #5. When asked if they saw any dressing to Resident #5's buttocks, C.N.A. C stated Resident #5 had wounds to her buttocks and still did not have any dressings on them. Resident #5 had open areas to her right and left buttocks since last week, but I reported to Unit Manager N since last Friday (10/14/2016). C.N.A. C further said that when aides report any skin condition to the nurses, they would do it verbally only, that they are not required to complete any paper form. C.N.A. C continued saying that since the beginning of October 2016, she had been reporting to different nurses that Resident #5 had skin redness and breakdown on her buttocks and that finally on 10/14/2016, she made the report to Unit Manager N. C.N.A. C then said that Resident #5 spends most of the time in bed. Observation on 10/17/2016 at 11:10 a.m. revealed that the Wound Care Nurse was inside Resident #5's room and said to surveyor I just did the wound care now because I had to change wound care orders. RN J got orders earlier but I had to change orders. In an interview on 10/17/2016 at 11:15 a.m. with Staff Development Manager, RN J, she stated that she got wound care orders for Resident #5's open wounds on her buttocks since 8:00 a.m Record review of Resident #5's telephone orders dated 10/17/2016 written by Staff Development Manager, RN J revealed in part: -Santyl collagen (wound [MEDICATION NAME] ointment) to bilateral buttocks wounds daily and cover with clean 4x4 dressing. -Vitamin C 500 mg via peg tube daily -Zinc Sulfate 220 mg via peg tube daily -Wound care to evaluate and treat Further record review of telephone orders revealed orders dated 10/17/2016 at 11:00 a.m. in part .- Discontinue previous wound care orders. -Apply Calcium alginate (seaweed dressing for moist wounds) to left upper buttocks area, cover with 4x4 after cleanse with normal saline daily. -Cleanse left buttock area with normal saline, Apply Zinc Oxide to open areas daily and as needed. -Cleanse right ishium (buttocks) wound with normal saline. Pat dry. Apply Zinc Oxide to open area daily and as needed. -Air mattress . In an interview on 10/17/2016 at 11:35 a.m. with the DON, Administrator, who was the abuse coordinator and Staff Development Manager, RN J, when asked about the delayed in wound care to Resident #5 since 1:15 a.m. that surveyor made them aware of Resident #5's open wounds to her buttocks and wounds were not protected until 11:10 a.m., the DON stated we were trying to investigate, we were in the process of investigating, but it takes time. We were pulling the scheduled. Continued interview at that time, the Staff Development Manager, RN J then said Santyl (wound [MEDICATION NAME] ointment) needed to be ordered. Then the order was discontinued and Calcium Alginate (seaweed dressing for moist wounds) was ordered. Staff Development Manager, RN J further said that the wound care MD was going to see Resident #5 on 10/18/2016. Further interview at that time, the Administrator stated that the facility had on-call MD that could had been called for wound care orders for Resident #5 when surveyor made the facility aware of the open areas of Resident #5 at 1:15 a.m. In an interview on 10/17/2016 at 11:55 a.m. with the Wound Care Nurse, she stated today was my first time looking at Resident #5's wounds. Wound Care Nurse then said that on 10/13/2016, C.N.A. C asked her for something more than Zinc ointment for Resident #5's open areas but that C.N.A. C did not specify that Resident #5 had wounds and that she told the C.N.A. to report the condition to the charge nurse because she only takes care of pressure sores. When asked if she went to assessed Resident #5 after C.N.A. C reported open areas, the Wound Care Nurse said I did not go and see Resident #5. I only asked her to tell the charge nurse and C.N.A. C said that she had already reported to the charge nurse. So I went and continued with my work. Wound Care Nurse said that she had been doing wound care in the facility for 1 year and that she had been certified for wound care and that as an LVN she was able to stage wounds because she had been certified for wound care. Further interview at that time, Wound Care Nurse stated that the left medial buttocks open area appeared like an unstageable wound because it got thick necrotic tissue on 50% of the wound base and that the left and right lower buttocks wounds were also unstageable wounds because of the necrotic tissue on the wound base. Wound Care Nurse continued saying that the wound on the left medial buttocks was pressure for being on that side for long periods of time. Wound Care Nurse further said that the pressure sores on the lower buttocks were due to pressure from the brief because the briefs were too small and the tightness of the brief was putting pressure to the area and by Resident #5 lying on her back. Continued interview with the Wound Care Nurse on 10/17/2016 at 12:10 p.m., when asked if she was made aware that Resident #5 had wound care orders as of 8:00 a.m. The Wound Care Nurse stated Staff Development Manager, RN J told me at around 9:00 a.m. of the wound orders for Resident #5 but I had to do the wound dressings for station 1 first then I came to station 3 and that's when I saw you (surveyor) coming out of Resident #5's room. Wound Care Nurse stated that she had not updated the care plan for Resident #5 because she had been busy. In an interview on 10/17/2016 at 12:15 p.m. with Unit Manager N, he stated that he was made aware on 10/14/2016 of Resident #5's skin condition and that he went to see the resident and that he saw a skin tear on the left buttocks area that was approx 3x5 inches and that he checked the orders and that he saw orders for [MEDICATION NAME] ointment. When asked if he wrote a skin assessment for Resident #5 when he went to assess her left buttocks, Unit Manager N stated No, I did not do wound assessments because it was documented that a skin assessment was recently done. When asked if he reviewed the skin assessment that was recently completed, the Unit Manager N stated No, I did not review the assessment. I thought that the open area had been already identified so I did not think I needed to further call the MD or re-do an assessment. In an interview on 10/17/2016 at 12:46 p.m. the DON stated that Resident #5 was getting an air mattress. In an interview on 10/18/2016 at 1:45 p.m. with RN F, she stated that whenever staff reports any skin condition, they were supposed to go and assess the area, then enter the assessment on the computer. RN F said that MD needed to be notified at that time and orders need to be carried out as soon as possible. RN F continued saying that she remembered that the day she placed the notification on the MD book regarding the open areas to Resident #5's buttocks, that she believed she saw other notifications on the MD book written by other nurses regarding the skin condition of Resident #5. In a phone interview on 10/19/2016 at 9:21 a.m. with C.N.A. D, he stated that he was the C.N.A. for Resident #5 on 10/16/2016 for the 2 to 10 p.m. shift. C.N.A.'s D further said that he first saw Resident #5 at around 2 p.m. on 10/16/2016 and did incontinent care to her. C.N.A. D then said that he saw wounds to Resident #5's right and left buttocks and then said the nurses know about the wounds, they would give us the ointment to put on Resident #5's wounds and further said I believed the diaper was too tight and then she would just lay on her back, then the wounds would bleed, the wounds were bleeding, they were not healing. When asked when was the last time he provided incontinent care to Resident #5 on 10/16/2016 before the end of his shift, C.N.A. D stated Resident #5 was not wet on my last round. I get off at 10:00 p.m. and she was supposed to be checked every 2 hours and we are supposed to turn her every 2 hours as well. Further interview at that time, C.N.A. D stated that he turned and repositioned Resident #5 to her side at 9:00 p.m during the last round and that Resident #5 was dry. When asked if he was aware that Resident #5 was found with her brief heavily soiled on 10/16/2016 at midnight, C.N.A. D stated Resident #5 is heavy wetter. In a phone interview on 10/19/2016 at 9:33 a.m. with LVN A, she stated that she was the charge nurse on 10/16/2016 during the 2 to 10 shift for Resident #5 and further said Resident #5 had wounds to her buttocks and she had orders for [MEDICATION NAME] ointment. I never give the ointment to the C.N.A's. When asked if she had left a clear ointment and a white powder at the bedside of Resident #5, LVN A stated No, I did not do it. I don't know who did it. I did the treatment myself. In an interview on 10/19/2016 at 10:08 a.m. with the DON, she stated that she had been the DON since 9/7/2016 and that she started training staff on anything that she saw a problem with. She said that staff had been trained on turning and repositioning residents, incontinent care and answering call lights timely. She then said Now the nurses are seeing the seriousness of reporting to the MD and being consistent with assessments, prevention and wound care, but now that we know that there was no system in place, we will work on the policies and procedures. Continued interview with the DON, when asked how she thought this incident of IJ came about, the DON stated Not communicating and reporting and not being consistent with it. Nurses who received instructions were not carrying out orders accordingly. DON then said that she was not aware of Resident #5's pressure sores and then said I don't want that situation to happened to any of the residents. If C.N.A's knew something was happening with Resident #5 and the nurses were not doing enough, they should had gone to the Unit Manager and the DON. Nobody reported anything to me. Further interview with the DON, she stated that the facility had the ambassador program where each department head has a group of residents to look after. DON said that Unit Manager N was the ambassador for Resident #5. DON continued saying When the C.N.A.'s went to Unit Manager N to let him know regarding the skin condition of Resident #5, he told them that everything was taking care of and that the Wound Care Nurse had assessed Resident #5. And when the C.N.A's went with the Wound Care Nurse and let her know about the wounds of Resident #5, the Wound Care Nurse told them to go back with the charge nurse. I think that's where the communication failure happened. I don't know how the whole situation got disordered. Record review of a facility policy with title Perineal care revised October 2015 revealed in part: .Perineal care: which includes care of the external genitalia and anal area, should be performed if the patient is incontinent after urination and bowel movements. The procedure promotes cleanliness and prevents infection. According to the CMS Form 672, there were 81 residents who were occasionally or frequently incontinent of bladder.

Based on observation, interview, and record review the facility failed to consult with the residents physician when a change of condition occurred for two residents (Resident #1 Resident CR#1) reviewed for notification of changes. - The facility failed to consult Resident #1 ' s physician when respiratory therapist assessed abnormal lung sounds. Resident#1 required hospitalization due to pneumonia and septic shock. - The facility failed to consult CR#1's physician when his weight loss was greater than 5% in less than one month. This failure affected two residents and placed 19 residents residing in the facility with respiratory treatments and unplanned weight loss at risk of not having their physicians aware of a need to alter their medical treatment which could cause extended durations of pain, side effects, complications of medication, a delay in medical treatment and a decline in their health condition well-being. Findings include: Intake #'s 0 and 7 Resident #1 Record review of Resident # 1's medical records revealed he was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. He was [AGE] years old. Record review of Resident #1 ' s care plan titled Respiratory dated 9/30/14, review dated 2/19/16 and statues to continue. The care plan revealed in part . problem respiratory risk related to oxygen delivery, [DIAGNOSES REDACTED]. The goal revealed the respiratory risks will be minimized with interventions and an approach identified was .notify the physician of change in status and observe the resident for signs and symptoms of infection. Record review of Resident #1 ' s physician notes titled Annual Exam dated 3/30/16 revealed in part . the resident ' s past medical history included [MEDICAL CONDITION] .the resident was seen and evaluated today and found in no acute distress .resident continues with chronic oxygen therapy due to [MEDICAL CONDITION], no signs of [MEDICAL CONDITION] exacerbation .The physical exam revealed in part .Respiratory: continued oxygen at 2 liters/minute via nasal cannula, slightly diminished bilaterally but over all clear to auscultation . Record review of Resident # 1's quarterly MDS assessment dated [DATE] revealed he understood and understands others. He was able to complete the Basic Interview for Mental Status (BIMS) with a score of 12 out of 15 which indicated his cognition was intact. The MDS identified the resident ' s functional status as bed mobility, locomotion on and off the unit as limited assistance if one staff member and his transfer, walking in room and in corridor as supervision with set up only. The resident was always continent of bowel and bladder. Record review of Resident #1 ' s Respiratory Therapy Daily Documentation dated 4/20/16 at 12:00 pm and 8:46 pm revealed in part .bilateral breath sounds diminished with scattered crackles (an abnormal popping lung sounds found in pneumonia) and rhonchi ( an abnormal coarse rattling breath sound caused by excessive secretions) .report given to relief and charge nurse . Record review of Resident #1 ' s Respiratory Therapy Daily Documentation dated 4/21/16 at 7:00 am and 1:00 pm revealed in part .bilateral breath sounds diminished with scattered crackles and rhonchi .report given to relief and charge nurse . Record review of Resident #1 ' s Respiratory Therapy Daily Documentation dated 4/22/16 at 7:00 am revealed in part .bilateral breath sounds diminished with scattered crackles and rhonchi .report given to relief as well as charge nurse . Record review of the nurse's progress notes for Resident #1 dated 4/20/16, 4/21/16 and 4/22/16 revealed no documentation the physician was notified of respirator ' s assessment of his abnormal breath sounds. Record review of the resident's clinical record dated 4/20/16, 4/21/16 and 4/22/16 did not reveal a physician ' s notification form for change of condition completed for the abnormal breath sounds. Record review of Resident #1's nurses notes dated 4/21/16, 4/22/16, 4/23/16 and 4/24/16 revealed the resident complained of nausea and vomiting. Record review of Resident #1' s clinical record revealed an abdominal X-ray dated 4/22/16 which was negative for any findings and laboratory blood tests for Basic Metabolic Panel and Complete Blood Count was completed. Record review of the nurse ' s progress notes for Resident #1 dated 4/26/16 at 10:33 am revealed in part .the resident was sitting in his chair and was showing signs of being lethargic .he was throwing his head back and was stiff. The resident ' s blood pressure was 70/32 on his right arm and 91/34 on his left arm. The resident was sent to the hospital. Record review of the hospital Chest X-Ray result dated 4/26/16 revealed in part .right mid to upper lung infiltrate . Record review of the hospital history and physical dated 4/26/16 revealed in part . resident was admitted on [DATE] for [MEDICAL CONDITION] with septic shock, right upper lobe pneumonia, urinary tract infection and altered mental status. Record review of the hospital emergency department assessment notes dated 4/26/16 revealed the resident ' s vital signs upon arrival were blood pressure 64/52, temperature 98 degrees, heart rate 79 beats per minute and respirations were 20 breathes per minute. The resident blood oxygen saturation was 100%. Observation and interview on 4/29/16 at 2:10 pm revealed Resident #1 in the hospital sitting in a chair. The resident was alert, his speech was clear. There were intravenous (IV) fluids Normal Saline and antibiotics infusing on an infusion pump. The resident stated he did not remember anything that happened prior to coming to the hospital. Record review of Resident #1 ' s physician progress notes [REDACTED]. Chief complaint .Readmission to facility, resident status [REDACTED].Resident was admitted to the hospital where he was found to be in septic shock and found to have a urinary tract infection and pneumonia. Observation on 5/12/16 at 8:40 am revealed Resident #1 in bed sleeping with his oxygen on. Observation and interview on 5/12/16 at 9:30 am revealed Resident #1 sitting in his room in his wheelchair eating breakfast independently. The resident stated he felt good. Observation on 5/13/16 at 8:30 am revealed Resident #1 sitting in his room awake and alert eating breakfast. In an interview on 5/13/16 at 10:00 am ADON stated if respiratory therapy (RT) assesses an abnormal breath sound on a resident they were to notify the nurse and the nurse was to notify the physician so further tests or treatment could be ordered. She continued and stated the physician should have been notified of resident # 1 ' s breath sounds so a chest x-ray could have been done earlier before he had to go to the hospital. In an interview on 5/13/16 at 12:25 pm RT A stated if something abnormal was discovered on a resident RT would notify the nurse then the nurse would notify the physician. She continued and stated crackles and rhonchi were not normal breaths and the charge nurse would be notified, then the physician. In an interview on 5/13/16 at 1:45 pm RN A stated if RT finds some abnormal breath sounds they notify the nurse and the nurse needed to notify the physician. The physician would need to be notified of abnormal breath sounds such as crackles and rhonchi. In an interview on 5/13/16 at 2:46 pm RN B stated she did work on 4/20/16 but she did not see anything abnormal or wrong with Resident #1. She continued and stated she did not remember RT telling her that the resident had abnormal breath sounds. If they did I would first go see the resident and listen to the breath sounds, get his vital signs and call the physician. I did not see any problem with the resident. Resident CR#1 Record review of CR#1's face sheet undated, revealed a [AGE] year old male, admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident CR#1's quarterly MDS assessment dated [DATE] revealed he usually understood and usually understands others. He was unable to complete the Brief Interview for Mental status. The MDS identified the resident ' s functional status for bed mobility, transfer, dressing and hygiene as an extensive assistance. Eating was with limited assistance , requiring one person assistance. Record review of Resident CR#1's electronic medical record revealed a weight of 158.5 pounds on 3-18-16 and a weight on 4-9-16 of 149.0 pounds, which was a 5.9 % weight loss over 22 days. Record review of Resident CR#1's Care Plan dated 3/30/16 revealed in part that he was at risk for dehydration and the facility was to monitor his weight monthly and report to the residents physician and Dietary Manager when he had greater than 5% weight loss. Record review of the facility nurse ' s progress notes for Resident CR #1 dated 4/3/16, 4/19/16 and 4/20/16 revealed no documentation that the physician was notified of his weight loss of 5.9%. Record review of Resident CR#1's Electronic Medical Record revealed an order for [REDACTED]. During an interview on 5/13/16 at 10:30 a.m. with LVN A, she states that the CNA will tell us when a resident won't eat, the nurse will assess the resident to see why the resident was not eating. She further stated if the resident won't eat after interventions, the nurse will notify the doctor. She further stated the ADON and DON looked at the residents weights. During an interview on 5/13/16 at 12:45 p.m. with the ADON, she stated that all admissions were to have weekly weights done for four weeks. Residents with a 5% weight loss or greater are at high risk and would be discussed at the facility's high risk meetings which are held every Wednesday. She further stated that she does not attend the meetings, the DON and Unit Managers do, and she's not sure what they discussed. She also stated that I will take responsibility for the weekly weights not being followed up on. Record review of the facility policy titled Changes in Resident Condition dated April 2005 and revised June 2008 revealed in part The resident attending physician and legal representative or designated family member are notified when changes in condition or certain events occur. The facility CMS form 672 revealed 3 residents with unplanned weight loss and 18 residents who received respiratory treatments.

Based on observation, interview and record review the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for one of six residents (Resident #1) reviewed for care and services provided. - The facility failed to consult Resident #1 ' s physician when he was found lethargic and later admitted to the hospital with [REDACTED]. This failure affected one resident and placed 46 other residents who resided on the 200 hall at risk of not receiving adequate assessments, medical care, pain and decline in their physical, mental and psychosocial health and self esteem. Findings include: Intake # 0 Resident #1 Record review of Resident # 1's medical records revealed he was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. He was [AGE] years old. Record review of Resident #1 ' s care plan titled Respiratory dated 9/30/14, review dated 2/19/16 and statues to continue. The care plan revealed in part . problem respiratory risk related to oxygen delivery, [DIAGNOSES REDACTED]. The goal revealed the respiratory risks will be minimized with interventions and an approach identified was .notify the physician of change in status and observe the resident for signs and symptoms of infection. Record review of Resident # 1's quarterly MDS assessment dated [DATE] revealed he understood and understands others. He was able to complete the Basic Interview for Mental Status (BIMS) with a score of 12 out of 15 which indicated his cognition was intact. The MDS identified the resident ' s functional status as bed mobility, locomotion on and off the unit as limited assistance if one staff member and his transfer, walking in room and in corridor as supervision with set up only. The resident was always continent of bowel and bladder. Record review of Resident #1 ' s physician notes titled Annual Exam dated 3/30/16 revealed in part . the resident ' s past medical history included [MEDICAL CONDITION] .the resident was seen and evaluated today and found in no acute distress .resident continues with chronic oxygen therapy due to [MEDICAL CONDITION], no signs of [MEDICAL CONDITION] exacerbation . The physical exam revealed in part .Respiratory: continued oxygen at 2 liters/minute via nasal cannula, slightly diminished bilaterally but over all clear to auscultation . Continued review of the resident ' s clinical record did not reveal physician progress notes [REDACTED]. Record review of Resident #1 ' s Respiratory Therapy Daily Documentation dated 4/20/16 at 12:00 pm and 8:46 pm revealed in part .bilateral breath sounds diminished with scattered crackles (an abnormal popping lung sounds found in pneumonia) and rhonchi ( an abnormal coarse rattling breath sound caused by excessive secretions) .report given to relief and charge nurse . Record review of Resident #1 ' s Respiratory Therapy Daily Documentation dated 4/21/16 at 7:00 am and 1:00 pm revealed in part .bilateral breath sounds diminished with scattered crackles and rhonchi .report given to relief and charge nurse . Record review of Resident #1 ' s Respiratory Therapy Daily Documentation dated 4/22/16 at 7:00 am revealed in part .bilateral breath sounds diminished with scattered crackles and rhonchi .report given to relief as well as charge nurse . Record review of the nurse's progress notes for Resident #1 dated 4/20/16, 4/21/16 and 4/22/16 revealed no documentation the physician was notified of respirator ' s assessment of his abnormal breath sounds. Record review of the resident's clinical record dated 4/20/16, 4/21/16 and 4/22/16 did not reveal a physician ' s notification form for change of condition completed for the abnormal breath sounds. Record review of Resident #1's nurses notes dated 4/21/16, 4/22/16, 4/23/16 and 4/24/16 revealed the resident complained of nausea and vomiting. Record review of Resident #1' s clinical record revealed an abdominal X-ray dated 4/22/16 which was negative for any findings and laboratory blood tests for Basic Metabolic Panel and Complete Blood Count was completed. No urine tests were ordered to be obtained. Record review of Resident #1's clinical record's physician orders dated 4/22/16, 4/23/16 4/25/16 did not reveal a physician's order to obtain a urine specimen. Record review of the nurse ' s progress notes for Resident #1 dated 4/26/16 at 10:33 am revealed in part .the resident was sitting in his chair and was showing signs of being lethargic .he was throwing his head back and was stiff. The resident ' s blood pressure was 70/32 on his right arm and 91/34 on his left arm. The resident was sent to the hospital. Record review of the hospital Chest X-Ray result dated 4/26/16 revealed in part .right mid to upper lung infiltrate . Record review of the hospital history and physical dated 4/26/16 revealed in part . resident was admitted on [DATE] for [MEDICAL CONDITION] with septic shock, right upper lobe pneumonia, urinary tract infection and altered mental status. Record review of the hospital emergency department assessment notes dated 4/26/16 revealed the resident ' s vital signs upon arrival were blood pressure 64/52, temperature 98 degrees, heart rate 79 beats per minute and respirations were 20 breathes per minute. The resident blood oxygen saturation was 100%. Observation and interview on 4/29/16 at 2:10 pm revealed Resident #1 in the hospital sitting in a chair. The resident was alert, his speech was clear. There were intravenous (IV) fluids Normal Saline and antibiotics infusing on an infusion pump. The resident stated he did not remember anything that happened prior to coming to the hospital. Record review of Resident #1 ' s physician progress notes [REDACTED]. Chief complaint .Readmission to facility, resident status [REDACTED].Resident was admitted to the hospital where he was found to be in septic shock and found to have a urinary tract infection and pneumonia. Observation on 5/12/16 at 8:40 am revealed Resident #1 in bed sleeping with his oxygen on. Observation and interview on 5/12/16 at 9:30 am revealed Resident #1 sitting in his room in his wheelchair eating breakfast independently. The resident stated he felt good. Observation on 5/13/16 at 8:30 am revealed Resident #1 sitting in his room awake and alert eating breakfast. In an interview on 5/13/16 at 10:00 am ADON stated if respiratory therapy (RT) assesses an abnormal breath sound on a resident they were to notify the nurse and the nurse was to notify the physician so further tests or treatment could be ordered. She continued and stated the physician should have been notified of resident # 1 ' s breath sounds so a chest x-ray could have been done earlier before he had to go to the hospital. In an interview on 5/13/16 at 12:25 pm RT A stated if something abnormal was discovered on a resident RT would notify the nurse then the nurse would notify the physician. She continued and stated crackles and rhonchi were not normal breaths and the charge nurse would be notified then the physician. In an interview on 5/13/16 at 1:45 pm RN A stated if RT finds some abnormal breath sounds they notify the nurse and the nurse needed to notify the physician. The physician would need to be notified of abnormal breath sounds such as crackles and rhonchi. In an interview on 5/13/16 at 2:46 pm RN B stated she did work on 4/20/16 but she did not see anything abnormal or wrong with Resident #1. She continued and stated she did not remember RT telling her that the resident had abnormal breath sounds. If they did I would first go see the resident and listen to the breath sounds, get his vital signs and call the physician. I did not see any problem with the resident. Record review of the facility policy titled Changes in Resident Condition dated April 2005 and revised June 2008 revealed in part The resident attending physician and legal representative or designated family member are notified when changes in condition or certain events occur. According to the facility roster 47 residents reside on the 200 hall.

Based on record review and interview, the facility failed to implement their policy on neglect for 1 of 7 residents (CR #2) reviewed for neglect, as evidenced by: -LVN A did not provide CPR to CR #2 who was found without a pulse or blood pressure on [DATE] due to confusing documentation on CR #2's chart. -Facility failed to have a clear method to identify residents who required lifesaving measures. -CR #2 died later on the day. An IJ was identified on [DATE], while the IJ was lowered on [DATE],the facility remained out of compliance at a scope of isolated and severity level of actual harm because all staff had not been trained on identifying residents' code status in a timely manner in an event of an emergency. This failure affected one CR and placed 100 residents on full code status at risk of not being provided medical care and services as needed/identified. Findings include: Review of CR #2's record revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of CR #2's chart revealed a white front page with bolded one inch letters that read FULL CODE. Record review of CR #2's Out-of-hospital Do-Not-Resuscitate form revealed signature dated [DATE] by Responsible Party and signed by 2 witnesses dated [DATE]. Further record review revealed no signature by the MD. Record review of CR #2's care plan dated [DATE] and last revised [DATE] revealed in part: CR #2 is a full code. Goal. Resident/family wishes will be honored for 90 days. Record review of CR #2's Resident/family conference notes dated [DATE] revealed no information related to current condition of resident or code status. Record review of CR #2's physician's orders [REDACTED]. Record review of CR #2's MD Progress notes dated [DATE] revealed in part: Code status: Attempt Resuscitation (CPR). Record review of CR #2's quarterly MDS with an assessment reference date [DATE] revealed she had short and long term memory problem and was unable to complete the Brief Interview for Mental Status due to rarely/never understood. Further record review revealed that she required total assistance for bed mobility, dressing, personal hygiene and bathing and supervision and assistance of one person with eating. Her assessment noted she did not have weight loss and was not on a physician prescribed weight loss regimen. CR#2 weighed 135 pounds and measured 65 inches in height. Record review of CR #2's SBAR Communication form dated [DATE] revealed in part: -Background: Vital Signs: Blood Pressure: no reading. Pulse: no reading. Respirations: 24. Temperature 94 degrees Fahrenheit. 1.- Mental Status Changes: Unresponsiveness. Non-verbal-lethargic without stimuli. 3.- Respiratory: Shortness of breath. Respiratory labored. Advance Care Planning information: Do Not Resuscitate. -Nursing Notes: . In CR #2's room to administer her medications. She is pale. Cold. Respirations 24. Head of bed up, oxygen administered. Respirations low. MD B called. No answer from Nurse Practitioner. Family called and informed of condition of CR #2. Stated don't send out to hospital, I want to come and see her. Arrived. Able to observed her mother. Non-responsive. RN back to pronounce resident's condition. CR #2 left at 10:35 a.m. via funeral home. DON notified. Record review of CR #2's nurses notes dated [DATE] at 8:50 a.m. and signed by RN C revealed in part: I verify that CR #2 expired on [DATE] at 8:50 a.m. In an interview on [DATE] at 12:58 p.m. with the DON, she stated that CR #2 had a change in condition over the weekend. She further said I think she was on hospice but probably she was not, let me see the chart. Continued interview and observation, DON stated as she looked at CR #2's chart she was non-verbal, lethargic. I think she just die because when they went to see her, she was pale and they administered oxygen. When asked about the code status of CR #2, the DON stated She was full code, let me see if they updated her DNR. Further interview and observation at that time, while DON read the partially completed CR #2's DNR form, she stated form needs to be signed by the family and MD. MD did not sign it. In an interview on [DATE] at 1:05 p.m. LVN A stated that she was the nurse for CR #2 the day she died . LVN A said that she was going to administer medications to CR #2 on [DATE] at 7:45 a.m. and when she entered the room, CR #2 was different her eyes had a staring look. LVN A further said that she tried calling her name and that CR #2 did not respond and that she tried to take her vital signs and that she first used an electronic blood pressure cuff and that she did not like the reading she got, but did not remember what was the reading. She continued saying that she then went to get the manual blood pressure cuff and that she was not able to get a blood pressure reading and that she tried to get CR #2's pulse and did not get a pulse either. She continued saying that she noticed CR #2 had labored breathing and gave her oxygen (did not remember how many liters). LVN A further said that at that time she went out of the room to the nursing station to try to call the Nurse Practitioner but did not answer (left message only), she then tried to call MD B and did not respond and that she then called CR #2's Responsible Party and that she notified her that CR #2 had a change in her condition and asked permission to send CR #2 to the hospital. LVN A continued saying that CR #2's Responsible Party said No, I will be there as soon as I can. LVN A further said that when the Responsible Party arrived at the facility, CR #2 was already deceased . When surveyor asked LVN A if anyone had stayed with CR #2 while she went outside to make the phone calls, she stated that she believed she told a C.N.A. to stay with CR #2 but did not remember who was the C.N.A. LVN A continued saying that CR #2 was DNR status. In an interview on [DATE] at 1:25 p.m. with the DON, she stated that CR #2's DNR form was incomplete and that the MD did not get to sign it and that CR #2 should had been considered a full code status. In a second interview on [DATE] at 1:45 p.m. with LVN A, when asked if Responsible Party was made aware that CR #2 had no blood pressure or pulse and that she was with labored breathing, LVN A stated No, I just told the family that CR #2 was not looking good and then she told me not to send her to the hospital, that she was going to be in the facility as soon as possible. I did not let her know the current condition of CR #2 because the family member might have a [MEDICAL CONDITION] herself. LVN A continued saying that she then went and got RN C to pronounce CR #2 dead. Further interview with LVN A, surveyor asked LVN A if she had noticed a white paper in the front of the chart of CR #2 that read FULL CODE. LVN A stated as she opened the chart's front page I believe there was a red paper that said DNR. I did not see this white paper that read FULL CODE, unless I looked at somebody else's chart. When asked if she checked CR #2's MD orders to verify the code status, LVN A responded No, I did not. LVN A continued saying that CR #2 did not receive any life saving measures because as far as she knew, CR #2 was DNR. In an interview on [DATE] at 2:05 p.m. with RN C, she stated that LVN A called her into the room of CR #2 on [DATE] just to pronounce her dead. She continued saying I went to see CR #2 because LVN A said that CR #2 was dead and that I needed to pronounced her dead. She further stated that when she entered the room, CR #2 was alone in the room and that she checked CR #2 for pulse with a stethoscope and that CR #2 had no heart beat, no blood pressure and no respirations. When asked if she verified the code status of CR #2 on the chart, RN C stated I saw the chart because I wrote the nursing notes, but I did not verify CR #2's code status. RN C continued saying that if a resident is a full code status, CPR needs to be started immediately and call 911. RN C further said that when residents are full code they are supposed to have a green paper in the front of the chart that reads full code and if residents are DNR, they are supposed to have a red paper in front of the chart that reads DNR. In an interview on [DATE] at 2:20 p.m. with RN D, she stated that when CR #2 expired, LVN A called her to CR #2's room to help her pronounce her dead and she was notified by LVN A that CR #2 was DNR. In continued interview, RN D said that RN C and herself went to the room of CR #2 and found her alone in her room and that upon assessment, CR #2 had no pulse or blood pressure and that both RN's pronounced CR #2 dead. When asked if she checked CR #2's chart to verify code status, she stated No, I did not, LVN A told us that CR #2 was DNR. In an interview on [DATE] at 2:30 p.m. with the DON, when asked who was in charge of updating the code status of the residents and verify that the documentation is clear to the staff in an event of an emergency, the DON replied I really don't know, it is not my department. The Social Services Director is in charge of that but he is not here and I have tried to get hold of him but he is not answering. The DON continued saying CR #2 was still a full code and then when the DNR gets completed and signed by the MD, then we need to change the physician orders. We should had been able to obtain the MD signature timely. The current DNR looks too old. I don't know what made them stop and not to continue (paper work process). CR #2 should had been treated as a full code. In an interview on [DATE] at 3:09 p.m. with MD B, she stated she was the Medical Director for the facility and the MD for CR #2 and said that she believed she had signed before a DNR for CR #2 but did not remember when. She further stated that she signed the Physician orders [REDACTED]. MD B continued saying that the mission of the Social Service Director not long ago was to check everybody's code status I gave the mission to the Social Service Director, we were on the process of instituting and updating the process of DNR information. I have requested a list of DNR residents within the last couple of weeks and have not been provided one yet. The information was brought up during our high risk meeting. I wanted the Social Service Director to match the DNR status with a red paper copy in the chart and then to make a list for me. In the last meeting I had I asked them about it. When asked MD B about the white paper in front of the chart of CR #2 that read FULL CODE, MD B stated I don't know where it came from. This is exactly why I told them that. Code status used to be up to date but not anymore. Facility is supposed to know who is DNR in the facility and make sure is obvious and clear. They are supposed to be able to look quick during an emergency. They need to get it fix quick and show me that is fix. They did not have the process in place. There is a system failure that needs to be fix related to which residents are DNR and which are Full Code. I had addressed it already 2 weeks ago and asked them for a list and what I expect from the facility is that they fix the problems as they go along with the list. I still have not received the list. In an interview on [DATE] at 4:10 p.m. with MD B and DON, the DON stated that facility has completed the list for MD B only for stations 1 and 2 but still needed to complete station 3. She further stated that CR #2 was on station 3. MD B further said lot of this is probably that we weren't verifying the MD orders that were being printed out every month. We need to get everybody train. DON continued saying We are doing a full check on all residents' charts who are in the facility. In a second interview with the DON on [DATE] at 2:02 p.m. she stated that IDT members had already discussed in the last high risk meeting on [DATE] that facility had problems with DNR/code status process, that was not in place for all residents and further said that the facility was in the process of updating them. DON continued saying that nurses were supposed to check on the front of the chart for the code status of the residents during an emergency and verify information by checking the Physician orders [REDACTED].#2's chart and did not completely verify that the DNR was not completely signed or verify orders by the MD. Record review of the facility's inservice record for July, August and [DATE] revealed no training related to code status. In an interview on [DATE] at 2:34 p.m. with the Administrator, he stated that he was not aware that there were problems with the facility's DNR/code status process and was not aware of MD B recommendations about instituting and updating the process of code status information for all residents in the facility. He further said that whatever MD B said to the Social Services Director E was between both of them only, that he was not aware of any recommendations given by MD B and that he was not aware of the list that MD B had been requesting from the facility since 2 weeks ago. Administrator continued saying that he believed that the only mistake LVN A did was not to check that the DNR form of CR #2 was not completely signed by the MD and that CR #2 was still a Full Code. Administrator further said that after CR #2 expired, one of the MDS nurses realized that the CR #2's DNR was not signed by the MD and that CR #2 was supposed to be a full code status and that the MDS nurse then placed the white paper that read Full Code in the front of CR #2's chart. Administrator further said that he was not made aware of the error until surveyor's arrival to the facility. In an interview on [DATE] at 3:05 p.m. with Social Services Director E, he stated that when he arrived to the facility, he started working on a system to identify residents' code status and that the assignment given by MD B has been completed already. Social Services Director E further said that he did not remember working with the code status documentation of CR #2 and that nurses should know that until all the elements are in place, the residents are considered a full code status. Social Services Director E continued saying that the current process to verify code status was that upon admission, facility is supposed to verify the code status during the morning meetings for all new admissions and that for residents who are long term in the facility, the code status was revised during the quarterly care conference meeting by the IDT members. When surveyor asked Social Services Director E if CR#2's code status was revised on [DATE] during the resident/family conference IDT meeting, he stated as he looked at the IDT notes I don't remember seeing the DNR documents or talking about the code status for CR#2 in last meeting, she was due again this week for care conference. Record review of facility's policy and procedure, Medical Emergency Management , revised [DATE] read in part: The facility ensures residents receive timely and appropriate intervention in the event of a medical emergency. Record review of facility policy, Advance Directives read in part, .6. The facility must document in a prominent part of the resident's clinical record whether the resident has issued an advance directive Record review of the facility abuse and neglect prohibition policy, revised [DATE], read in part: .Neglect means failure to provide goods and services necessary to avoid physical harm .: An IJ was identified on [DATE] at 1:55 pm and the Administrator was informed at that time. The POR was accepted on [DATE] at ¿¿¿¿¿¿4:30 p.m. The POR included: Code Status Review On [DATE] staff initiated the process of reviewing the medical records of all residents to determine their code status to include any new admissions the facility receives. This review of medical records was completed on [DATE]. At this point the staff has determined that 100 residents have been identified as full code status. Any resident identified not to have clear code status orders have had families or resident contacted for clarification of the resident's code status. During this review we identified the following issues regarding resident code status: Station 1 · (resident name) is a DNR; the physicians order was correct. A red sheet with the words DNR was added to the front of the chart. · (resident name) is a DNR; the physician order [REDACTED]. · (resident name) is full, the physician order [REDACTED]. Station 2 · (resident name) was changed to a DNR from full code; the resident's order was correct; but the directive flash sheet had a comment stating CPR for 90 seconds only. The resident's physician was here and discussed code status with the responsible party. The RP decided to change the code status to DNR. Station 3 · The following residents listed below had the green sheet with the words Full Code in front of the chart, but did not have a current code status order for full code. The nursing staff received clarification orders to update each of the resident's code status as Full Code: (10 resident names) · (resident name) resident had his red sheet with the word DNR properly signed but there was no physicians order for the DNR. The nursing staff received an order for [REDACTED].>The above corrections for residents on stations 1, 2, And 3 were completed on [DATE]. The resident's physician wrote new orders and/or the physician was contacted for clarification orders of code status. Licensed nursing staff have assured that the medical records of all residents clearly identifies those residents who wish to be fully resuscitated in the event of a code and those residents who do not wish to be resuscitated in the event of a code. The licensed nurses checked for the most current physicians orders regarding the resident ' s code status. This was completed on [DATE]. The Administrator or designee will conduct admission audits within ,[DATE] hours after admission. On [DATE] the facility established a new system whereby the code status of all residents will be maintained in a binder at each nursing station. This will help expedite care to a coding resident by allowing staff to quickly and accurately identify the code status of the resident. During a code situation, licensed staff will attend to the affected resident and either provide life saving measures if the resident is a full code or comfort measures if the resident has a DNR order. Then nurse will engage the call light in the resident's room. The licensed staff will remain with the coding resident and call for assistance from available staff at the nursing station who will relay the code status of the resident to the licensed staff and retrieve the crash cart and deliver it to the affected residents room and then initiate calling emergency services and family/responsible party/guardian as appropriate. Beginning on [DATE] the Staff Development Coordinator is in the process of re-educating the nursing staff regarding the facility's policies related to advanced directives. This training included the following: The nurses have been re-educated that the most current physician's orders [REDACTED]. During the discussion nurses were reminded of the importance of assuring that residents who are full code and found to be without heartbeat or respirations will have CPR initiated immediately and emergency personnel will be notified. The licensed nurse who is the first responder will resuscitate those residents who are identified as full code in the event of a code. Staff who respond to the code will ensure that emergency service personnel is called and resuscitation for full code residents is continued until the resident is resuscitated or emergency services personnel responds and takes over the code. As of [DATE] nursing staff who are schedule to work have been provided this training and the training will be on-going to ensure that all scheduled nursing staff have attended the training prior to working their next shift. Licensed staff are qualified to perform CPR in the event life sustaining measures are required. On [DATE] an ad hoc subcommittee of the Quality Assurance and Assessment Committee met to discuss and approve the pan with the Medical Director. The Medical Director approved the plan. The surveyor confirmed the POR had been implemented sufficiently to remove the IJ by: Record Review of the In-Service sign-in sheet revealed that nursing staff representing all three shifts had been in-serviced from [DATE] to [DATE]. The topics included, using the call bell system to call for assistance during emergencies, verification of the code status of the residents and initiation of emergency services. Interviews conducted from [DATE] - [DATE] with nursing staff revealed staff was able to verbalize the information from the recent in-services such as identifying code status by checking binder at each nursing station. In an interview on [DATE] at 12:25 pm, LVN A stated the staff had been trained to check a resident's code status by looking at the first sheet of the resident's chart, verify the Physician orders, verify that if a resident is DNR, that all signatures are in place and to check a binder which was located at the nurse's station. The Administrator and DON were informed on [DATE], at 2:37 p.m. that the IJ was lowered; however the facility remained out of compliance at a isolated level and a severity of actual harm that is not an IJ to resident health or safety due to facility needing more time to train the staff. According to the DON, there were 100 residents on full code status.

Based on record review and interview, the facility failed to implement their written policy that prohibited neglect for 1 of 7 residents (CR #2) reviewed for neglect, as evidenced by: -LVN A did not provide CPR to CR #2 who was found without a pulse or blood pressure on [DATE] due to confusing documentation on CR #2's chart. -Facility failed to have a clear method to identify residents who required lifesaving measures. -CR #2 died later on the day. An IJ was identified on [DATE], while the IJ was lowered on [DATE],the facility remained out of compliance at a scope of isolated and severity level of actual harm because all staff had not been trained on identifying residents' code status in a timely manner in an event of an emergency. This failure affected one CR and placed 100 residents on full code status at risk of not being provided medical care and services as needed/identified. Findings included: Record review of the facility abuse and neglect prohibition policy, revised [DATE], read in part: .Neglect means failure to provide goods and services necessary to avoid physical harm .: Review of CR #2's record revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of CR #2's chart revealed a white front page with bolded one inch letters that read FULL CODE . Record review of CR #2's Out-of-hospital Do-Not-Resuscitate form revealed signature dated [DATE] by Responsible Party and signed by 2 witnesses dated [DATE]. Further record review revealed no signature by the MD. Record review of CR #2's care plan dated [DATE] and last revised [DATE] revealed in part: CR #2 is a full code. Goal. Resident/family wishes will be honored for 90 days. Record review of CR #2's Resident/family conference notes dated [DATE] revealed no information related to current condition of resident or code status. Record review of CR #2's physician's orders [REDACTED]. Record review of CR #2's MD Progress notes dated [DATE] revealed in part: Code status: Attempt Resuscitation (CPR). Record review of CR #2's quarterly MDS with an assessment reference date [DATE] revealed she had short and long term memory problem and was unable to complete the Brief Interview for Mental Status due to rarely/never understood. Further record review revealed that she required total assistance for bed mobility, dressing, personal hygiene and bathing and supervision and assistance of one person with eating. Her assessment noted she did not have weight loss and was not on a physician prescribed weight loss regimen. CR#2 weighed 135 pounds and measured 65 inches in height. Record review of CR #2's SBAR Communication form dated [DATE] revealed in part: -Background: Vital Signs: Blood Pressure: no reading. Pulse: no reading. Respirations: 24. Temperature 94 degrees Fahrenheit. 1.- Mental Status Changes: Unresponsiveness. Non-verbal-lethargic without stimuli. 3.- Respiratory: Shortness of breath. Respiratory labored. Advance Care Planning information: Do Not Resuscitate. -Nursing Notes: . In CR #2's room to administer her medications. She is pale. Cold. Respirations 24. Head of bed up, oxygen administered. Respirations low. MD B called. No answer from Nurse Practitioner. Family called and informed of condition of CR #2. Stated don't send out to hospital, I want to come and see her. Arrived. Able to observed her mother. Non-responsive. RN back to pronounce resident's condition. CR #2 left at 10:35 a.m. via funeral home. DON notified. Record review of CR #2's nurses notes dated [DATE] at 8:50 a.m. and signed by RN C revealed in part: I verify that CR #2 expired on [DATE] at 8:50 a.m. In an interview on [DATE] at 12:58 p.m. with the DON, she stated that CR #2 had a change in condition over the weekend. She further said I think she was on hospice but probably she was not, let me see the chart. Continued interview and observation, DON stated as she looked at CR #2's chart she was non-verbal, lethargic. I think she just die because when they went to see her, she was pale and they administered oxygen. When asked about the code status of CR #2, the DON stated She was full code, let me see if they updated her DNR. Further interview and observation at that time, while DON read the partially completed CR #2's DNR form, she stated form needs to be signed by the family and MD. MD did not sign it. In an interview on [DATE] at 1:05 p.m. LVN A stated that she was the nurse for CR #2 the day she died . LVN A said that she was going to administer medications to CR #2 on [DATE] at 7:45 a.m. and when she entered the room, CR #2 was different her eyes had a staring look. LVN A further said that she tried calling her name and that CR #2 did not respond and that she tried to take her vital signs and that she first used an electronic blood pressure cuff and that she did not like the reading she got, but did not remember what was the reading. She continued saying that she then went to get the manual blood pressure cuff and that she was not able to get a blood pressure reading and that she tried to get CR #2's pulse and did not get a pulse either. She continued saying that she noticed CR #2 had labored breathing and gave her oxygen (did not remember how many liters). LVN A further said that at that time she went out of the room to the nursing station to try to call the Nurse Practitioner but did not answer (left message only), she then tried to call MD B and did not respond and that she then called CR #2's Responsible Party and that she notified her that CR #2 had a change in her condition and asked permission to send CR #2 to the hospital. LVN A continued saying that CR #2's Responsible Party said No, I will be there as soon as I can. LVN A further said that when the Responsible Party arrived at the facility, CR #2 was already deceased . When surveyor asked LVN A if anyone had stayed with CR #2 while she went outside to make the phone calls, she stated that she believed she told a C.N.A. to stay with CR #2 but did not remember who was the C.N.A. LVN A continued saying that CR #2 was DNR status. In an interview on [DATE] at 1:25 p.m. with the DON, she stated that CR #2's DNR form was incomplete and that the MD did not get to sign it and that CR #2 should had been considered a full code status. In a second interview on [DATE] at 1:45 p.m. with LVN A, when asked if Responsible Party was made aware that CR #2 had no blood pressure or pulse and that she was with labored breathing, LVN A stated No, I just told the family that CR #2 was not looking good and then she told me not to send her to the hospital, that she was going to be in the facility as soon as possible. I did not let her know the current condition of CR #2 because the family member might have a [MEDICAL CONDITION] herself. LVN A continued saying that she then went and got RN C to pronounce CR #2 dead. Further interview with LVN A, surveyor asked LVN A if she had noticed a white paper in the front of the chart of CR #2 that read FULL CODE. LVN A stated as she opened the chart's front page I believe there was a red paper that said DNR. I did not see this white paper that read FULL CODE, unless I looked at somebody else's chart. When asked if she checked CR #2's MD orders to verify the code status, LVN A responded No, I did not. LVN A continued saying that CR #2 did not receive any life saving measures because as far as she knew, CR #2 was DNR. In an interview on [DATE] at 2:05 p.m. with RN C, she stated that LVN A called her into the room of CR #2 on [DATE] just to pronounce her dead. She continued saying I went to see CR #2 because LVN A said that CR #2 was dead and that I needed to pronounced her dead. She further stated that when she entered the room, CR #2 was alone in the room and that she checked CR #2 for pulse with a stethoscope and that CR #2 had no heart beat, no blood pressure and no respirations. When asked if she verified the code status of CR #2 on the chart, RN C stated I saw the chart because I wrote the nursing notes, but I did not verify CR #2's code status. RN C continued saying that if a resident is a full code status, CPR needs to be started immediately and call 911. RN C further said that when residents are full code they are supposed to have a green paper in the front of the chart that reads full code and if residents are DNR, they are supposed to have a red paper in front of the chart that reads DNR. In an interview on [DATE] at 2:20 p.m. with RN D, she stated that when CR #2 expired, LVN A called her to CR #2's room to help her pronounce her dead and she was notified by LVN A that CR #2 was DNR. In continued interview, RN D said that RN C and herself went to the room of CR #2 and found her alone in her room and that upon assessment, CR #2 had no pulse or blood pressure and that both RN's pronounced CR #2 dead. When asked if she checked CR #2's chart to verify code status, she stated No, I did not, LVN A told us that CR #2 was DNR. In an interview on [DATE] at 2:30 p.m. with the DON, when asked who was in charge of updating the code status of the residents and verify that the documentation is clear to the staff in an event of an emergency, the DON replied I really don't know, it is not my department. The Social Services Director is in charge of that but he is not here and I have tried to get hold of him but he is not answering. The DON continued saying CR #2 was still a full code and then when the DNR gets completed and signed by the MD, then we need to change the physician orders. We should had been able to obtain the MD signature timely. The current DNR looks too old. I don't know what made them stop and not to continue (paper work process). CR #2 should had been treated as a full code. In an interview on [DATE] at 3:09 p.m. with MD B, she stated she was the Medical Director for the facility and the MD for CR #2 and said that she believed she had signed before a DNR for CR #2 but did not remember when. She further stated that she signed the Physician orders [REDACTED]. MD B continued saying that the mission of the Social Service Director not long ago was to check everybody's code status I gave the mission to the Social Service Director, we were on the process of instituting and updating the process of DNR information. I have requested a list of DNR residents within the last couple of weeks and have not been provided one yet. The information was brought up during our high risk meeting. I wanted the Social Service Director to match the DNR status with a red paper copy in the chart and then to make a list for me. In the last meeting I had I asked them about it. When asked MD B about the white paper in front of the chart of CR #2 that read FULL CODE, MD B stated I don't know where it came from. This is exactly why I told them that. Code status used to be up to date but not anymore. Facility is supposed to know who is DNR in the facility and make sure is obvious and clear. They are supposed to be able to look quick during an emergency. They need to get it fix quick and show me that is fix. They did not have the process in place. There is a system failure that needs to be fix related to which residents are DNR and which are Full Code. I had addressed it already 2 weeks ago and asked them for a list and what I expect from the facility is that they fix the problems as they go along with the list. I still have not received the list. In an interview on [DATE] at 4:10 p.m. with MD B and DON, the DON stated that facility has completed the list for MD B only for stations 1 and 2 but still needed to complete station 3. She further stated that CR #2 was on station 3. MD B further said lot of this is probably that we weren't verifying the MD orders that were being printed out every month. We need to get everybody train. DON continued saying We are doing a full check on all residents' charts who are in the facility. In a second interview with the DON on [DATE] at 2:02 p.m. she stated that IDT members had already discussed in the last high risk meeting on [DATE] that facility had problems with DNR/code status process, that was not in place for all residents and further said that the facility was in the process of updating them. DON continued saying that nurses were supposed to check on the front of the chart for the code status of the residents during an emergency and verify information by checking the Physician orders [REDACTED].#2's chart and did not completely verify that the DNR was not completely signed or verify orders by the MD. Record review of the facility's inservice record for July, August and [DATE] revealed no training related to code status. In an interview on [DATE] at 2:34 p.m. with the Administrator, he stated that he was not aware that there were problems with the facility's DNR/code status process and was not aware of MD B recommendations about instituting and updating the process of code status information for all residents in the facility. He further said that whatever MD B said to the Social Services Director E was between both of them only, that he was not aware of any recommendations given by MD B and that he was not aware of the list that MD B had been requesting from the facility since 2 weeks ago. Administrator continued saying that he believed that the only mistake LVN A did was not to check that the DNR form of CR #2 was not completely signed by the MD and that CR #2 was still a Full Code. Administrator further said that after CR #2 expired, one of the MDS nurses realized that the CR #2's DNR was not signed by the MD and that CR #2 was supposed to be a full code status and that the MDS nurse then placed the white paper that read Full Code in the front of CR #2's chart. Administrator further said that he was not made aware of the error until surveyor's arrival to the facility. In an interview on [DATE] at 3:05 p.m. with Social Services Director E, he stated that when he arrived to the facility, he started working on a system to identify residents' code status and that the assignment given by MD B has been completed already. Social Services Director E further said that he did not remember working with the code status documentation of CR #2 and that nurses should know that until all the elements are in place, the residents are considered a full code status. Social Services Director E continued saying that the current process to verify code status was that upon admission, facility is supposed to verify the code status during the morning meetings for all new admissions and that for residents who are long term in the facility, the code status was revised during the quarterly care conference meeting by the IDT members. When surveyor asked Social Services Director E if CR#2's code status was revised on [DATE] during the resident/family conference IDT meeting, he stated as he looked at the IDT notes I don't remember seeing the DNR documents or talking about the code status for CR#2 in last meeting, she was due again this week for care conference. Record review of facility's policy and procedure, Medical Emergency Management , revised [DATE] read in part: The facility ensures residents receive timely and appropriate intervention in the event of a medical emergency. Record review of facility policy, Advance Directives read in part, .6. The facility must document in a prominent part of the resident's clinical record whether the resident has issued an advance directive An IJ was identified on [DATE] at 1:55 pm and the Administrator was informed at that time. The POR was accepted on [DATE] at ¿¿¿¿¿¿¿¿¿¿¿¿4:30 p.m. The POR included: Code Status Review On [DATE] staff initiated the process of reviewing the medical records of all residents to determine their code status to include any new admissions the facility receives. This review of medical records was completed on [DATE]. At this point the staff has determined that 100 residents have been identified as full code status. Any resident identified not to have clear code status orders have had families or resident contacted for clarification of the resident's code status. During this review we identified the following issues regarding resident code status: Station 1 · (resident name) is a DNR; the physicians order was correct. A red sheet with the words DNR was added to the front of the chart. · (resident name) is a DNR; the physician order [REDACTED]. · (resident name) is full, the physician order [REDACTED]. Station 2 · (resident name) was changed to a DNR from full code; the resident ' s order was correct; but the directive flash sheet had a comment stating CPR for 90 seconds only. The resident's physician was here and discussed code status with the responsible party. The RP decided to change the code status to DNR. Station 3 · The following residents listed below had the green sheet with the words Full Code in front of the chart, but did not have a current code status order for full code. The nursing staff received clarification orders to update each of the resident ' s code status as Full Code: (10 resident names) · (resident name) resident had his red sheet with the word DNR properly signed but there was no physicians order for the DNR. The nursing staff received an order for [REDACTED].>The above corrections for residents on stations 1, 2, And 3 were completed on [DATE]. The resident's physician wrote new orders and/or the physician was contacted for clarification orders of code status. Licensed nursing staff have assured that the medical records of all residents clearly identifies those residents who wish to be fully resuscitated in the event of a code and those residents who do not wish to be resuscitated in the event of a code. The licensed nurses checked for the most current physicians orders regarding the resident ' s code status. This was completed on [DATE]. The Administrator or designee will conduct admission audits within ,[DATE] hours after admission. On [DATE] the facility established a new system whereby the code status of all residents will be maintained in a binder at each nursing station. This will help expedite care to a coding resident by allowing staff to quickly and accurately identify the code status of the resident. During a code situation, licensed staff will attend to the affected resident and either provide life saving measures if the resident is a full code or comfort measures if the resident has a DNR order. Then nurse will engage the call light in the resident's room. The licensed staff will remain with the coding resident and call for assistance from available staff at the nursing station who will relay the code status of the resident to the licensed staff and retrieve the crash cart and deliver it to the affected residents room and then initiate calling emergency services and family/responsible party/guardian as appropriate. Beginning on [DATE] the Staff Development Coordinator is in the process of re-educating the nursing staff regarding the facility's policies related to advanced directives. This training included the following: The nurses have been re-educated that the most current physician's orders [REDACTED]. During the discussion nurses were reminded of the importance of assuring that residents who are full code and found to be without heartbeat or respirations will have CPR initiated immediately and emergency personnel will be notified. The licensed nurse who is the first responder will resuscitate those residents who are identified as full code in the event of a code. Staff who respond to the code will ensure that emergency service personnel is called and resuscitation for full code residents is continued until the resident is resuscitated or emergency services personnel responds and takes over the code. As of [DATE] nursing staff who are schedule to work have been provided this training and the training will be on-going to ensure that all scheduled nursing staff have attended the training prior to working their next shift. Licensed staff are qualified to perform CPR in the event life sustaining measures are required. On [DATE] an ad hoc subcommittee of the Quality Assurance and Assessment Committee met to discuss and approve the pan with the Medical Director. The Medical Director approved the plan. The surveyor confirmed the POR had been implemented sufficiently to remove the IJ by: Record Review of the In-Service sign-in sheet revealed that nursing staff representing all three shifts had been in-serviced from [DATE] to [DATE]. The topics included, using the call bell system to call for assistance during emergencies, verification of the code status of the residents and initiation of emergency services. Interviews conducted from [DATE] - [DATE] with nursing staff revealed staff was able to verbalize the information from the recent in-services such as identifying code status by checking binder at each nursing station. In an interview on [DATE] at 12:25 pm, LVN A stated the staff had been trained to check a resident's code status by looking at the first sheet of the resident's chart, verify the Physician orders, verify that if a resident is DNR, that all signatures are in place and to check a binder which was located at the nurse's station. The Administrator and DON were informed on [DATE], at 2:37 p.m. that the IJ was lowered; however the facility remained out of compliance at a isolated level and a severity of actual harm that is not an IJ to resident health or safety due to facility needing more time to train the staff. According to the DON, there were 100 residents on full code status.

Based on record review and interview, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being in accordance with the care plan and comprehensive assessment, for 1 of 7 residents (CR #2) reviewed for compliance, as evidenced by: -LVN A did not provide CPR to CR #2 who was found without a pulse or blood pressure on [DATE] due to confusing documentation on CR #2's chart. -Facility failed to have a clear method to identify residents who required lifesaving measures. -CR #2 died later on the day. An IJ was identified on [DATE], while the IJ was lowered on [DATE],the facility remained out of compliance at a scope of isolated and severity level of actual harm because all staff had not been trained on identifying residents' code status in a timely manner in an event of an emergency. This failure affected one CR and placed 100 residents on full code status at risk of not being provided medical care and services as needed/identified. Findings include: Review of CR #2's record revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of CR #2's chart revealed a white front page with bolded one inch letters that read FULL CODE . Record review of CR #2's Out-of-hospital Do-Not-Resuscitate form revealed signature dated [DATE] by Responsible Party and signed by 2 witnesses dated [DATE]. Further record review revealed no signature by the MD. Record review of CR #2's care plan dated [DATE] and last revised [DATE] revealed in part: CR #2 is a full code. Goal. Resident/family wishes will be honored for 90 days. Record review of CR #2's Resident/family conference notes dated [DATE] revealed no information related to current condition of resident or code status. Record review of CR #2's physician's orders [REDACTED]. Record review of CR #2's MD Progress notes dated [DATE] revealed in part: Code status: Attempt Resuscitation (CPR). Record review of CR #2's quarterly MDS with an assessment reference date [DATE] revealed she had short and long term memory problem and was unable to complete the Brief Interview for Mental Status due to rarely/never understood. Further record review revealed that she required total assistance for bed mobility, dressing, personal hygiene and bathing and supervision and assistance of one person with eating. Her assessment noted she did not have weight loss and was not on a physician prescribed weight loss regimen. CR#2 weighed 135 pounds and measured 65 inches in height. Record review of CR #2's SBAR Communication form dated [DATE] revealed in part: -Background: Vital Signs: Blood Pressure: no reading. Pulse: no reading. Respirations: 24. Temperature 94 degrees Fahrenheit. 1.- Mental Status Changes: Unresponsiveness. Non-verbal-lethargic without stimuli. 3.- Respiratory: Shortness of breath. Respiratory labored. Advance Care Planning information: Do Not Resuscitate. -Nursing Notes: . In CR #2's room to administer her medications. She is pale. Cold. Respirations 24. Head of bed up, oxygen administered. Respirations low. MD B called. No answer from Nurse Practitioner. Family called and informed of condition of CR #2. Stated don't send out to hospital, I want to come and see her. Arrived. Able to observed her mother. Non-responsive. RN back to pronounce resident's condition. CR #2 left at 10:35 a.m. via funeral home. DON notified. Record review of CR #2's nurses notes dated [DATE] at 8:50 a.m. and signed by RN C revealed in part: I verify that CR #2 expired on [DATE] at 8:50 a.m. In an interview on [DATE] at 12:58 p.m. with the DON, she stated that CR #2 had a change in condition over the weekend. She further said I think she was on hospice but probably she was not, let me see the chart. Continued interview and observation, DON stated as she looked at CR #2's chart she was non-verbal, lethargic. I think she just die because when they went to see her, she was pale and they administered oxygen. When asked about the code status of CR #2, the DON stated She was full code, let me see if they updated her DNR. Further interview and observation at that time, while DON read the partially completed CR #2's DNR form, she stated form needs to be signed by the family and MD. MD did not sign it. In an interview on [DATE] at 1:05 p.m. LVN A stated that she was the nurse for CR #2 the day she died . LVN A said that she was going to administer medications to CR #2 on [DATE] at 7:45 a.m. and when she entered the room, CR #2 was different her eyes had a staring look. LVN A further said that she tried calling her name and that CR #2 did not respond and that she tried to take her vital signs and that she first used an electronic blood pressure cuff and that she did not like the reading she got, but did not remember what was the reading. She continued saying that she then went to get the manual blood pressure cuff and that she was not able to get a blood pressure reading and that she tried to get CR #2's pulse and did not get a pulse either. She continued saying that she noticed CR #2 had labored breathing and gave her oxygen (did not remember how many liters). LVN A further said that at that time she went out of the room to the nursing station to try to call the Nurse Practitioner but did not answer (left message only), she then tried to call MD B and did not respond and that she then called CR #2's Responsible Party and that she notified her that CR #2 had a change in her condition and asked permission to send CR #2 to the hospital. LVN A continued saying that CR #2's Responsible Party said No, I will be there as soon as I can. LVN A further said that when the Responsible Party arrived at the facility, CR #2 was already deceased . When surveyor asked LVN A if anyone had stayed with CR #2 while she went outside to make the phone calls, she stated that she believed she told a C.N.A. to stay with CR #2 but did not remember who was the C.N.A. LVN A continued saying that CR #2 was DNR status. In an interview on [DATE] at 1:25 p.m. with the DON, she stated that CR #2's DNR form was incomplete and that the MD did not get to sign it and that CR #2 should had been considered a full code status. In a second interview on [DATE] at 1:45 p.m. with LVN A, when asked if Responsible Party was made aware that CR #2 had no blood pressure or pulse and that she was with labored breathing, LVN A stated No, I just told the family that CR #2 was not looking good and then she told me not to send her to the hospital, that she was going to be in the facility as soon as possible. I did not let her know the current condition of CR #2 because the family member might have a [MEDICAL CONDITION] herself. LVN A continued saying that she then went and got RN C to pronounce CR #2 dead. Further interview with LVN A, surveyor asked LVN A if she had noticed a white paper in the front of the chart of CR #2 that read FULL CODE. LVN A stated as she opened the chart's front page I believe there was a red paper that said DNR. I did not see this white paper that read FULL CODE, unless I looked at somebody else's chart. When asked if she checked CR #2's MD orders to verify the code status, LVN A responded No, I did not. LVN A continued saying that CR #2 did not receive any life saving measures because as far as she knew, CR #2 was DNR. In an interview on [DATE] at 2:05 p.m. with RN C, she stated that LVN A called her into the room of CR #2 on [DATE] just to pronounce her dead. She continued saying I went to see CR #2 because LVN A said that CR #2 was dead and that I needed to pronounced her dead. She further stated that when she entered the room, CR #2 was alone in the room and that she checked CR #2 for pulse with a stethoscope and that CR #2 had no heart beat, no blood pressure and no respirations. When asked if she verified the code status of CR #2 on the chart, RN C stated I saw the chart because I wrote the nursing notes, but I did not verify CR #2's code status. RN C continued saying that if a resident is a full code status, CPR needs to be started immediately and call 911. RN C further said that when residents are full code they are supposed to have a green paper in the front of the chart that reads full code and if residents are DNR, they are supposed to have a red paper in front of the chart that reads DNR. In an interview on [DATE] at 2:20 p.m. with RN D, she stated that when CR #2 expired, LVN A called her to CR #2's room to help her pronounce her dead and she was notified by LVN A that CR #2 was DNR. In continued interview, RN D said that RN C and herself went to the room of CR #2 and found her alone in her room and that upon assessment, CR #2 had no pulse or blood pressure and that both RN's pronounced CR #2 dead. When asked if she checked CR #2's chart to verify code status, she stated No, I did not, LVN A told us that CR #2 was DNR. In an interview on [DATE] at 2:30 p.m. with the DON, when asked who was in charge of updating the code status of the residents and verify that the documentation is clear to the staff in an event of an emergency, the DON replied I really don't know, it is not my department. The Social Services Director is in charge of that but he is not here and I have tried to get hold of him but he is not answering. The DON continued saying CR #2 was still a full code and then when the DNR gets completed and signed by the MD, then we need to change the physician orders. We should had been able to obtain the MD signature timely. The current DNR looks too old. I don't know what made them stop and not to continue (paper work process). CR #2 should had been treated as a full code. In an interview on [DATE] at 3:09 p.m. with MD B, she stated she was the Medical Director for the facility and the MD for CR #2 and said that she believed she had signed before a DNR for CR #2 but did not remember when. She further stated that she signed the Physician orders [REDACTED]. MD B continued saying that the mission of the Social Service Director not long ago was to check everybody's code status I gave the mission to the Social Service Director, we were on the process of instituting and updating the process of DNR information. I have requested a list of DNR residents within the last couple of weeks and have not been provided one yet. The information was brought up during our high risk meeting. I wanted the Social Service Director to match the DNR status with a red paper copy in the chart and then to make a list for me. In the last meeting I had I asked them about it. When asked MD B about the white paper in front of the chart of CR #2 that read FULL CODE, MD B stated I don't know where it came from. This is exactly why I told them that. Code status used to be up to date but not anymore. Facility is supposed to know who is DNR in the facility and make sure is obvious and clear. They are supposed to be able to look quick during an emergency. They need to get it fix quick and show me that is fix. They did not have the process in place. There is a system failure that needs to be fix related to which residents are DNR and which are Full Code. I had addressed it already 2 weeks ago and asked them for a list and what I expect from the facility is that they fix the problems as they go along with the list. I still have not received the list. In an interview on [DATE] at 4:10 p.m. with MD B and DON, the DON stated that facility has completed the list for MD B only for stations 1 and 2 but still needed to complete station 3. She further stated that CR #2 was on station 3. MD B further said lot of this is probably that we weren't verifying the MD orders that were being printed out every month. We need to get everybody train. DON continued saying We are doing a full check on all residents' charts who are in the facility. In a second interview with the DON on [DATE] at 2:02 p.m. she stated that IDT members had already discussed in the last high risk meeting on [DATE] that facility had problems with DNR/code status process, that was not in place for all residents and further said that the facility was in the process of updating them. DON continued saying that nurses were supposed to check on the front of the chart for the code status of the residents during an emergency and verify information by checking the Physician orders [REDACTED].#2's chart and did not completely verify that the DNR was not completely signed or verify orders by the MD. Record review of the facility's inservice record for July, August and [DATE] revealed no training related to code status. In an interview on [DATE] at 2:34 p.m. with the Administrator, he stated that he was not aware that there were problems with the facility's DNR/code status process and was not aware of MD B recommendations about instituting and updating the process of code status information for all residents in the facility. He further said that whatever MD B said to the Social Services Director E was between both of them only, that he was not aware of any recommendations given by MD B and that he was not aware of the list that MD B had been requesting from the facility since 2 weeks ago. Administrator continued saying that he believed that the only mistake LVN A did was not to check that the DNR form of CR #2 was not completely signed by the MD and that CR #2 was still a Full Code. Administrator further said that after CR #2 expired, one of the MDS nurses realized that the CR #2's DNR was not signed by the MD and that CR #2 was supposed to be a full code status and that the MDS nurse then placed the white paper that read Full Code in the front of CR #2's chart. Administrator further said that he was not made aware of the error until surveyor's arrival to the facility. In an interview on [DATE] at 3:05 p.m. with Social Services Director E, he stated that when he arrived to the facility, he started working on a system to identify residents' code status and that the assignment given by MD B has been completed already. Social Services Director E further said that he did not remember working with the code status documentation of CR #2 and that nurses should know that until all the elements are in place, the residents are considered a full code status. Social Services Director E continued saying that the current process to verify code status was that upon admission, facility is supposed to verify the code status during the morning meetings for all new admissions and that for residents who are long term in the facility, the code status was revised during the quarterly care conference meeting by the IDT members. When surveyor asked Social Services Director E if CR#2's code status was revised on [DATE] during the resident/family conference IDT meeting, he stated as he looked at the IDT notes I don't remember seeing the DNR documents or talking about the code status for CR#2 in last meeting, she was due again this week for care conference. Record review of facility's policy and procedure, Medical Emergency Management , revised [DATE] read in part: The facility ensures residents receive timely and appropriate intervention in the event of a medical emergency. Record review of facility policy, Advance Directives read in part, .6. The facility must document in a prominent part of the resident's clinical record whether the resident has issued an advance directive Record review of the facility abuse and neglect prohibition policy, revised [DATE], read in part: .Neglect means failure to provide goods and services necessary to avoid physical harm .: An IJ was identified on [DATE] at 1:55 pm and the Administrator was informed at that time. The POR was accepted on [DATE] at ¿¿¿¿¿¿¿¿¿¿¿¿4:30 p.m. The POR included: Code Status Review On [DATE] staff initiated the process of reviewing the medical records of all residents to determine their code status to include any new admissions the facility receives. This review of medical records was completed on [DATE]. At this point the staff has determined that 100 residents have been identified as full code status. Any resident identified not to have clear code status orders have had families or resident contacted for clarification of the resident's code status. During this review we identified the following issues regarding resident code status: Station 1 · (resident name) is a DNR; the physicians order was correct. A red sheet with the words DNR was added to the front of the chart. · (resident name) is a DNR; the physician order [REDACTED]. · (resident name) is full, the physician order [REDACTED]. Station 2 · (resident name) was changed to a DNR from full code; the resident's order was correct; but the directive flash sheet had a comment stating CPR for 90 seconds only. The resident's physician was here and discussed code status with the responsible party. The RP decided to change the code status to DNR. Station 3 · The following residents listed below had the green sheet with the words Full Code in front of the chart, but did not have a current code status order for full code. The nursing staff received clarification orders to update each of the resident's code status as Full Code: (10 resident names) · (resident name) resident had his red sheet with the word DNR properly signed but there was no physicians order for the DNR. The nursing staff received an order for [REDACTED].>The above corrections for residents on stations 1, 2, And 3 were completed on [DATE]. The resident's physician wrote new orders and/or the physician was contacted for clarification orders of code status. Licensed nursing staff have assured that the medical records of all residents clearly identifies those residents who wish to be fully resuscitated in the event of a code and those residents who do not wish to be resuscitated in the event of a code. The licensed nurses checked for the most current physicians orders regarding the resident's code status. This was completed on [DATE]. The Administrator or designee will conduct admission audits within ,[DATE] hours after admission. On [DATE] the facility established a new system whereby the code status of all residents will be maintained in a binder at each nursing station. This will help expedite care to a coding resident by allowing staff to quickly and accurately identify the code status of the resident. During a code situation, licensed staff will attend to the affected resident and either provide life saving measures if the resident is a full code or comfort measures if the resident has a DNR order. Then nurse will engage the call light in the resident's room. The licensed staff will remain with the coding resident and call for assistance from available staff at the nursing station who will relay the code status of the resident to the licensed staff and retrieve the crash cart and deliver it to the affected residents room and then initiate calling emergency services and family/responsible party/guardian as appropriate. Beginning on [DATE] the Staff Development Coordinator is in the process of re-educating the nursing staff regarding the facility's policies related to advanced directives. This training included the following: The nurses have been re-educated that the most current physician's orders [REDACTED]. During the discussion nurses were reminded of the importance of assuring that residents who are full code and found to be without heartbeat or respirations will have CPR initiated immediately and emergency personnel will be notified. The licensed nurse who is the first responder will resuscitate those residents who are identified as full code in the event of a code. Staff who respond to the code will ensure that emergency service personnel is called and resuscitation for full code residents is continued until the resident is resuscitated or emergency services personnel responds and takes over the code. As of [DATE] nursing staff who are schedule to work have been provided this training and the training will be on-going to ensure that all scheduled nursing staff have attended the training prior to working their next shift. Licensed staff are qualified to perform CPR in the event life sustaining measures are required. On [DATE] an ad hoc subcommittee of the Quality Assurance and Assessment Committee met to discuss and approve the pan with the Medical Director. The Medical Director approved the plan. The surveyor confirmed the POR had been implemented sufficiently to remove the IJ by: Record Review of the In-Service sign-in sheet revealed that nursing staff representing all three shifts had been in-serviced from [DATE] to [DATE]. The topics included, using the call bell system to call for assistance during emergencies, verification of the code status of the residents and initiation of emergency services. Interviews conducted from [DATE] - [DATE] with nursing staff revealed staff was able to verbalize the information from the recent in-services such as identifying code status by checking binder at each nursing station. In an interview on [DATE] at 12:25 pm, LVN A stated the staff had been trained to check a resident's code status by looking at the first sheet of the resident's chart, verify the Physician orders, verify that if a resident is DNR, that all signatures are in place and to check a binder which was located at the nurse's station. The Administrator and DON were informed on [DATE], at 2:37 p.m. that the IJ was lowered; however the facility remained out of compliance at a isolated level and a severity of actual harm that is not an IJ to resident health or safety due to facility needing more time to train the staff. According to the DON, there were 100 residents on full code status.

Based on observation, interview and record review the Administrator and DON failed to administer the facility in a manner that adequately identified the code status of residents timely and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The Administrator failed to: -- implement the facility abuse, neglect, medical emergency and advanced directives policies to prevent neglect; -- develop and implement an effective system to determine a resident's code status timely so staff could immediately initiate CPR in the event of an emergency; --supervise the DON to ensure nursing staff completed timely assessments of unresponsive residents with full code status; --supervise the DON to ensure nursing staff provided CPR to a full code resident. The DON failed to: --monitor and supervise nursing staff competence in assessing unresponsive resident with full code status. --train staff to be able to identify residents' code status in a timely manner. -failed to ensure that correct residents' code status were up to date on the chart. An IJ was identified on [DATE], while the IJ was lowered on [DATE],the facility remained out of compliance at a scope of isolated and severity level of actual harm because all staff had not been trained on identifying residents' code status in a timely manner in an event of an emergency. This failure affected one CR and placed 118 current residents at risk of not having their final wishes carried out in the event of an emergency. Findings include: Review of CR #2's record revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Observation on [DATE] during initial tour from 8:40 a.m. to 9:52 a.m. revealed that CR #2 was not in the facility. In an interview on [DATE] at 12:58 p.m. with the DON, she stated that CR #2 had a change in condition over the weekend. She further said I think she was on hospice but probably she was not, let me see the chart. Continued interview and observation, DON stated as she looked at CR #2's chart she was non-verbal, lethargic. I think she just die because when they went to see her, she was pale and they administered oxygen. When asked about the code status of CR #2, the DON stated She was full code, let me see if they updated her DNR. Review of CR#2's Mortician's Receipt dated [DATE], revealed that the resident was released to the mortuary on [DATE] at 10:35 a.m. In an interview on ,[DATE] at 2:02 pm the DON was asked how did she think the IJ came about; she stated that she really did not know because LVN A told her that she saw something red in front of CR #2 ' s chart but did not verify the orders or noticed that the DNR that was on the chart was not completely singed so she could treat CR #2 as a full code. The DON further stated that IDT members had already discussed in the last high risk meeting on [DATE] that facility had problems with DNR/code status process, that was not in place for all residents and further said that the facility was in the process of updating them. DON continued saying that nurses were supposed to check on the front of the chart for the code status of the residents during an emergency and verify information by checking the Physician orders [REDACTED].#2 ' s chart and did not completely verify that the DNR was not completely signed or verify orders by the MD. In an interview on [DATE] at 2:34 pm, the Administrator was asked how did he think this IJ came about and he stated that he believed that the only mistake LVN A did was not to check that the DNR form of CR #2 was not completely signed by the MD and that CR #2 was still a Full Code. Administrator further said that after CR #2 expired, one of the MDS nurses realized that the CR #2's DNR was not signed by the MD and that CR #2 was supposed to be a full code status and that the MDS nurse then placed the white paper that read Full Code in the front of CR #2's chart. Administrator further said that he was not made aware of the error until surveyor's arrival to facility. Administrator continued saying that he was not aware that there were problems with the facility's DNR/code status process and was not aware of MD B recommendations of instituting and updating the process of code status information for all residents in the facility. He further said that whatever MD B said to Social Services Director E was between both of them only, that he was not aware of any recommendations given by MD B and that he was not aware of the list that MD B had been requesting from the facility since 2 weeks ago. Administrator continued saying that he supervised the DON by doing daily rounds including coming to the facility sometimes over the weekends, by monitoring the daily care tracker documentation, skin sheets and during daily morning meetings. Administrator further said that he monitored the training and inservices provided to facility staff. Record Review of the POS [REDACTED]. Plans, develops, directs, monitors and supports all operational, administrative, clinical, human resources, customer service and fiscal activities for the facility's programs and services. Essential duties and responsibilities: · Ensures the quality and appropriateness of resident/patient care meets or exceeds company and regulatory standards . Record Review of the POS [REDACTED]. Responsible for the overall direction, coordination and evaluation of nursing care and services provided to the residents. Ensures quality care that is consistent with company and regulatory standards Record review of CR #2's chart revealed a white front page with bolded one inch letters that read FULL CODE . Record review of CR #2's Out-of-hospital Do-Not-Resuscitate form revealed signature dated [DATE] by Responsible Party and signed by 2 witnesses dated [DATE]. Further record review revealed no signature by the MD. Record review of CR #2's care plan dated [DATE] and last revised [DATE] revealed in part: CR #2 is a full code. Goal. Resident/family wishes will be honored for 90 days. Record review of CR #2's Resident/family conference notes dated [DATE] revealed no information related to current condition of resident or code status. Record review of CR #2's physician's orders [REDACTED]. Record review of CR #2's MD Progress notes dated [DATE] revealed in part: Code status: Attempt Resuscitation (CPR). Record review of CR #2's SBAR Communication form dated [DATE] revealed in part: -Background: Vital Signs: Blood Pressure: no reading. Pulse: no reading. Respirations: 24. Temperature 94 degrees Fahrenheit. 1.- Mental Status Changes: Unresponsiveness. Non-verbal-lethargic without stimuli. 3.- Respiratory: Shortness of breath. Respiratory labored. Advance Care Planning information: Do Not Resuscitate. -Nursing Notes: . In CR #2's room to administer her medications. She is pale. Cold. Respirations 24. Head of bed up, oxygen administered. Respirations low. MD B called. No answer from Nurse Practitioner. Family called and informed of condition of CR #2. Stated don't send out to hospital, I want to come and see her. Arrived. Able to observed her mother. Non-responsive. RN back to pronounce resident's condition. CR #2 left at 10:35 a.m. via funeral home. DON notified. Record review of CR #2's nurses notes dated [DATE] at 8:50 a.m. and signed by RN C revealed in part: I verify that CR #2 expired on [DATE] at 8:50 a.m. In an interview on [DATE] at 12:58 p.m. with the DON, she stated that CR #2 had a change in condition over the weekend. She further said I think she was on hospice but probably she was not, let me see the chart. Continued interview and observation, DON stated as she looked at CR #2's chart she was non-verbal, lethargic. I think she just die because when they went to see her, she was pale and they administered oxygen. When asked about the code status of CR #2, the DON stated She was full code, let me see if they updated her DNR. Further interview and observation at that time, while DON read the partially completed CR #2's DNR form, she stated form needs to be signed by the family and MD. MD did not sign it. In an interview on [DATE] at 1:05 p.m. LVN A stated that she was the nurse for CR #2 the day she died . LVN A said that she was going to administer medications to CR #2 on [DATE] at 7:45 a.m. and when she entered the room, CR #2 was different her eyes had a staring look. LVN A further said that she tried calling her name and that CR #2 did not respond and that she tried to take her vital signs and that she first used an electronic blood pressure cuff and that she did not like the reading she got, but did not remember what was the reading. She continued saying that she then went to get the manual blood pressure cuff and that she was not able to get a blood pressure reading and that she tried to get CR #2's pulse and did not get a pulse either. She continued saying that she noticed CR #2 had labored breathing and gave her oxygen (did not remember how many liters). LVN A further said that at that time she went out of the room to the nursing station to try to call the Nurse Practitioner but did not answer (left message only), she then tried to call MD B and did not respond and that she then called CR #2's Responsible Party and that she notified her that CR #2 had a change in her condition and asked permission to send CR #2 to the hospital. LVN A continued saying that CR #2's Responsible Party said No, I will be there as soon as I can. LVN A further said that when the Responsible Party arrived at the facility, CR #2 was already deceased . When surveyor asked LVN A if anyone had stayed with CR #2 while she went outside to make the phone calls, she stated that she believed she told a C.N.A. to stay with CR #2 but did not remember who was the C.N.A. LVN A continued saying that CR #2 was DNR status. In an interview on [DATE] at 1:25 p.m. with the DON, she stated that CR #2's DNR form was incomplete and that the MD did not get to sign it and that CR #2 should had been considered a full code status. In a second interview on [DATE] at 1:45 p.m. with LVN A, when asked if Responsible Party was made aware that CR #2 had no blood pressure or pulse and that she was with labored breathing, LVN A stated No, I just told the family that CR #2 was not looking good and then she told me not to send her to the hospital, that she was going to be in the facility as soon as possible. I did not let her know the current condition of CR #2 because the family member might have a [MEDICAL CONDITION] herself. LVN A continued saying that she then went and got RN C to pronounce CR #2 dead. Further interview with LVN A, surveyor asked LVN A if she had noticed a white paper in the front of the chart of CR #2 that read FULL CODE. LVN A stated as she opened the chart's front page I believe there was a red paper that said DNR. I did not see this white paper that read FULL CODE, unless I looked at somebody else's chart. When asked if she checked CR #2's MD orders to verify the code status, LVN A responded No, I did not. LVN A continued saying that CR #2 did not receive any life saving measures because as far as she knew, CR #2 was DNR. In an interview on [DATE] at 2:05 p.m. with RN C, she stated that LVN A called her into the room of CR #2 on [DATE] just to pronounce her dead. She continued saying I went to see CR #2 because LVN A said that CR #2 was dead and that I needed to pronounced her dead. She further stated that when she entered the room, CR #2 was alone in the room and that she checked CR #2 for pulse with a stethoscope and that CR #2 had no heart beat, no blood pressure and no respirations. When asked if she verified the code status of CR #2 on the chart, RN C stated I saw the chart because I wrote the nursing notes, but I did not verify CR #2's code status. RN C continued saying that if a resident is a full code status, CPR needs to be started immediately and call 911. RN C further said that when residents are full code they are supposed to have a green paper in the front of the chart that reads full code and if residents are DNR, they are supposed to have a red paper in front of the chart that reads DNR. In an interview on [DATE] at 2:20 p.m. with RN D, she stated that when CR #2 expired, LVN A called her to CR #2's room to help her pronounce her dead and she was notified by LVN A that CR #2 was DNR. In continued interview, RN D said that RN C and herself went to the room of CR #2 and found her alone in her room and that upon assessment, CR #2 had no pulse or blood pressure and that both RN's pronounced CR #2 dead. When asked if she checked CR #2's chart to verify code status, she stated No, I did not, LVN A told us that CR #2 was DNR. In an interview on [DATE] at 2:30 p.m. with the DON, when asked who was in charge of updating the code status of the residents and verify that the documentation is clear to the staff in an event of an emergency, the DON replied I really don't know, it is not my department. The Social Services Director is in charge of that but he is not here and I have tried to get hold of him but he is not answering. The DON continued saying CR #2 was still a full code and then when the DNR gets completed and signed by the MD, then we need to change the physician orders. We should had been able to obtain the MD signature timely. The current DNR looks too old. I don't know what made them stop and not to continue (paper work process). CR #2 should had been treated as a full code. In an interview on [DATE] at 3:09 p.m. with MD B, she stated she was the Medical Director for the facility and the MD for CR #2 and said that she believed she had signed before a DNR for CR #2 but did not remember when. She further stated that she signed the Physician orders [REDACTED]. MD B continued saying that the mission of the Social Service Director not long ago was to check everybody's code status I gave the mission to the Social Service Director, we were on the process of instituting and updating the process of DNR information. I have requested a list of DNR residents within the last couple of weeks and have not been provided one yet. The information was brought up during our high risk meeting. I wanted the Social Service Director to match the DNR status with a red paper copy in the chart and then to make a list for me. In the last meeting I had I asked them about it. When asked MD B about the white paper in front of the chart of CR #2 that read FULL CODE, MD B stated I don't know where it came from. This is exactly why I told them that. Code status used to be up to date but not anymore. Facility is supposed to know who is DNR in the facility and make sure is obvious and clear. They are supposed to be able to look quick during an emergency. They need to get it fix quick and show me that is fix. They did not have the process in place. There is a system failure that needs to be fix related to which residents are DNR and which are Full Code. I had addressed it already 2 weeks ago and asked them for a list and what I expect from the facility is that they fix the problems as they go along with the list. I still have not received the list. In an interview on [DATE] at 4:10 p.m. with MD B and DON, the DON stated that facility has completed the list for MD B only for stations 1 and 2 but still needed to complete station 3. She further stated that CR #2 was on station 3. MD B further said lot of this is probably that we weren't verifying the MD orders that were being printed out every month. We need to get everybody train. DON continued saying We are doing a full check on all residents' charts who are in the facility. In a second interview with the DON on [DATE] at 2:02 p.m. she stated that IDT members had already discussed in the last high risk meeting on [DATE] that facility had problems with DNR/code status process, that was not in place for all residents and further said that the facility was in the process of updating them. DON continued saying that nurses were supposed to check on the front of the chart for the code status of the residents during an emergency and verify information by checking the Physician orders [REDACTED].#2's chart and did not completely verify that the DNR was not completely signed or verify orders by the MD. Record review of the facility's inservice record for July, August and [DATE] revealed no training related to code status. In an interview on [DATE] at 2:34 p.m. with the Administrator, he stated that he was not aware that there were problems with the facility's DNR/code status process and was not aware of MD B recommendations about instituting and updating the process of code status information for all residents in the facility. He further said that whatever MD B said to the Social Services Director E was between both of them only, that he was not aware of any recommendations given by MD B and that he was not aware of the list that MD B had been requesting from the facility since 2 weeks ago. Administrator continued saying that he believed that the only mistake LVN A did was not to check that the DNR form of CR #2 was not completely signed by the MD and that CR #2 was still a Full Code. Administrator further said that after CR #2 expired, one of the MDS nurses realized that the CR #2's DNR was not signed by the MD and that CR #2 was supposed to be a full code status and that the MDS nurse then placed the white paper that read Full Code in the front of CR #2's chart. Administrator further said that he was not made aware of the error until surveyor's arrival to the facility. In an interview on [DATE] at 3:05 p.m. with Social Services Director E, he stated that when he arrived to the facility, he started working on a system to identify residents' code status and that the assignment given by MD B has been completed already. Social Services Director E further said that he did not remember working with the code status documentation of CR #2 and that nurses should know that until all the elements are in place, the residents are considered a full code status. Social Services Director E continued saying that the current process to verify code status was that upon admission, facility is supposed to verify the code status during the morning meetings for all new admissions and that for residents who are long term in the facility, the code status was revised during the quarterly care conference meeting by the IDT members. When surveyor asked Social Services Director E if CR#2's code status was revised on [DATE] during the resident/family conference IDT meeting, he stated as he looked at the IDT notes I don't remember seeing the DNR documents or talking about the code status for CR#2 in last meeting, she was due again this week for care conference. Record review of facility's policy and procedure, Medical Emergency Management , revised [DATE] read in part: The facility ensures residents receive timely and appropriate intervention in the event of a medical emergency. Record review of facility policy, Advance Directives read in part, .6. The facility must document in a prominent part of the resident's clinical record whether the resident has issued an advance directive Record review of the facility abuse and neglect prohibition policy, revised [DATE], read in part: .Neglect means failure to provide goods and services necessary to avoid physical harm .: An IJ was identified on [DATE] at 1:55 pm and the Administrator was informed at that time. In an interview on [DATE] at 12:25 pm, LVN A stated the staff had been trained to check a resident's code status by looking at the first sheet of the resident's chart, verify the Physician orders, verify that if a resident is DNR, that all signatures are in place and to check a binder which was located at the nurse's station. The POR was accepted on [DATE] at ¿¿¿¿¿¿¿¿¿¿¿¿4:30 p.m. The POR included: Code Status Review On [DATE] staff initiated the process of reviewing the medical records of all residents to determine their code status to include any new admissions the facility receives. This review of medical records was completed on [DATE]. At this point the staff has determined that 100 residents have been identified as full code status. Any resident identified not to have clear code status orders have had families or resident contacted for clarification of the resident's code status. During this review we identified the following issues regarding resident code status: Station 1 · (resident name) is a DNR; the physicians order was correct. A red sheet with the words DNR was added to the front of the chart. · (resident name) is a DNR; the physician order [REDACTED]. · (resident name) is full, the physician order [REDACTED]. Station 2 · (resident name) was changed to a DNR from full code; the resident's order was correct; but the directive flash sheet had a comment stating CPR for 90 seconds only. The resident's physician was here and discussed code status with the responsible party. The RP decided to change the code status to DNR. Station 3 · The following residents listed below had the green sheet with the words Full Code in front of the chart, but did not have a current code status order for full code. The nursing staff received clarification orders to update each of the resident's code status as Full Code: (10 resident names) · (resident name) resident had his red sheet with the word DNR properly signed but there was no physicians order for the DNR. The nursing staff received an order for [REDACTED].>The above corrections for residents on stations 1, 2, And 3 were completed on [DATE]. The resident's physician wrote new orders and/or the physician was contacted for clarification orders of code status. Licensed nursing staff have assured that the medical records of all residents clearly identifies those residents who wish to be fully resuscitated in the event of a code and those residents who do not wish to be resuscitated in the event of a code. The licensed nurses checked for the most current physicians orders regarding the resident's code status. This was completed on [DATE]. The Administrator or designee will conduct admission audits within ,[DATE] hours after admission. On [DATE] the facility established a new system whereby the code status of all residents will be maintained in a binder at each nursing station. This will help expedite care to a coding resident by allowing staff to quickly and accurately identify the code status of the resident. During a code situation, licensed staff will attend to the affected resident and either provide life saving measures if the resident is a full code or comfort measures if the resident has a DNR order. Then nurse will engage the call light in the resident ' s room. The licensed staff will remain with the coding resident and call for assistance from available staff at the nursing station who will relay the code status of the resident to the licensed staff and retrieve the crash cart and deliver it to the affected residents room and then initiate calling emergency services and family/responsible party/guardian as appropriate. Beginning on [DATE] the Staff Development Coordinator is in the process of re-educating the nursing staff regarding the facility's policies related to advanced directives. This training included the following: The nurses have been re-educated that the most current physician's orders [REDACTED]. During the discussion nurses were reminded of the importance of assuring that residents who are full code and found to be without heartbeat or respirations will have CPR initiated immediately and emergency personnel will be notified. The licensed nurse who is the first responder will resuscitate those residents who are identified as full code in the event of a code. Staff who respond to the code will ensure that emergency service personnel is called and resuscitation for full code residents is continued until the resident is resuscitated or emergency services personnel responds and takes over the code. As of [DATE] nursing staff who are schedule to work have been provided this training and the training will be on-going to ensure that all scheduled nursing staff have attended the training prior to working their next shift. Licensed staff are qualified to perform CPR in the event life sustaining measures are required. On [DATE] an ad hoc subcommittee of the Quality Assurance and Assessment Committee met to discuss and approve the pan with the Medical Director. The Medical Director approved the plan. The surveyor confirmed the POR had been implemented sufficiently to remove the IJ by: Record Review of the In-Service sign-in sheet revealed that nursing staff representing all three shifts had been in-serviced from [DATE] to [DATE]. The topics included, using the call bell system to call for assistance during emergencies, verification of the code status of the residents and initiation of emergency services. Interviews conducted from [DATE] - [DATE] with nursing staff revealed staff was able to verbalize the information from the recent in-services such as identifying code status by checking binder at each nursing station. In an interview on [DATE] at 12:25 pm, LVN A stated the staff had been trained to check a resident's code status by looking at the first sheet of the resident's chart, verify the Physician orders, verify that if a resident is DNR, that all signatures are in place and to check a binder which was located at the nurse's station. The Administrator and DON were informed on [DATE], at 2:37 p.m. that the IJ was lowered; however the facility remained out of compliance at a isolated level and a severity of actual harm that is not an IJ to resident health or safety due to facility needing more time to train the staff. Refer to F0224 and F0226. According to the DON, there were 100 residents on full code status.

Based on observation, interview and record review the facility failed to ensure 2 of 10 residents (Resident #5 and #4) reviewed for changes in care, were provided care and services to attain or maintain their highest practicable physical, mental and psychosocial well-being. Staff did not intervene timely when Resident #5, who had a history of [REDACTED]. The resident was sent to the emergency room and was placed on a ventilator shortly after admission to the ER and remains hospitalized on a ventilatior. Facility did not train nursing staff on [MEDICAL CONDITION] management. Staff did not intervene timely when Resident #4 experienced nausea and vomiting. The physician was not notified for 7 days. After family intervention the physician was notified of the resident ' s abdominal pain and the resident was sent to the hospital. This failure affected 2 residents by placing both residents in the hospital and placed 141 residents at risk of not being properly assessed and treated for [REDACTED]. Intake # 0 Findings include: Resident #5 Record review of Resident #5 ' s face sheet revealed a [AGE] year old female who was admitted on [DATE]. [DIAGNOSES REDACTED]. Record review of Resident #5's MDS dated [DATE] revealed the resident was alert, could communicate verbally, was dependent on staff for all ADLs and had a [DIAGNOSES REDACTED]. Record review of Resident # 5 ' s December 2013 active orders revealed: Levetiracetam ([MEDICATION NAME]) 750 mg by mouth or via [DEVICE] every 12 hours. The dose was increased on a physician's order on 11/6/13 from 500 mg due to a [MEDICATION NAME] blood level of 3.2 on 10/31/13. (Normal [MEDICATION NAME] range is 12.0-46.0). Further review revealed the resident was not on any other anti-[MEDICAL CONDITION] medications. Record review of Resident #5 ' s nurses notes revealed the following: 12/5/13 1900 (7:00 P.M.): Resident noted up in wheelchair sitting by nursing station. Conversating and singing with staff. 12/6/13 0600 (6:00 A.M.) LVN #6 documented: "RCS ( a certified nurse's aide) notified charge nurse during med pass that something was different about resident. Observed (resident #5) lying supine in bed, HOB up at least 30 degrees. Bed (low position) Eyes open to touch stimuli like rubbing sternum with knuckle and will move lips. Doesn ' t respond to voice stimuli like name. Semi lethargic state. V/S (vital signs) taken and WNL ( within normal limits) Lungs clear bilaterally upon auscultation. (Increased) saliva from mouth noted. (hx of dysphagia and peg tube. O2 sat 96% RA (room air) No immediate distress noted." 12/6/13 0630 (6:30 A.M.) LVN #20 documented about Resident #5 that she had received report that (Resident #5) pulled her peg tube out yesterday. 12/6/13 0635 (6:35 A.M.) LVN #20 documented that the resident had been observed lying in bed. The resident's eyes were opened. Resident #5 seemed semi-lethargic. The resident did not respond to her name. 12/6/13 0645 (6:45 A.M.) LVN #6 documented: On-call answering service for resident ' s physician was called to report Resident #5's change of condition. The nurse was told by the answering service a call back would be made at 7:00 A.M. 12/6/13 0650 (6:50 A.M.) LVN #6 documented: A call was made to the responsible party (RP) of Resident #5. The responsible party was told the signs/symptoms the resident was experiencing and that the resident was in "...no distress so a call was made to the doctor first. If distress noted then 9-1-1 would be made..." 12/6/13 0710 (7:10 A.M.) LVN #6 documented: RP arrived and stated her concern that 911 services should have been called right away. The nurse documented she told the RP that protocol was followed referring to the resident had normal vital signs (BP103/56, HR104, R 18) oxygen saturation (96% RA), and her lungs clear. The RP requested for the resident to be sent to hospital. 12/6/13 0730 (7:30 A.M.) LVN #6 documented: The resident left the facility via ambulance. Record review of the facility's report of the review of Resident #5 ' s events on the morning of 12/6/13 revealed in part the following: " ...Review of chart showed although physical assessment was done, neurological assessment was not which could have benefited resident in staff response to acuity of situation ... " Interview on 12/17/2013 at 3:10 P.M. the RP stated Resident #5 remained in ICU at the hospital on a ventilator and remained unresponsive. Interview on 12/18/13 at 12:50 P.M. RN #3 stated she would call 9-1-1 if a resident had a history of [REDACTED]. She further stated if the changes were minor she would call the physician. She also said if she placed a call to the physician she would not wait for a return call before calling 9-1-1 if needed. She stated the facility had not provided any training on handling emergency situations, change of condition for residents or [MEDICAL CONDITION] management. Interview on 12/18/13 at 3:15 P.M. LVN #24, unit manager, stated Resident #5 was a one-person transfer, loved to sing, was pleasantly confused, was able to take her medications by mouth and ate well. She also stated the resident pulled her PEG tube out on 12/5/13 but her mental status was unchanged. She further stated staff do not have to ask permission to call 9-1-1 and if a resident ' s vital signs were ok but the resident ' s condition had changed she would expect the nurse to call 9-1-1. Interview on 12/19/13 at 9:30 A.M. the DON stated "I can tell you right now there is not specific training for [MEDICAL CONDITION] management." Interview on 12/19/13 at 11:00 A.M. the Medical Director stated if a resident had a [MEDICAL CONDITION] she would expect staff to call 9-1-1 because they are not trained in [MEDICAL CONDITION] management and the facility does not have on hand the medications required to treat [MEDICAL CONDITION]. Interview on 12/23/13 at 9:25 A.M. LVN #9 stated she does not remember ever having an in-service on [MEDICAL CONDITION] management or signs and symptoms of [MEDICAL CONDITION]. Interview on 12/23/13 at 9:40 A.M. RN #2 stated she was never trained or educated on [MEDICAL CONDITION] management or signs and symptoms of [MEDICAL CONDITION]. Interview on 12/23/13 at 11:45 A.M. RN #8 stated this was his first day on the floor. He stated the facility had not provided any education or instruction on [MEDICAL CONDITION] management or resident change in condition before 12/18/13. Interview on 12/23/13 at 12:15 P.M. LVN #3 stated the facility had not provided any education or inservices on [MEDICAL CONDITION] recognition or management or resident's change in condition. Interview on 12/23/13 at 1:45 P.M. the DON stated she was notified of the change of condition for Resident #5 after the resident went to the hospital. She said she was told on the phone the resident was opening her eyes even though she was not talking. She further stated if the resident was in a post-ictal state the nurse responded appropriately since the resident had a history of [REDACTED]. She stated the facility had not provided any training on resident change of condition and what to do or on [MEDICAL CONDITION] recognition and management. Record review of Resident #5 ' s medical record did not reveal any documentation in the physician ' s progress notes related to the resident ' s change in condition on 12/6/13. Continued review of Resident #5's medical record for 12/5/2013 and 12/6/2013 did not reveal any documentation of the physician/NP was notified of the resident's condition. Record review of the emergency department physician documentation for Resident #5 revealed the following: The resident arrived at theER on [DATE] at 0755 (7:55 A.M.) Diagnoses: [REDACTED]. Continued review of the ER record revealed in part the following: " ...8:20 A.M. The patient presents with decreased mental status, decreased responsiveness. 8:41 A.M. the patient appears lethargic. No [MEDICAL CONDITION] activity however opens eyes to voice and has gaze to the left. Not oriented. Does not follow commands. 8:45 A.M. Patient was intubated and put on a ventilator..." Resident #4 Record review of Resident #4 ' s admission information revealed he was admitted to the facility on [DATE]. He was [AGE] years old. His [DIAGNOSES REDACTED]. Record review of Resident #4 ' s Significant change MDS dated [DATE] revealed the resident ' s BIMS score was 00 which indicated the resident was severely impaired in cognition for daily decision making skills. The resident was also totally dependent on staff for all ADL ' s. Record review of Resident #4 ' s nurses notes revealed in part the following documentation: 10/10/13 10 P.M.-6 A.M. Patient had one emesis (vomiting) during the night. Vital signs taken. HOB elevated. Residual checked (<100). ([DEVICE]) Placement checked, patient was being monitored during the night. 10/11/13 7:00 A.M. Resident combative. Screaming with inappropriate words, spitting on the nurse and threatening, fighting care. Will continue to monitor for changes. 10/15/13 (unable to determine time) Patient with noted emesis color of feeding. HOB elevated, BS (bowel sounds) present X4 quadrants. No tenderness to abdomen voiced. [DEVICE] in place, intact, flushing without difficulty. Report to oncoming nurse. Continue to monitor. 10/16/13 1:00 P.M. Small amount of emesis X1 this shift noted. Patient putting his 2 fingers towards his throat and redirected X2. [DEVICE] in place and intact, no residual noted, flushing without difficulty. Will continue to monitor. 10/16/13 7:00 P.M. Patient resting in bed. Call made to the physician for n/v (nausea/vomiting) meds. No n/v at this time. 10/16/13 7:30 P.M. Obtained [MEDICATION NAME] 25 mg every 6 hours suppository as needed for n/v. Family made aware. 10/17/13 10:45 A.M. Patient in bed, c/o (complains of) pain to abdomen. Family in to visit, requesting doctor visit or patient be sent out to the hospital. Call made to the physician, order to send to local hospital. [DEVICE] patent, no s/s (signs or symptoms) of infection. 10/17/13 11:30 A.M. Upon assessment noted extensive abdominal pain upon touch 20 cc residual upon aspiration [DEVICE]. And a 3x2 cm knot to abdomen close to [DEVICE] site. 10/17/13 12:20 P.M. EMS to facility to transport resident to hospital. Record review of Resident #4's October 2013 MAR indicated [REDACTED]. Interview on 12/23/13 at 1:45 P.M. the DON stated she would expect staff to complete a change of condition sheet indicating the physician was notified of the resident ' s emesis and the physician should have been notified no later than the next day after the resident began having emesis. Record review of the facility policy titled: Changes in Resident Condition dated 2005 and revised June 2008 revealed in part the following: " ...The resident, attending physician and legal representative or designated family member are notified when changes in condition or certain events occur. Guidelines 1. For life-threatening events: Call 9-1-1 if initial assessment indicates such action is necessary. " No policy concerning management of [MEDICAL CONDITION] was provided for review. The facility reported a census of 143.