Every finding on record at Focused Care at Cedar Bayou

Based on interview and record review the facility failed to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 4 residents (CR#1) reviewed for pain management. The facility failed to provide CR#1 an adequate supply of scheduled hydrocodone-acetaminophen 10-325 mg during a 72-hour therapeutic leave, resulting in medication being unavailable for 4 scheduled doses. During that period, CR#1 reported pain of 8 on a scale of 0 to 10 (0 being no pain 10 being the worse pain), that interfered with her ability to sleep and function. This failure placed residents at risk for unmanaged pain and diminished quality of life. Findings included: Record review of CR #1's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: fibromyalgia (a long-term condition that causes widespread muscle and body pain, tenderness, tiredness and sometimes problems with sleep, memory, or concentration), Type II diabetes mellitus (a chronic metabolic condition where the body develops insulin resistance and inadequate insulin production, leading to high blood sugar), low back pain (pain in lower back), anxiety disorder (condition causing excessive worry, fear, or nervousness). Record review of CR #1's MDS dated [DATE] revealed a BIMS score of 15 out of 15 indicating her cognition was intact. Further review of the discharge summary revealed, resident received scheduled and pain medication regimen within the last 5 days. Record review of CR #1's care plan initiated on 5/6/2025 revealed a focus area for potential for pain and at risk for injury from decreased in ADLs related to fibromyalgia, chronic back pain. Interventions are assesses for pain location, severity, type and frequency. Administer pain medications as ordered. Monitor for potential side effects of pain medication. Record review of CR #1's physician's orders dated 4/19/2026 revealed an order started on 4/19/2026 for Hydrocodone-Acetaminophen Tablet 10-325 MG, give 1 tablet by mouth three times a day for chronic pain. Record review of CR#1's MAR dated August 2026 revealed, Hydrocodone-Acetaminophen Tablet 10-325 MG, give 1 tablet by mouth three times a day for chronic pain was administered 8/26/2026 morning dose (8:00am), 8/26/2026 administered afternoon dose (2:00pm), and 8/26/2026 administered evening dose (8:00 pm) Telephone interview on 8/27/2026 at 4:24 pm, CR#1's Family Member said on 8/26/2026 between 6:00 pm - 7:00 pm he picked up CR#1 from the facility for a 72-hour therapeutic leave. The Family Member said LVN A gave him all of CR #1's medications, including the blister pack containing one hydrocodone-acetaminophen 10-325 mg tablet. The Family Member said when they got home, they checked and realized LVN A gave him a blister pack with only one of CR#1's hydrocodone pills. Family member said he called and asked them about the medication, and LVN A said it was a problem with the pharmacy and to call back the following day to check if it was in. The Family member said CR#1 took the tablet of hydrocodone-acetaminophen on 8/27/2026 at 8:00 am and had no additional hydrocodone-acetaminophen available. The Family Member said he called around 1:00 pm on 8/27/2026 and someone at the facility told him CR #1's medication still had not been delivered. The Family Member said he was worried because CR #1's pain level was 8 out of 10 (a 1-10 pain scale is a tool that lets you use numbers to describe how much pain you feel. On this scale, 0 means you have no pain at all, and 10 means the worst pain you can ever imagine) and would get worse. Interview on 8/27/2026 at 4:30 pm, CR #1 said she left facility for a 72-hour therapeutic leave with one hydrocodone-acetaminophen 10-325 mg tablet. She said she took the tablet on 8/27/2026 at approximately 8:00 am and had no additional hydrocodone-acetaminophen available. CR #1 reported her current pain level was 8 out of 10, located in her lower back and shoulders. CR#1 said it affected her ability to sleep and function. CR #1 said, my level of pain is like a 4 or 5 out of 10, when she recieved the hydrocodone-acetaminophen three times a day as ordered, stating that the pain level with the medication was tolerable. Interview on 8/28/2026 at 4:11 pm, the DON said when residents go on therapeutic leave, CNAs help pack belongings, nurses would prepare medications needed for the duration of the leave. The DON said the medications would be provided to the family/RP or responsible party while out of the facility. The DON said the risk of resident not having pain medication is increase in pain, anxiety, and heart rate. The DON said on 8/26/2026, a refill request for CR#1's hydrocodone-acetaminophen was sent to the physician on 8/26/2026 at 1:22 pm. The DON said the physician replied at 1:50 pm that the refill had been sent. The DON said she spoke with the family member on 8/27/2026 between 11:00 am and 1:00 pm regarding CR#1's insulin, but the family member didn't say CR #1 was out of pain medication. The DON said if she had known the CR #1 was experiencing pain, she would have told the family member and CR #1 to return to the facility so the facility could provide pain medication from the emergency medication supply. The DON said she was never notified by LVN A that CR #1 went on therapeutic leave without enough hydrocodone-acetaminophen medication. The DON said if LVN A couldn't get CR #1's hydrocodone-acetaminophen medication before the resident's therapeutic leave, the DON and Doctor should've been notified. Telephone interview on 8/29/2026 at 3:51pm, CR#1 said her pain was much better. CR#1 said on 8/28/2026, the pain was so bad she was crying. CR#1 said the pain affected her sleep, the way she could sit on the toilet and use the bathroom. She said her family member had to assist more with her shower by washing her. CR#1 said she got upset with her family member and snapped at him. CR#1 said her pain level was 7 out of 10 on a scale of 0 to 10, which was tolerable. CR#1 said the medicine had to catch up in her system. CR#1 said it was nice to be able to sleep. Telephone interview on 8/29/2026 at 3:09 pm, MD A said she was not CR#1's current physician but had previously provided care to the resident. MD A said the hydrocodone-acetaminophen was a scheduled medication. MD A said the risks if CR #1did not receive scheduled hydrocodone-acetaminophen, she could experience increased pain. Record review of Facility's Pain Management Policy revised 11/2/2024 revealed in part, .It is the policy of this community that residents experiencing pain will be assessed and pain management provided to the degree possible to provide comfort and enhanced the resident's quality of life. Record review of Facility Out-on Pass Medications/Leave of Absence policy revised August 2020 revealed in part, .The nurse on duty or in accordance with facility policy, ensures that residents have their necessary medications before leaving the facility on pass or for a therapeutic leave of absence.

Based on interview, and record review, the facility failed to provide pharmaceutical services, including procedures to ensure the accurate acquiring, receiving, dispensing, and administering of medications, to meet the needs for 1 of 4 residents (CR #1) reviewed for pharmaceutical services. The facility failed to ensure CR #1's prescribed hydrocodone-acetaminophen 10-325 mg was reordered and available as prescribed during her 72-hour therapeutic leave, resulting in the medication being unavailable for 4 scheduled administration times on 8/27/2026 and 8/28/2026. During the period the medication was unavailable, CR #1 reported pain of 8 out of 10 that affected her ability to sleep and function. This failure placed residents at risk for unmanaged pain, interruption of essential medications, and decline in condition. Findings included: Record review of CR #1's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: fibromyalgia (a long-term condition that causes widespread muscle and body pain, tenderness, tiredness and sometimes problems with sleep, memory, or concentration), Type II diabetes mellitus (a chronic metabolic condition where the body develops insulin resistance and inadequate insulin production, leading to high blood sugar), low back pain (pain in lower back), anxiety disorder (condition causing excessive worry, fear, or nervousness). Record review of CR #1's quarterly MDS dated [DATE] revealed a BIMS score of 15 out of 15 indicating her cognition was intact. Further review of the discharge summary revealed, resident received scheduled and pain medication regimen within the last 5 days. Record review of CR #1's care plan initiated on 5/6/2025 revealed a focus area for potential for pain and at risk for injury from decreased in ADLs related to fibromyalgia, chronic back pain. Interventions were to assesses for pain location, severity, type and frequency. Administer pain medications as ordered. Monitor for potential side effects of pain medication. Record review of CR #1's physician's orders dated 4/19/2026 revealed an order started on 4/19/2026 for Hydrocodone-Acetaminophen Tablet 10-325 MG, give 1 tablet by mouth three times a day for chronic pain. Record review of CR#1's MAR dated August 2026 revealed, Hydrocodone-Acetaminophen Tablet 10-325 MG, give 1 tablet by mouth three times a day for chronic pain was administered 8/26/2026 morning dose (8:00am), 8/26/2026 administered afternoon dose (2:00pm), and 8/26/2026 administered evening dose (8:00 pm). Record review of CR#1's Hydrocodone-Acetaminophen 10-325 mg Controlled Drug Administration Record dated 8/19/2026 to 8/26/2026 revealed documentation that CR#1 left the facility with one Hydrocodone-APAP 10-325mg tablet and the medication was reordered; she had a refill for 30 tablets. Record review of CR #1's Progress Note dated 8/26/2026 at 6:00 pm by LVN A revealed, out on pass with [family] for 3 days, left building via walker, with medication accompany by [family], insulin and supplies for blood glucose monitoring. Telephone interview on 8/27/2026 at 4:24 pm, CR#1's Family Member said on 8/26/2026 between 6:00 pm - 7:00 pm he picked up CR#1 from the facility for a 72-hour therapeutic leave. The Family Member said LVN A gave him all of CR #1's medications, including the blister pack containing one hydrocodone-acetaminophen 10-325 mg tablet. The Family Member said when they got home, they checked and realized LVN A gave him a blister pack with only one of CR#1's hydrocodone pills. Family member said he called and asked them about the medication, and LVN A said it was a problem with the pharmacy and to call back the following day to check if it was in. The Family member said CR#1 took the tablet of hydrocodone-acetaminophen on 8/27/2026 at 8:00 am and had no additional hydrocodone-acetaminophen available. The Family Member said he called around 1:00 pm on 8/27/2026 and someone at the facility told him CR #1's medication still had not been delivered. The Family Member said he was worried because CR #1's pain level was 8 out of 10 (a 1-10 pain scale is a tool that lets you use numbers to describe how much pain you feel. On this scale, 0 means you have no pain at all, and 10 means the worst pain you can ever imagine) and would get worse. Interview on 8/27/2026 at 4:30 pm, CR #1 said she left facility for a 72-hour therapeutic leave with one hydrocodone-acetaminophen 10-325 mg tablet. She said she took the tablet on 8/27/2026 at approximately 8:00 am and had no additional hydrocodone-acetaminophen available. CR #1 reported her current pain level was 8 out of 10, located in her lower back and shoulders. CR#1 said it affected her ability to sleep and function. CR #1 said, my level of pain is like a 4 or 5 out of 10, when she recieved the hydrocodone-acetaminophen three times a day as ordered, stating that the pain level with the medication was tolerable. Record review of the facility work schedule dated 8/26/2026 revealed LVN A and MA B were assigned to work with CR #1. Interview on 8/28/2026 at 2:10 pm, MA C said when a resident's medications were running low, they would notify the nurse who ordered it. MA C said for CR#1 when the hydrocodone-acetaminophen got down to 15 pills they would notify the nurse to reorder it. MA C said was not at work when CR #1 ran out of medications. She said the last day she worked was 8/20/2026. Telephone interview on 8/28/2026 at 3:30 pm, CR#1 said her pain level was 10 out of 10, located in her hands, arms, shoulder, neck and back. CR#1 said she was sick to her stomach and couldn't sleep. Interview on 8/28/2026 at 4:00 pm, the Receptionist said CR #1's family member called the facility three times on 8/28/2026 regarding CR#1's pain medication. The Receptionist said for the first call RN A was not available, so the Receptionist spoke with MA B who said the medication had not been delivered and there was an issue with the pharmacy. The Receptionist said the second time the family member called RN A was at lunch and for the third call the medication still had not arrived. The Receptionist said she never notified the ADON or DON. Interview on 8/28/2026 at 4:11 pm, DON said there was no written facility policy, but nursing staff was expected to request refills for medications within 7 days of when the medication would run out. The DON said their expectation when a resident was leaving for therapeutic leave was that the nurse would make sure the resident had enough medication for the leave, and if not they would request a refill. The DON said on 8/26/2026 a refill request for CR#1's hydrocodone-acetaminophen was sent to the physician on 8/26/2026 at 1:22 pm. The DON said the physician replied at 1:50 pm that the refill had been sent. The DON said she spoke with the family member on 8/27/2026 between 11:00 am and 1:00 pm regarding CR#1's insulin, but the family member didn't say CR #1 was out of pain medication. The DON said if she had known the CR #1 was experiencing pain, she would have told the family member and CR #1 to return to the facility so the facility could provide pain medication from the emergency medication supply. The DON said she was never notified by LVN A that CR #1 went on therapeutic leave without enough hydrocodone-acetaminophen medication. The DON said if LVN A couldn't get CR #1's hydrocodone-acetaminophen medication before the resident's therapeutic leave, the DON and Doctor should've been notified. The DON said the risks of resident not taking her hydrocodone-acetaminophen was increased pain, hypertension, and anxiety. Interview and observation on 8/28/2028 at 5:12 pm, observed the DON with 4 hydrocodone pills in plastic bag with a paper labeled with CR#1's name, name and medication, and instructions. The DON said she tried to contact the family member but was unable. The DON said she spoke to CR #1 and told her she could come pick up her hydrocodone-acetaminophen medications. Record review of CR#1's Progress Note by the DON on 8/28/2026 at 5:58 pm revealed, The writer greeted resident at nurse's station; Resident ambulating well using rollator. No signs of distress noted, no complaints of pain or discomfort. This writer provided pain medication, provided explanation of medication dispensed, dosing, instructions and schedule for administration. Resident was smiling and greeting nurses at Nurse Station. [Family] was present, voiced no questions or concerns. Interview on 8/28/2026 at 5:32 pm, LVN B said nurses reordered resident medications. LVN B said she would reorder a medication when there was a weeks worth left so they did not run out. LVN B said if a resident ran out of a medication they could call the pharmacy to see if they could send it stat (as soon as possible), which took 3 to 4 hours to get it. LVN B said they would contact the doctor, and he may write a prescription for something else. Interview 8/28/2026 at 6:04 pm, MA B said on 8/26/2026 around dinner time she was told by CR#1 they were going on therapeutic leave that evening. MA B said she gave CR#1's medications, that were located in her medication cart to, LVN A. MA B said the family member came to pick up CR #1, LVN A gave him all CR#1's medications, and told the family member they needed to come back the next day and see if her hydrocodone-acetaminophen had come in or CR #1 could wait until Friday, 8/28/2026, to take a therapeutic leave. MA B she said CR#1 left the facility for 72-hour therapeutic leave with all her medications including 1 hydrocodone-acetaminophen 10-325 mg tablet. Interview on 8/29/2026 at 11:02 am, RN A said medication refills should be ordered when the resident had a week supply of medication left. Interview on 8/29/2026 at 11:08 am, RN B said she refilled a medication when it got to 7 days supply remaining. RN B said if the medication was given more than once a day she calculated to see how many pills made a seven day supply so that she could order it. RN B said the risk of not reordering it on time was the resident may run out of an important medication. Interview on 8/29/2026 at 12:40 pm, LVN A said she was a PRN nurse working at the facility for 2 months. LVN A said on 8/26/2026 during dinner time CR #1 said that her family member was picking her up for 72-hour therapeutic leave. LVN A said MA B gathered CR #1's medications and told her that CR#1 had only 1 hydrocodone- acetaminophen 10-325 mg tablet to take on therapeutic pass. LVN A said she checked the timeframe to get the hydrocodone-acetaminophen in the building for CR #1 to leave with it, they did not t have enough time. LVN A said when the family member arrived, she gave him CR #1's medications and he became upset when he saw the blister pack with only 1 hydrocodone-acetaminophen 10-325 mg tablet. LVN A said she didn't notify anyone that the CR #1 left the facility without enough hydrocodone medication. LVN A said she should have notified the DON and the doctor. LVN A said she did not know why she failed to do so. LVN A said that refills for medications should be ordered when the medication got s down to a 7 day supply remaining. LVN A said the risks of CR #1 running out of hydrocodone-acetaminophen was her pain might be more severe and not getting medication as ordered. Telephone interview on 8/29/2026 at 3:51 pm, CR#1 said her pain was much better than yesterday, her pain level right now was 7 out of 10, on a scale of 1-10, which was tolerable. CR #1 said she had taken 2 hydrocodone-acetaminophen tablets today, at 8:00 am and 2:00 pm. CR#1 said it was nice to be able to sleep. Telephone interview on 8/29/2026 at 3:09 pm, MD A said she was not CR#1's current physician but had previously provided care to the resident. MD A said CR#1's insurance limited the quantity of hydrocodone-acetaminophen dispensed. MD A said the hydrocodone-acetaminophen was a scheduled medication. MD A said the risks if CR #1 did not receive scheduled hydrocodone-acetaminophen, she could experience increased pain and could use other pain medications if available. Telephone interview on 8/31/2026 at 11:58 am, Pharmacist A said CR#1 had an order for hydrocodone-acetaminophen 10-325 mg, one tablet by mouth every eight hours. Pharmacist A said the pharmacy last dispensed 30 tablets, a 10-day supply to the facility on 8/11/2026 at 3:30pm. Pharmacist A said the facility should have requested a refill on 8/21/2026. Pharmacist A said the pharmacy received the next refill request through the PCC system (the facility's computerized medical record system) on 8/26/2026 at 5:12 pm. Pharmacist A said the facility was expected to request a refill when CR#1's remaining supply reached approximately one to two days, or three to six tablets. Pharmacist A said the pharmacy routinely dispensed 30 tablets at a time for CR#1 and that the facility could request a change in dispensing instructions if a larger quantity was needed. Pharmacist A said failure to receive CR#1's scheduled hydrocodone-acetaminophen could result in exacerbation of the resident's pain, depending on the resident's other prescribed pain medications. Record review of Facility Out-on Pass Medications/Leave of Absence policy revised August 2020 revealed in part, .The nurse on duty or in accordance with facility policy, ensures that residents have their necessary medications before leaving the facility on pass or for a therapeutic leave of absence.The nurse should determine the total number of doses of each medication that will be needed based on the length of the leave of absence. Record review of Facility Controlled Substance Prescriptions Policy #2.2 revised August 2020 revealed in part, .Verbal orders for controlled medications are permitted for Schedule II substances only in emergency situations. Verbal orders for controlled medications received by facility nursing staff should be noted in the resident's medical record and nursing facility staff must confirm that the prescriber or the prescriber's agent has communicated the order to the pharmacy. 4. A verbal prescription for a Schedule II medication may be called in to a pharmacist directly by the prescriber only, if: c. The quantity prescribed and dispensed is limited to the amount adequate to treat the patient during the emergency period (72 hours or less) or as permissible by state regulations. The supply can be delivered from the pharmacy or retrieved from the emergency or back-up supply.

Based on record review and interview, the facility failed to transmit accurate, encoded, complete MDS assessments to the CMS system within 14 days of admission for 1 of 17 residents records reviewed for MDS transmission (Residents # 68).The facility failed to ensure that CR 68's admission MDS dated [DATE] was completed within 14 days of admission.This failure put residents at risk of not having their assessments completed timely which could result in denial of services or denial of payment for services. Findings included:Record review of CR #68's face sheet dated 02/06/26 revealed CR #68 was admitted to the facility on [DATE]. Her diagnoses included fracture of right femur, malignant neoplasm unspecified female breast (Breast cancer) diabetes mellitus (body inability to process glucose), dementia, essential hypertension (high blood pressure), major depressive disorder, and muscle weakness.Record review of CR #26's admission MDS dated with ARD date of 02/12/26 revealed the admission MDS was signed as completed on 02/26/26 which was 20 days after admission. Interview with the MDS Coordinator on 6/18/26 at 10:00 AM., She said she was new to the position during the time of the MDS and she was in the process of doing new admission and trying to meet up with the workload. She said Late MDS assessment may result in late care plans and delay services as well as the facility's billing process. In an interview with the DON on 06/18/26 at 3:00pm, she said she was new to the facility she was a month. Record review of the facility's provided policy on resident assessment, dated 01/20/21 revised 04/25/21 did not address completing the MDS in a timely manner.During an interview with the facility Administrator on 06/18/26 at 3:40pm, he said that was what the facility had. revealed Policy: Section: Resident Assessment Policy: Comprehensive Care Planthe policy did not addressed Resident's assessment and completion.

Based on interview and record review, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 1 (Resident #22) of 6 residents reviewed for accuracy of assessments.The facility failed to accurately complete the MDS assessment to indicate Resident #22 did not receive insulin. This failure could place the residents at risk of not receiving the appropriate care and services to maintain their highest level of well-being. Record review of Resident #22's face sheet dated 6/18/2026 revealed she was admitted into the facility originally on 11/16/2018 and readmitted on [DATE] with diagnoses that included Parkinsonism (an umbrella term that refers to conditions with similar, movement-related effects). unspecified diastolic congestive heart failure (when the heart muscle is too stiff to relax and fill properly with blood between beats), unspecified atrial fibrillation (an irregular and chaotic heartbeat.), and obesity (an unhealthy, excessive amount of body fat that increases the risk of other health problems). Record review of Resident #22's MDS assessment completed on 4/10/2026 revealed in section N- Medication, Resident #22 was coded to have received one insulin injection during the last 7 days or since admission/entry or reentry if less than 7 days. Record review of Residents #22 order summary dated 6/18/2026 and medication administration record date 6/18/2026 for the month of June 2026, did not reveal any current or discontinued insulin orders. During an interview on 6/17/2026 at 3:58 pm, the MDS coordinator stated that Ozempic is considered insulin and was the reason Resident #22 was coded as receiving insulin within the last 7 days on her most recent MDS assessment. The MDS coordinator stated that Ozempic lowered blood sugar, was GLP-1 receptor agonist, and was an injection. The MDS coordinator stated she would double check on Ozempic's drug classification.During an interview on 6/17/2018 at 4:00 pm, the MDS coordinator stated that Ozempic is not considered insulin and she would do a modification MDS immediately.During an interview on 6/18/2026 at 2:45 pm, the MDS coordinator stated that she was employed at the facility since December 2025. The MDS coordinator stated that her training included 1-2 weeks with the Regional Director of Clinical Reimbursement (RDCI) onsite at the facility. The MDS coordinator stated that she used a drug manual as a resource for completing part N- Medication on MDS assessments. The MDS coordinator stated that the RDCI is also a resource she could utilize. The MDS coordinator stated she incorrectly coded Ozempic as insulin. The MDS Coordinator stated that Resident #22's incorrect coding was an isolated discrepancy. The MDS coordinator stated that the corporate reimbursement does audits of her MDS assessments. The MDS coordinator stated that the risk to residents of not coding MDS assessments correctly could lead to inaccurate development of the care plan.During an interview on 6/18/2026 at 12:00 p.m., the ADON stated she was responsible for opening a MDS assessment for new residents but was not involved in coding medications in section N. During an interview on 6/18/2026 at approximately 2:34 pm, the DON stated that she does not complete any part of the MDS assessment and only served to provide clinical input as needed.During an interview on 6/18/2026 at 2:42, the RDCI stated he had worked for the facility for one year. The RDCI stated that Ozempic is not insulin. The RDCI stated that MDS coordinator should look up a medication if not sure what classification it fell under. The RDCI stated that there is a resource in PCC the MDS coordinator could utilize. The RDCI stated there had not been any specific training performed on Ozempic's classification for the MDS coordinator. The RDCI states that he visits the facility at least once every 2 weeks. The RDCI stated that the risk of coding medication incorrectly depended on why a resident received it. During an interview on 6/18/2026 at 3:00 p.m., the Administrator stated he was not involved with completing MDS assessments. The Administrator stated his involvement was limited to ensuring MDS assessments were completed and submitted in a timely manner.Record review of facility policy titled Resident Assessment: Comprehensive Care Plan effective 1/20/2021 and revised on 4/25/2021 reads in part. The Interdisciplinary Team will continue to develop the plan in conjunction with the RAI (MDS3.0) and CAAS.Record review of the Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual effective October 1, 2025, reads in part on page 481. Code medications in Item N0415 according to the medication's therapeutic category and/or pharmacological classification, not how it used. Record review of the FDA's Drug Approval and Database, Ozempic's medication guide dated 10/14/2025 revealed Ozempic is a glucagon-like peptide receptor agonist.

Based on observation, interview, and record review the facility failed to ensure that its medication error rate was not greater than 5 percent or greater. The facility had a medication error rate of 16.67% based on 5 errors and 30 opportunities which involved 3 of 4 residents (Resident #71, Resident #62, and Resident #11) reviewed for medication administration.1.RN A failed to administer 3 medications separately through Resident #71's gastrostomy tube (G-tube). 2.RN A failed to flush in between administering medications through Resident #11's G-tube. 3.RN B failed to administer the correct order of Senna oral tablet 8.6 mg to Resident #62.RN B administered Senna Plus 50 mg to Resident #62. These failures could place residents at risk of increased hospitalization, adverse side effects, and a decline in health. Record review of Resident #71's face sheet dated 6/17/2026 revealed a [AGE] year old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Cerebral Infarction (the most common type of stroke which occurs when a blood vessel in the brain becomes blocked, cutting off oxygen supply to brain tissue), Gastrostomy Status (the presence of a Gastrostomy tube), and Aphasia (primarily a language disorder that affects an individual's ability to communicate effectively and lead to difficulties in speaking, understanding, reading, and writing). Record review of Resident #62 face sheet dated 6/17/2026 revealed a [AGE] year old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Acquired Hemolytic Anemia (a condition where your body doesn't have enough healthy red blood cells), Rheumatoid Arthritis (an autoimmune disease where the body's immune system mistakenly attacks its own tissues leading to inflammation in the joints potentially affecting other organs), Anxiety Disorder (a type of mental health condition where a person experiences excessive, persistent fear, worry, or nervousness that is harder to control than normal anxiety and can interfere with daily life), Discoid Lupus Erythematosus (a long-lasting skin condition that causes round, coin-shaped patches of skin to become red, scaly, and sometimes raised), and Type 2 Diabetes Mellitus (a chronic disease that is characterized by high levels of sugar in the blood).Record review of Resident #11's face sheet dated 6/17/2026 revealed a [AGE] year old female admitted to the facility initially on 12/30/2023 and readmitted on [DATE] with diagnoses that included unspecified sequelae of cerebral infarction(long-term effects that remain after a person has had a stroke caused by a blockage in a brain artery), Dysarthria following cerebral infarction (speech problem that happens when part of the brain that controls speech gets damaged by a stroke), aphasia (primarily a language disorder that affects an individual's ability to communicate effectively and lead to difficulties in speaking, understanding, reading, and writing), and gastrostomy status (the presence of a Gastrostomy tube). Record review of Resident #71's order summary dated 6/17/2026 revealed the following active orders :1.Do not cocktail medications. Order date 6/6/2023 with a start date of 6/6/2023.2.Give 5-10 cc of water between each medication. Order date 6/6/2023 with a start date of 6/6/2023.3. Amlodipine 5 mg. Give one tablet via G-tube one time a day. Hold if SBP <100; DBP <60. 4. Propranolol hydrochloride 40 mg. Give one tablet three times a day for HTN. Hold for SBP<100 or DBP <60 or HR <55.5. Multivitamin tablet. Give one tablet via G-tube one time a day for supplement. Record review of Resident #62's order summary dated 6/17/2018 revealed the following active order:1.Senna Oral Tablet 8.6 mg. Give one tablet by mouth two times a day for constipation with a start date of 9/7/2022. Record review of Resident #11's order summary dated 6/17/2018 revealed the following active orders:1.Sucralfate oral suspension 1gm/10 ml- Give 10 ml via G-tube every 6 hours for stomach ulcers with a start date of 2/19/2026. 2.Lactulose oral solution 10gm/15ml (Lactulose) Give 60 ml via G-tube four times a day for elevated ammonia level with a start date of 2/20/2026. During an observation on 6/17/2026 at 8:40 a.m., RN A was observed as she prepared to administer medications to Resident #71. RN A placed one Multivitamin 1 tablet, one Amlodipine 5 mg tablet (lowers blood pressure), one Propranolol hydrochloride 40 mg tablet (lowers blood pressure and heart rate) inside a plastic medication crushing pouch and crushed the 3 tablets together. RN A poured the crushed medications into one medication cup and entered Resident #71's room. RN A entered Resident #71's room and informed him she was going to administer his medications. RN A placed the medication cup with crushed meds on Resident #71's bedside table and poured water into the medication cup. RN A aspirated the contents of the medication cup into a 60 ml syringe, stopped the current tube feeding that was in progress, and administered the 3 medications together through Resident #71's G-tube. During an observation on 6/17/2026 at 9:02 a.m., RN B was observed as she prepared to administer medications to Resident #62. RN B removed from one tablet of Senna Plus 50 mg and placed it into a medication cup. RN B was then observed handing the medication cup to Resident #62 who swallowed the tablet.During an observation on 6/17/2026 at 1:00 pm, RN A was observed as she prepared to administer medication to Resident # 11. RN A entered Resident #11's room with three medication cups. One cup had 10 ml of Sucralfate oral suspension 1gm/10 ml, and the other 2 cups had 30 ml each of Lactulose oral solution 10gm/15 ml. RN A put on PPE, informed Resident #11 she was going to administer medication, raised the bed, inspected the G-tube site, stopped the feeding that was in progress, and flushed the G-tube with 30 ml of water. RN A administered 60 ml of Lactulose 60 ml followed by 10 ml of Sucralfate. RN flushed 30 ml of water after administration of Sucralfate and resumed the tube feeding. During an interview on 6/17/2026 at approximately 8:55 a.m., RN A stated she had been employed at the facility since February 2026. RN A stated she the facility had educated her on G-tube medication administration. RN A stated her opinion of do not cocktail medication meant not to mix medication solutions. RN A stated she was aware that she should have flushed in between administrations of medications and administered each medication separately for Resident #71. RN A stated she felt there would have been too many flushes of water for Resident #71. RN A stated she had never taken her concerns to the DON or Resident #71's physician. RN A stated that nursing judgement should be used. RN A stated the risk to residents of administering multiple crushed medications simultaneously through a G-tube was drug incompatibility.During an interview on 6/17/2026 at 11:55 a.m., RN B was asked to show surveyor the bottle of Senna that Resident #62 received earlier that morning. RN B opened her medication cart and retrieved a bottle of Senna Plus 50 mg tablets. Surveyor asked RN B if that was the correct order for Resident #62. RN B looked at Resident #62's medication order and stated it was not. RN B stated that Resident #62 should have received one Senna 8.6 mg tablet. RN B agreed that the difference between the two Senna medications was that Senna Plus 50 mg included docusate sodium. RN B stated she had made a mistake. RN B stated that she had been trained on medication administration. RN B stated that the risk of administering incorrect medication to a resident includes adverse drug effects. During an interview on 6/17/2026 at 1:15 pm, RN A stated she should have flushed in between the medications she had administered to resident #11. RN A stated the facility had trained her in medication administration through a G-tube. RN A stated that the risk of not flushing in between medications was drug incompatibility, and adverse effects. During an interview on 6/18/2026 at 12:00 p.m., the ADON stated she has been employed by the facility since March 2026. The ADON stated that cocktailing medication is not allowed at the facility per policy. The ADON stated that cocktailing medication meant mixing medication together and administering to a resident. The ADON stated that nurses should be flushing the G-tube in between medication administrations. The ADON stated that nurses and medication aides had been trained in medication administration and should always use medication rights when administering medication. The ADON stated that nurses had been trained in medication administration through a G-tube. The ADON stated that risk to residents of not following facility policy when administering medication through a G-tube included a clogged G-tube and hospitalization. During an interview on 6/18/2026 at 2:34 pm, the DON stated nurses should be flushing in between administering medication through a feeding tube and should never mix medication. The DON stated nurses and med aides should always be referring to the foundational medication rights when administering medication and facility policy The DON stated that nurses and medication aides had been trained in medication administration and should always use medication rights when administering medication The DON stated nurses had been trained in medication administration through a G-tube The DON stated the risk to residents of not following facility policy for medication administration could lead to resident harm and adverse effects. During an interview on 6/18/2026 at 3:00 p.m., the Administrator stated that all nurses and med aides should be using the medication rights for administration. The Administrator stated he was not aware of the clinical steps of administering medication through a gastrostomy tube. The Administrator stated the risk to residents of not receiving the correct medication was adverse health effects. Record review of facility policy titled General Guidelines for Administering Medication via Enteral Tube with an effective date of 9/2018 and revised 8/2020 reads in part.4. Enteral tubes are flushed with at least 15 ml of purified or sterile water before administering medications between each medication, and after all medications have administered. 5. Crushed medications are not mixed. 6. Each medication is administered separately to avoid interaction and clumping. The enteral tubing is flushed with at least 15 ml of water between each medication to avoid physical interaction of the medications. Record review of facility policy titled General Guidelines for Medication Administration with an effective date of 9/2018 and revised in 8/2020 reads in part.4. At a minimum, the 5 rights-right resident, right drug, right dose, right route, and right time should be applied to all medication administration and reviewed at three steps in the process of preparation: when the medication is selected, when the dose is removed from the container, and after the dose is prepared and the medication is put away.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicate disease and infections for 2 of 4 residents reviewed for infection control. RN A failed to utilize PPE prior to administering medication to Resident #71 through a gastrostomy tube.RN B failed to use clean technique while preparing medication for Resident # 62 by placing a medication capsule into her left hand before placing the capsule into a medication cup.RN B failed to perform hand hygiene after administering medication and exiting Resident #62's room. This failure could place residents at risk by exposing them to care that could lead to the spread of infection and communicable diseases.Record review of Resident #71's face sheet dated 6/17/2026 revealed a [AGE] year old male originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Cerebral Infarction (the most common type of stroke which occurs when a blood vessel in the brain becomes blocked, cutting off oxygen supply to brain tissue), Gastrostomy Status (the presence of a Gastrostomy tube), and Aphasia (primarily a language disorder that affects an individual's ability to communicate effectively and lead to difficulties in speaking, understanding, reading, and writing). Record review of Resident #71 order summary dated 6/17/20126 revealed Resident #71 had an active order for Enhanced Barrier Precautions with a start date of 5/6/2026 due to the presence of a G-tube. Record review of Resident #62 face sheet dated 6/17/2026 revealed a [AGE] year old female originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Acquired Hemolytic Anemia (a condition where your body doesn't have enough healthy red blood cells), Rheumatoid Arthritis (an autoimmune disease where the body's immune system mistakenly attacks its own tissues leading to inflammation in the joints potentially affecting other organs), Anxiety Disorder (a type of mental health condition where a person experiences excessive, persistent fear, worry, or nervousness that is harder to control than normal anxiety and can interfere with daily life), Discoid Lupus Erythematosus (a long-lasting skin condition that causes round, coin-shaped patches of skin to become red, scaly, and sometimes raised), and Type 2 Diabetes Mellitus (a chronic disease that is characterized by high levels of sugar in the blood). During an observation on 6/17/2026 at 8:40 a.m., RN A was observed as she prepared to administer medications to Resident #71. RN A entered Resident #71's room and informed him she was going to administer his medications. Observation revealed a bright orange Enhanced Barrier Precautions laminated poster on the wall directly behind Resident #71's bed. Observation of RN A revealed she stopped the continuous feeding that was in process, lifted Resident #71's gown, grabbed the G-tube extension from Resident #71's abdomen, and attached a syringe for a medication administration flush. Surveyor asked RN A if facility policy required PPE for medication administration through G-tube. RN A stated no, not typically if it is just a G-tube. Survyeor discreetly pointed to EBP poster on wall. RN A stated oh, I better stop what I'm doing right now. RN A proceeded to don PPE retrieved from a 3-drawer plastic cabinet located inside Resident #71's room. During an interview on 6/17/2026 at approximately 8:55 a.m., RN A stated she had been employed at the facility since February 2026. RN A stated she did not receive a full orientation and was placed on the floor the first day of her employment. RN A stated the facility did not educate her on EBP and EBP was a relatively new practice. RN A stated EBP was started one to two months ago. RN A stated if the facility trained her on EBP, she did not remember it. RN A stated she felt nervous and may have missed steps. RN A stated the risk to residents of not following EBP included cross contamination and infection. During an observation on 6/17/2026 at 9:02 a.m., RN B was observed as she prepared medication for administration to Resident #62. RN B was observed as she removed a medication bottle from her medication cart, poured one capsule into the palm of her left hand, closed the medication bottle, and placed the capsule that was in her left hand into a medication cup. RN B walked into Resident #62's room with the medication cup she had prepared, and a cup of water. RN B informed Resident #62 it was time to take morning medication. RN B moved the bedside table away from Resident #62's bed and moved closer to Resident #62. RN B handed the medication cup and the cup of water to Resident #62. Afterwards, RN B returned the bedside table to its original position and left Resident #62's room. RN B immediately walked back to her medication cart and began to chart on the laptop without performing hand hygiene. During an interview on 6/17/2026 at approximately 9:10 a.m., RN B stated she had been employed by the facility since February 2026. RN B stated she had been trained in infection control and medication administration. RN B stated had received training on infection control. RN B stated PPE should be used when performing any direct care activity with residents who have wounds, catheters, trach's, or G-tubes. RN B stated that the training she had received included the importance of hand hygiene. RN B stated she should have performed hand hygiene immediately after leaving Resident #62's room. RN B also stated that medication should have never been placed in her bare palm but should have been poured from the medication bottle directly into a medication cup. RN B stated she knew better and realized her mistakes. RN B stated she was nervous while being observed by surveyor. RN B stated the risk to residents when staff do not follow correct infection control practices included cross contamination and infection. During an interview on 6/17/2026 at 11:41 a.m., LVN C stated she had been employed by the facility for four years. LVN C stated she had been trained in infection control which included EBP. LVN C stated that EBP means she would don PPE if she provided any direct care to a resident with a wound, G-tube, central line, or trach. LVN C stated the facility had an in-service regarding EBP on 6/12/2026. LVN C stated for medication administration, she would pour the tablet or capsule directly from it's original container into a medication cup. LVN C stated placing a medication directly into the bare palm would be a break in infection control. LVN C stated if staff did not follow proper infection control measures, the risk to residents could lead to preventable infections.During an interview on 6/17/2026 at approximately 1:00 p.m., CNA D stated when a resident was on EBP, she would put on PPE if she provided any direct care such as providing incontinent care. CNA D stated residents would be placed on EBP if they had wounds, a trach, or devices such as a urinary catheter, or a feeding tube. CNA D stated the risk to residents if staff did not follow EBP could lead to infection. During an interview on 6/18/2026 at 12:00 p.m., the ADON stated she has been employed by the facility since March 2026. The ADON stated she had been enforcing EBP as soon as she arrived at the facility. The ADON stated the most recent staff training on EBP was performed on 6/8/2026. The ADON stated the staff had also been trained on handwashing recently. The ADON stated that any resident who has a foley catheter, trach, or any type of indwelling device, PPE should be donned by staff if providing direct high contact care which included g-tube medication administration. The ADON stated that hand hygiene should be performed after leaving a resident's room. The ADON stated the expectation was for staff to handwash and/or sanitize their hands before and after administering medication. The ADON stated that the expectation for staff was to pour medication into a cup. The ADON stated staff should never put medication in their hands. The ADON stated the risk to residents of not following correct infection control practices could lead to infection.During an interview on 6/18/2026 at 2:34 pm, the DON stated she had been employed at the facility for one month. The DON stated that EBP training for staff had been performed almost weekly and was also addressed during morning meetings. The DON stated during morning meetings she would randomly ask staff members which residents were on EBP and what did that meant for the care being provided. The DON stated the ADON does rounds every morning which included PPE supplies were available for staff. The DON stated that hand hygiene was also addressed in morning meeting with a common phrase repeated of Gel in, Gel out which reminded staff to sanitize their hands before and after they left a resident's room. The DON stated the risk to residents of not following correct infection control procedures would be cross contamination, and the spread of infection. During an interview on 6/18/2026 at 2:52 pm, Med Aide E stated that she had been trained by the facility on EBP. Med Aide E stated if a resident was on EBP, it meant she would need to put on PPE if she provided any direct care such as incontinent care. Med Aide E pointed to an EBP poster that listed activities where PPE would be required to be used. Med Aide E stated that medication should always be poured from the original container into a medication cup. Med Aide E stated the risk to residents of not following EBP could lead to infection and staff taking an infection home with them.During an interview on 6/18/2026 at 3:00 p.m., the Administrator stated that all staff had been educated on EBP by the ADON which included the importance of hand hygiene. The Administrator stated staff who do not follow correct infection control practices placed residents at risk for the spread of infection. Record review of facility policy titled Infection Control: Enhanced Barrier Precautions, effective 4/1/2024, reads in part. EBP are a CDC guidance to reduce the transmission of MDRO in health care settings, including nursing homes. EBP require team members to wear a gown and gloves while performing high-contact care activities with residents who are infection or colonized with a targeted MDRO or have open wound or indwelling medical device.2. Determine if any of the following indwelling medical devices are in use:.g-tube. EBP will be implemented if any of the above wounds or invasive medical devices are present. 4. High contact resident care activities: device care or use of: feeding tube. Record review of facility policy titled Infection control: Hand Hygiene effective 8/4/2021 and revised 10/24/2022, reads in part. You should always perform hand hygiene: before and after providing any type of care. after contact with medical equipment or other environmental surfaces that may be contaminated. Record review of facility policy titled General Guidelines for Medication Administration, effective 9/2018 and revised on 8/2020, reads in part.'Medications are administered as prescribed in accordance with good nursing principles and practices.

Based on interview and record review, the facility failed to immediately consult with the resident's physician and resident's representative when there was a deterioration in the resident's physical and mental status for 1 of 1 CR (CR #1). The facility failed to notify the resident's physician and the resident's representative of CR #1's restless nighttime behavior with repeated attempts to get out of bed and crawl onto the floor, and the need for a mattress on the floor for CR#1 to sleep on. This failure could place residents at risk of not receiving adequate and timely intervention and a decline in condition. Record review of CR#1's admission record dated [DATE] revealed a [AGE] year old female, admitted [DATE] and discharged [DATE] to the hospital, with diagnoses that included peripheral vascular disease (a slow and progressive disorder of the blood vessels), heart failure (a condition in which the heart muscle cannot pump enough blood to meet the body's needs for blood and oxygen), aphasia (primarily a language disorder that affects an individual's ability to communicate effectively and lead to difficulties in speaking, understanding, reading, and writing), type 2 diabetes mellitus (a chronic disease that is characterized by high levels of sugar in the blood.), hemiplegia (a condition where one side of the body experiences paralysis or weakness due to damage to the brain or spinal cord), cerebral infarction (most common type of stroke. It occurs when a blood vessel in the brain becomes blocked, cutting off oxygen supply to brain tissue), and end stage renal disease (a condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life). Record review of CR#1'S MDS, dated [DATE], revealed a BIMS score of 00, indicating severe cognitive impairment.Record review of CR#1's Baseline Careplan Section C, behavioral concerns was blank.Record review of CR#1's electronic medical record in the miscellaneous document section, revealed a document titled MPOA- Designation of Healthcare Agent, dated and notarized on [DATE]. The MPOA listed FM E as the first agent, and FM F as the second agent. Record review of CR#1's admission summary, written by RN A, with effective date of [DATE], revealed CR#1 was awake, alert, oriented x 1, uncooperative and combative. Record review of an addendum to CR#1's admission summary written by RN A, dated [DATE] at 1:03 p.m., revealed a mattress was left on the floor at bedside in CR#1's room because CR# 1 would not stay in bed, was observed sleeping on the mattress on the floor, and other interactions indicated CR#1 was content lying on the mattress that was on the floor. Record review of CR#1's blood sugar log, dated [DATE] at 7:48 a.m. and recorded by LVN B, revealed CR#'1's blood sugar was 124 mg/dL, and at 11:06 a.m. was 141 mg/dL.Record review of CR#1's progress note, dated [DATE] at 8:34 a.m. written by LVN B, revealed the resident remained resting, was compliant with wound care, and denied discomfort. Record review of CR#1's BP and pulse log dated [DATE] recorded by LVN B at 11:11 a.m. revealed CR#1's blood pressure was 121/52 with a pulse of 60 bpm.Record review of CR#1's progress note, dated [DATE] at 11:22 a.m. written by LVN B, revealed resident was resting on the mattress at bedside and was responsive to voice.Record review of CR#1 progress note, dated [DATE] at 12:36 p.m. written by LVN B, revealed CR#1 had a change in condition, was slow to respond, had audible moaning, required CPR, and was transferred to the emergency room. CR#1 had a heard rate of 48, and a weak and thready radial pulse. CR#1 blood pressure could not be obtained because the Dinamap (blood pressure machine) was not reading it. During an interview on [DATE] at 6:22 pm, FM F stated she arrived at the facility on [DATE] and observed CR#1 laying on the mattress on the floor. FM F stated she observed CR#1 drooling from the mouth and was present when CR#1 was discharged to the hospital.During an interview on [DATE] at 4:18 p.m., FM E stated he was CR#1'S MPOA. FM E stated he visited CR#1 on [DATE] and left that night. FM E stated CR#1 was sitting up in her wheelchair, smiling, and appeared to be fine. FM E stated FM F called him on [DATE] a little after 12:00 p.m. and stated CR#1 was on the floor. FM E stated that no one from the facility notified him CR#1 was being placed on a mat on the floor. FM E stated that the only problem CR#1 had was that she liked to sit on the edge of the bed. FM E stated that CR#1 would not try to get out of bed by herself. During an interview on [DATE] at 10:21 a.m., LVN B stated she worked at the facility for 1 year and 5 months. LVN B stated that on [DATE], she informed FM E during his visit that CR#1 had trouble sleeping the night before. LVN B stated that was the extent to what she notified FM E. LVN B stated when she arrived at the facility on [DATE] for her day shift, she received report from the night shift nurse assigned to CR#1, RN A, who informed her that that CR#1 was up all night yelling and constantly tried to get out of bed. LVN B stated when she first saw CR#1 during her initial rounds on [DATE] between 7:30 a.m. and 8:00 a.m., CR#1 was on the mattress on the ground and appeared to be resting quietly and did not appear in any distress. LVN B stated at approximately 11:00 a.m. on [DATE], CR#1 was still resting on the mattress on the floor with her eyes closed and her chest rising and falling. LVN B stated CR#1 had no audible moaning. LVN B stated she asked CR#1 if she needed anything for pain, and CR#1 said no. LVN B stated CNA C did not notify her if CR #1 had refused breakfast. LVN B stated she did not ask RN A if she had notified CR#1's physician or her representative about CR#1's overnight behavior and the need for a mattress on the floor. LVN B stated she did not think that CR#1 was able to make her own decisions. LVN B stated she did not know if CR#1 had a MPOA. LVN B stated that CR#1's physician and representative should have been made aware that CR#1's was up all night and slept on the floor. LVN B stated the risk of not notifying appropriate parties for a change in condition or deterioration in the status of a resident included possible missed interventions. During an interview on [DATE] at 11:33 a.m., CNA C stated she had worked at the facility for a couple of months as a CNA. CNA C stated she cared for CR#1 for the first time on [DATE] during her shift of 6:00 a.m. to 2 p.m. CNA C stated that she first saw CR #1 during her initial rounds in the 6:00 o'clock hour and CR#1 was okay and breathing. CNA C stated she later delivered CR#1's breakfast tray. CNA C stated that she got on the floor to check on CR #1 who appeared to still be asleep. CNA stated that CR#1 looked okay. She was normal, not someone who was having a problem. She was breathing and she looked calm looking. CNA C stated she placed the breakfast tray on the nightstand inside CR#1's room and notified LVN B the tray was left on the nightstand for CR#1. CNA C stated that LVN B instructed her to leave the tray in the room and let CR #1 sleep. CNA C stated that she checked on CR#1 at least 3-5 times before lunch. CNA C stated she bent down to check on CR#1 and watched CR#1's chest rise and fall, since CR#1 was still asleep on the floor.During an interview on [DATE] at 11:56 a.m., the ADON stated she had worked at the facility for about one month. The ADON stated the only issue she heard about CR#1 was that she was trying to get out of the bed into her wheelchair during the day. The ADON stated that she became aware on [DATE] that night staff had difficulty with CR#1. The ADON stated the physician, and the family should have been notified about CR#1's nighttime behavior, aggressiveness, and about CR#1 sleeping on the floor on a mattress. The ADON stated the expectation for nurses was to notify the family, administration, or the physician regarding aggressiveness and inability to sleep. The ADON stated that the physician could have helped by ordering medication or another intervention. The ADON stated that the risk of not notifying appropriate parties of resident changes or deterioration could lead to hospitalization or death. During an interview on [DATE] at 12:31 p.m., RN D stated that she had worked at the facility since [DATE]. RN D stated that the was not directly caring for CR#1. RN D stated on [DATE], FM E who was the MPOA of CR#1 asked RN D why did not the facility notify him that CR#1 slept on a floor the night before. RN D stated FM E stated if he were notified of CR#1's behavior that led to her sleeping on the floor, he would have returned to the facility to check on CR#1. RN D stated that she would notify a resident's representative when there for any change in condition, not just for emergencies. RN D stated that she would have expected the family to have been notified if a resident was sleeping on the floor or had behavior that kept them from sleeping. RN D stated the risk of not notifying appropriate parties in a change in condition or a deterioration in status included no new orders.During a telephone interview attempt on [DATE] at 1:15 p.m., a phone call was placed to RN A but RN A did not answer. The Surveyor left a voicemail that explained purpose of call with a request to return the call. RN A did not call the Surveyor back as of exit date from facility. During an interview on [DATE] at 1:23 p.m., the DON stated that she had worked at the facility for about 9 months. The DON stated she was not familiar with CR#1 who had been discharged to the hospital. The DON stated she had not worked in the facility during the days that CR#1 was an active resident. The DON stated that a reasonable nurse would have notified CR#1's family and physician for help with CR#1's behavior. The DON stated that her expectation for nurses was to notify the family of CR#1 if the behavior of CR#1 was bad enough to put a mattress on the floor. The DON stated that the risk to residents of not communicating deterioration of resident's behavior or a change in condition was missed communication and lack of care. During a telephone interview on [DATE] at 2:39 p.m., CNA G stated was the CNA that cared for CR#1 on the night of [DATE]. CNA G stated that CR#1 was a difficult resident, refused care, and would not stay on the bed. CNA G stated that CR#1would crawl down from the bed onto the floor where she would be restless, and was constantly tried to move around. CNA G CNA G stated the idea of the mattress on the floor was for CR#1 not to land hard on the floor. CNA G stated that CR#1's nurse was fully aware of CR#1's behavior and the mattress on the floor.During an interview on [DATE] at 4:25 p.m., the Administrator stated from his understanding CR#1 kept trying to get out of the bed by herself. The Administrator stated that the CR#1 displayed real time changes. The Administrator stated that prior to the night of [DATE] and morning of [DATE], CR#1 had not slept on the floor on a mattress. The Administrator stated that on [DATE] LVN B informed the family that CR#1 had trouble sleeping. The Administrator stated that LVN B did not inform the physician or the MPOA of CR#1's inability to sleep the night of [DATE] nor of her yelling throughout the night, nor that CR#1 slept on the floor. Record review of facility policy titled, Resident Rights, dated 2001 and revised in December of 2016, revealed, .these rights include the resident's rights to.be treated with respect, kindness, and dignity.be notified of his or her medication condition and of any changes in his or her condition.

Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality of the resident for 1 (CR#1) of 1 resident reviewed for baseline care plans. The facility failed to provide the CR#1's representative with a summary copy of the baseline care plan. The facility failed to incorporate CR#1's sleeping preferences in the baseline care plan. This failure could result in residents not receiving inadequate care or having their needs met. Record review of CR#1's admission record dated 4/21/2026 revealed a [AGE] year old female, admitted [DATE] and discharged [DATE] to the hospital , with diagnoses that included peripheral vascular disease (a slow and progressive disorder of the blood vessels), heart failure (a condition in which the heart muscle cannot pump enough blood to meet the body's needs for blood and oxygen), aphasia (primarily a language disorder that affects an individual's ability to communicate effectively and lead to difficulties in speaking, understanding, reading, and writing), type 2 diabetes mellitus (a chronic disease that is characterized by high levels of sugar in the blood.), hemiplegia (a condition where one side of the body experiences paralysis or weakness due to damage to the brain or spinal cord), cerebral infarction (most common type of stroke. It occurs when a blood vessel in the brain becomes blocked, cutting off oxygen supply to brain tissue), and end stage renal disease (a condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life). Record review of CR#1'S MDS, dated [DATE], revealed a BIMS score of 00, indicating severe cognitive impairment.Record review of CR#1's electronic medical record in the miscellaneous document section revealed a document titled MPOA- Designation of Healthcare Agent dated and notarized on 4/3/2025. The MPOA listed FM E as the first agent, and FM F as the second agent.Record review of CR#1's baseline care plan section 1 part I, signed by the ADON and dated 4/17/2026, revealed no comments under section 1 part I of additional comments or preferences. During an interview on 4/21/2026 at 4:18 p.m., FM E stated he was CR#1'S MPOA. FM E stated that CR#1 did not like to lay down flat but preferred to sit up right to sleep. FM E stated that CR#1 could verbalize yes or no to questions. FM E stated he did not receive a summary copy of CR#1's baseline care plan. During an interview on 4/22/2026 at 1:23 p.m., the DON stated that baseline care plans should be completed with a resident's representative if they have one or if the resident was cognitively impaired. The DON stated that the risks to residents of not including resident's preferences and not giving a copy to the resident's representative of the baseline care plan could lead to missed communication, and a lack of care. During an interview on 4/22/2026 at 4:25 p.m., the Administrator stated a summary copy of the baseline care plan would be given to the resident or a resident's representative if requested. The Administrator then stated that the facility should have included CR#1's representative in the baseline care plan creation, and that a summary should have been given to CR#'1's representative per facility policy.Record review of facility policy titled Baseline Care Plan effective 11/01/2019 reads in part.The facility must provide the resident and their representative with a summary of the baseline care plan to include the minimum: Resident initial goals, a summary of medications and dietary instructions, any services and treatments administered by the facility and personnel acting on behalf of the facility such as therapy or psych services, information to properly care for the resident upon admission, address specific health and safety concerns.

Based on observation, interviews, and record reviews, the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's condition or need to alter treatment significantly for 1 of 5 residents (CR#1) reviewed for physician notification. The facility failed to properly identify and intervene in CR#1's acute change in condition related to his diabetes mellitus and congestive heart failure. The facility failed to notify physician after CR#1's vitals were declining, which lead to CR#1's hospitalization with vital organ impairment or failure. An Immediate Jeopardy (IJ) was identified on 05/07/2025 at 5:30 p.m. While the IJ was removed on 05/08/2025 at 10:50pm the facility remained out of compliance at the severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could affect residents by placing them at risk of delayed treatment that has the propensity to lead to death. Findings Included: Record review of CR#1's undated face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE] from the local hospital with diagnoses of coronary artery disease (reduction of blood flow to heart muscle), heart failure (the heart fails to pump enough blood to meet the body needs), hypertension (high blood pressure), diabetes mellitus (blood sugar is too high), Hyperlipidemia (too much fat in the blood), arthritis (swelling and tenderness in the joints), diverticulosis (inflammation of the colon), and other fractures. CR#1 discharged to the hospital on 5/3/2025. The discharge instructions listed primary diagnosis, reason for hospitalization, procedures and tests performed while in the hospital, taking medications and follow information regarding heart failure. Record review of CR#1's Quarterly MDS dated [DATE] revealed CR#1 has a BIMS score of 12 (means resident cognition is intact). Record review of CR#1's orders dated 5/1/2025-5/31/2025 revealed blood sugar checks two times a day for DIABETES; Midodrine HCI Oral Tablet 5 MG-give 1 tablet by mouth every 8 hours PRN (as needed) as needed for hypotension. Hold for SBR (blood Pressure) less than 90 (no date); Sodium Polystyrene Sulfonate Suspension 15GM/60ML-Give 15 gram by mouth one time only for Hyperkalemia (elevated potassium in the blood) until 5/3/2025 11:59p.m; Cozaar Tablet 100 MG (Losartan Potassium) give 1 tablet by mouth one time a day for hypertension. Hold for ABP <100 or DBP <60. Start date 4/23/2025 9:00am; Farxiga (diabetes) Oral tablet 5 mg (Dapagliflozin Propanediaol) Give 1 tablet by mouth one time a day for DM-start date 4/23/25 9:00am. Hold from 5/3/2025 to 5/5/2025 4:41pm; Prabastatin Sodium Oral Tablet 10 MG (Pravastatin Sodium) Give 1 tablet by mouth one time a day for Hyperlipidemia (for high cholesterol levels). Start date 4/23/2025 9:00am; Carvedilol Oral tablet 25 MG give one tablet by mouth two times a day for HTN (hypertension) hold for SBP <110 or HR <60. Start date 4/23/2025; Eliquis Oral tablet 5 MG (Apixaban) (blood thinner) give 1 tablet by mouth two times a day for Anticoagulant. Start date 4/23/2025 9:00am; Gilmepride (treats high blood pressure) Oral tablet 4 MG give 1 tablet by mouth two times a day for DM. Start date 4/23/2025 9:00am-Hold date 5/3/2025-5-5-2025. Record review of CR #1's care plan dated 4/22/2025, revealed the following care areas: Focus: [CR #1] I am at risk for frequent infections, pressure/venous/stasis ulcers, vision impairment, hyper/hypoglycemia, renal failure, cognitive/physical impairment/skin desensitized to pain or pressure related to diabetes melillitus. Date initiated and revision on 5/5/2025. Interventions: [CR #1] I will have no complications related to diabetes through the review date. Date initiated and revision on 5/5/2025. Target date on 5/1/2025. Interventions: [CR #1] Monitor/document/report PRN (as needed) any s/sx (signs or symptoms) of hyperglycemia (difficulty waking up); increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abd (abdomen pain), Kassmaul (rapid) breathing, acetone breath (smells fruity), stupor (stated of reduced consciousness or responsiveness, where a person is almost unconscious but can be aroused by vigorous stimulation), coma (deep unconsciousness)-date initiated 5/5/2025; Monitor/document/report PRN (as needed) any s/sx (signs or symptoms) of hypoglycemia: Sweating, Tremor, increased heart rate (Tachycardia), pallor (Paleness), nervousness, confusion, slurred speech, lack of coordination, staggering gait (unsteady). Date initiated 5/5/2025. Focus: [CR #1] Potential for complications, s/sx related to diagnosis of hypertension. Receives anti hypertension and is at risk for side effects. Dated initiated 5/5/2025. Goal: [CR #1] My B/P (blood pressure) will stay within their normal limits, will not have s/s of hyper/hypo tension throughout the review date. Date initiated 5/5/2025. Target date 5/1/2025. Interventions: [CR #1] Administer anti-hypertensive medications as ordered. Monitor B/P and for side effects such as orthostatic hypotension (low blood pressure) and increased heart rate (Tachycardia), increased edema (swelling), headache, chest pain, and report abnormalities to physician. Dated initiated 5/5/2025; Monitor/Document/Report PRN any s/s of malignant hypertension (blood pressure rises rapidly): Headache, visual problems, confusion, disorientation, lethargy (usually tired, sluggish, and lacking energy), nausea (feeling sick in the stomach) and vomiting, irritability, seizure activity, and difficulty breathing (Dyspnea). Date initiated 5/5/2025. Record Review of facility's last vitals taken for CR#1's Blood Pressure 5/2/2025 at 10:18am - 98/56 5/2/2025 at 7:58pm - 80/47 5/3/2025 at 7:05am - 82/47 5/3/2025 at 2:37pm - 81/43 5/3/2025 at 4:58pm - 99/51 Record Review of facility's last vitals taken for CR#1's 02 Stats 5/2/2025 10:18am 90.0% Room Air 5/2/2025 7:59pm 92.0% Room Air 5/3/2025 7:05am 93.0% Room Air 5/3/2025 4:58pm 82.0% Room Air Record Review of facility's last vitals taken for CR#1's Blood Sugar vitals 5/3/2025 2:37pm 64.0mg (manual) 5/3/2025 3:40pm 94.0mg (manual) Record Review of skilled charting for CR#1 dated 5/2/2025 at 7:33pm by LVN A, revealed the following: vital signs taken on 5/2/2025 at 10:18am were: Temperature 97.5 taken forehead (non-contact), pulse 77(bpm), Respiration 18.0(breaths/min), Blood pressure 98/56, O2 stats 92.0% (room air). Section D: Mood and Behavior: 1b: Notable changes in mood and behavior: Resident sleeping a lot more than usual. Record Review of skilled charting for CR#1 dated 5/2/2025 at 7:56pm by LVN A revealed the following: vital signs taken on 5/2/2025 at 7:59pm were: Temperature 96.8 taken forehead (non-contact), pulse 68(bpm), Respiration 20.0(breaths/min), Blood pressure 80/47, O2 stats 92.0% (room air). Section D: Mood and Behavior: 1b: Notable changes in mood and behavior: Resident sleeping a lot more than usual. Record Review of nursing notes for CR#1 dated 5/2/2025 revealed, there were no nursing notes for this date. Record Review of nursing notes for CR#1 dated 5/3/2025 at 9:16am, revealed, Change in Condition reported on the CIC Evaluation are/were: Other change in condition Tired, Weak, Confused, or Drowsy. At the time of evaluation resident/patient vital signs, weight and blood sugar were: -Blood Pressure: 82/47 - 5/3/2025 07:05 Position: Lying r/arm -Pulse: P 68 - 5/3/2025 07:05 Pulse Type: Regular -RR: R 18.0 - 5/3/2025 07:05 -Temp: T 97.3 - 5/3/2025 07:05 Route: Forehead (Non-Contact) -Weight: W 280.0 lb - 4/29/2025 14:38 (2:38pm) Scale: Mechanical Lift -Pulse Oximetry: O2 93.0% - 5/3/2025 07:05 Method: Room Air -Blood Glucose: Record Review of nursing notes for CR#1 dated 5/3/2025 at 7:20pm, revealed, Note Text: Resident lethargic this am, blood pressure low, notified vanguard received new orders: N/O: Midodrine HCI Oral Tablet 5 MG (Midodrine HCI). Record Review of Local Hospital admission dated 5.3.2025 revealed, CR#1 presented to the ED yesterday via EMS from the facility with fatigue (extreme tiredness), lethargy (lack of energy and enthusiasm), and altered mental status (a deviation form norm). EMS found CR#1 to be hypotensive (low blood pressure) (87/58), hypoglycemic (drop in blood sugar) with blood glucose (body primary source of energy) of 35 and hyperkalemic (causes kidney disease) with a potassium level of (6) six. CR#1 received D50 (intravenous), Kayexalate (treat high levels of potassium in the blood), and midodrine (treats low blood pressure) enroute to the ED. Workup (thorough diagnostic evaluation to determine the cause of symptoms or health condition) in the ED found CR#1 to be acute hypoxic (decrease in oxygen levels in the blood) and hypercapnic respiratory failure (respiratory system cannot remove carbon dioxide from the body), septic shock (a life threatening condition that occurs with body response to a severe infection causes low blood pressure and multiple organ dysfunction), acute renal failure (Kidney failure), and persistent hyperglycemia (high blood sugar levels consistently exceeding target range). CR#1 was placed on BIPAP and initiated on a D10 infusion (IV) to maintain glucose. CR#1 was fluid resuscitated per sepsis guidelines and initiated on vasopressors (medications to cause blood vessels to constrict) to maintain adequate blood pressure. CR#1 transferred to ICU for management. Foley placed in CR#1with 1200cc returned immediately after placement. The local hospital's disposition: CR#1 to remain in ICU: CR#1 at high risk for complications CR#1 is critically ill with vital organ impairment or failure. There is a high probability of imminent or life-threatening deterioration in the patient's condition Patient is unable or incompetent to participate in giving a history and/or making decisions and discussion is necessary for determining treatment decisions. In a telephone interview on 5/6/2025 at 2:03 p.m., FM A said she is a relative of CR#1 and wanted to reiterate what was in her complaint. She stated CR#1 did not have pneumonia or sepsis before arriving to the facility 11 days ago. She stated his blood pressure has been extremely low. She stated CR#1 is in the local hospital. Stated the nursing staff did nothing to help CR#1 while in the facility. She stated if the nursing staff had checked his blood sugar like he told them they did in the hospital, they would have known that he was going into a diabetic coma. In an interview and observation on 5/6/2025 at 2:30 p.m. (at the hospital), CR#1 said he was in the facility for 11 days for rehab after having back surgery. CR#1 said after 3 days he began asking questions of the nurse regarding his glucose and checking his blood sugar levels because he was starting to feel very tired and couldn't stay awake. He said the nurse would only tell him she will be right back she had to check his orders. The nurse never returned. He said he asked this question on multiple shifts and multiple times and received the same answer. He said he started feeling lethargic and couldn't stay awake. He said he was so sleepy he went a day or two without eating. CR#1 said there was a LVN who had returned from vacation this past Saturday who listened to him, and his concerns, and she ordered labs. No other nurse did. In an Interview 5/6/2025 at 2:50pm at the hospital with FM B and FM C they stated last Thursday (5/1/2025) they tried calling resident and didn't get an answer. Both stated they called the front desk and were told he was asleep. They received the same response on Friday (5/2/2025). However, when they called Saturday (5/3/2025) and CR#1's phone went to his voicemail they had concerns and therefore called the facility. At this time FM A told FM B and FM C she didn't like what she was seeing and that she couldn't wake CR#1 after several tries. FM B said she demanded that FM D tell the facility to call 911 immediately. In a Telephone Interview 5/6/2025 at 5:30pm FM D stated this past Thursday (5/1/2025) morning CR#1 appeared unusually sleepy. She stated the nurse told her that she had given CR#1 pain medications which was why he was sleepy. FM D stated on Saturday (5/3/2025) she received a call from facility and said CR#1 was sleeping and lethargic and nurse stated she called doctor. FM D stated when she arrived at the facility Saturday (5/3/2025) the nurse had just taken his blood sugar and at that time it was 65. The nurse left the room to get some orange juice. However, while the nurse was away getting juice, FM D stated she observed the food tray with tea, and she put two packets of sugar and gave it to CR#1 herself. She stated a few moments later, the nurse returned with orange juice and sugar and gave it to resident. Stated after 30 minutes nurse re-took sugar levels and it was 93. She stated the nurse took labs. Nurse returned with lab results and said he had critical potassium levels and creatine were elevated as well. She stated the nurse said she called the doctor. However, FM D and other family members requested CR#1 go to hospital via 911. Stated the nurse returned with critical labs and stated the doctor had ordered Kayexalate (treats high blood potassium) and IV fluids; however, the nurse told her she had to get someone to come and start the IV because it was out of her range as a nurse. During this time the family continued to request CR#1 be sent out to hospital. She stated nursing staff never checked his blood sugar prior to this episode even though CR#1 and the family told the nursing staff that the hospital checked 3 times daily. She stated CR#1 asked about his blood sugar being checked and he was told by one of the nurses that the hospital told her (nurse) that he was no longer diabetic so there was no need to check his blood sugar. FM D stated CR#1 was very congested during her visit on Saturday 5/3/2025 and she told the nurse she could hear wheezing when CR#1 coughed. She stated the nurse checked CR#1's blood sugar after the family requested on Saturday, 5/3/2025. Interview on 5/6/2025 at 6:21p.m., with MA B stated she was familiar with CR#1. She stated CR#1's family members were always in the room. She stated blood sugars were to be taken before and after meals. She stated even if it was not in the orders, typically you do it for persons who were diabetic. She stated the nurse was responsible for taking the blood sugar. She stated checking the blood sugar was on the MAR. She stated the nurse will make the notation on MAR and if she hasn't noted she would find the nurse prior to giving medication. She stated she did not make any efforts to find the nurse and inquire about the blood sugar being taken. She stated she must of gotten busy. In an interview on 5/6/2025 at 6:46 p.m., LVN A stated she was familiar with CR#1. She returned to work on Monday 4/28/25 from vacation and worked with CR#1 for the first time then. She stated she worked with CR#1 on that Tuesday (4/29/2025) and again on Saturday 5/3/2025 She stated while she was working on 5/3/2025 and during her rounds she noticed CR#1 didn't look well as his face was pale looking. She stated she took his blood pressure, and it was low (82/47). She telephoned the doctor answering service and left a message. LVN A stated she honestly did not know he was diabetic until Saturday 5/3/2025. Nurse stated upon admission the medication list delivered from the hospital was sent to the doctor. The doctor was supposed to okay the orders. She stated the NP made rounds on 4/29/2025 at which time she told her that resident had serious back surgery and Tylenol was not strong enough for him. She stated the NP gave resident a prescription for an additional pain medication. LVN A stated if she had done the admission and noted the type of medication resident was taking she would have informed nursing staff that he needed blood sugar taken prior to meals and sometimes afterwards. In an interview on 5/6/2025 at 7:30 p.m., the IDON stated he spoke with the CR#1 on Friday 5/2/2025. He stated CR#1 was talking and stated he didn't feel well; however, IDON contributed it to the back issues. He stated he listened to CR#1's chest and lungs and did not get anything alarming. He stated the facility did a chest x-ray but when the results returned CR#1 had already gone to the hospital. The IDON stated the admitting nurse (facility) was responsible for submitting any resident information upon admittance to the doctor. When asked if a diabetic patient should have a glucose test before meals, he stated they could. He stated it was a nursing judgement to draw blood for glucose labs. The IDON was asked how long it takes to develop pneumonia and sepsis and he stated the resident may have come to the facility from the hospital with that diagnosis. He was asked what should have been done when resident blood pressure taken was low and he stated that the resident's medical condition will sometimes have a low blood pressure; however, it should have been documented and possibly noted as a change of condition. The IDON stated on 5/3/2025 the nurse completed a change of condition; gave resident some orange juice and it appeared his blood glucose was increasing. He initially stated he was contacted and wanted the nurse to call 911, then he was reminded that according to the nursing notes the family requested 911. In a follow-up interview on 5/7/2025 at 9:10 p.m., with IDON - He stated the blood pressure readings on 5.2.2025 were out of range and not normal. He stated he was not aware the resident was having issues on this date (5/2/2025). He stated the blood pressure on 5/2/2025 represented someone who is hypotensive. He stated the nurses should have called the doctor. He stated the nurses erred for not contacting the doctor for the decrease in blood pressure. He stated the expectation was to re-check the blood pressure every 15-30 minutes. In a follow-up telephone interview on 5/7/2025 at 11:14am with LVN A she stated a COC is anything going on with patient and out of the ordinary. Protocol is to notify doctor and get new orders. She stated CR#1's blood pressure was low after taking it 4 times 5.3.2025. CR#1's family member told her she noticed a cough and phlegm (thick mucus) afterwards. LVN A stated she contacted the doctor who ordered CR#1 to have a chest x-ray, but he didn't get it cause resident went out to hospital. LVN A stated she would not have considered a change of condition on 5.2.2025 because he was talking to her. However, he was sleeping a lot, but easily aroused. LVN A stated this is why she did not call the doctor. In an Interview on 5/7/2025 at 11:26am with CMA A is familiar with CR#1. She stated CR#1 told her that he was nausea and felt like he wanted to throw up and refused his medication on 5/2/2025. She stated he looked normal and was talking to her as usual. CMA A stated she notified LVN A who was his charge nurse. She stated throughout the day, CMA A received a phone call at the nurses' station on Friday 5/2/2025 from CR#1's family members who was concerned he was not answering his cell phone. CMA A stated she went back to CR#1's room to get him to answer his cell phone. CR#1 told her that he heard the phone and that he was just sleeping. In an Interview on 5/7/2025 at 12:55pm the NP stated she believed she examined the CR#1. She consider a change of condition for resident mental status, shortness of breath, chest pain, changes in vital signs. Staff should notify the doctor immediately. She stated staff had her private number as well and if the resident vitals being in the 80's or 90's she should have been called. She expected the nursing staff to use their own judgement. She stated due to the blood pressure levels; resident should have been placed on repeat 5 to 15 minutes. She stated she expected the nurse to take the blood sugar. She stated the protocol at this facility was to use nursing judgement, which should have been to check blood sugar. In an Interview on 5/7/2025 at 1:17pm with RN A defined a resident's Change in condition as a deviation from what was normal for the resident. She stated Notifying a physician depends on the resident and what is out of the ordinary. RN A stated A drop in blood pressure was a change of condition and using her nursing intervention, she'd do a sternum rub until resident responds, contact doctor, increase hydration, and check his cognition. RN A stated the 80/47 blood pressure was a change of condition. She stated she documented in her own notes but not in her notes. She stated she did not contact the doctor and she should have contacted the doctor. RN a stated she spoke with CR#1 and he was in good spirits. RN A stated she kept up with him (vitals) in her own records but did not document in the nursing notes. RN A stated resident's blood sugar was 68 at 9pm on 5/2/2025. She stated on 5/3/2025 at 4:00am blood pressure was 110/66. She stated she should have notified the doctor and documented a change in condition. Record Review of Facility's Change in a Resident's Condition or Status policy dated May 2017 revealed the following: 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): d. significant change in the resident's physical/emotional/mental condition. 2. A significant change of condition is a major decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease- related clinical interventions (is not self-limiting) An Immediate Jeopardy (IJ) was identified on 05/07/2025 at which time the IJ template was provided to the IDON on 5/7/2025 at 5:30pm. The following Plan of Removal submitted by the facility was accepted on 5/8/2025 at 11:02 a.m. Allegation: The facility failed to notify physician when CR#1 had a change in condition in that his blood pressure was dropping. PLAN OF REMOVAL Name of facility: Date: 5.7.2025 Immediate action: On 5/6/2025 an investigation survey was initiated. On 5/7/2025 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safety. The notification of Immediate Jeopardy states as follows: The facility failed to notify physician when CR#1 had a change in condition in that his blood pressure was dropping. Resident CR#1 was discharged to the hospital on 5/3/2025 and remains in hospital at this time. 5/7/25 Charge Nurse (LVN/RN) will receive re-education and will receive disciplinary action if residents are not assessed timely and physicians notified of resident change in conditions, to include changes related to Diabetes mellitus and congestive heart failure. 5/7/25 Director of Nursing in-serviced LVN A and RN A on 5/7/25 on timely assessing residents of change in condition, continual documentation of change in condition to include vitals for resident until resident is stable or discharged to hospital, timely notification of change in condition of a resident to physician and/or medical director. 5/7/25 Facilities Plan to ensure compliance quickly F-580 Notification Physician of Change in Condition On 5/7/2025 Regional Nurse initiated Inservice with Nursing Staff (Assisted Director of Nursing, Director of Nursing, Certified Medication Aides, Charge Nurses, Certified Nurse Aide) on Point of Care Document- STOPWATCH. The in-service reads: Certified Nurse Aides must notify Charge Nurse of Change in Condition of Residents verbally and must document change in condition on resident Electronic Medical Records under Alerts to ensure timely follow-up of resident condition. Notifications of changes in condition will be monitored by the Assisted Director of Nursing/Designee during the daily clinical meeting and ongoing. DON will monitor this process during monthly QA. All nursing staff expected to be in-serviced prior to the next shift worked. Staff will not be allowed to provide direct care until services have been completed. This education will also be included in all new nurse orientations for any newly hired nurses and any Agency staff. The staff will not be allowed to provide resident care until training is completed. This in-service is to be completed on 5/8/2025. On 5/7/2025 Regional Nurse initiated Inservice with Nursing Staff (Assisted Director of Nursing, Director of Nursing, Certified Medication Aides, Charge Nurses) on physician notification of change in condition. The in-service reads: Resident noted with a change in condition is to be assessed by nurse and Md must be notified timely. Residents must continue to assess if the physician is unable to be reached within 2 hours by repeating the call and involve the medical director. If a resident condition appears emergent send to ER. The Charge nurses will notify MD of notifications, and the Charge Nurses will insure timely staff interventions if residents conditions are emergent. Will be monitored by the Assisted Director of Nursing/Designee during the daily clinical meeting and ongoing. DON will monitor this process during monthly QA. All nursing staff expected to be in-serviced prior to the next shift worked. This education will also be included in all new nurse orientations for any newly hired nurses and any Agency staff. The staff will not be allowed to provide resident care until training is completed. This in-service is to be completed on 5/8/2025. On 5/7/2025 Regional Nurse initiated Inservice with Nursing Staff (Assisted Director of Nursing, Director of Nursing, Certified Medication Aides, Charge Nurses) on physician notification of change in condition. The in-service reads: Resident noted with a change in condition reflecting BP out of normal range must notify physician for further guidance for resident care. Will be monitored by the Assisted Director of Nursing/Designee during the daily clinical meeting and ongoing. DON will monitor this process during monthly QA. All nursing staff expected to be in-serviced prior to the next shift worked. This education will also be included in all new nurse orientations for any newly hired nurses and any Agency staff. This in-service is to be completed on 5/8/2025. On 5/7/2025 Regional Nurse initiated Inservice with Nursing Staff (Assisted Director of Nursing, Director of Nursing, Certified Medication Aides, Charge Nurses, Therapy, Certified Nurse Aide) on Signs and symptoms of Hypoglycemia The in-service reads: TO ALL LICENSED NURSES- THIS IS IMPORTANT Abnormal low blood glucose below 70 mg/dl for a person with diabetes, and below 50 mg/dl for a person without diabetes is hypoglycemia and can be a direct effect from a medication or disease process. ASSESSMENT includes the following symptoms: Perspiring or sweating; weakness, dizziness or faintness, blurred or impaired vision, numbness to tongue or lips, headache, unconsciousness, seizures, coma. TREATMENT: j. Administer 1 tube of glucose gel (15-20 gms) orally (available in E-kit) k. Recheck glucose level in 15 minutes. l. If glucose is still <70 mg/dl administer an additional tube of oral glucose gel. m. Recheck glucose in 15 minutes. n. If a regular meal is not available within ½ hour of episode, give snack/food items o. If blood glucose levels decreases despite oral glucose administer glycogen (syringes available in E-kit.) p. Recheck blood glucose in 30 minutes and notify MD. q. If no response or resident is unconscious call 911 for emergency transport and obtain/document vital signs per vital sign instructional in-service. r. IF RESIDENT CAN'T SWALLOW give glycogen immediately and recheck glucose level in 30 minutes. Call MD anytime. Glycogen injections are given. IF NO RESPONSE TO GLYCOGON OR PATIENT BECOMES UNCONSCIOUS CALL 911 AND NOTIFY MD. YOU DO NOT HAVE TO WAIT FOR MD ORDERS TO SEND TO HOSPITAL THIS IS A LIFE-THREATENING EMERGENCY THAT REQUIRES IMMEDIATE EMERGENCY INTERVENTIONS. Residents displaying signs of hypoglycemia blood glucose below 70mg/dl for persons with diabetes, and below 50mg/dl for a person without diabetes must contact physician. MD will be notified by Charge nurse and will notify him timely. Will be monitored by the Assisted Director of Nursing/Designee during the daily clinical meeting and ongoing. DON will monitor this process during monthly QA. All nursing staff expected to be in-serviced prior to the next shift worked. Staff will not be allowed to provide direct care until services have been completed. This education will also be included in all new nurse orientations for any newly hired nurses and Agency staff. This in-service is to be completed on 5/8/2025. On 5/7/2025 Regional Nurse initiated Inservice with Nursing Staff (Assisted Director of Nursing, Director of Nursing, Staffing Nurse, Treatment Nurse, MDS Nurse) on daily monitoring of clinical records for Change in Condition. The in-service reads: Daily review of skilled charting, diagnostic test results, vitals during morning meeting to ensure areas not within normal ranges are addressed timely. All nursing staff expected to be in-serviced prior to the next shift worked. Staff will not be allowed to provide direct care until services have been completed. This education will also be included in all new nurse orientations for any newly hired nurses and Agency staff. This in-service is to be completed on 5/8/2025. Director of Nursing completed audit on 5/7/2025 of residents with DX of Diabetes to ensure sliding scale orders are in place and parameter for contacting the physician. There are no indications of non-compliance from the audit. Completed 5/7/2025 Director of Nursing completed audit on 5/7/2025 of residents with Blood pressure medication to ensure parameter for holding and contacting the physician are in place. There are no indications of non-compliance from the audit. Completed 5/7/2025 Director of Nursing completed audit on 5/7/2025 of residents with Change of Condition to ensure physician notification was completed and timely interventions put in place. There are no indications of non-compliance from the audit. Completed 5/7/2025 The Medical Director has been notified on 5/7/2025 of immediate jeopardy and reviewed the current change in condition p[TRUNCATED]

Based on observation, interviews and record review, the facility failed to ensure CR#1 received treatment and care in accordance with professional standards of practice for 1 of 5 residents (CR#1) reviewed for quality of care. The facility failed to properly identify and intervene in CR#1's acute change in condition related to his diabetes mellitus and congestive heart failure. The facility initially became aware of CR#1's declining vitals on 5/2/25 at 10:18am based on the timeline of vitals listed in nursing notes. 911 was not called until 5/3/25 at 5:30pm, which was more than 24 hours later. An Immediate Jeopardy (IJ) was identified on 05/07/2025 at 5:30 p.m. While the IJ was removed on 05/08/2025 at 10:50pm, the facility remained out of compliance at the severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for possible serious injuries, harm and death to residents who require supervision. Findings Include: Record review of CR#1's undated face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE] from the local hospital with diagnoses of coronary artery disease (reduction of blood flow to heart muscle), heart failure (the heart fails to pump enough blood to meet the body needs), hypertension (high blood pressure), diabetes mellitus (blood sugar is too high), Hyperlipidemia (too much fat in the blood), arthritis (swelling and tenderness in the joints), diverticulosis (inflammation of the colon), and other fractures. CR#1 discharged to the hospital on 5/3/2025. The discharge instructions listed primary diagnosis, reason for hospitalization, procedures and tests performed while in the hospital, taking medications and follow information regarding heart failure. Record review of CR#1's Quarterly MDS dated [DATE] revealed CR#1 has a BIMS score of 12 (means resident cognition is intact). Record review of CR#1's orders dated 5/1/2025-5/31/2025 revealed blood sugar checks two times a day for DIABETES; Midodrine HCI Oral Tablet 5 MG-give 1 tablet by mouth every 8 hours PRN (as needed) as needed for hypotension. Hold for SBR (blood Pressure) less than 90 (no date); Sodium Polystyrene Sulfonate Suspension 15GM/60ML-Give 15 gram by mouth one time only for Hyperkalemia (elevated potassium in the blood) until 5/3/2025 11:59p.m; Cozaar Tablet 100 MG (Losartan Potassium) give 1 tablet by mouth one time a day for hypertension. Hold for ABP <100 or DBP <60. Start date 4/23/2025 9:00am; Farxiga (diabetes) Oral tablet 5 mg (Dapagliflozin Propanediaol) Give 1 tablet by mouth one time a day for DM-start date 4/23/25 9:00am. Hold from 5/3/2025 to 5/5/2025 4:41pm; Prabastatin Sodium Oral Tablet 10 MG (Pravastatin Sodium) Give 1 tablet by mouth one time a day for Hyperlipidemia (for high cholesterol levels). Start date 4/23/2025 9:00am; Carvedilol Oral tablet 25 MG give one tablet by mouth two times a day for HTN (hypertension) hold for SBP <110 or HR <60. Start date 4/23/2025; Eliquis Oral tablet 5 MG (Apixaban) (blood thinner) give 1 tablet by mouth two times a day for Anticoagulant. Start date 4/23/2025 9:00am; Gilmepride (treats high blood pressure) Oral tablet 4 MG give 1 tablet by mouth two times a day for DM. Start date 4/23/2025 9:00am-Hold date 5/3/2025-5-5-2025. Record review of CR #1's care plan dated 4/22/2025, revealed the following care areas: Focus: [CR #1] I am at risk for frequent infections, pressure/venous/stasis ulcers, vision impairment, hyper/hypoglycemia, renal failure, cognitive/physical impairment/skin desensitized to pain or pressure related to diabetes melillitus. Date initiated and revision on 5/5/2025. Interventions: [CR #1] I will have no complications related to diabetes through the review date. Date initiated and revision on 5/5/2025. Target date on 5/1/2025. Interventions: [CR #1] Monitor/document/report PRN (as needed) any s/sx (signs or symptoms) of hyperglycemia (difficulty waking up); increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abd (abdomen pain), Kassmaul (rapid) breathing, acetone breath (smells fruity), stupor (stated of reduced consciousness or responsiveness, where a person is almost unconscious but can be aroused by vigorous stimulation), coma (deep unconsciousness)-date initiated 5/5/2025; Monitor/document/report PRN (as needed) any s/sx (signs or symptoms) of hypoglycemia: Sweating, Tremor, increased heart rate (Tachycardia), pallor (Paleness), nervousness, confusion, slurred speech, lack of coordination, staggering gait (unsteady). Date initiated 5/5/2025. Focus: [CR #1] Potential for complications, s/sx related to diagnosis of hypertension. Receives anti hypertension and is at risk for side effects. Dated initiated 5/5/2025. Goal: [CR #1] My B/P (blood pressure) will stay within their normal limits, will not have s/s of hyper/hypo tension throughout the review date. Date initiated 5/5/2025. Target date 5/1/2025. Interventions: [CR #1] Administer anti-hypertensive medications as ordered. Monitor B/P and for side effects such as orthostatic hypotension (low blood pressure) and increased heart rate (Tachycardia), increased edema (swelling), headache, chest pain, and report abnormalities to physician. Dated initiated 5/5/2025; Monitor/Document/Report PRN any s/s of malignant hypertension (blood pressure rises rapidly): Headache, visual problems, confusion, disorientation, lethargy (usually tired, sluggish, and lacking energy), nausea (feeling sick in the stomach) and vomiting, irritability, seizure activity, and difficulty breathing (Dyspnea). Date initiated 5/5/2025. Record Review of facility's last vitals taken for CR#1's Blood Pressure revealed: 5/2/2025 at 10:18am - 98/56 5/2/2025 at 7:58pm - 80/47 5/3/2025 at 7:05am - 82/47 5/3/2025 at 2:37pm - 81/43 5/3/2025 at 4:58pm - 99/51 Record Review of facility's last vitals taken for CR#1's 02 Stats revealed: 5/2/2025 10:18am 90.0% Room Air 5/2/2025 7:59pm 92.0% Room Air 5/3/2025 7:05am 93.0% Room Air 5/3/2025 4:58pm 82.0% Room Air Record Review of facility's last vitals taken for CR#1's Blood Sugar vitals revealed: 5/3/2025 2:37pm 64.0mg (manual) 5/3/2025 3:40pm 94.0mg (manual) Record Review of skilled charting for CR#1 dated 5/2/2025 at 7:33pm by LVN A, revealed the following: vital signs taken on 5/2/2025 at 10:18am were: Temperature 97.5 taken forehead (non-contact), pulse 77(bpm), Respiration 18.0(breaths/min), Blood pressure 98/56, O2 stats 92.0% (room air). Section D: Mood and Behavior: 1b: Notable changes in mood and behavior: Resident sleeping a lot more than usual. Record Review of skilled charting for CR#1 dated 5/2/2025 at 7:56pm by LVN A revealed the following: vital signs taken on 5/2/2025 at 7:59pm were: Temperature 96.8 taken forehead (non-contact), pulse 68(bpm), Respiration 20.0(breaths/min), Blood pressure 80/47, O2 stats 92.0% (room air). Section D: Mood and Behavior: 1b: Notable changes in mood and behavior: Resident sleeping a lot more than usual. Record Review of nursing notes for CR#1 dated 5/2/2025 revealed, there were no nursing notes for this date. Record Review of nursing notes for CR#1 dated 5/3/2025 at 9:16am, revealed, Change in Condition reported on the CIC Evaluation are/were: Other change in condition Tired, Weak, Confused, or Drowsy. At the time of evaluation resident/patient vital signs, weight and blood sugar were: -Blood Pressure: 82/47 - 5/3/2025 07:05 Position: Lying r/arm -Pulse: P 68 - 5/3/2025 07:05 Pulse Type: Regular -RR: R 18.0 - 5/3/2025 07:05 -Temp: T 97.3 - 5/3/2025 07:05 Route: Forehead (Non-Contact) -Weight: W 280.0 lb - 4/29/2025 14:38 (2:38pm) Scale: Mechanical Lift -Pulse Oximetry: O2 93.0% - 5/3/2025 07:05 Method: Room Air -Blood Glucose: Record Review of nursing notes for CR#1 dated 5/3/2025 at 7:20pm, revealed, Note Text: Resident lethargic this am, blood pressure low, notified vanguard received new orders: N/O: Midodrine HCI Oral Tablet 5 MG (Midodrine HCI). Record Review of Local Hospital admission dated 5.3.2025 revealed, CR#1 presented to the ED yesterday via EMS from the facility with fatigue (extreme tiredness), lethargy (lack of energy and enthusiasm), and altered mental status (a deviation form norm). EMS found CR#1 to be hypotensive (low blood pressure) (87/58), hypoglycemic (drop in blood sugar) with blood glucose (body primary source of energy) of 35 and hyperkalemic (causes kidney disease) with a potassium level of (6) six. CR#1 received D50 (intravenous), Kayexalate (treat high levels of potassium in the blood), and midodrine (treats low blood pressure) enroute to the ED. Workup (thorough diagnostic evaluation to determine the cause of symptoms or health condition) in the ED found CR#1 to be acute hypoxic (decrease in oxygen levels in the blood) and hypercapnic respiratory failure (respiratory system cannot remove carbon dioxide from the body), septic shock (a life threatening condition that occurs with body response to a severe infection causes low blood pressure and multiple organ dysfunction), acute renal failure (Kidney failure), and persistent hyperglycemia (high blood sugar levels consistently exceeding target range). CR#1 was placed on BIPAP and initiated on a D10 infusion (IV) to maintain glucose. CR#1 was fluid resuscitated per sepsis guidelines and initiated on vasopressors (medications to cause blood vessels to constrict) to maintain adequate blood pressure. CR#1 transferred to ICU for management. Foley placed in CR#1with 1200cc returned immediately after placement. The local hospital's disposition: CR#1 to remain in ICU. CR#1 at high risk for complications CR#1 is critically ill with vital organ impairment or failure. There is a high probability of imminent or life-threatening deterioration in the patient's condition. Patient is unable or incompetent to participate in giving a history and/or making decisions and discussion is necessary for determining treatment decisions. In a telephone interview on 5/6/2025 at 2:03 p.m., FM A stated CR#1 did not have pneumonia or sepsis before arriving to the facility 11 days ago. She stated his blood pressure has been extremely low. She stated CR#1 was in the local hospital. She stated the nursing staff did nothing to help CR#1 while in the facility. She stated if the nursing staff had checked his blood sugar like he told them they did in the hospital, they would have known that he was going into a diabetic coma. In an interview and observation on 5/6/2025 at 2:30 p.m. (at the hospital), CR#1 said he was in the facility for 11 days for rehab after having back surgery. CR#1 said after 3 days he began asking questions of the nurse regarding his glucose and checking his blood sugar levels because he was starting to feel very tired and couldn't stay awake. He said the nurse would only tell him she will be right back she had to check his orders. The nurse never returned. He said he asked this question on multiple shifts and multiple times and received the same answer. He said he started feeling lethargic and couldn't stay awake. He said he was so sleepy he went a day or two without eating. CR#1 said there was a LVN who had returned from vacation this past Saturday who listened to him, and his concerns, and she ordered labs. No other nurse did. In an Interview 5/6/2025 at 2:50pm at the hospital with FM B and FM C they stated last Thursday (5/1/2025) they tried calling resident and didn't get an answer. Both stated they called the front desk and were told he was asleep. They received the same response on Friday (5/2/2025). However, when they called Saturday (5/3/2025) and CR#1's phone went to his voicemail they had concerns and therefore called the facility. At this time FM A told FM B and FM C she didn't like what she was seeing and that she couldn't wake CR#1 after several tries. FM B said she demanded that FM D tell the facility to call 911 immediately. In a Telephone Interview 5/6/2025 at 5:30pm FM D stated this past Thursday (5/1/2025) morning CR#1 appeared unusually sleepy. She stated the nurse told her that she had given CR#1 pain medications which was why he was sleepy. FM D stated on Saturday (5/3/2025) she received a call from facility and said CR#1 was sleeping and lethargic and nurse stated she called doctor. FM D stated when she arrived at the facility Saturday (5/3/2025) the nurse had just taken his blood sugar and at that time it was 65. The nurse left the room to get some orange juice. However, while the nurse was away getting juice, FM D stated she observed the food tray with tea, and she put two packets of sugar and gave it to CR#1 herself. She stated a few moments later, the nurse returned with orange juice and sugar and gave it to resident. Stated after 30 minutes nurse re-took sugar levels and it was 93. She stated the nurse took labs. Nurse returned with lab results and said he had critical potassium levels and creatine were elevated as well. She stated the nurse said she called the doctor. However, FM D and other family members requested CR#1 go to hospital via 911. Stated the nurse returned with critical labs and stated the doctor had ordered Kayexalate (treats high blood potassium) and IV fluids; however, the nurse told her she had to get someone to come and start the IV because it was out of her range as a nurse. During this time the family continued to request CR#1 be sent out to hospital. She stated nursing staff never checked his blood sugar prior to this episode even though CR#1 and the family told the nursing staff that the hospital checked 3 times daily. She stated CR#1 asked about his blood sugar being checked and he was told by one of the nurses that the hospital told her (nurse) that he was no longer diabetic so there was no need to check his blood sugar. FM D stated CR#1 was very congested during her visit on Saturday 5/3/2025 and she told the nurse she could hear wheezing when CR#1 coughed. She stated the nurse checked CR#1's blood sugar after the family requested on Saturday, 5/3/2025. Interview on 5/6/2025 at 6:21p.m., with MA B stated she was familiar with CR#1. She stated CR#1's family members were always in the room. She stated blood sugars were to be taken before and after meals. She stated even if it was not in the orders, typically you do it for persons who were diabetic. She stated the nurse was responsible for taking the blood sugar. She stated checking the blood sugar was on the MAR. She stated the nurse will make the notation on MAR and if she hasn't noted she would find the nurse prior to giving medication. She stated she did not make any efforts to find the nurse and inquire about the blood sugar being taken. She stated she must of gotten busy. In an interview on 5/6/2025 at 6:46 p.m., LVN A stated she was familiar with CR#1. She returned to work on Monday 4/28/25 from vacation and worked with CR#1 for the first time then. She stated she worked with CR#1 on that Tuesday (4/29/2025) and again on Saturday 5/3/2025 She stated while she was working on 5/3/2025 and during her rounds she noticed CR#1 didn't look well as his face was pale looking. She stated she took his blood pressure, and it was low (82/47). She telephoned the doctor answering service and left a message. LVN A stated she honestly did not know he was diabetic until Saturday 5/3/2025. Nurse stated upon admission the medication list delivered from the hospital was sent to the doctor. The doctor was supposed to okay the orders. She stated the NP made rounds on 4/29/2025 at which time she told her that resident had serious back surgery and Tylenol was not strong enough for him. She stated the NP gave resident a prescription for an additional pain medication. LVN A stated if she had done the admission and noted the type of medication resident was taking she would have informed nursing staff that he needed blood sugar taken prior to meals and sometimes afterwards. In an interview on 5/6/2025 at 7:30 p.m., the IDON stated he spoke with the CR#1 on Friday 5/2/2025. He stated CR#1 was talking and stated he didn't feel well; however, IDON contributed it to the back issues. He stated he listened to CR#1's chest and lungs and did not get anything alarming. He stated the facility did a chest x-ray but when the results returned CR#1 had already went to the hospital. The IDON stated the admitting nurse (facility) was responsible for submitting any resident information upon admittance to the doctor. When asked if a diabetic patient should have a glucose test before meals, he stated they could. He stated it was a nursing judgement to draw blood for glucose labs. The IDON was asked how long it takes to develop pneumonia and sepsis and he stated the resident may have come to the facility from the hospital with that diagnosis. He was asked what should have been done when resident blood pressure taken was low and he stated that the resident's medical condition will sometimes have a low blood pressure; however, it should have been documented and possibly noted as a change of condition. The IDON stated on 5/3/2025 the nurse completed a change of condition; gave resident some orange juice and it appeared his blood glucose was increasing. He initially stated he was contacted and wanted the nurse to call 911, then he was reminded that according to the nursing notes the family requested 911. In a follow-up interview on 5/7/2025 at 9:10 p.m., the IDON stated the blood pressure readings on 5/2/2025 were out of range and not normal. He stated he was not aware the resident was having issues on this date (5/2/2025). He stated the blood pressure on 5/2/2025 represented someone who was hypotensive. He stated the nurses should have called the doctor. He stated the nurses erred for not contacting the doctor for the decrease in blood pressure. He stated the expectation was to re-check the blood pressure every 15-30 minutes. In a telephone interview on 5/7/2025 at 9:52am with LVN B she stated she did the intake admission for the CR#1 when he arrived at the facility and CR#1 was oriented to facility. She stated she sent the discharge summary to the physician, via celo (nursing service that communicates with the doctor); which allows the doctor to review and make changes to the discharge summary from the hospital or allow all instructions to remain in accordance with the discharge summary from the hospital. She stated in CR#1's case everything remained the same and the hospital discharge summary did not indicate taking blood glucose from CR#1 before or after meals. She stated the physician will add addendums. LVN B stated she did CR#1's vitals upon admission to facility and there were no concerns. She stated CR#1 was alert and oriented times 3-4. LVN B stated in an event a resident has a change of condition you must Notify physician and place resident on monitoring. Look at medical diagnosis because a resident with blood glucose issues could be Asymptomatic (showing no symptoms), so you must look at his medical history to see if there's a history of being hypo or hyper glycemic, orders prescribed, to see if resident has diabetes, and you must check blood sugar. In a follow-up telephone interview on 5/7/2025 at 11:14am with LVN A she stated a COC was anything going on with patient and out of the ordinary. Protocol was to notify doctor and get new orders. She stated CR#1's blood pressure was low after taking it 4 times on 5/3/2025. CR#1's family member told her she noticed a cough and phlegm (thick mucus) afterwards. LVN A stated she contacted the doctor who ordered CR#1 to have a chest x-ray, but he didn't get it because resident went out to hospital. LVN A stated she would not have considered a change of condition on 5/2/2025 because he was talking to her. However, he was sleeping a lot, but easily aroused. LVN A stated this was why she did not call the doctor. In an Interview on 5/7/2025 at 11:26am with MA A was familiar with CR#1. She stated CR#1 told her that he had nausea and felt like he wanted to throw up and refused his medication on 5/2/2025. She stated he looked normal and was talking to her as usual. MA A stated she notified LVN A who was his charge nurse. She stated throughout the day, MA A received a phone call at the nurses' station on Friday 5/2/2025 from CR#1's family members who was concerned he was not answering his cell phone. MA A stated she went back to CR#1's room to get him to answer his cell phone. CR#1 told her that he heard the phone and that he was just sleeping. In an Interview on 5/7/2025 at 12:55pm the NP stated she believed she examined the CR#1. She consider a change of condition for resident mental status, shortness of breath, chest pain, changes in vital signs. Staff should notify the doctor immediately. She stated staff had her private number as well and if the resident vitals being in the 80's or 90's she should have been called. She expected the nursing staff to use their own judgement. She stated due to the blood pressure levels; resident should have been placed on repeat 5 to 15 minutes. She stated she expected the nurse to take the blood sugar. She stated the protocol at this facility was to use nursing judgement, which should have been to check blood sugar. In an Interview on 5/7/2025 at 1:17pm with RN A defined a resident's Change in condition as a deviation from what was normal for the resident. She stated Notifying a physician depends on the resident and what is out of the ordinary. RN A stated A drop in blood pressure was a change of condition and using her nursing intervention, she'd do a sternum rub until resident responds, contact doctor, increase hydration, and check his cognition. RN A stated the 80/47 blood pressure was a change of condition. She stated she documented in her own notes but not in her notes. She stated she did not contact the doctor and she should have contacted the doctor. RN a stated she spoke with CR#1 and he was in good spirits. RN A stated she kept up with him (vitals) in her own records but did not document in the nursing notes. RN A stated resident's blood sugar was 68 at 9pm on 5/2/2025. She stated on 5/3/2025 at 4:00am blood pressure was 110/66. She stated she should have notified the doctor and documented a change in condition. An Immediate Jeopardy (IJ) was identified on 05/07/2025 at which time the IJ template was provided to the IDON on 5/7/2025 at 5:30pm. The following Plan of Removal submitted by the facility was accepted on 5/8/2025 at 11:02 a.m. Allegation: The facility failed to promptly identify and intervene in CR#1's acute change in condition related to his diabetes mellitus and congestive heart failure from 5/2/2025-5/3/2025, which resulted in hospitalization. PLAN OF REMOVAL Name of facility: Date: 5.7.2025 Immediate action: On 5/6/2025 an investigation survey was initiated. On 5/7/2025 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safety. The notification of Immediate Jeopardy states as follows: The facility failed to promptly identify and intervene in CR #1's acute change in condition related to his diabetes mellitus and congestive heart failure, from 5/2/25-5/3/25, which resulted in the family requesting he be sent to the ER on [DATE]. Resident CR#1 was discharged to the hospital on 5/3/2025 and remains in hospital at this time. 5/7/25 Charge Nurse (LVN/RN) will receive re-education and will receive disciplinary action if residents are not assessed timely and physicians notified of resident change in conditions, to include changes related to Diabetes mellitus and congestive heart failure. 5/7/25 Director of Nursing in-serviced LVN A and RN A on 5/7/25 on timely assessing residents of change in condition, continual documentation of change in condition to include vitals for resident until resident is stable or discharged to hospital, timely notification of change in condition of a resident to physician and/or medical director. 5/7/25 Facilities Plan to ensure compliance quickly F-684 Quality of Care On 5/7/2025 Regional Nurse initiated Inservice with Nursing Staff (Assisted Director of Nursing, Director of Nursing, Certified Medication Aides, Charge Nurses, Certified Nurse Aide) on Point of Care Document- STOPWATCH. The in-service reads: Certified Nurse Aides must notify Charge Nurse of Change in Condition of Residents verbally and must document change in condition on resident Electronic Medical Records under Alerts to ensure timely follow-up of resident condition. Notifications of changes in condition will be monitored by the Assisted Director of Nursing/Designee during the daily clinical meeting and ongoing. DON will monitor this process during monthly QA. All nursing staff expected to be in-serviced prior to the next shift worked. Staff will not be allowed to provide direct care until services have been completed. This education will also be included in all new nurse orientations for any newly hired nurses and any Agency staff. The staff will not be allowed to provide resident care until training is completed. This in-service is to be completed on 5/8/2025. On 5/7/2025 Regional Nurse initiated Inservice with Nursing Staff (Assisted Director of Nursing, Director of Nursing, Certified Medication Aides, Charge Nurses) on physician notification of change in condition. The in-service reads: Resident noted with a change in condition is to be assessed by nurse and Md must be notified timely. Residents must continue to assess if the physician is unable to be reached within 2 hours by repeating the call and involve the medical director. If a resident condition appears emergent send to ER. The Charge nurses will notify MD of notifications, and the Charge Nurses will insure timely staff interventions if residents conditions are emergent. Will be monitored by the Assisted Director of Nursing/Designee during the daily clinical meeting and ongoing. DON will monitor this process during monthly QA. All nursing staff expected to be in-serviced prior to the next shift worked. This education will also be included in all new nurse orientations for any newly hired nurses and any Agency staff. The staff will not be allowed to provide resident care until training is completed. This in-service is to be completed on 5/8/2025. On 5/7/2025 Regional Nurse initiated Inservice with Nursing Staff (Assisted Director of Nursing, Director of Nursing, Certified Medication Aides, Charge Nurses) on physician notification of change in condition. The in-service reads: Resident noted with a change in condition reflecting BP out of normal range must notify physician for further guidance for resident care. Will be monitored by the Assisted Director of Nursing/Designee during the daily clinical meeting and ongoing. DON will monitor this process during monthly QA. All nursing staff expected to be in-serviced prior to the next shift worked. This education will also be included in all new nurse orientations for any newly hired nurses and any Agency staff. This in-service is to be completed on 5/8/2025. On 5/7/2025 Regional Nurse initiated Inservice with Nursing Staff (Assisted Director of Nursing, Director of Nursing, Certified Medication Aides, Charge Nurses, Therapy, Certified Nurse Aide) on Signs and symptoms of Hypoglycemia. The in-service reads: TO ALL LICENSED NURSES- THIS IS IMPORTANT ]Abnormal low blood glucose below 70 mg/dl for a person with diabetes, and below 50 mg/dl for a person without diabetes is hypoglycemia and can be a direct effect from a medication or disease process. ASSESSMENT includes the following symptoms: Perspiring or sweating; weakness, dizziness or faintness, blurred or impaired vision, numbness to tongue or lips, headache, unconsciousness, seizures, coma. TREATMENT: a. Administer 1 tube of glucose gel (15-20 gms) orally (available in E-kit) b. Recheck glucose level in 15 minutes. c. If glucose is still <70 mg/dl administer an additional tube of oral glucose gel. d. Recheck glucose in 15 minutes. e. If a regular meal is not available within ½ hour of episode, give snack/food items f. If blood glucose levels decreases despite oral glucose administer glycogen (syringes available in E-kit.) g. Recheck blood glucose in 30 minutes and notify MD. h. If no response or resident is unconscious call 911 for emergency transport and obtain/document vital signs per vital sign instructional inservice. i. IF RESIDENT CANT SWALLOW give glycogen immediately and recheck glucose level in 30 minutes. Call MD anytime Glycogen injections are given. IF NO RESPONSE TO GLYCOGON OR PATIENT BECOMES UNCONSCIOUS CALL 911 AND NOTIFY MD. YOU DO NOT HAVE TO WAIT FOR MD ORDERS TO SEND TO HOSPITAL THIS IS A LIFE-THREATENING EMERGENCY THAT REQUIRES IMMEDIATE EMERGENCY INTERVENTIONS. Residents displaying signs of hypoglycemia blood glucose below 70mg/dl for persons with diabetes, and below 50mg/dl for a person without diabetes must contact physician. MD will be notified by Charge nurse and will notify him timely. Will be monitored by the Assisted Director of Nursing/Designee during the daily clinical meeting and ongoing. DON will monitor this process during monthly QA. All nursing staff expected to be in-serviced prior to the next shift worked. Staff will not be allowed to provide direct care until services have been completed. This education will also be included in all new nurse orientations for any newly hired nurses and Agency staff. This in-service is to be completed on 5/8/2025. On 5/7/2025 Regional Nurse initiated Inservice with Nursing Staff (Assisted Director of Nursing, Director of Nursing, Staffing Nurse, Treatment Nurse, MDS Nurse) on daily monitoring of clinical records for Change in Condition. The in-service reads: Daily review of skilled charting, diagnostic test results, vitals during morning meeting to ensure areas not within normal ranges are addressed timely. All nursing staff expected to be in-serviced prior to the next shift worked. Staff will not be allowed to provide direct care until services have been completed. This education will also be included in all new nurse orientations for any newly hired nurses and Agency staff. This in-service is to be completed on 5/8/2025. Director of Nursing completed audit on 5/7/2025 of residents with DX of Diabetes to ensure sliding scale orders are in place and parameter for contacting the physician. There are

Based on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plans for one (Resident #1) of seven residents reviewed for comprehensive care plans in that: The facility failed to notify the PCP according to the resident care plan and physician orders when Resident #1's blood sugar level was over 401 after a blood sugar level check on 6/9/2025. This failure could place the residents at risk of harm, injuries, and delayed treatment. Findings included: Record review of Resident #1's face sheet, dated 6/11/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 diagnosis was Diabetes mellitus (high blood sugar levels). Record review of Resident #1's quarterly MDS dated [DATE] revealed he had a BIMS score of 9 (moderately cognitive impairment). Section I- Active Diagnoses included diabetes mellitus. Section N - Medications received insulin injections. Record review of Resident #1's care plan, revised on 6/11/2025, revealed the following in part: Focus: The resident [Resident #] has hyperglycemia (condition related to high sugar in the blood) r/t diabetes. Goal: The resident [Resident #1] will be free from any s/sx of hyperglycemia through the review date. Interventions: Monitor/document/report PRN for s/sx of hyperglycemia . Record review of Resident #1's Order Summary Report dated 6/11/2023 revealed the following in part: Order date 6/23/2022. Start date 6/24/2022. Insulin Lispro (1 unit dial) 100 unit/ML Solution pen-injector- Inject as per sliding scale if: 61 - 150 = 0 151 - 200 = 3 201 - 250 = 5 251 - 300 = 8 301 - 350 = 10 351 - 400 = 12 401 - 450 = 15 CALL MD, subcutaneously before meals for diabetes Record review of Resident #1's blood sugar vital log dated 6/11/2025 revealed on 6/9/2025 at 15:05 (3:05 p.m.) his blood sugar level was 403.0 mg/dL and recorded by LVN A. Record review of Resident #1's MAR dated 6/11/2025 revealed the follow: Insulin Lispro (1 unit Dial) 100 Unit/ML Solution pen injector. Inject as per sliding scale: 61 - 150 = 0 151 - 200 = 3 201 - 250 = 5 251 - 300 = 8 301 - 350 = 10 351 - 400 = 12 401 - 450 = 15 CALL MD, subcutaneously before meals for diabetes. Resident #1's MAR further revealed on 6/9/2025 at the scheduled time of 1800 hours (4:00 p.m.) revealed Resident #1 was administered 15 units of insulin subcutaneously by LVN A and the blood sugar level documented was 403. Record review of Resident #1's nursing notes dated 5/12/2025 - 6/11/2025 revealed not a nursing documentation related to Resident #1's PCP being notified of his elevated blood sugar level on 6/9/2025. Record review of the 24-hour report binder (100 hall binder for Resident #1) revealed there was not a documented nursing note related to Resident #1's PCP was notified about his elevated blood sugar level on 6/9/2025. Interview and observation on 6/11/2025 at 3:35 p.m., the DON said she was not aware of Resident #1's elevated blood sugar level on 6/9/2025. She reviewed Resident #1's parameters for insulin on his order and the MAR from 6/9/2025. The DON said the PCP should have been notified immediately along with herself. The DON said LVN A should have follow instruction given by the PCP. The DON said the resident was at risk of fatigue, lethargy, or diabetic coma. She said she was responsible for monitoring elevated vitals and reviewed them in the daily meetings. She said nurses had been trained to follow physician orders. Interview on 6/11/2025 at 3:48 p.m. with LVN A said she did not notify Resident #1's PCP on 6/9/2025 after Resident #1's blood sugar level was elevated to 403. She said, I am a new nurse and did not read the order fully. She said she had worked at the facility for two weeks. She said she was trained on medication administration by the facility. She said the resident was at risk for declining into a diabetic coma. Interview on 6/11/2025 at 4:20 p.m. with Resident #1's PCP said he was not notified on 6/9/2025 of Resident #1's elevated blood sugar level of 403. He said if he was notified, he would have advised the nursing staff to monitor the resident for signs and symptoms of diabetes, check the blood sugar level again and if it increased, he would have possibly increased the insulin dosage. He said the resident was at risk of becoming lethargic, thirst, and various side effects of elevated blood sugar levels. Interview on 6/11/2025 at 4:35 p.m., Resident #1 said he did not remember if he was told by LVN A that his blood sugar level was 403 and she needed to notify the doctor. He said he had not felt different in the last 2 days. Record review (after surveyor intervention) of Resident #1's nursing notes (by ADON) dated 6/11/2025 revealed the following: Follow up to blood sugar of 403 on 6/9/25 no new orders where given will continue monitor for any further episodes. Record Review of Facility's Change in a Resident's Condition or Status policy (revised) May 2017 revealed the following: Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status . 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): . i. specific instruction to notify the Physician of changes in the resident's condition.

Based on interview and record review, the comprehensive assessment of a resident, the facility must 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 1 of 5 residents (CR #1) reviewed for quality care. The facility failed to ensure CR #1 did not receive Hydrocodone-Acetaminophen (Norco) after it was discontinued after her hospital visit on [DATE] but was not discontinued in her chart. CR #1 received Norco more frequently than the order that remained in her chart on [DATE]. She experienced lethargy, nausea, vomiting, and decreased response to stimuli and expired at the hospital later that evening. An Immediate Jeopardy was identified on [DATE] at 4:33 p.m. While the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place the resident at risk for not receiving medications as ordered resulting in serious injury, decline in health, and death. Findings included: Record review of CR #1's admission record dated [DATE] revealed a [AGE] year-old female who was readmitted to the facility on [DATE]. Her diagnoses included hypotension (low blood pressure), muscle weakness, type 2 diabetes, end stage renal disease, dependence on renal dialysis, other abnormalities of gait and mobility, need for assistance with personal care, and chronic embolism and thrombosis of other specified veins (conditions involving persistent blood clots that can obstruct blood flow). Record review of CR #1's Discharge MDS assessment-return anticipated dated [DATE] revealed her cognitive skills for daily decision making were moderately impaired. She required assistance from staff with ADL care. Record review of CR #1's care plan dated [DATE] revealed the resident was full code (providing chest compressions in the event of cardia arrest). Interventions were to monitor for decrease in change of condition and report to the MD and responsible party. Record review of CR #1's Nursing note dated [DATE] written by LVN G read in part, During morning assessment resident noted to be lethargic and not answering nurse when asking question resident eyes PERRLA aroused to touch . BP 130/86 P 87 MD made aware new orders received for stat labs CBC/BMP labs were collected. Resident went to dialysis BP was low Midodrine was given BP went up to 108/67 then started dropping again . (family) came to visit resident stated resident looks worse then [sic] yesterday and wanted her sent to ER MD made aware of family request and called for preferred to pickup . Record review of CR #1's hospital record dated [DATE] -[DATE] read in part, .chief complaint: weakness - generalized pt from (facility) and report pt has been getting weaker for several days .ED course . [DATE] at 11:32 p.m. Pt more alert on re eval, counseled on findings. Suspect that her symptoms may be due to Norco. Counseled on cessation of Norco for the next few days . Final Diagnoses: generalized weakness . Medication changes: Hydrocodone/acetaminophen 10-325 mg 1 tablet every 6 hours prn (there was a line struck through it). Record review of CR #1's nursing note dated [DATE] written by LVN N read in part, .resident return from hospital this morning aprx, 0530 (5:30 a.m.), via ambulance . resident stable, no c/o pain or discomfort noted at time of arrival . discharge instructions include DC of Norco 10-325 no other changes to medications made . Record review of CR #1's Order Summary Report dated [DATE] revealed an order for Hydrocodone-Acetaminophen (Norco) 10-325 mg 1 tablet by mouth every 6 hours as needed for pain, order date [DATE], discontinued [DATE]. Record review of CR #1's Medication Administration Record for [DATE] revealed Hydrocodone-Acetaminophen 10-325 mg 1 tablet every 6 hours as needed for pain was documented as administered on [DATE] at 8:10 a.m. There was no other administration documented on [DATE] for Hydrocodone-Acetaminophen. Record review of CR #1's Controlled Drug Administration Record for Hydrocodone-Acetaminophen (Norco) 10-325 mg dated [DATE] revealed one tablet was documented as administered to CR #1 on 4/4/(24) at 6 a.m. by LVN D and another tablet was documented as administered 2 hours later on 4/4/(24) at 8 a.m. by LVN J. Record review of CR #1's nursing note dated [DATE] at 12:38 p.m. written by LVN J read in part, 'Resident is drowsy; Norco's overdose noted. Resident has refused meals: breakfast and lunch. Monitoring in progress. Record review of CR #1's nursing note dated [DATE] at 12:56 p.m. written by the previous DON read in part, DON was called to resident's room due to resident being drowsy after returning from dialysis around on assessment resident was arousable and verbally responsive stating she was tired and wants to sleep. Charge Nurse stated resident was given PRN Norco before going to dialysis. Record review indicated resident was given an extra dose of Norco 2 hours after the previous dose instead of every 6 hours. MD made aware. MD instructed to monitor resident for responsiveness. Record review of a text message conversation provided by the facility with MD R dated [DATE] at 12:56 p.m. read, Also (CR #1) can [sic] given Norco sooner 2 hours apart instead of 6 hrs because night did not document in emar that she gave a dose a 6 pm [sic]. Morning nurse gave it again when resident asked for pain meds. She is talking but more sleepy . MD R responded, Yes she can have the early dose. Record review of CR #1's nursing note dated [DATE] at 3:06 p.m. written by LVN J read in part, Resident has nausea and vomiting. Change of condition. Has called physician for new order. Message left via voicemail. Record review of CR #1's vital signs on [DATE] at 3:36 p.m. revealed her blood pressure was 80/57 mmHg. Her respirations were 16 breaths/minute and oxygen was 96% on [DATE] at 2:11 p.m. Record review of CR #1's nursing note dated [DATE] at 6:19 p.m. written by LVN D read Patient administer oxygen per nasal canula at 3L. The EMS received vital signs and decided to transport patient for acute care . Record review of CR #1's nursing note dated [DATE] at 8:18 p.m. written by LVN D read, Upon attempting to administer patient scheduled medication, patient appears to have increased lethargy. O2 level obtained at 90% on RA upon assessment. Patient sternal rubbed and minimally responsive to stimuli. EMS Service contacted for acute care transport to ED. Pt assessed via 6 EMS transport to (hospital). Record review of CR #1's hospital records dated [DATE] read in part, .Patient presents with cardiac arrest . EMS reports (facility) staff stated pt was in respiratory distress all day and progressively getting worse. Per EMS pt was having agonal breaths upon arrival to scene and pt went inyo [sic] cardiac arrest on ambulance. Patient downtime wa [sic] 1 minute before arrival to ED, no meds given en route Medical Decision Making . EMS reports they were called to the patient's nursing home due to severe respiratory distress, on their arrival patient was obtunded, severe respiratory distress, and route to ER patient became apneic and lost pulses and they started CPR. CPR was initiated 2 minutes prior to arrival . after 20 minutes of CPR, decision was made to terminate interventions. Time of death called at 9:09 p.m. In a telephone interview on [DATE] at 10:38 a.m. the previous DON said the night nurse administered Norco to CR #1 prior to leaving her shift and documented it in the narcotic book but did not document it in the eMAR. She said the morning nurse arrived and the resident asked for pain medicine, and he administered the same medication within 2 hours instead of 6 hours. She said the Norco was scheduled for every 6 hours. She said the facility notified MD R and he said it was not a problem and ok to give the medication sooner and to just keep an eye on her. She said she could not recall if CR #1 had an order for the Norco. She said CR #1 was a little sleepy but was herself and they monitored her. She said CR #1 was in and out of the hospital very frequently and did not remember if she went out to the hospital that day. She said she in serviced LVN J who was an agency nurse and did not allow him to come back to the facility. She said staff should document administered narcotics in both the eMAR and narcotic book because there could be a risk of double dosing the resident. In an interview on [DATE] at 10:53 a.m. CR #1's family member said the resident admitted to the facility for rehabilitation. He said hospital staff informed him a few times that CR #1 was overmedicated with pain medication. He said when he visited her at the facility, she was not all the way there, she was in and out, more quiet, exhausted, and not there at all. He said she deteriorated at the facility and was never like that before. He said on [DATE] he went to the facility to check on her and she was particularly out of it that day. Her body was cold, she was responsive but was in and out. He said she vomited on herself around 11:30 a.m. - 12:30 p.m. He reported it and staff arrived but did not ask about the vomiting. He said she went to sleep and later that evening around 10:45 p.m. the facility called another family member to inform her she was at the local hospital and her oxygen was low, but blood pressure was fine. He said when he arrived at the ER he was met with an empty room and a body bag on top of the gurney. In a telephone interview on [DATE] at 11:16 a.m. LVN D said she did not remember a possible overdose and did not remember sending CR #1 to the hospital. In a telephone interview on [DATE] at 11:38 a.m. MD R said CR #1 went to the hospital on 3/22-23/24 due to generalized weakness. He said if the Norco was supposed to be stopped the facility should reconcile with the MD and it should be stopped but said he was not sure if it was discontinued because he did not see the DC in the hospital records. He said the ED recommended to stop CR #1's Norco due to weakness, not from overdosing. He said he was unsure if he was notified of the Norco overdose (on [DATE]). He said the risk of a Norco overdose would depend on the patient and monitoring was important. He said CR #1 had ESRD and should be monitored pretty closely. In a telephone interview on [DATE] at 12:02 p.m. MD G said she did not recall the incident and was not notified of anything regarding CR #1. She said if the Norco order was for every 6 hours she did not know why it was administered in 2 hours. She said Norco could upset the stomach and lethargy could happen if Norco was given too early. In an interview on [DATE] at 12:15 p.m. the Regional Nurse said she was unsure of when the facility stopped using nursing agencies. She said she was unsure of anything that happened to CR #1, only what was in the chart. She said the expectation was for nurses to document when giving the medication to the residents and they should follow the order as prescribed. If there was a change in condition the resident should be assessed, and the physician notified and documented. If the physician did not respond, staff should call back and if no response, the medical director is to be called. Depending on the status of the resident, if the resident was in respiratory distress or vital signs too low or high, staff could use nursing judgement for the resident's safety. For medication pass, it is documented on the eMAR and the narcotic count book/log. If doing medication pass, both the eMAR and narcotic book should be reviewed before administering the medication. When residents return from the hospital the discharge summary is reviewed by the nurse who is accepting the resident. The nurse will then input the discharge summary into PCC. They are checking the medications are input correctly into PCC. They are to verify the orders with the attending doctor to ensure they agree for the resident's care. If a resident is given discontinued medication, they did not follow the MD orders and the resident could be at risk. She noticed when the resident came back from the hospital, the nurse wrote D/C Norco, but it was not discontinued. She did not review the discharge hospital summary. She also read that the resident received extra Norco. Per the notes, the resident was lethargic and not as responsive. She did know she had cardiac arrest and passed away. She did not believe the extra Norco caused CR #1's death. She was unsure if the resident was to be on the Norco but noticed that it was discontinued, and did not know why. She did read the resident asked to go to the hospital previously to get Morphine. Record review of the discontinued medications policy, states the nurse documents the order to discontinue the medication in the resident's record. The Physician's order sheet (POS) and the medication administration record (MAR) are updated to indicate that the order is discontinued. Alternatively, the discontinuation order is entered into the facility's EHR system. Record review of the general guidelines for medication administration policy, states always employ the MAR during medication administration. Prior to the administration of any medication, the medication and dosage schedule on the resident's MAR are compared with the medication label. The individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR to ensure that necessary doses were administered and documented. In no case should the individual who administered the medication report off-duty without first recording the administration of any medications. Record review of Change in condition policy, states that once the nurse has notified the physician for a change in condition the resident/patient will be monitored for 1 hour until the physician has responded. The monitoring will include vital signs, pulse ox, and finger stick blood sugar if diabetic (one time only). A physical assessment should be completed relative to the symptoms present and a pain assessment. If resident/patient condition appears emergent transfer to local ER may occur without physician order. On [DATE] at 4:33 p.m. the regional nurse and administrator were informed that an Immediate Jeopardy situation was identified due to the above failures and a Plan of Removal was requested. The following Plan of Removal was submitted by the facility and accepted on [DATE] at 9:47 p.m. On [DATE] an investigation survey was initiated. On [DATE] the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safety. The notification of Immediate Jeopardy states as follows: The facility failed to ensure CR #1 did not receive Hydrocodone-Acetaminophen more frequently than prescribed by the MD on [DATE]. Resident CR#1 was discharged to the hospital on [DATE] and expired due to Cardiac Arrest. Charge Nurse (LVN/RN) will receive education and/or disciplinary action if medication administration is not documented in MAR and Narcotic Control log for all Narcotic medications. Charge Nurse J was in serviced on 4/4 on medication administration and followed physician orders by director of nursing. The nurse was an agency nurse, and we will never select to use this nurse again. Facility's Plan to ensure compliance quickly. oOn [DATE] Regional Nurse initiated Inservice with Nursing Staff (Assistant Director of Nursing, Director of Nursing, Certified Medication Aides, Charge Nurses) on Following of Physician Orders. The in-service reads: Medications are to be administered as ordered by MD. PRN Narcotic medication is to be documented on MAR and Narcotic Control Log. All nursing staff expected to be in-serviced prior to the next shift worked. Staff will not be allowed to provide direct care until services have been completed. This education will also be included in all new nurse orientations for any newly hired nurses and any Agency staff. This in-service is to be completed on [DATE]. oOn [DATE] Regional Nurse initiated Inservice with Nursing Staff (Assistant Director of Nursing, Director of Nursing, Certified Medication Aides, Charge Nurses) on Medication Administration. The in-service reads: Charge nurses (LVN/RN) and Certified Medication Aides are to follow the 5 rights of medication administration. Right medication, Right patient, Right Dosage, Right Route, Right Time. All nursing staff expected to be in-serviced prior to the next shift worked. This education will also be included in all new nurse orientations for any newly hired nurses and any Agency staff. This in-service is to be completed on [DATE]. oOn [DATE] Regional Nurse initiated Inservice with Nursing Staff (Assistant Director of Nursing, Director of Nursing, Certified Medication Aides, Charge Nurses) on Change in Condition. The in-service reads: Resident noted with a change in condition is to be assessed by nurse and Md must be notified. Residents continue to be assessed if physician is unable to be reached within 2 hours repeat call and involve medical director. If resident condition appears emergent send to ER. All nursing staff expected to be in-serviced prior to the next shift worked. Staff will not be allowed to provide direct care until services have been completed. This education will also be included in all new nurse orientations for any newly hired nurses and Agency staff. This in-service is to be completed on [DATE]. oOn [DATE] Regional Nurse initiated Inservice with Nursing Staff (Assistant Director of Nursing, Director of Nursing, Certified Medication Aides, Charge Nurses) on Medication Errors. The in-service reads: Physician is to be notified of all medication errors and resident is to be monitored closely for any adverse reactions. All nursing staff expected to be in-serviced prior to the next shift worked. Staff will not be allowed to provide direct care until services have been completed. This education will also be included in all new nurse orientations for any newly hired nurses and Agency staff. This in-service is to be completed on [DATE]. oRegional Nurse/Designee initiated medication pass competency check offs on Nursing Staff (Assistant Director of Nursing, Director of Nursing, Certified Medication Aides, Charge Nurses) All nursing staff expected to be in-serviced prior to the next shift worked. Staff will not be allowed to provide direct care until services have been completed. Agency Staff medication pass competency to be completed at start of shift. This observation is to be completed on [DATE]. oAudit conducted on [DATE] of residents PRN narcotics orders to ensure MARS reflects medications are administered as indicated by physician orders for the past 30 days. On [DATE] MAR to Narcotic count sheet check completed to confirm medications are documented on MAR and Narcotic log. There are no indications of medication errors from the audit. Completed on [DATE]. oThe Medical Director has been notified on [DATE] of immediate jeopardy and reviewed the current change in condition policy and procedures, following physician order policy and procedure, medication administration policy and procedure, and medication error policy and procedure. Plan of action reviewed with the Medical Director with no changes to the current policies. This practice will be reviewed monthly with the QA committee to ensure we are compliant with the change in condition policy and procedures, medication administration policy and procedure, and medication error policy and procedure. Start Date: [DATE]. Completion Date: [DATE] Responsible: Regional Nurse/Designee Monitoring was conducted on [DATE] and [DATE] to verify the facility's plan of removal. The monitoring included: Record review of Dialyzable drugs - acetaminophen was listed, but did not affect toxicity. Hydrocodone was not listed. (Dialyzable drugs are drugs that can be removed by dialysis). Record review of In-service dated [DATE] with previous DON- transcribing medication orders in PCC. Following Hospital Medication orders; clarification and confirming orders. Identifying hazard drug alert on EMAR and blister pack. Record review of In-service dated [DATE] at 6 p.m. with previous DON - for medication administration, pain *unreadable* meds as you go in EMAR. Narcotics should be divided in eMAR and also documented in narcotic log. Record review of In-service & Education Record dated [DATE] - Description: Nurses/CMAs to follow MD orders when administering meds. Review discharge summary from hospital for current med reconciliation. Any medication that resident was receiving previously must be discontinued if not on hospital discharge summary. MD to be notified of admission and verification of meds. There were 9 signatures. Record review of Inservice & Education Record dated [DATE] - Inputting orders into PCC (an electronic medical record) - make sure order is accurate - 5 rights of med administration - order is assigned a schedule and is on correct MAR - all PRN meds go on nurses MAR (LMAR). There were 9 signatures Record review of Inservice & Education Record dated [DATE] - Medication is to be administered as ordered by the MD. Charge nurses are to follow the 5 rights of med administration - right med, right patient, right dosage, right route and right time. Staff not following the above will receive disciplinary action up to and including termination. There were 10 signatures (MA, RN, LVN) Record review of Inservice & Education Record dated [DATE] - Resident noted with a change in condition is to be assessed by the nurse and MD notified - res is to continue to be assessed if unable to reach physician within 2 hours. Repeat call - if you still cannot reach MD call the Medical Director - if resident/pt condition appears emergent send to ER. There were 8 nurse signatures. Record review of Inservice & Education Record dated [DATE] - Medication error - MD is to be notified of any medication error and resident is to be monitored for any adverse reactions. There were 8 nurse signatures. Record review of Inservice & Education Record dated [DATE] - PRN medications are to be documented on narcotic count sheet and on MAR in resident chart after medication administered. Resident to be assessed for pain with shift and document effectiveness of pain medication. There were 8 nurse signatures. Record review of Medication Pass Audits dated [DATE]. There were 5 audits conducted with no errors. Record review of Inservice & Education Record dated [DATE] - Medication Administration, prn documentation, following 6 rights of medication pass, preventing medication errors. Check and balance of admission/discharge medication reconciliation, MD orders - PCC, notification of medication error to MD, med pass audit will be observed 1st day back to work before hitting the floor to pass meds. There were 4 nurse signatures. In an interview on [DATE] at 1:18 p.m. LVN B (Charge nurse 6 a.m. - 6 p.m.) said she was trained to document changes in condition, monitor, and follow up with the MD and Medical Director. If the situation was emergent, she would send them out so the patient is not compromised. The 5 rights of medication administration include to use the right medication, patient, route, time, and document pain on MAR and on narcotic sheet and ensure the times match too because it could be a medication error. She said you document a change in condition in the assessments einteract SBAR, notify the MD right away let them know what is going on, and notify the DON of changes. She said she would keep assessing the patient for any changes either better or worse and document if interventions have helped. She said PRN medications should be reassessed around 15-45 minutes later to ensure efficacy. If there was a medication error, she would notify the DON right away, go through the steps of what happened, do an investigation, notify the MD, assess the resident for adverse reactions, and monitor them very closely for any issues. She would monitor vital signs, alertness, cognition and compare to baseline. For hospital discharge orders she would verify the medications from the hospital with the MD and enter the medication in properly. She said if a medication was discontinued, she would discontinue medication from the system, put in a progress note, and remove medication from the cart. She said she had to do a medication pass with a staff member. She said the MD order would say how often you can administer the medication; she would go in the computer to see when it was last administered and to see if it was too soon or not. She said she also checked the narcotic book just in case it was not documented in the eMAR. In an interview on [DATE] at 1:32 p.m. RN B said the 5 rights of medication pass were to ensure the right person, route, dose, medication, and time. She said a medication pass was conducted. For change in condition, she would document and notify the MD, get a timely response and follow up, send the resident out to the hospital if necessary and report to MD and oncoming shift for follow up. She said she could also reach out to the DON and Administrator and follow up with the Medical Director on what needs to get done. If severe enough send out resident to 911. For hospital discharge orders she said she would reconcile the medication and compare what is new and notify MD who does the final reconciliation. For a change in condition she would assess for new pain, assess the vital signs, check alertness/change in cognition, notify findings to MD and follow orders. She would always do a progress note and look for a change in condition form. If there was a medication error, she would complete an incident report, document, and notify superiors, MD, RP, assess the patient for changes, adverse effects, signs and symptoms to watch for, and continue to monitor the resident. When administering prn narcotics, she would document the prn narcotic in PCC and narcotic log because they do not serve the same purpose. She said PCC showed when the medication was given last, and the narcotic log count sheet purpose was to obtain a proper count. In an interview on [DATE] at 1:52 p.m. LVN F (6 a.m. - 6 p.m.) said she was trained on documenting in the MAR and narcotic book when administering a prn medication so that you do not overdose but give the proper dosage. If there was a change in condition, she would notify the MD and if they did not respond within 2 hours she would go to the medical director, if emergent call 911, don't wait. She would document the change in condition under assessments with option for change in condition. She would determine the symptoms, if new or chronic, which body system did it pertain to, most recent vitals, and situation. She would monitor the resident and implement intervention. If the intervention did not work, she would notify the doctor again. For discharge hospital orders she said if a medication was not on the discharge list you could not give it and could not just go back to what they had prior to the hospital. She said she would reconcile the orders with the MD. She said the 5 rights of medication administration were - right patient, right dosage, right form, route, and time. She said every medication should have the right time if not, question the doctor. She said for a medication error she was trained to alert whoever was in charge, start monitoring for side effects such as respiratory depression, and notify the MD. She said she would monitor the resident for at least 24 hours depending on the drug. In an interview on [DATE] at 2:13 p.m. MA J (2 p.m. - 10 p.m.) said the 5 rights of medication administration were the right patient, medication, dose, time, and route. She said she was trained to follow MD orders. She said if the resident asked for pain medication that was already given, she would notify the nurse that it was already given. She said narcotic medication should be documented on the narcotic book and on the computer. In an interview on [DATE] at 7:46 p.m. LVN E said she had recent in services on medication administration, 5 rights of medication, identifying the patients, when to send residents out, and many others. When administering medications, she would first look up the patient and go over the eMAR, verify the order is correct, and current, then she would locate the medication and ensure the order is what she is supposed to give. She would do hand hygiene, identify pt by photo and by confirming with pt. then she would verify medication at bedside, check expiration date, look over eMAR, make sure it's the right medication, then administer medication. She would document the medication on the eMAR. As soon as she realized she gave the wrong medication, she would contact provider, get baseline set of vitals and monitor condition and mental status and continue to monitor for any change in condition. She would contact 911 if change in condition or if doctor orders her to send pt out. In an interview on [DATE] at 7:55 p.m. LVN C said she had in services on medication administration, when to contact Physician, RP, POA, change in condition in services. They were given yesterday. She said she knows the 5 rights, patient, drug, dose, routes, time, follow up effectiveness, allergies, when to notify MD and antibiotics and safety concerns. She would first identify pt, double check drug, drug label against eMAR, correct dose, correct route, and time, monitor for any adverse effects. She said that she would monitor vital signs, if suspected over dose, notify physician, DON, RP , and if critical or obstruction of airway, loss of conscious, then move to code status, notify hospice if necessary, make determination if sent out for evaluation or treatment. She said if suspected over dose by resident having drugs on themselves if history of Substance abuse there may be an order of Narcan. In an observation on [DATE] at 11:18 a.m. MA J eMAR pulled up for one resident at a time. eMAR states hydrocodone/acetaminophen 1 tablet every six hours not prn. Narcotic sheet and med tablet pulled out. MA confirmed and verified medication with eMAR. Popped in medication into a medication cup and given to resident. Resident pain level 8.5 out of 10, 4 tablets remaining in blister pack. In an interview on [DATE] at 10:40 a.m. LVN K said she does not share a cart with anyone during the day. Before giving out narcotic, ask why they are asking, where the pain is, pain scale, check eMAR for when the last time medication was administered, check orders on eMAR, and on the card to verify how it is to be administered, document reason and for how much pain, verify the times match in eMAR and narcotic sheet to confirm its correct, check pills before administering. Only give if prn, but no more for the day. In an interview on [DATE] at 10:49 a.m. MA G said Last in-service was yesterday over the phone on the 5 rights, right time, right dose, right documentation, right route, right medication. Gives narcotics at noon and 1 pm, they are not prn. Check eMaR, check resident room and information 3 times, and sign out the time given. Explain to the resident what it is, locking everything up, sanitize and give to resident. In an interview on [DATE] at 11:52 a.m. CNA Z said she has been at the facility for two months. Last in-service was this past week on, abuse and neglect. The different types of physical, sexual, emotional, mental, and misappropriation of funds. She has not ever witne[TRUNCATED]

Based on 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 5 residents (CR #1) reviewed for pharmacy services in that:. The facility failed to ensure CR #1 did not receive Hydrocodone-Acetaminophen (Norco) after it was discontinued after her hospital visit on [DATE] but was not discontinued in her chart. CR #1 received Norco more frequently than the order that remained in her chart on [DATE]. She experienced lethargy, nausea, vomiting, and decreased response to stimuli and expired at the hospital later that evening. An Immediate Jeopardy was identified on [DATE] at 4:33 p.m. While the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place the resident at risk for not receiving medications as ordered resulting in serious injury, decline in health, and death. Findings included: Record review of CR #1's admission record dated [DATE] revealed a [AGE] year-old female who was readmitted to the facility on [DATE]. Her diagnoses included hypotension (low blood pressure), muscle weakness, type 2 diabetes, end stage renal disease, dependence on renal dialysis, other abnormalities of gait and mobility, need for assistance with personal care, and chronic embolism and thrombosis of other specified veins (conditions involving persistent blood clots that can obstruct blood flow). Record review of CR #1's Discharge MDS assessment-return anticipated dated [DATE] revealed her cognitive skills for daily decision making were moderately impaired. She required assistance from staff with ADL care. Record review of CR #1's care plan dated [DATE] revealed the resident was full code (providing chest compressions in the event of cardia arrest). Interventions were to monitor for decrease in change of condition and report to the MD and responsible party. Record review of CR #1's Nursing note dated [DATE] written by LVN G read in part, During morning assessment resident noted to be lethargic and not answering nurse when asking question resident eyes PERRLA aroused to touch . BP 130/86 P 87 MD made aware new orders received for stat labs CBC/BMP labs were collected. Resident went to dialysis BP was low Midodrine was given BP went up to 108/67 then started dropping again . (family) came to visit resident stated resident looks worse then [sic] yesterday and wanted her sent to ER MD made aware of family request and called for preferred to pickup . Record review of CR #1's hospital record dated [DATE] -[DATE] read in part, .chief complaint: weakness - generalized pt from (facility) and report pt has been getting weaker for several days .ED course . [DATE] at 11:32 p.m. Pt more alert on re eval, counseled on findings. Suspect that her symptoms may be due to Norco. Counseled on cessation of Norco for the next few days . Final Diagnoses: generalized weakness . Medication changes: Hydrocodone/acetaminophen 10-325 mg 1 tablet every 6 hours prn (there was a line struck through it). Record review of CR #1's nursing note dated [DATE] written by LVN N read in part, .resident return from hospital this morning aprx, 0530 (5:30 a.m.), via ambulance . resident stable, no c/o pain or discomfort noted at time of arrival . discharge instructions include DC of Norco 10-325 no other changes to medications made . Record review of CR #1's Order Summary Report dated [DATE] revealed an order for Hydrocodone-Acetaminophen (Norco) 10-325 mg 1 tablet by mouth every 6 hours as needed for pain, order date [DATE], discontinued [DATE]. Record review of CR #1's Medication Administration Record for [DATE] revealed Hydrocodone-Acetaminophen 10-325 mg 1 tablet every 6 hours as needed for pain was documented as administered on [DATE] at 8:10 a.m. There was no other administration documented on [DATE] for Hydrocodone-Acetaminophen. Record review of CR #1's Controlled Drug Administration Record for Hydrocodone-Acetaminophen (Norco) 10-325 mg dated [DATE] revealed one tablet was documented as administered to CR #1 on 4/4/(24) at 6 a.m. by LVN D and another tablet was documented as administered 2 hours later on 4/4/(24) at 8 a.m. by LVN J. Record review of CR #1's nursing note dated [DATE] at 12:38 p.m. written by LVN J read in part, 'Resident is drowsy; Norco's overdose noted. Resident has refused meals: breakfast and lunch. Monitoring in progress. Record review of CR #1's nursing note dated [DATE] at 12:56 p.m. written by the previous DON read in part, DON was called to resident's room due to resident being drowsy after returning from dialysis around on assessment resident was arousable and verbally responsive stating she was tired and wants to sleep. Charge Nurse stated resident was given PRN Norco before going to dialysis. Record review indicated resident was given an extra dose of Norco 2 hours after the previous dose instead of every 6 hours. MD made aware. MD instructed to monitor resident for responsiveness. Record review of a text message conversation provided by the facility with MD R dated [DATE] at 12:56 p.m. read, Also (CR #1) can [sic] given Norco sooner 2 hours apart instead of 6 hrs because night did not document in emar that she gave a dose a 6 pm [sic]. Morning nurse gave it again when resident asked for pain meds. She is talking but more sleepy . MD R responded, Yes she can have the early dose. Record review of CR #1's nursing note dated [DATE] at 3:06 p.m. written by LVN J read in part, Resident has nausea and vomiting. Change of condition. Has called physician for new order. Message left via voicemail. Record review of CR #1's vital signs on [DATE] at 3:36 p.m. revealed her blood pressure was 80/57 mmHg. Her respirations were 16 breaths/minute and oxygen was 96% on [DATE] at 2:11 p.m. Record review of CR #1's nursing note dated [DATE] at 6:19 p.m. written by LVN D read Patient administer oxygen per nasal canula at 3L. The EMS received vital signs and decided to transport patient for acute care . Record review of CR #1's nursing note dated [DATE] at 8:18 p.m. written by LVN D read, Upon attempting to administer patient scheduled medication, patient appears to have increased lethargy. O2 level obtained at 90% on RA upon assessment. Patient sternal rubbed and minimally responsive to stimuli. EMS Service contacted for acute care transport to ED. Pt assessed via 6 EMS transport to (hospital). Record review of CR #1's hospital records dated [DATE] read in part, .Patient presents with cardiac arrest . EMS reports (facility) staff stated pt was in respiratory distress all day and progressively getting worse. Per EMS pt was having agonal breaths upon arrival to scene and pt went inyo [sic] cardiac arrest on ambulance. Patient downtime wa [sic] 1 minute before arrival to ED, no meds given en route Medical Decision Making . EMS reports they were called to the patient's nursing home due to severe respiratory distress, on their arrival patient was obtunded, severe respiratory distress, and route to ER patient became apneic and lost pulses and they started CPR. CPR was initiated 2 minutes prior to arrival . after 20 minutes of CPR, decision was made to terminate interventions. Time of death called at 9:09 p.m. Observation and Interview on [DATE] at 8:15 a.m. revealed that one tablet of Senna 8.6 mg was administered by MA G to Resident #59 and Folic Acid was not administered to Resident #59. MA G said that the medication was not available and came from the pharmacy. In a telephone interview on [DATE] at 10:38 a.m. the previous DON said the night nurse administered Norco to CR #1 prior to leaving her shift and documented it in the narcotic book but did not document it in the eMAR. She said the morning nurse arrived and the resident asked for pain medicine, and he administered the same medication within 2 hours instead of 6 hours. She said the Norco was scheduled for every 6 hours. She said the facility notified MD R and he said it was not a problem and ok to give the medication sooner and to just keep an eye on her. She said she could not recall if CR #1 had an order for the Norco. She said CR #1 was a little sleepy but was herself and they monitored her. She said CR #1 was in and out of the hospital very frequently and did not remember if she went out to the hospital that day. She said she in serviced LVN J who was an agency nurse and did not allow him to come back to the facility. She said staff should document administered narcotics in both the eMAR and narcotic book because there could be a risk of double dosing the resident. In an interview on [DATE] at 10:53 a.m. CR #1's family member said the resident admitted to the facility for rehabilitation. He said hospital staff informed him a few times that CR #1 was overmedicated with pain medication. He said when he visited her at the facility, she was not all the way there, she was in and out, more quiet, exhausted, and not there at all. He said she deteriorated at the facility and was never like that before. He said on [DATE] he went to the facility to check on her and she was particularly out of it that day. Her body was cold, she was responsive but was in and out. He said she vomited on herself around 11:30 a.m. - 12:30 p.m. He reported it and staff arrived but did not ask about the vomiting. He said she went to sleep and later that evening around 10:45 p.m. the facility called another family member to inform her she was at the local hospital and her oxygen was low, but blood pressure was fine. He said when he arrived at the ER he was met with an empty room and a body bag on top of the gurney. In a telephone interview on [DATE] at 11:16 a.m. LVN D said she did not remember a possible overdose and did not remember sending CR #1 to the hospital. In a telephone interview on [DATE] at 11:38 a.m. MD R said CR #1 went to the hospital on 3/22-23/24 due to generalized weakness. He said if the Norco was supposed to be stopped the facility should reconcile with the MD and it should be stopped but said he was not sure if it was discontinued because he did not see the DC in the hospital records. He said the ED recommended to stop CR #1's Norco due to weakness, not from overdosing. He said he was unsure if he was notified of the Norco overdose (on [DATE]). He said the risk of a Norco overdose would depend on the patient and monitoring was important. He said CR #1 had ESRD and should be monitored pretty closely. In a telephone interview on [DATE] at 12:02 p.m. MD G said she did not recall the incident and was not notified of anything regarding CR #1. She said if the Norco order was for every 6 hours she did not know why it was administered in 2 hours. She said Norco could upset the stomach and lethargy could happen if Norco was given too early. In an interview on [DATE] at 12:15 p.m. the Regional Nurse said she was unsure of when the facility stopped using nursing agencies. She said she was unsure of anything that happened to CR #1, only what was in the chart. She said the expectation was for nurses to document when giving the medication to the residents and they should follow the order as prescribed. If there was a change in condition the resident should be assessed, and the physician notified and documented. If the physician did not respond, staff should call back and if no response, the medical director is to be called. Depending on the status of the resident, if the resident was in respiratory distress or vital signs too low or high, staff could use nursing judgement for the resident's safety. For medication pass, it is documented on the eMAR and the narcotic count book/log. If doing medication pass, both the eMAR and narcotic book should be reviewed before administering the medication. When residents return from the hospital the discharge summary is reviewed by the nurse who is accepting the resident. The nurse will then input the discharge summary into PCC. They are checking the medications are input correctly into PCC. They are to verify the orders with the attending doctor to ensure they agree for the resident's care. If a resident is given discontinued medication, they did not follow the MD orders and the resident could be at risk. She noticed when the resident came back from the hospital, the nurse wrote D/C Norco, but it was not discontinued. She did not review the discharge hospital summary. She also read that the resident received extra Norco. Per the notes, the resident was lethargic and not as responsive. She did know she had cardiac arrest and passed away. She did not believe the extra Norco caused CR #1's death. She was unsure if the resident was to be on the Norco but noticed that it was discontinued, and did not know why. She did read the resident asked to go to the hospital previously to get Morphine. Record review of the discontinued medications policy, states the nurse documents the order to discontinue the medication in the resident's record. The Physician's order sheet (POS) and the medication administration record (MAR) are updated to indicate that the order is discontinued. Alternatively, the discontinuation order is entered into the facility's EHR system. Record review of the general guidelines for medication administration policy, states always employ the MAR during medication administration. Prior to the administration of any medication, the medication and dosage schedule on the resident's MAR are compared with the medication label. The individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR to ensure that necessary doses were administered and documented. In no case should the individual who administered the medication report off-duty without first recording the administration of any medications. Record review of Change in condition policy, states that once the nurse has notified the physician for a change in condition the resident/patient will be monitored for 1 hour until the physician has responded. The monitoring will include vital signs, pulse ox, and finger stick blood sugar if diabetic (one time only). A physical assessment should be completed relative to the symptoms present and a pain assessment. If resident/patient condition appears emergent transfer to local ER may occur without physician order. On [DATE] at 4:33 p.m. the regional nurse and administrator were informed that an Immediate Jeopardy situation was identified due to the above failures and a Plan of Removal was requested. The following Plan of Removal was submitted by the facility and accepted on [DATE] at 9:47 p.m. On [DATE] an investigation survey was initiated. On [DATE] the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safety. The notification of Immediate Jeopardy states as follows: The facility failed to ensure CR #1 did not receive Hydrocodone-Acetaminophen more frequently than prescribed by the MD on [DATE]. Resident CR#1 was discharged to the hospital on [DATE] and expired due to Cardiac Arrest. Charge Nurse (LVN/RN) will receive education and/or disciplinary action if medication administration is not documented in MAR and Narcotic Control log for all Narcotic medications. Charge Nurse J was in serviced on 4/4 on medication administration and followed physician orders by director of nursing. The nurse was an agency nurse, and we will never select to use this nurse again. Facility's Plan to ensure compliance quickly. Tag cited: F-760 oOn [DATE] Regional Nurse initiated Inservice with Nursing Staff (Assistant Director of Nursing, Director of Nursing, Certified Medication Aides, Charge Nurses) on Following of Physician Orders. The in-service reads: Medications are to be administered as ordered by MD. PRN Narcotic medication is to be documented on MAR and Narcotic Control Log. All nursing staff expected to be in-serviced prior to the next shift worked. Staff will not be allowed to provide direct care until services have been completed. This education will also be included in all new nurse orientations for any newly hired nurses and any Agency staff. This in-service is to be completed on [DATE]. oOn [DATE] Regional Nurse initiated Inservice with Nursing Staff (Assistant Director of Nursing, Director of Nursing, Certified Medication Aides, Charge Nurses) on Medication Administration. The in-service reads: Charge nurses (LVN/RN) and Certified Medication Aides are to follow the 5 rights of medication administration. Right medication, Right patient, Right Dosage, Right Route, Right Time. All nursing staff expected to be in-serviced prior to the next shift worked. This education will also be included in all new nurse orientations for any newly hired nurses and any Agency staff. This in-service is to be completed on [DATE]. oOn [DATE] Regional Nurse initiated Inservice with Nursing Staff (Assistant Director of Nursing, Director of Nursing, Certified Medication Aides, Charge Nurses) on Change in Condition. The in-service reads: Resident noted with a change in condition is to be assessed by nurse and Md must be notified. Residents continue to be assessed if physician is unable to be reached within 2 hours repeat call and involve medical director. If resident condition appears emergent send to ER. All nursing staff expected to be in-serviced prior to the next shift worked. Staff will not be allowed to provide direct care until services have been completed. This education will also be included in all new nurse orientations for any newly hired nurses and Agency staff. This in-service is to be completed on [DATE]. oOn [DATE] Regional Nurse initiated Inservice with Nursing Staff (Assistant Director of Nursing, Director of Nursing, Certified Medication Aides, Charge Nurses) on Medication Errors. The in-service reads: Physician is to be notified of all medication errors and resident is to be monitored closely for any adverse reactions. All nursing staff expected to be in-serviced prior to the next shift worked. Staff will not be allowed to provide direct care until services have been completed. This education will also be included in all new nurse orientations for any newly hired nurses and Agency staff. This in-service is to be completed on [DATE]. oRegional Nurse/Designee initiated medication pass competency check offs on Nursing Staff (Assistant Director of Nursing, Director of Nursing, Certified Medication Aides, Charge Nurses) All nursing staff expected to be in-serviced prior to the next shift worked. Staff will not be allowed to provide direct care until services have been completed. Agency Staff medication pass competency to be completed at start of shift. This observation is to be completed on [DATE]. oAudit conducted on [DATE] of residents PRN narcotics orders to ensure MARS reflects medications are administered as indicated by physician orders for the past 30 days. On [DATE] MAR to Narcotic count sheet check completed to confirm medications are documented on MAR and Narcotic log. There are no indications of medication errors from the audit. Completed on [DATE]. oThe Medical Director has been notified on [DATE] of immediate jeopardy and reviewed the current change in condition policy and procedures, following physician order policy and procedure, medication administration policy and procedure, and medication error policy and procedure. Plan of action reviewed with the Medical Director with no changes to the current policies. This practice will be reviewed monthly with the QA committee to ensure we are compliant with the change in condition policy and procedures, medication administration policy and procedure, and medication error policy and procedure. Start Date: [DATE]. Completion Date: [DATE] Responsible: Regional Nurse/Designee Monitoring was conducted on [DATE] and [DATE] to verify the facility's plan of removal. The monitoring included: Record review of Dialyzable drugs - acetaminophen was listed, but did not affect toxicity. Hydrocodone was not listed. (Dialyzable drugs are drugs that can be removed by dialysis). Record review of In-service dated [DATE] with previous DON- transcribing medication orders in PCC. Following Hospital Medication orders; clarification and confirming orders. Identifying hazard drug alert on EMAR and blister pack. Record review of In-service dated [DATE] at 6 p.m. with previous DON - for medication administration, pain *unreadable* meds as you go in EMAR. Narcotics should be divided in eMAR and also documented in narcotic log. Record review of In-service & Education Record dated [DATE] - Description: Nurses/CMAs to follow MD orders when administering meds. Review discharge summary from hospital for current med reconciliation. Any medication that resident was receiving previously must be discontinued if not on hospital discharge summary. MD to be notified of admission and verification of meds. There were 9 signatures. Record review of Inservice & Education Record dated [DATE] - Inputting orders into PCC (an electronic medical record) - make sure order is accurate - 5 rights of med administration - order is assigned a schedule and is on correct MAR - all PRN meds go on nurses MAR (LMAR). There were 9 signatures Record review of Inservice & Education Record dated [DATE] - Medication is to be administered as ordered by the MD. Charge nurses are to follow the 5 rights of med administration - right med, right patient, right dosage, right route and right time. Staff not following the above will receive disciplinary action up to and including termination. There were 10 signatures (MA, RN, LVN) Record review of Inservice & Education Record dated [DATE] - Resident noted with a change in condition is to be assessed by the nurse and MD notified - res is to continue to be assessed if unable to reach physician within 2 hours. Repeat call - if you still cannot reach MD call the Medical Director - if resident/pt condition appears emergent send to ER. There were 8 nurse signatures. Record review of Inservice & Education Record dated [DATE] - Medication error - MD is to be notified of any medication error and resident is to be monitored for any adverse reactions. There were 8 nurse signatures. Record review of Inservice & Education Record dated [DATE] - PRN medications are to be documented on narcotic count sheet and on MAR in resident chart after medication administered. Resident to be assessed for pain with shift and document effectiveness of pain medication. There were 8 nurse signatures. Record review of Medication Pass Audits dated [DATE]. There were 5 audits conducted with no errors. Record review of Inservice & Education Record dated [DATE] - Medication Administration, prn documentation, following 6 rights of medication pass, preventing medication errors. Check and balance of admission/discharge medication reconciliation, MD orders - PCC, notification of medication error to MD, med pass audit will be observed 1st day back to work before hitting the floor to pass meds. There were 4 nurse signatures. In an interview on [DATE] at 1:18 p.m. LVN B (Charge nurse 6 a.m. - 6 p.m.) said she was trained to document changes in condition, monitor, and follow up with the MD and Medical Director. If the situation was emergent, she would send them out so the patient is not compromised. The 5 rights of medication administration include to use the right medication, patient, route, time, and document pain on MAR and on narcotic sheet and ensure the times match too because it could be a medication error. She said you document a change in condition in the assessments einteract SBAR, notify the MD right away let them know what is going on, and notify the DON of changes. She said she would keep assessing the patient for any changes either better or worse and document if interventions have helped. She said PRN medications should be reassessed around 15-45 minutes later to ensure efficacy. If there was a medication error, she would notify the DON right away, go through the steps of what happened, do an investigation, notify the MD, assess the resident for adverse reactions, and monitor them very closely for any issues. She would monitor vital signs, alertness, cognition and compare to baseline. For hospital discharge orders she would verify the medications from the hospital with the MD and enter the medication in properly. She said if a medication was discontinued, she would discontinue medication from the system, put in a progress note, and remove medication from the cart. She said she had to do a medication pass with a staff member. She said the MD order would say how often you can administer the medication; she would go in the computer to see when it was last administered and to see if it was too soon or not. She said she also checked the narcotic book just in case it was not documented in the eMAR. In an interview on [DATE] at 1:32 p.m. RN B said the 5 rights of medication pass were to ensure the right person, route, dose, medication, and time. She said a medication pass was conducted. For change in condition, she would document and notify the MD, get a timely response and follow up, send the resident out to the hospital if necessary and report to MD and oncoming shift for follow up. She said she could also reach out to the DON and Administrator and follow up with the Medical Director on what needs to get done. If severe enough send out resident to 911. For hospital discharge orders she said she would reconcile the medication and compare what is new and notify MD who does the final reconciliation. For a change in condition she would assess for new pain, assess the vital signs, check alertness/change in cognition, notify findings to MD and follow orders. She would always do a progress note and look for a change in condition form. If there was a medication error, she would complete an incident report, document, and notify superiors, MD, RP, assess the patient for changes, adverse effects, signs and symptoms to watch for, and continue to monitor the resident. When administering prn narcotics, she would document the prn narcotic in PCC and narcotic log because they do not serve the same purpose. She said PCC showed when the medication was given last, and the narcotic log count sheet purpose was to obtain a proper count. In an interview on [DATE] at 1:52 p.m. LVN F (6 a.m. - 6 p.m.) said she was trained on documenting in the MAR and narcotic book when administering a prn medication so that you do not overdose but give the proper dosage. If there was a change in condition, she would notify the MD and if they did not respond within 2 hours she would go to the medical director, if emergent call 911, don't wait. She would document the change in condition under assessments with option for change in condition. She would determine the symptoms, if new or chronic, which body system did it pertain to, most recent vitals, and situation. She would monitor the resident and implement intervention. If the intervention did not work, she would notify the doctor again. For discharge hospital orders she said if a medication was not on the discharge list you could not give it and could not just go back to what they had prior to the hospital. She said she would reconcile the orders with the MD. She said the 5 rights of medication administration were - right patient, right dosage, right form, route, and time. She said every medication should have the right time if not, question the doctor. She said for a medication error she was trained to alert whoever was in charge, start monitoring for side effects such as respiratory depression, and notify the MD. She said she would monitor the resident for at least 24 hours depending on the drug. In an interview on [DATE] at 2:13 p.m. MA J (2 p.m. - 10 p.m.) said the 5 rights of medication administration were the right patient, medication, dose, time, and route. She said she was trained to follow MD orders. She said if the resident asked for pain medication that was already given, she would notify the nurse that it was already given. She said narcotic medication should be documented on the narcotic book and on the computer. In an interview on [DATE] at 7:46 p.m. LVN E said she had recent in services on medication administration, 5 rights of medication, identifying the patients, when to send residents out, and many others. When administering medications, she would first look up the patient and go over the eMAR, verify the order is correct, and current, then she would locate the medication and ensure the order is what she is supposed to give. She would do hand hygiene, identify pt by photo and by confirming with pt. then she would verify medication at bedside, check expiration date, look over eMAR, make sure it's the right medication, then administer medication. She would document the medication on the eMAR. As soon as she realized she gave the wrong medication, she would contact provider, get baseline set of vitals and monitor condition and mental status and continue to monitor for any change in condition. She would contact 911 if change in condition or if doctor orders her to send pt out. In an interview on [DATE] at 7:55 p.m. LVN C said she had in services on medication administration, when to contact Physician, RP, POA, change in condition in services. They were given yesterday. She said she knows the 5 rights, patient, drug, dose, routes, time, follow up effectiveness, allergies, when to notify MD and antibiotics and safety concerns. She would first identify pt, double check drug, drug label against eMAR, correct dose, correct route, and time, monitor for any adverse effects. She said that she would monitor vital signs, if suspected over dose, notify physician, DON, RP , and if critical or obstruction of airway, loss of conscious, then move to code status, notify hospice if necessary, make determination if sent out for evaluation or treatment. She said if suspected over dose by resident having drugs on themselves if history of Substance abuse there may be an order of Narcan. In an observation on [DATE] at 11:18 a.m. MA J eMAR pulled up for one resident at a time. eMAR states hydrocodone/acetaminophen 1 tablet every six hours not prn. Narcotic sheet and med tablet pulled out. MA confirmed and verified medication with eMAR. Popped in medication into a medication cup and given to resident. Resident pain level 8.5 out of 10, 4 tablets remaining in blister pack. In an interview on [DATE] at 10:40 a.m. LVN K said she does not share a cart with anyone during the day. Before giving out narcotic, ask why they are asking, where the pain is, pain scale, check eMAR for when the last time medication was administered, check orders on eMAR, and on the card to verify how it is to be administered, document reason and for how much pain, verify the times match in eMAR and narcotic sheet to confirm its correct, check pills before administering. Only give if prn, but no more for the day. In an interview on [DATE] at 10:49 a.m. MA G said Last in-service was yesterday over the phone on the 5 rights, right time, right dose, right documentation, right route, right medication. Gives narcotics at noon and 1 pm, they are not prn. Check eMaR, check resident room and information 3 times, and sign out the time given. Explain to the resident what it is, locking everything up, sanitize and give to re[TRUNCATED]

Based on interview and record review the facility failed to ensure residents were free of any significant medication errors for 1 of 5 residents (CR #1) reviewed for significant medication errors. The facility failed to ensure CR #1 did not receive Hydrocodone-Acetaminophen (Norco) after it was discontinued after her hospital visit on [DATE] but was not discontinued in her chart. CR #1 received Norco more frequently than the order that remained in her chart on [DATE]. She experienced lethargy, nausea, vomiting, and decreased response to stimuli and expired at the hospital later that evening. An Immediate Jeopardy was identified on [DATE] at 4:33 p.m. While the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place the resident at risk for not receiving medications as ordered resulting in serious injury, decline in health, and death. Findings included: Record review of CR #1's admission record dated [DATE] revealed a [AGE] year-old female who was readmitted to the facility on [DATE]. Her diagnoses included hypotension (low blood pressure), muscle weakness, type 2 diabetes, end stage renal disease, dependence on renal dialysis, other abnormalities of gait and mobility, need for assistance with personal care, and chronic embolism and thrombosis of other specified veins (conditions involving persistent blood clots that can obstruct blood flow). Record review of CR #1's Discharge MDS assessment-return anticipated dated [DATE] revealed her cognitive skills for daily decision making were moderately impaired. She required assistance from staff with ADL care. Record review of CR #1's care plan dated [DATE] revealed the resident was full code (providing chest compressions in the event of cardia arrest). Interventions were to monitor for decrease in change of condition and report to the MD and responsible party. Record review of CR #1's Nursing note dated [DATE] written by LVN G read in part, During morning assessment resident noted to be lethargic and not answering nurse when asking question resident eyes PERRLA aroused to touch . BP 130/86 P 87 MD made aware new orders received for stat labs CBC/BMP labs were collected. Resident went to dialysis BP was low Midodrine was given BP went up to 108/67 then started dropping again . (family) came to visit resident stated resident looks worse then [sic] yesterday and wanted her sent to ER MD made aware of family request and called for preferred to pickup . Record review of CR #1's hospital record dated [DATE] -[DATE] read in part, .chief complaint: weakness - generalized pt from (facility) and report pt has been getting weaker for several days .ED course . [DATE] at 11:32 p.m. Pt more alert on re eval, counseled on findings. Suspect that her symptoms may be due to Norco. Counseled on cessation of Norco for the next few days . Final Diagnoses: generalized weakness . Medication changes: Hydrocodone/acetaminophen 10-325 mg 1 tablet every 6 hours prn (there was a line struck through it). Record review of CR #1's nursing note dated [DATE] written by LVN N read in part, .resident return from hospital this morning aprx, 0530 (5:30 a.m.), via ambulance . resident stable, no c/o pain or discomfort noted at time of arrival . discharge instructions include DC of Norco 10-325 no other changes to medications made . Record review of CR #1's Order Summary Report dated [DATE] revealed an order for Hydrocodone-Acetaminophen (Norco) 10-325 mg 1 tablet by mouth every 6 hours as needed for pain, order date [DATE], discontinued [DATE]. Record review of CR #1's Medication Administration Record for [DATE] revealed Hydrocodone-Acetaminophen 10-325 mg 1 tablet every 6 hours as needed for pain was documented as administered on [DATE] at 8:10 a.m. There was no other administration documented on [DATE] for Hydrocodone-Acetaminophen. Record review of CR #1's Controlled Drug Administration Record for Hydrocodone-Acetaminophen (Norco) 10-325 mg dated [DATE] revealed one tablet was documented as administered to CR #1 on 4/4/(24) at 6 a.m. by LVN D and another tablet was documented as administered 2 hours later on 4/4/(24) at 8 a.m. by LVN J. Record review of CR #1's nursing note dated [DATE] at 12:38 p.m. written by LVN J read in part, 'Resident is drowsy; Norco's overdose noted. Resident has refused meals: breakfast and lunch. Monitoring in progress. Record review of CR #1's nursing note dated [DATE] at 12:56 p.m. written by the previous DON read in part, DON was called to resident's room due to resident being drowsy after returning from dialysis around on assessment resident was arousable and verbally responsive stating she was tired and wants to sleep. Charge Nurse stated resident was given PRN Norco before going to dialysis. Record review indicated resident was given an extra dose of Norco 2 hours after the previous dose instead of every 6 hours. MD made aware. MD instructed to monitor resident for responsiveness. Record review of a text message conversation provided by the facility with MD R dated [DATE] at 12:56 p.m. read, Also (CR #1) can [sic] given Norco sooner 2 hours apart instead of 6 hrs because night did not document in emar that she gave a dose a 6 pm [sic]. Morning nurse gave it again when resident asked for pain meds. She is talking but more sleepy . MD R responded, Yes she can have the early dose. Record review of CR #1's nursing note dated [DATE] at 3:06 p.m. written by LVN J read in part, Resident has nausea and vomiting. Change of condition. Has called physician for new order. Message left via voicemail. Record review of CR #1's vital signs on [DATE] at 3:36 p.m. revealed her blood pressure was 80/57 mmHg. Her respirations were 16 breaths/minute and oxygen was 96% on [DATE] at 2:11 p.m. Record review of CR #1's nursing note dated [DATE] at 6:19 p.m. written by LVN D read Patient administer oxygen per nasal canula at 3L. The EMS received vital signs and decided to transport patient for acute care . Record review of CR #1's nursing note dated [DATE] at 8:18 p.m. written by LVN D read, Upon attempting to administer patient scheduled medication, patient appears to have increased lethargy. O2 level obtained at 90% on RA upon assessment. Patient sternal rubbed and minimally responsive to stimuli. EMS Service contacted for acute care transport to ED. Pt assessed via 6 EMS transport to (hospital). Record review of CR #1's hospital records dated [DATE] read in part, .Patient presents with cardiac arrest . EMS reports (facility) staff stated pt was in respiratory distress all day and progressively getting worse. Per EMS pt was having agonal breaths upon arrival to scene and pt went inyo [sic] cardiac arrest on ambulance. Patient downtime wa [sic] 1 minute before arrival to ED, no meds given en route Medical Decision Making . EMS reports they were called to the patient's nursing home due to severe respiratory distress, on their arrival patient was obtunded, severe respiratory distress, and route to ER patient became apneic and lost pulses and they started CPR. CPR was initiated 2 minutes prior to arrival . after 20 minutes of CPR, decision was made to terminate interventions. Time of death called at 9:09 p.m. In a telephone interview on [DATE] at 10:38 a.m. the previous DON said the night nurse administered Norco to CR #1 prior to leaving her shift and documented it in the narcotic book but did not document it in the eMAR. She said the morning nurse arrived and the resident asked for pain medicine, and he administered the same medication within 2 hours instead of 6 hours. She said the Norco was scheduled for every 6 hours. She said the facility notified MD R and he said it was not a problem and ok to give the medication sooner and to just keep an eye on her. She said she could not recall if CR #1 had an order for the Norco. She said CR #1 was a little sleepy but was herself and they monitored her. She said CR #1 was in and out of the hospital very frequently and did not remember if she went out to the hospital that day. She said she in serviced LVN J who was an agency nurse and did not allow him to come back to the facility. She said staff should document administered narcotics in both the eMAR and narcotic book because there could be a risk of double dosing the resident. In an interview on [DATE] at 10:53 a.m. CR #1's family member said the resident admitted to the facility for rehabilitation. He said hospital staff informed him a few times that CR #1 was overmedicated with pain medication. He said when he visited her at the facility, she was not all the way there, she was in and out, more quiet, exhausted, and not there at all. He said she deteriorated at the facility and was never like that before. He said on [DATE] he went to the facility to check on her and she was particularly out of it that day. Her body was cold, she was responsive but was in and out. He said she vomited on herself around 11:30 a.m. - 12:30 p.m. He reported it and staff arrived but did not ask about the vomiting. He said she went to sleep and later that evening around 10:45 p.m. the facility called another family member to inform her she was at the local hospital and her oxygen was low, but blood pressure was fine. He said when he arrived at the ER he was met with an empty room and a body bag on top of the gurney. In a telephone interview on [DATE] at 11:16 a.m. LVN D said she did not remember a possible overdose and did not remember sending CR #1 to the hospital. In a telephone interview on [DATE] at 11:38 a.m. MD R said CR #1 went to the hospital on 3/22-23/24 due to generalized weakness. He said if the Norco was supposed to be stopped the facility should reconcile with the MD and it should be stopped but said he was not sure if it was discontinued because he did not see the DC in the hospital records. He said the ED recommended to stop CR #1's Norco due to weakness, not from overdosing. He said he was unsure if he was notified of the Norco overdose (on [DATE]). He said the risk of a Norco overdose would depend on the patient and monitoring was important. He said CR #1 had ESRD and should be monitored pretty closely. In a telephone interview on [DATE] at 12:02 p.m. MD G said she did not recall the incident and was not notified of anything regarding CR #1. She said if the Norco order was for every 6 hours she did not know why it was administered in 2 hours. She said Norco could upset the stomach and lethargy could happen if Norco was given too early. In an interview on [DATE] at 12:15 p.m. the Regional Nurse said she was unsure of when the facility stopped using nursing agencies. She said she was unsure of anything that happened to CR #1, only what was in the chart. She said the expectation was for nurses to document when giving the medication to the residents and they should follow the order as prescribed. If there was a change in condition the resident should be assessed, and the physician notified and documented. If the physician did not respond, staff should call back and if no response, the medical director is to be called. Depending on the status of the resident, if the resident was in respiratory distress or vital signs too low or high, staff could use nursing judgement for the resident's safety. For medication pass, it is documented on the eMAR and the narcotic count book/log. If doing medication pass, both the eMAR and narcotic book should be reviewed before administering the medication. When residents return from the hospital the discharge summary is reviewed by the nurse who is accepting the resident. The nurse will then input the discharge summary into PCC. They are checking the medications are input correctly into PCC. They are to verify the orders with the attending doctor to ensure they agree for the resident's care. If a resident is given discontinued medication, they did not follow the MD orders and the resident could be at risk. She noticed when the resident came back from the hospital, the nurse wrote D/C Norco, but it was not discontinued. She did not review the discharge hospital summary. She also read that the resident received extra Norco. Per the notes, the resident was lethargic and not as responsive. She did know she had cardiac arrest and passed away. She did not believe the extra Norco caused CR #1's death. She was unsure if the resident was to be on the Norco but noticed that it was discontinued, and did not know why. She did read the resident asked to go to the hospital previously to get Morphine. Record review of the discontinued medications policy, states the nurse documents the order to discontinue the medication in the resident's record. The Physician's order sheet (POS) and the medication administration record (MAR) are updated to indicate that the order is discontinued. Alternatively, the discontinuation order is entered into the facility's EHR system. Record review of the general guidelines for medication administration policy, states always employ the MAR during medication administration. Prior to the administration of any medication, the medication and dosage schedule on the resident's MAR are compared with the medication label. The individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR to ensure that necessary doses were administered and documented. In no case should the individual who administered the medication report off-duty without first recording the administration of any medications. Record review of Change in condition policy, states that once the nurse has notified the physician for a change in condition the resident/patient will be monitored for 1 hour until the physician has responded. The monitoring will include vital signs, pulse ox, and finger stick blood sugar if diabetic (one time only). A physical assessment should be completed relative to the symptoms present and a pain assessment. If resident/patient condition appears emergent transfer to local ER may occur without physician order. On [DATE] at 4:33 p.m. the regional nurse and administrator were informed that an Immediate Jeopardy situation was identified due to the above failures and a Plan of Removal was requested. The following Plan of Removal was submitted by the facility and accepted on [DATE] at 9:47 p.m. On [DATE] an investigation survey was initiated. On [DATE] the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safety. The notification of Immediate Jeopardy states as follows: The facility failed to ensure CR #1 did not receive Hydrocodone-Acetaminophen more frequently than prescribed by the MD on [DATE]. Resident CR#1 was discharged to the hospital on [DATE] and expired due to Cardiac Arrest. Charge Nurse (LVN/RN) will receive education and/or disciplinary action if medication administration is not documented in MAR and Narcotic Control log for all Narcotic medications. Charge Nurse J was in serviced on 4/4 on medication administration and followed physician orders by director of nursing. The nurse was an agency nurse, and we will never select to use this nurse again. Facility's Plan to ensure compliance quickly. oOn [DATE] Regional Nurse initiated Inservice with Nursing Staff (Assistant Director of Nursing, Director of Nursing, Certified Medication Aides, Charge Nurses) on Following of Physician Orders. The in-service reads: Medications are to be administered as ordered by MD. PRN Narcotic medication is to be documented on MAR and Narcotic Control Log. All nursing staff expected to be in-serviced prior to the next shift worked. Staff will not be allowed to provide direct care until services have been completed. This education will also be included in all new nurse orientations for any newly hired nurses and any Agency staff. This in-service is to be completed on [DATE]. oOn [DATE] Regional Nurse initiated Inservice with Nursing Staff (Assistant Director of Nursing, Director of Nursing, Certified Medication Aides, Charge Nurses) on Medication Administration. The in-service reads: Charge nurses (LVN/RN) and Certified Medication Aides are to follow the 5 rights of medication administration. Right medication, Right patient, Right Dosage, Right Route, Right Time. All nursing staff expected to be in-serviced prior to the next shift worked. This education will also be included in all new nurse orientations for any newly hired nurses and any Agency staff. This in-service is to be completed on [DATE]. oOn [DATE] Regional Nurse initiated Inservice with Nursing Staff (Assistant Director of Nursing, Director of Nursing, Certified Medication Aides, Charge Nurses) on Change in Condition. The in-service reads: Resident noted with a change in condition is to be assessed by nurse and Md must be notified. Residents continue to be assessed if physician is unable to be reached within 2 hours repeat call and involve medical director. If resident condition appears emergent send to ER. All nursing staff expected to be in-serviced prior to the next shift worked. Staff will not be allowed to provide direct care until services have been completed. This education will also be included in all new nurse orientations for any newly hired nurses and Agency staff. This in-service is to be completed on [DATE]. oOn [DATE] Regional Nurse initiated Inservice with Nursing Staff (Assistant Director of Nursing, Director of Nursing, Certified Medication Aides, Charge Nurses) on Medication Errors. The in-service reads: Physician is to be notified of all medication errors and resident is to be monitored closely for any adverse reactions. All nursing staff expected to be in-serviced prior to the next shift worked. Staff will not be allowed to provide direct care until services have been completed. This education will also be included in all new nurse orientations for any newly hired nurses and Agency staff. This in-service is to be completed on [DATE]. oRegional Nurse/Designee initiated medication pass competency check offs on Nursing Staff (Assistant Director of Nursing, Director of Nursing, Certified Medication Aides, Charge Nurses) All nursing staff expected to be in-serviced prior to the next shift worked. Staff will not be allowed to provide direct care until services have been completed. Agency Staff medication pass competency to be completed at start of shift. This observation is to be completed on [DATE]. oAudit conducted on [DATE] of residents PRN narcotics orders to ensure MARS reflects medications are administered as indicated by physician orders for the past 30 days. On [DATE] MAR to Narcotic count sheet check completed to confirm medications are documented on MAR and Narcotic log. There are no indications of medication errors from the audit. Completed on [DATE]. oThe Medical Director has been notified on [DATE] of immediate jeopardy and reviewed the current change in condition policy and procedures, following physician order policy and procedure, medication administration policy and procedure, and medication error policy and procedure. Plan of action reviewed with the Medical Director with no changes to the current policies. This practice will be reviewed monthly with the QA committee to ensure we are compliant with the change in condition policy and procedures, medication administration policy and procedure, and medication error policy and procedure. Start Date: [DATE]. Completion Date: [DATE] Responsible: Regional Nurse/Designee Monitoring was conducted on [DATE] and [DATE] to verify the facility's plan of removal. The monitoring included: Record review of Dialyzable drugs - acetaminophen was listed, but did not affect toxicity. Hydrocodone was not listed. (Dialyzable drugs are drugs that can be removed by dialysis). Record review of In-service dated [DATE] with previous DON- transcribing medication orders in PCC. Following Hospital Medication orders; clarification and confirming orders. Identifying hazard drug alert on EMAR and blister pack. Record review of In-service dated [DATE] at 6 p.m. with previous DON - for medication administration, pain *unreadable* meds as you go in EMAR. Narcotics should be divided in eMAR and also documented in narcotic log. Record review of In-service & Education Record dated [DATE] - Description: Nurses/CMAs to follow MD orders when administering meds. Review discharge summary from hospital for current med reconciliation. Any medication that resident was receiving previously must be discontinued if not on hospital discharge summary. MD to be notified of admission and verification of meds. There were 9 signatures. Record review of Inservice & Education Record dated [DATE] - Inputting orders into PCC (an electronic medical record) - make sure order is accurate - 5 rights of med administration - order is assigned a schedule and is on correct MAR - all PRN meds go on nurses MAR (LMAR). There were 9 signatures Record review of Inservice & Education Record dated [DATE] - Medication is to be administered as ordered by the MD. Charge nurses are to follow the 5 rights of med administration - right med, right patient, right dosage, right route and right time. Staff not following the above will receive disciplinary action up to and including termination. There were 10 signatures (MA, RN, LVN) Record review of Inservice & Education Record dated [DATE] - Resident noted with a change in condition is to be assessed by the nurse and MD notified - res is to continue to be assessed if unable to reach physician within 2 hours. Repeat call - if you still cannot reach MD call the Medical Director - if resident/pt condition appears emergent send to ER. There were 8 nurse signatures. Record review of Inservice & Education Record dated [DATE] - Medication error - MD is to be notified of any medication error and resident is to be monitored for any adverse reactions. There were 8 nurse signatures. Record review of Inservice & Education Record dated [DATE] - PRN medications are to be documented on narcotic count sheet and on MAR in resident chart after medication administered. Resident to be assessed for pain with shift and document effectiveness of pain medication. There were 8 nurse signatures. Record review of Medication Pass Audits dated [DATE]. There were 5 audits conducted with no errors. Record review of Inservice & Education Record dated [DATE] - Medication Administration, prn documentation, following 6 rights of medication pass, preventing medication errors. Check and balance of admission/discharge medication reconciliation, MD orders - PCC, notification of medication error to MD, med pass audit will be observed 1st day back to work before hitting the floor to pass meds. There were 4 nurse signatures. In an interview on [DATE] at 1:18 p.m. LVN B (Charge nurse 6 a.m. - 6 p.m.) said she was trained to document changes in condition, monitor, and follow up with the MD and Medical Director. If the situation was emergent, she would send them out so the patient is not compromised. The 5 rights of medication administration include to use the right medication, patient, route, time, and document pain on MAR and on narcotic sheet and ensure the times match too because it could be a medication error. She said you document a change in condition in the assessments einteract SBAR, notify the MD right away let them know what is going on, and notify the DON of changes. She said she would keep assessing the patient for any changes either better or worse and document if interventions have helped. She said PRN medications should be reassessed around 15-45 minutes later to ensure efficacy. If there was a medication error, she would notify the DON right away, go through the steps of what happened, do an investigation, notify the MD, assess the resident for adverse reactions, and monitor them very closely for any issues. She would monitor vital signs, alertness, cognition and compare to baseline. For hospital discharge orders she would verify the medications from the hospital with the MD and enter the medication in properly. She said if a medication was discontinued, she would discontinue medication from the system, put in a progress note, and remove medication from the cart. She said she had to do a medication pass with a staff member. She said the MD order would say how often you can administer the medication; she would go in the computer to see when it was last administered and to see if it was too soon or not. She said she also checked the narcotic book just in case it was not documented in the eMAR. In an interview on [DATE] at 1:32 p.m. RN B said the 5 rights of medication pass were to ensure the right person, route, dose, medication, and time. She said a medication pass was conducted. For change in condition, she would document and notify the MD, get a timely response and follow up, send the resident out to the hospital if necessary and report to MD and oncoming shift for follow up. She said she could also reach out to the DON and Administrator and follow up with the Medical Director on what needs to get done. If severe enough send out resident to 911. For hospital discharge orders she said she would reconcile the medication and compare what is new and notify MD who does the final reconciliation. For a change in condition she would assess for new pain, assess the vital signs, check alertness/change in cognition, notify findings to MD and follow orders. She would always do a progress note and look for a change in condition form. If there was a medication error, she would complete an incident report, document, and notify superiors, MD, RP, assess the patient for changes, adverse effects, signs and symptoms to watch for, and continue to monitor the resident. When administering prn narcotics, she would document the prn narcotic in PCC and narcotic log because they do not serve the same purpose. She said PCC showed when the medication was given last, and the narcotic log count sheet purpose was to obtain a proper count. In an interview on [DATE] at 1:52 p.m. LVN F (6 a.m. - 6 p.m.) said she was trained on documenting in the MAR and narcotic book when administering a prn medication so that you do not overdose but give the proper dosage. If there was a change in condition, she would notify the MD and if they did not respond within 2 hours she would go to the medical director, if emergent call 911, don't wait. She would document the change in condition under assessments with option for change in condition. She would determine the symptoms, if new or chronic, which body system did it pertain to, most recent vitals, and situation. She would monitor the resident and implement intervention. If the intervention did not work, she would notify the doctor again. For discharge hospital orders she said if a medication was not on the discharge list you could not give it and could not just go back to what they had prior to the hospital. She said she would reconcile the orders with the MD. She said the 5 rights of medication administration were - right patient, right dosage, right form, route, and time. She said every medication should have the right time if not, question the doctor. She said for a medication error she was trained to alert whoever was in charge, start monitoring for side effects such as respiratory depression, and notify the MD. She said she would monitor the resident for at least 24 hours depending on the drug. In an interview on [DATE] at 2:13 p.m. MA J (2 p.m. - 10 p.m.) said the 5 rights of medication administration were the right patient, medication, dose, time, and route. She said she was trained to follow MD orders. She said if the resident asked for pain medication that was already given, she would notify the nurse that it was already given. She said narcotic medication should be documented on the narcotic book and on the computer. In an interview on [DATE] at 7:46 p.m. LVN E said she had recent in services on medication administration, 5 rights of medication, identifying the patients, when to send residents out, and many others. When administering medications, she would first look up the patient and go over the eMAR, verify the order is correct, and current, then she would locate the medication and ensure the order is what she is supposed to give. She would do hand hygiene, identify pt by photo and by confirming with pt. then she would verify medication at bedside, check expiration date, look over eMAR, make sure it's the right medication, then administer medication. She would document the medication on the eMAR. As soon as she realized she gave the wrong medication, she would contact provider, get baseline set of vitals and monitor condition and mental status and continue to monitor for any change in condition. She would contact 911 if change in condition or if doctor orders her to send pt out. In an interview on [DATE] at 7:55 p.m. LVN C said she had in services on medication administration, when to contact Physician, RP, POA, change in condition in services. They were given yesterday. She said she knows the 5 rights, patient, drug, dose, routes, time, follow up effectiveness, allergies, when to notify MD and antibiotics and safety concerns. She would first identify pt, double check drug, drug label against eMAR, correct dose, correct route, and time, monitor for any adverse effects. She said that she would monitor vital signs, if suspected over dose, notify physician, DON, RP , and if critical or obstruction of airway, loss of conscious, then move to code status, notify hospice if necessary, make determination if sent out for evaluation or treatment. She said if suspected over dose by resident having drugs on themselves if history of Substance abuse there may be an order of Narcan. In an observation on [DATE] at 11:18 a.m. MA J eMAR pulled up for one resident at a time. eMAR states hydrocodone/acetaminophen 1 tablet every six hours not prn. Narcotic sheet and med tablet pulled out. MA confirmed and verified medication with eMAR. Popped in medication into a medication cup and given to resident. Resident pain level 8.5 out of 10, 4 tablets remaining in blister pack. In an interview on [DATE] at 10:40 a.m. LVN K said she does not share a cart with anyone during the day. Before giving out narcotic, ask why they are asking, where the pain is, pain scale, check eMAR for when the last time medication was administered, check orders on eMAR, and on the card to verify how it is to be administered, document reason and for how much pain, verify the times match in eMAR and narcotic sheet to confirm its correct, check pills before administering. Only give if prn, but no more for the day. In an interview on [DATE] at 10:49 a.m. MA G said Last in-service was yesterday over the phone on the 5 rights, right time, right dose, right documentation, right route, right medication. Gives narcotics at noon and 1 pm, they are not prn. Check eMaR, check resident room and information 3 times, and sign out the time given. Explain to the resident what it is, locking everything up, sanitize and give to resident. In an interview on [DATE] at 11:52 a.m. CNA Z said she has been at the facility for two months. Last in-service was this past week on, abuse and neglect. The different types of physical, sexual, emotional, mental, and misappropriation of funds. She has not ever witnessed abuse or neglect at this facility. If suspected, it should be reported immediately to the nurse and DON and the abuse coordinator, [TRUNCATED]

Based on observation, interview, record review, the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 7 residents reviewed for pain management. The facility failed to provide medications Hydrocodone-Acetaminophen 10- 325mg per order for Resident #129 when admitted on [DATE] and after Resident #129 complained of continued pain and requested medication. No pain medication was provided until 2/6/24 when MD visited and changed medication orders. An Immediate Jeopardy (IJ) situation was identified on 2/08/2024. The IJ template was provided to the facility on [DATE] at 3:03 PM While the IJ was removed on 2/12/2024, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents on controlled pain medication at risk of not receiving appropriate pain management resulting in pain. Findings included: Record review of Resident #129's Admission Record revealed he was a [AGE] year-old male who admitted to the facility on [DATE]. His diagnoses included chronic gout (a painful condition in which uric acid builds in the blood and causes inflammation in the joints), metabolic encephalopathy (problem in the brain caused by chemical imbalance in the blood), type 2 diabetes mellitus (the body's impaired used of blood sugar), and stroke (impaired blood flow to the brain). No MDS to review [new admit]. No baseline or comprehensive care plan to review. Record review of the Resident #129's orders revealed that his pain medications ordered upon admission included: Hydrocodone- Acetaminophen Oral Tablet 10-325 MG (Give 1 tablet by mouth every 6 hours as needed for pain)- Ordered by LVN G on 2/4/24 at 3:22 PM. [Resident #129 did not receive this medication prior to 2/08/2024.] Record review of the Nexsys inventory sheet dated 2/7/2024 revealed the electronic dispensing medication device Nexsys (used as e-kit) contained both Eliquis (Position B 3-8) and Hydrocodone 10/325 (Position A-1). Record review of Resident #129 Medication Administration Record dated 2/8/24 revealed: Resident #129 did not receive any pain medication of any kind on the following days: 2/4/24-none given 2/5/24-none given 2/6/24- none given in the morning Resident #129 received first dose of pain medication (Acetaminophen-codeine 30mg) on 2/6/24 at 3PM. Resident #129 had no documented pain levels on 2/4/24 or 2/5/24. Record review of progress notes revealed there was no nursing documentation concerning Resident #129's pain. Record review of therapy noted dated 2/5/24 at 12:57 PM by PT M revealed: Patient with significant [NAME] arthritis pain but participated with evaluation. Record review of therapy note dated 2/6/2024 5:21 PM by OT H revealed: Pt required frequent rest breaks d/t pain in BUE (bilateral upper extremities) Record review of therapy note dated 2/6/2024 7:17 PM by SLP C revealed: Pt participated with conversations and cognitive task. He did indicate that he was unhappy and needed additional help. Will continue to monitor. Observation and interview on 2/7/24 at 9:15 AM with Resident #129, he said that he feels his problems are not being addressed: gout flare, lack of therapy. Resident #129 lifted his left arm and showed where he was unable to move his wrist and hand, then said that the pain in his left hand is a 9/10 and the pain in his right thumb is 6/10. He said the pain was due to being in a gout flare. He said that he did not feel enough was being done to get it under control so that he could participate in therapy. He said he had been in bed since Sunday [3 days], and that's just making everything worse. He said that he complained of pain to everyone that came to his room on those days including the therapists. He said that he did ask about the hydrocodone and a different medicine [Eliquis] that he was on prior to facility admit, but he was never given an answer as to why it was not being provided to him. Interview on 2/7/24 at 9:30 AM with PTA N, he said CNA L called him yesterday to see Resident #129 because he was very upset. He said that he went to talk with the Resident #129, and that the resident expressed concerns about desiring therapy but being unable to tolerate due to gout pain. PTA N said, after his encounter with Resident #129, he talked to the OT N to let her know that the resident was in pain before she went to work with him. PTA N said that he also told the nurse aide. He said he was not sure who Resident #129's nurse was but thought the aide would pass along the message. Interview on 2/7/24 at 9:40 AM CNA L, she said that she asked PT N to see Resident #129 because she has seen the resident feed himself but then he asks for help with simple tasks like getting a drink of water or using the remote to change the channels on the television. She said he has complained about some pain, but when he does, she will let the nurse know and the nurse will give him something. Interview on 2/7/23 at 9:45 AM with OTA N, she said that she worked Resident #129 yesterday, but her visit was limited due to him being in pain. She said that she was unable to notify the nurse right away but did notify the ADON when she found her later. Interview on 2/7/24 at 1:57 PM with LVN G. She said that she was the admitting nurse for Resident #129. She said that she reconciled his medications upon admission and notified the physician for review. She said that she only entered the orders and did not follow up with the pharmacy because that's something that would have been done by the oncoming morning nurse, LVN K. She said she was unaware that Resident #129 was in pain. Interview on 2/7/2024 at 2:35 pm with MD R. He said Resident #129 admitted to the facility from the hospital with a prescription for Hydrocodone. He said that he did approve use of this medication for severe pain and sent an order to the pharmacy on 2/4/24. He said that he cannot explain why the medication was not provided to the resident. He said that the Acetaminophen Codeine was added on 2/6/24 as a scheduled medication to address moderate pain . He said he was not made aware that Resident #129's pain was not being managed with Tylenol #3. Attempted to call LVN K on 2/7/24 at 2:55 PM and on 2/8/24 at 8:53 AM, voicemails left requesting a call back. LVN K was Resident #129's nurse on 2/5/24 and 2/6/24. Interview on 2/8/24 at 9:15 AM with the DON. She said residents should be assessed for pain before receiving pain medications and a half an hour to 1 hour after pain medication has been administered. She said this is to ensure that the medication is working. The DON said if a resident experiences pain during therapy, then therapy should communicate that with the resident's nurse immediately. She said the timing of the pain medication can be modified so that the resident receives their medication prior to therapy to keep them resident comfortable. The DON said that failure to follow this process could result in the resident being in pain. The DON said that failure to provide pain management can result in the resident being in pain. Record review and interview on 2/8/24 at 9:15 am, the DON reviewed Resident #129's orders and said that she was able to identify where Resident #129 was ordered Hydrocodone upon admission on 2/4/24 but did not receive it or any alternative pain medication until he was ordered a different one on 2/6/24. She said failure to administer pain medication could result in unnecessary pain. Interview on 2/8/24 at 9:20 AM with the ADON. She said at no point did therapy notify her Resident #129 was experiencing pain on 2/5/24 or 2/6/24. She said if a resident is in pain, they would be assessed by a nurse, then administered pain medication per order. She said failure to do so could result in the resident experiencing pain. Interview on 2/8/24 at 9:50 AM with the Administrator. She said she expected her nursing staff to follow up to the extent necessary to make sure the residents receive their medications. She said failure to receive pain medications in a timely manner can result in the resident being in pain. Record review of the facility's Pain Management Policy dated 8/10/2021 revealed in part: It is the policy of this community that residents experiencing pain will be assessed and pain management provided to the degree possible to provided comfort and enhance the resident's quality of life. 1. Each resident's pain will be assessed using the Pain Tool UDA in PCC upon admission, readmission, the onset, or an increase in pain, quarterly, and whenever there is a significant change in condition that may cause an increase in pain. 2. The community promotes residents self-reporting as the most reliable indicator of pain. 5. The community will treat the resident under the premise that pain is present whenever the resident says that it is. 6. Nursing staff will identify situations or interventions where an increase in the resident's pain may be anticipated (i.e., wound care, ambulation, repositioning). Pain medication will be offered appropriately preceding these identified activities. 7. The resident's pain will be evaluated routinely each shift. Documentation will be done on the EMAR/ETAR. 9. Nursing staff will evaluate how pain is affecting mood, activities of daily living, sleep and the resident's quality of life including complications. (i. e., falls, gait disturbance, social isolation). 10. The physician will order appropriate pain medication intervention both routine and PRN to address the individual's pain. 11. Residents with unrelieved pain will be evaluated by the nurse and the physician notified. Pain interventions will be adjusted accordingly and may include non-pharmacological measures. 13. A care plan will be completed with goals for pain treatment, pharmacological and nonpharmacological interventions. Plan will be updated appropriately. Record review of the facility's Controlled Substance Prescriptions Policy dated 8/2020 revealed in part: A chart order is not equivalent to a prescription for controlled medications. Therefore, the prescriber issuing the chart order must also provide the pharmacy with a valid prescription to ensure delivery of medication. The written prescription may be faxed to the pharmacy for long-term care facility residents. Verbal orders for controlled medications are permitted for Schedule II substances only in emergency situations. Verbal orders for controlled medications received by facility nursing staff should be noted in the resident's medical record and nursing facility staff must confirm that the prescriber or the prescriber's agent has communicated the order to the pharmacy. 2. The prescriber is contacted for direction when the medication is not or will not be available for administration or in accordance with facility policy. An Immediate Jeopardy (IJ) was identified on 2/08/2024. The Administrator, and DON were notified. The IJ template was provided to the administrator via email on 2/08/2024 at 3:03 pm and a POR was requested. The following Plan of Removal was submitted by the facility and accepted on 2/10/2024 at 9:50 AM: On 2/7/2024 an abbreviated survey was initiated. On 2/8/2024 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safety. The notification of Immediate Jeopardy states as follows: The facility failed to ensure pain management was provided to residents who require such services. F-697 Action: The RDCO will provide education on pain management to the DCO. 2/8/2024 The RDCO provided education to the therapy team on pain management and the need to communicate to nursing when a resident complains of pain. 2/8/2024 In-services on Pain Management Policy and Procedures and use of Nexys machine for first-time medication doses initiated by DCO on 2/8/2024 to all licensed nurses. All licensed nurses expected to be in-serviced prior to the next shift worked. All licensed nurses expected to be in-serviced by 2/9/2024. Charge nurse were in-serviced on what to do if a resident is in pain and what the charge nurses responsibility is for residents that are in pain 2/9/2024 All residents were assessed for pain to ensure no resident had any unidentified pain issues that were not being addressed by DCO/Designee. No residents were assessed to have any unidentified pain issue. Completed 2/8/2024 Cart audits were completed to ensure physician-ordered pain medications were present in the community by DCO/Designee. No physician-pain medications were not present in the community. Completed 2/8/2024 DCO/Designee to complete new admission chart reviews daily during the clinical meeting to ensure medication availability and pain management is in place. 2/9/2024 Daily Focus Care rounds will be completed by management staff to ensure residents are free from pain through resident interviews and to ensure companies policy and procedures for pain management are being followed. 2/9/2024 The Medical Director has been notified of the allegation and reviewed current policy and procedures for pain management and pharmacy procedures. Plan of action reviewed with Medical Director with no changes to the current policy. This practice will be reviewed monthly with the QA committee to ensure we are in compliance with the pain management and pharmacy procedures policy and procedures. 2/8/2024 Resident #129 was assessed for pain. Physician was notified and ordered Hydrocodone 10/325 1 tab every 6 hours 2/8/2024 Care plans and interventions were reviewed for resident that are high risk for pain 2/9/2024 Start Date: 2/8/2024. Completion Date: 2/9/2024 Responsible: RDCO and DCO/Designee Monitoring: Record review of the In-Service and Education Record dated 2/8/2024 revealed the corporate nurse provided the DON with training on Medication Administration- Routine Meds & Emergency Meds- Use of Nexsys. Record review of the In-Service and Education Record dated 2/8/2024 revealed the DON provided therapists, education on Pain Notification- When a resident complains of pain, you need to immediately let the charge nurse know. Record review of the In-Service and Education Record dated 2/8/2024 revealed the DON provided licensed nursing staff training on Pain Assessment- Administering Pain Medication- Available medication in the Nexsys of not available in community. Record review of the In-Service and Education Record dated 2/10/2023 revealed the DON gave licensed nursing staff additional training on Steps to Obtaining Medication from Nexsys when required. Record review of the Pain Assessment Scoring Report dated 2/26/2024 revealed all residents had their pain assessed on 2/8/2024. Record review of Resident #129's pain assessment dated [DATE] revealed that his pain frequency at the time of assessment was occasionally and pain rating was a 5/10. It further revealed that Resident #129 was on a scheduled pain medication regimen of Hydrocodone 10/325 MG 1 PO (by mouth) every 6 hours. Record review of Resident #129's Medication Administration Record [2/11/2024] revealed that Hydrocodone 13/125 had been added as a scheduled medication every 6 hours and his pain was being assessed. Record review of cart audits revealed that this process was overseen by the DON and all medication carts were audited for narcotic pain meds and contained the appropriate medications with orders. Licensed nurses and med aides were interviewed [2/11/2024 between 11:14 AM to 9:35 PM] to verify the training they had received regarding pain management and pharmacy procedures for obtaining controlled pain medications. They were able to verbalize their policy and process for pain management and provision of pain medication. Nurse aides were interviewed [2/11/2024 between 11:14 AM to 9:35 PM] to assess their response to resident complaints of pain. All were able to identify verbal and nonverbal indicators of pain and know to notify the nurse immediately and document on a Stop-and Watch Form. The DON was interviewed on 2/11/2024 at 11:50 AM. She said the regional corporate nurse (RDCO) provided her training on pain management. She said if the resident has pain, then nurses should administer pain medication per physician order. She said if the medication is not readily available from the pharmacy, for instance, if the resident is new, then the nurse should go to the Nexsys to see if the medication is available, get a doctor's order to obtain it from emergency supply, and then follow up with pharmacy to ensure the prescription has been received and there is no issue. If for whatever reason, the medication is not in the Nexsys, the nurse would contact the physician for an alternative medication. She said after receiving her training, she relayed this training to her licensed nurses. The information provided by the DON was verified with the previous interviews of nursing staff. The DON said that on 2/8/2024, she verified that all residents were assessed for pain to ensure no residents had any unidentified pain issues that were not being addressed. Residents on controlled pain medication were interviewed and observed [2/11/24 between 12:30 PM and 1:45 PM]. None had complaints of pain or expressed issues concerning administration of pain medicine. Verbal residents were able to verify that their pain was being assessed per shift by a nurse with pain medication being dispensed as appropriate. They verified that a manager [DON] W daily was providing frequent checks on them . Resident #129 was interviewed and observed on 2/11/2024 at 1:30 PM. He said that since Thursday [2/8/2024] he had been receiving his Hydrocodone and was feeling much better. He said the nurses were being very attentive and checking on him frequently to ask if he was in pain, and if he needed pain medication. He said if he needs it, he accepts and if he doesn't then he declines. He said appreciated that it was being offered. Observed resident lift left arm, and he said that he was not hurting at that time. The Admin was notified on 2/12/2024 at 9:20AM, the Immediate Jeopardy was removed. While the IJ was removed on 2/12/24, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing education to facility staff.

Based on interview and record review, the facility failed to provide routine and emergency drugs for 1 of 8 residents (Resident #129) reviewed for pharmacy services. -The facility failed to provide Resident #129 with ordered routine medications, Eliquis 5mg (blood thinner) and Hydrocodone-Acetaminophen 10- 325mg (pain medication) upon admission and for two days thereafter resulting in the resident experiencing continued pain. An Immediate Jeopardy (IJ) situation was identified on 2/08/2024. The IJ template was provided to the facility on [DATE] at 3:03 PM. While the IJ was removed on 2/11/2024, the facility remained out of compliance at a severity level of potential harm that was not immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of not receiving their medications as prescribed resulting in decline in health and quality of life. Findings included: Record review of Resident #129's Admission Record revealed he was a [AGE] year-old male who admitted to the facility on [DATE]. His diagnoses included chronic gout (a painful condition in which uric acid builds in the blood and causes inflammation in the joints), metabolic encephalopathy (problem in the brain caused by chemical imbalance in the blood), type 2 diabetes mellitus (the body's impaired used of blood sugar), and stroke (impaired blood flow to the brain). No MDS to review [new admit]. No baseline or comprehensive care plan to review. Record review of the Resident #129's orders revealed that his medications ordered upon admission included: Hydrocodone- Acetaminophen Oral Tablet 10-325 MG (Give 1 tablet by mouth every 6 hours as needed for pain)- Ordered by LVN G on 2/4/24 at 3:22 PM. Eliquis Oral Tablet 5 MG (Give 1 tablet by mouth twice a day for A-fib (irregular/rapid heart rhythim)- Ordered by LVN G on 2/4/24 at 3:24 PM. Acetaminophen- Codeine Tablet 300-30 mg (Give 1 tablet by mouth every 8 hours for pain)- Ordered by LVN A on 2/6/ 24 at 11:11 AM. Record review of the Nexsys inventory sheet dated2/7/2024 revealed the electronic dispensing medication device Nexsys (used as e-kit) contained both Eliquis (Position B 3-8) and Hydrocodone 10/325 (Position A-1). Record review of Resident #129 Medication Administration dated 2/8/24 revealed in part: Resident #129 missed 4 doses of Eliquis including: 2/4/24-6 PM dose 2/5/24- 9 AM dose 2/5/24- 6 PM dose 2/6/24- 9 AM dose Resident #129 did not receive any pain medication of any kind on the following days: 2/4/24-none given 2/5/24-none given Resident #129 received first dose of pain medication (Acetaminophen-codeine 30mg) on 2/6/24 at 3PM. Observation and interview on 2/7/24 at 9:15 AM with Resident #129, he said that he feels his problems are not being addressed, and he was not receiving his medications that he was on prior to his admission. Resident #129 lifted his left arm and showed where he was unable to move his wrist and hand, then said that the pain in his left hand is a 9/10 and the pain in his right thumb is 6/10. He said the pain was due to being in a gout flare. He said he took Hydrocodone before he got here [to the facility] to manage that and to his knowledge, it was not taken off his medication list. He said he could not understand why he got here [to the facility] and the nurses were not following his medication routine. Resident #129 said that he was given Tylenol #3 starting on 2/6/24, but it didn't do anything for him. He said prior to that, he was not getting any pain medication at all. Resident #129 also said he was not getting his Eliquis at first, and he has been on that for a while prior to his back when he had a stroke. He said he was in pain and angry because he was paying his money to be here and get therapy but couldn't really do it because they won't give him the right pain medication. Interview on 2/7/24 at 1:57pm with LVN G, she said that she was the admitting nurse for Resident #129 and that she reconciled and entered orders for all of his medications. She said the process for entering meds for a new admit is that the admitting receives a medication list and verifies the medications with the doctor . She said if the doctor is in agreement, the orders are entered. She said pharmacy receives the orders as they are entered, however, certain medications like controlled substances require an e-script directly from the physician. She said if the medication is not received or delayed, then the oncoming nurse should follow up with the pharmacy to address the issue and then follow up with the doctor in the event that an alternate is needed. LVN G said the staff must follow physician's orders because those constituted the only care a resident should receive. LVN G said if a resident was not receiving pain medication that would be concerning. LVN G said if a resident was not receiving pain medication as ordered the resident's pain may not be managed, and he/she may not be able to participate in care services. Interview on 2/7/2024 at 2:35 PM with MD R, he said that he reconciled Resident #129's medications upon admission on 2/04/2024 and sent off scripts for the medications that required them on that same day. He said if the resident did not receive the medications as ordered, that would be on nursing staff and he really cannot answer to why . Observed and interviewed on 2/7/2024 at 3:20 PM, the Nexsys electronic dispensing machine in the locked medication room, accompanied by the DON. She said that she could not physically remove medication from the machine without a pharmacy authorization number, however, the contents of the machine are tracked via the Nexsys Inventory List, list provided and reviewed. Unsuccessfully attempted to interview LVN K (morning nurse for Resident #129 day 1 after admit) by phone 2/7/24 and 2/8/24, voicemails left requesting a call back. Interview on 2/8/24 at 9:15 AM the DON, she said when a resident is admitted into the facility, their medications are reconciled meaning the admitting nurse enters them into the system, the physician is notified and reviews the medication, and the physician will send prescription(s) to the pharmacy. She said if the medication does not come in at the expected time or by the next shift, the oncoming nurse should follow up with the pharmacy to see why the medication has not been sent. The DON said if the problem is that the medication is not available, then the nurse would follow up with the physician to order an alternative medication. She reviewed Resident #129's orders and said that she was able to identify the lapse in medication administration and that it was unacceptable. She said according to the Nexsys Inventory List, both the Eliquis and Hydrocodone were available. She said an oversight occurred in that the Eliquis was simply not given despite being ordered and available. She said the Eliquis would be available to the med aides on the carts, however, they hydrocodone would have to be given by a licensed nurse. She said even if it was not available with the resident's other medications on the nurse's cart, it could have been obtained from the e-kit. She said failure to administer the resident's blood thinner could be dangerous for the resident and missed pain medication could result in unnecessary pain . Interview on 2/8/24 at 9:30 AM with the Administrator, she said if a medication is not here, then the nurse should immediately contact the pharmacy to find out why and contact the doctor . She said failure to provide medication can negatively impact a resident's health condition or cause the resident to be in pain. Interview on 2/8/24 at 12:45 PM with Resident #129, he said that he did notify staff that came to his room on 2/5/24 and 2/6/24 that he was in pain and asked for medication. He said that they started him on Tylenol #3 (Acetaminophen-Codeine) on the 6th, but it doesn't do anything. He said that his pain had been managed with Hydrocodone without a problem prior to his arrival in this facility. Interview on 2/11/2024 at 11:14 AM, LVN K said that she was aware of Resident #129 not receiving his Hydrocodone , but was unaware about the Eliquis. She said there was a drop off on the doctor's end in that the doctor's (MD R) office was saying they sent the prescription, but the pharmacy did not receive it. She said it is the nurses' responsibility to follow up with the physician and the pharmacy when a medication does not arrive. LVN K said that she followed up with doctor and the pharmacy on the morning and afternoon of 2/05/2024 , but did not document it. She said she did not notify the DON that there was an issue with Resident #129's medication. She said she thought she documented in a progress of Resident #129 having an issue with medication, but she must not have saved it. She said she did not have a reason as to why the medication was not accessed from the e-kit, but she has received training on accessing medication from the e-kit and following up with the physician and pharmacy. S he said failure to follow up on unreceived medications can result in residents being in pain or something else depending on the condition being treated. Record review of the facility's policy for Medication and Treatment Orders dated July 2016 revealed in part: Orders for medications and treatments will be consistent with principles of safe and effective order writing. 1. Medications shall be administered only upon the written order upon the written order of a person duly licensed and authorized to prescribe such medications in this state. 2. Only authorized, licensed practitioners, or individuals authorized to take verbal orders from practitioners, shall be allowed to write orders in the medical record. 10. Only authorized personnel shall call in orders for prescribed medications to the pharmacy. An Immediate Jeopardy (IJ) was identified on 2/08/2024. The Administrator, and DON were notified. The IJ template was provided to the administrator via email on 2/08/2024 at 3:03 pm. The following Plan of Removal was submitted by the facility and accepted on 2/09/2024 at 2:51 PM: On 2/7/2024 an abbreviated survey was initiated at Focused Care at Cedar Bayou. On 2/8/2024 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safety. The notification of Immediate Jeopardy states as follows: The facility failed to provide routine and emergency drugs for 1 of 8 residents reviewed for medication administration. F-755 o Action: o The RDCO will provide education on medication administration of routine and emergency medication to the DCO. 2/8/2024 o The RDCO provided education to the therapy team on pain management and the need to communicate to nursing when a resident complains of pain. 2/8/2024 o In-service on the use of Nexsys machine for first-time medication doses initiated by DCO on 2/8/2024 to all licensed nurses. All licensed nurses expected to be in-serviced prior to the next shift worked. All licensed nurses expected to be in-serviced by 2/9/2024. o All residents were assessed for pain to ensure no resident had any unidentified pain issues that were not being addressed by DCO/Designee. No residents were assessed to have any unidentified pain issue. Completed 2/8/2024 o Cart audits were completed to ensure physician-ordered pain medications and anticoagulants were present in the community by DCO/Designee. No physician-pain medications or anticoagulants were not present in the community. Completed 2/8/2024 o DCO/Designee to complete new admission chart reviews daily during the clinical meeting to ensure medication availability and pain management is in place. 2/9/2024 o Daily Focus Care rounds will be completed by management staff to ensure residents are free from pain and receiving their medications through resident interviews and to ensure companies policy and procedures for pain management and anticoagulants are being followed. 2/9/2024 o The Medical Director has been notified of the allegation and reviewed current policy and procedures for pain management and pharmacy procedures. Plan of action reviewed with Medical Director with no changes to the current policy. This practice will be reviewed monthly with the QA committee to ensure we are in compliance with the pain management and pharmacy procedures policy and procedures. 2/8/2024 o DCO or designee will review all new admissions medication orders to ensure that medications are received and administered as ordered during morning clinical meeting 2/9/2024 o DCO or designee will review all new admissions with a controlled medication order to ensure that medication is received and administered as ordered during the morning clinical meeting 2/9/2024 o Resident #129 was assessed for pain and Physician was notified. Physician ordered routine Hydrocodone every 6 hours for pain 2/8/2024 o Admission policy and procedure was reviewed by DCO and EDO 2/9/2024 o Audit of all new admission completed to ensure that medications were administered as ordered. 2/9/2024 Start Date: 2/8/2024. Completion Date: 2/9/2024 Responsible: RDCO and DCO/Designee Monitoring: Record review of the In-Service and Education Record dated 2/8/2024 revealed the corporate nurse provided the DON with training on Medication Administration- Routine Meds & Emergency Meds- Use of Nexsys. Record review of the In-Service and Education Record dated 2/8/2024 revealed the DON provided therapists, education on Pain Notification- When a resident complains of pain, you need to immediately let the charge nurse know. Record review of the In-Service and Education Record dated 2/8/2024 revealed the DON provided licensed nursing staff training on Pain Assessment- Administering Pain Medication- Available medication in the Nexsys of not available in community. Record review of the In-Service and Education Record dated 2/10/2023 revealed the DON gave licensed nursing staff additional training on Steps to Obtaining Medication from Nexsys when required. Record review of Resident #129's Medication Administration Record dated 2/26/2024 revealed that Hydrocodone 13/125 was added as a scheduled medication every 6 hours and his pain was being assessed, and medication administered accordingly. It also revealed that the resident did not miss any more doses of Eliquis after 2/6/24 at 6 PM. Record review of cart audits revealed that this process was overseen by the DON and all medication carts were audited for narcotic pain meds and contained the appropriate medications with orders. Licensed nurses and med aides were interviewed [2/11/2024 between 11:14 AM to 9:35 PM] to verify the training they had received regarding pain management and pharmacy procedures for obtaining controlled pain medications. They were able to verbalize their policy and process for pain management and provision of pain medication. Nurse aides were interviewed [2/11/2024 between 11:14 AM to 9:35 PM] to assess their response to resident complaints of pain. All were able to identify verbal and nonverbal indicators of pain and know to notify the nurse immediately and document on a Stop-and Watch Form. The DON was interviewed on 2/11/2024 at 11:50 AM. She said the regional corporate nurse (RDCO) provided her training on pain management. She said if the resident has pain, then nurses should administer pain medication per physician order. She said if the medication is not readily available from the pharmacy, for instance, if the resident is new, then the nurse should go to the Nexsys to see if the medication is available, get a doctor's order to obtain it from emergency supply, and then follow up with pharmacy to ensure the prescription has been received and there is no issue. If for whatever reason, the medication is not in the Nexsys, the nurse would contact the physician for an alternative medication. She said after receiving her training, she relayed this training to her licensed nurses. The information provided by the DON was verified with the previous interviews of nursing staff. The DON said that on 2/8/2024, she verified that all residents were assessed for pain to ensure no residents had any unidentified pain issues that were not being addressed. Residents on controlled pain medication were interviewed and observed [2/11/24 between 12:30 PM and 1:45 PM]. None had complaints of pain or expressed issues concerning administration of pain medicine. Verbal residents were able to verify that their pain was being assessed per shift by a nurse with pain medication being dispensed as appropriate. They verified that a manager [DON] W daily was providing frequent checks on them . Resident #129 was interviewed and observed on 2/11/2024 at 1:30 PM. He said that since Thursday [2/8/2024] he had been receiving his Hydrocodone and was feeling much better. He said the nurses were being very attentive and checking on him frequently to ask if he was in pain, and if he needed pain medication. He said if he needs it, he accepts and if he doesn't then he declines. He said appreciated that it was being offered. Observed resident lift left arm, and he said that he was not hurting at that time. He said that he was receiving his Eliquis and all of his medications as he should. The Admin was notified on 2/12/2024 at 8:46 AM, the Immediate Jeopardy was removed. While the IJ was removed on 2/11/24, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing education to facility staff.

Based on interview, observation, and record review, the facility failed to ensure one of twelve residents (Resident #3) reviewed for abuse, neglect, and/or exploitation remained free of abuse. -Resident #3 alleged that LVN B kicked her in her side/back after she had fallen in her restroom in November 2023 This failure could place residents at risk for abuse, pain, fear, and psychosocial impairment. The noncompliance was identified as PNC. The IJ began on 11/20/2023 and ended on 11/21/2023. The facility had corrected the noncompliance before the survey began. Findings include: Record review of Resident #3's face sheet dated 2/6/2024 revealed a [AGE] year-old woman admitted on [DATE]. The face sheet documented her diagnoses included dementia (group of symptoms that affects memory, thinking and interferes with daily life), major depressive disorder (MDD, mental health disorder having episodes of psychological depression), a history of falling, cerebral infarction (stroke), unspecified psychosis (symptoms of more than one disorder that don't fit the full criteria for any and can't be explained by another medical condition), schizoaffective disorder(mental disorder in which a person experiences a combination of symptoms of schizophrenia and mood disorder), unsteadiness on her feet, contractures (abnormal shortening of muscle tissue), abnormal posture, lack of coordination, hemiplegia (paralysis of one side of the body) and hemiparesis(one-sided muscle weakness), and chronic embolism and thrombosis (blood clots) of the deep veins on her right lower extremity. Record review of Resident #3's quarterly MDS dated [DATE] with an ARD of 1/1/2024 revealed a BIMS score of 9 indicating significant cognitive impairment. The MDS documented she had no potential indicators of psychosis, behaviors affecting others, rejection of care, or wandering behaviors. Per the MDS, Resident #3 had impairment to one side of her upper and lower extremities and used a wheelchair for mobility. The MDS revealed she either did not, or it was unknown if she had any unplanned or unexpected significant weight loss. The MDS documented she had received OT but it ended on 1/1/2024, and she had received PT from 9/6/2023 to 9/28/2023. Record review of Resident #3's care plan dated 1/17/2024 revealed a focus on her history of falls with interventions including encouragement to ask for assistance, ensuring the call light was within reach, and therapy as per physician's orders. The care plan documented a focus on her actual falls with interventions including an assistance bar in the restroom, bed in a low position, fall mats, ensuring her wheelchair was accessible from her bed, pharmacy consultation, and posting signs to remind her to ask for assistance. The care plan included a focus on her ADL deficit with interventions including assistance with bathing/showering, bed mobility, dressing, toileting, and transfers. The care plan revealed a focus on her physical mobility limitations with interventions including use of a wheelchair, monitoring to ensure the contractures were not worsening, and PT and OT as ordered. Record review of Resident #3's incident note dated 11/19/2023 revealed she had fallen while using the restroom unassisted. The note documented she was assessed and found with no injury. Record review of Resident #3's progress note dated 11/20/2023 revealed she was found lying on the floor in her bathroom. The note documented she had gone to the restroom unattended and fallen. Record review of Resident #3's nurse's note dated 11/22/023 revealed she was found on the floor next to her wheelchair in the bathroom. The note documented the CNA had assisted her to the restroom and stepped out for privacy. Per the note, when the CNA returned to the restroom Resident #3 was on the floor. The note revealed Resident #3 did not request assistance or press the call light prior to falling. The note documented no injuries were observed. Interview on 2/7/2024 at 1:14 PM with Resident #3, she said she had fallen many times recently, but she did not know why. Resident #3 said she recalled when a nurse had become upset with her after Resident #3 had fallen in November of 2023. Resident #3 said she did not know why the nurse became upset with her. Resident #3 said the nurse kicked her. Resident #3 said the nurse kicked her in the side or back. Resident #3 said it had hurt when she was kicked. Resident #3 said she did not know why the nurse kicked her. Resident #3 said she had not seen the nurse since that time. Resident #3 said she had never been treated in a similar manner by other staff at the facility. Interview on 2/7/2024 at 4:01 PM with Resident #3, she said when LVN B kicked her she felt like she was crazy. Resident #3 said the incident made her think something was wrong with her, and she had caused LVN B to kick her. Resident #3 said she was afraid of being thrown out of the facility. Resident #3 said she was also afraid she may be hurt again by other staff. Resident #3 said she was afraid of LVN B. Interview on 2/6/2024 at 8:38 AM with Resident #56 he said he had never had any concerns with abuse, neglect, and/or exploitation at the facility. Resident #56 said the CNA's were good, but the nurses would not answer the call lights. Mr. [NAME] said he had never seen or heard other residents being abused, neglected, and/or exploited. Interview on 2/8/2024 at 11:36 AM with Resident #22, he said he had no concerns with the care he received. Resident #22 said the staff took care of all his needs. Resident #22 said he had never told anyone he had any concerns with the care he received. Resident #22 denied ever being the victim of abuse, neglect, and/or exploitation. Interview on 2/8/2024 at 12:55 with Resident #71, she said she did not have any concerns with the staff being rude any longer. Resident #71 said she had informed the facility of her concerns and were immediately addressed. Resident #71 said she had never seen any staff being abusive to her or other residents. Resident #71 said she had no concerns with the care provided. Interview on 2/8/2024 at 1:01 PM with Resident #24, she said she did not recall ever telling anyone she had any concerns with the care she received. Resident #24 said she had no concerns with the care she received. Resident #24 denied ever being the victim of abuse, neglect, and or exploitation at the facility. Interview on 2/7/2024 at 1:51 PM with the Admin, she said she had interviewed Resident #3 on 11/20/2023 after former CNA A reported LVN B had kicked Resident #3. The Admin said she also sat in during the interview with LVN B and the DON after the incident. The Admin said LVN B had reported she put her foot on Resident #3's legs to stop her from getting up after she had fallen in her restroom. The Admin said LVN B said she had used her foot to stop Resident #3 from getting up so Resident #3 did not hurt herself. The Admin said she informed LVN B that she should not restrain a resident, and especially with her foot. The Admin said when she interviewed Resident #3, she said she had fallen in the restroom and LVN B was angry at her. The Admin said Resident #3 reported LVN came into the restroom and kicked her. The Admin said Resident #3 reported she was kicked in the upper body. The Admin said she informed LVN B that her actions constituted abuse. The Admin said LVN B's employment was terminated at that time. The Admin said Resident #3 was assessed by the DON and there were no injuries observed. The Admin said the facility provided an in-service training to all staff related to abuse, neglect, and/or exploitation of a resident. The Admin said typically after any allegation of abuse, neglect, and/or exploitation of a resident the facility surveyed all other residents related to the parties to ensure they were not any other victims. The Admin said she believed that was done after this incident. Interview on 2/7/2024 at 1:51 PM with the DON, she said she was informed on 11/20/2023 by CNA C that she had observed LVN B putting her foot on Resident #3's legs. The DON said she asked Resident #3 what had occurred. The DON said Resident #3 responded that LVN B had kicked her. The DON said Resident #3 said Resident #3 said LVN B kicked her because LVN B was upset that Resident #3 had fallen. The DON said she and the Admin interviewed LVN B. The DON said LVN B said she had put her foot on Resident #3 to stop her from getting up from a fall. The DON said LVN B was sent home at that time. The DON said she and the Admin investigated the allegations and CNA A reported she had seen LVN B kick Resident #3. The DON said LVN B was terminated at that time. The DON said after the incident the staff were provided with an in-service training related to abuse, neglect, and/or exploitation of the residents. The DON said other residents were interviewed and none reported any concerns. The DON said the staff are trained regularly to report any concerns that a resident may be the victim of abuse, neglect, and/or exploitation to the abuse coordinator. The DON said the abuse coordinator is the Admin. Interview on 2/8/2024 at 8:56 AM with CNA F, she said she had been employed for one year. CNA F said her primary duties included ensuring all residents' needs were met and their ADL's were completed. CNA F said she had been trained by the facility on resident abuse, neglect, and exploitation. CNA F said the different types of abuse included physical, verbal, sexual, mental, and neglect. CNA F said a resident who had been abused may become scared or withdrawn. CNA F said a resident may have physical signs or symptoms such as bruising. CNA F said if she thought a resident was the victim of abuse, neglect, and/or exploitation she would inform the Admin immediately. Interview on 2/8/2024 with at 8:59 AM with LVN G, she said she had been employed for two weeks. LVN G said she had been trained by the facility on resident abuse, neglect, and exploitation. LVN G said the different types of abuse included physical, sexual, mental, verbal, and financial. LVN G said she would inform the abuse coordinator immediately if she was concerned a resident was the victim of abuse, neglect, and/or exploitation. LVN G said the Admin was the abuse coordinator. Interview on 2/8/2024 at 9:08 AM with MA H, she said she had been employed for five years. MA H said her primary duties included medication administration and resident care. MA H said she had been trained by the facility on resident abuse, neglect, and/or exploitation. MA H said abuse included verbal, physical, and sexual abuses and neglect. MA H said if she felt a resident was the victim of abuse, neglect, and/or exploitation she would inform the Admin immediately. Interview on 2/8/2024 at 9:46 AM with CNA D, she said she had been employed for three years. CNA D said her primary duties included providing resident care and assisting the residents with ADL's. CNA D said she had received resident abuse, neglect, and exploitation training from the facility. CNA D said the had been informed on different types of abuse including verbal, physical, and sexual, and what neglect entailed. CNA D said if she ever suspected a resident was the victim of abuse, neglect, and/or exploitation she would report that to the abuse coordinator immediately. CNA D said the abuse coordinator was the Admin. Interview on 2/8/2024 at 9:52 AM with CNA E, she said she had been employed since August of 2023. CNA E said she her primary duties included direct resident care and ensuring residents ADL's were completed. CNA E said she had been trained by the facility on resident abuse, neglect, and exploitation. CNA E said physical, verbal, sexual, and mental were types of abuse. CNA E said a resident may act scared, aggressive, or have other behavior changes if they were the victim of abuse, neglect, and/or exploitation. CNA E said a resident may have bruises or other physical signs of abuse as well. CNA E said she would immediately report any concerns a resident was the victim of abuse, neglect, and/or exploitation to her abuse coordinator, the Admin. Telephone interview on 2/8/2024 at 1:30 PM with LVN B, she said she had been in the room next door to Resident #3 and heard a loud noise. LVN B said she went to Resident #3's room and found her on the floor in her bathroom. LVN B said Resident #3 was lying with her head facing the door. LVN B said she had placed her foot under Resident #3's head to ensure it did not hit the floor. LVN B said she was informed that someone had said she had tried to kick Resident #3. LVN B denied kicking Resident #3 or any other residents at any time. LVN B said she did not know why anyone would say she had kicked a resident. LVN B said Resident #3 continually attempted to go to the restroom unassisted and fell . LVN B said she heard Resident #3 fall, and she put her foot under Resident #3's head to stop her head from falling to the ground. Interview on 2/9/2024 at 11:28 AM with LVN S, she said she had been employed for almost two years. LVN S said her primary duties included obtaining resident blood glucose levels, obtaining vital signs, tracheostomy care, calling physicians and families, and documentation. LVN S said she had been recently trained on resident abuse, neglect, and exploitation. LVN S said abuse included physical, verbal, and sexual abuses, and resident exploitation. LVN S said a resident may become fearful, pull away from someone who had abused them, have behavior changes, bruising, and unexplained injuries if he/she had been the victim of abuse. LVN S said if she was concerned a resident was the victim of abuse, neglect, and/or exploitation she would inform the facility's abuse coordinator. LVN S said the facility's abuse coordinator was the Admin. LVN S said she had also received in-service training related to resident rights and restraints. LVN S said a resident should never be restrained without physician orders, and she was to report any incidents of a resident who was restrained without physician orders. Interview on 2/9/2024 at 11:34 AM with PTA N, he said he had recently received training related to resident abuse, neglect, and exploitation. PTA N said he was instructed to ask residents about their care and look for signs and symptoms of resident abuse, neglect, and/or exploitation. PTA N said he was instructed to inform the facility's abuse coordinator if he had any indication a resident was the victim of abuse, neglect, and/or exploitation. PTA N said he had also received in-service training related to resident restraints and rights. PTA N said he was informed that residents should never be restrained without physician's orders. PTA N said if he observed a resident being restrained without orders, he was required to inform the Admin and DON. PTA N said residents rights were protected by law. Interview on 2/9/2024 at 11:39 AM with CNA T, she said she had recently received an in-service training. CNA T said abuse included verbal, physical, and emotional abuse. CNA T said a resident may exhibit bruising or begin acting fearful if he/she was the victim of abuse, neglect, and/or exploitation. CNA T said if she had any concerns a resident was the victim of abuse, neglect, and/or exploitation she was required to inform the Admin. CNA T said she had also received in-service training related to resident restraint and rights. CNA T said residents were not to be restrained without a physician's order and to inform the Admin if she ever observed a resident restrained. CNA T said resident rights were the same as everyone else's and were protected by law. Interview on 2/9/2024 at 1:16 PM with MA Q, she said she had recently received an in-service training related to resident abuse, neglect, and exploitation. MA Q said she had learned that abused could include physical, verbal, mental, or sexual abuses, neglect, and/or misappropriation of resident property or funds. MA Q said if she was ever concerned a resident was the victim of abuse, neglect, and/or exploitation she would immediately inform the Admin. MA Q said a resident may become scared, isolate more often, act out in inappropriate manners, or have bruises or unexplained injuries if she/he was the victim of abuse, neglect, and/or exploitation. MA Q said she also was informed that residents were never to be restrained. MA Q said if a resident was acting out in an inappropriate manner, she was required to redirect him/her verbally or distract her/him. Interview on 2/10/2024 at 10:44 AM with LVN K, she said she had been employed for seven months. LVN K said her primary duties included ensuring the residents' safety and care, assessing vital signs, medication administration, providing tracheostomy care, and documentation of care. LVN K said she had recently received in-service training related to resident restraints, resident abuse, neglect, and exploitation, resident elopement, and resident rights. LVN K said the in-service related to resident abuse, neglect, and exploitation informed her that abuse included physical, mental, sexual, and verbal abuse, neglect, and exploitation of residents' property or funds. LVN K said was also informed how to prevent resident abuse, neglect, and/or exploitation and the signs and symptoms of abuse. LVN K said if she was concerned a resident was the victim of abuse, neglect, and/or exploitation she would immediately report those concerns to the Admin, who was the facility's abuse coordinator. LVN K said she learned during the resident restraint in-service training that residents were never to be restrained. LVN K said a restraint could include anything prohibiting the movement of a resident including placing a bedside table in front of them or putting pillow around them. LVN K said if she was concerned a resident was restrained, she would first remove the restraint, and then she would tell the Admin and DON. LVN K said during the resident rights in-service training she was taught that residents had the same rights as anyone else, including the right to refuse care or treatment. LVN K said a resident's rights were protected by the staff, administration, and the law. Interview on 2/10/2024 at 10:50 AM with the ADON, she said she had recently received in-service training related to resident restraints, resident rights, and resident abuse, neglect, and exploitation. The ADON said she had learned during those in-service trainings the different types of abuse including physical, mental, sexual, neglect, and exploitation. The ADON said she also learned that no resident should ever be restrained. The ADON said she was instructed to inform the Admin if she was ever concerned a resident was the victim of abuse, neglect, and/or exploitation, or was restrained. The ADON said she was instructed that residents should have the same expectation of rights as anyone else. The ADON said residents could refuse care and/or treatments. Record review of the facility's internal investigation revealed that Resident #3 was restrained by a nurse, LVN B, after Resident #3 fell . The investigation documented LVN B was observed by another team member, CNA A, reported she observed LVN B kick and speak rudely to Resident #3. Per the investigation, Resident #3 was observed with no injuries after the incident. The investigation revealed LVN B denied kicking Resident #3, but she admitted to using her foot to hold Resident #3 down because she would not be still. The investigation documented the incident was confirmed to have occurred. Record review of a written statement prepared by the DON, documenting the statement from LVN B, dated 11/20/2023 revealed LVN B entered Resident #3's room and found her lying on the floor trying to get up. The statement documented LVN B held Resident #3 down and told her not to get up because she would hurt herself. Per the statement, Resident #3 continued to attempt to get up and LVN B used her foot to hold Resident #3 down while using her arms to attempt to take Resident #3's blood pressure. The note revealed LVN B attempted to hold Resident #3's hand down because Resident #3 was trying to mover her arm when LVN B was taking her blood pressure. The note documented when the incident was concluded, LVN B and CNA A helped Resident #3 back into her wheelchair. The statement was signed by the DON, the Admin, and LVN B. Record review of a written statement prepared by the DON, documenting the statement of CNA A, dated 11/20/2023 revealed LVN B had asked CNA A to assist her transferring Resident #3 from the floor. The statement documented CNA A observed LVN B kick Resident #3 in the back and shove her hand because LVN B needed to take Resident #3's blood pressure. Per the statement, Resident #3 tried to move her arm again and LVN B shoved Resident #3's arm. The note revealed that CNA A said after she and LVN B moved Resident #3 to her wheelchair, LVN B told Resident #3 that she was going to break her neck and must want to die because she did not listen to LVN B. The statement was signed by the DON and CNA A. Record review of a written statement prepared by the DON, documenting the statement of CNA C, dated 11/20/2023 revealed Resident #3 had put herself on her toilet and fallen. The statement documented CNA C heard LVN B tell Resident #3 to lay there before I put my foot on your head so you don't move. Per the statement, CNA C went to Resident #3's room and found her on the floor and another CNA went to help her off the floor. The statement revealed CNA C did not witness any abuse but heard a verbally abusive statement. The DON said CNA C reported the incident to the ADON. Record review of Safe Survey Interviews dated 11/21/2023 revealed that seven interviews were conducted on the 100-Hall of the facility. Of the seven interviews, one reported the resident had experienced staff being physically abusive, rude, or rough with him at the facility. The resident reported the staff had placed mustard and milk on his tray indicating this was the abuse. All the residents denied seeing staff physically aggressive, rude, or abusive with other residents. All the resident reported they knew who to report concerns of abuse, neglect, and/or exploitation to. Record review of LVN B's personnel file revealed a copy of the facility's 5/7/2018 Abuse policy signed by LVN B. The file included two Acknowledgement of Abuse Policy forms dated 5/13/2019 and 7/22/2019. Two Abuse and Neglect exams dated 1/19/2021 and 4/14 of an unknown year that were completed by LVN B was in her personnel file. Record review of LVN B's employee termination form dated 11/22/2023 revealed she was terminated for misconduct. The form included a note which read Resident fell and kept trying to get up and team member restrained res with her foot to keep res from getting up. Res stated team member kicked her. Record review of the facility's Abuse policy dated 2/1/2017 revealed a policy statement which read The purpose of this policy is to ensure that each resident has the right to be free from any type of Abuse, Neglect, Intimidation, Involuntary Seclusion/Confinement, and or Misappropriation of property. The policy documented residents would not be subjected to abuse by anyone in the facility. Per the policy, if a resident was the alleged victim of abuse, the facility would identify the perpetrator and remove him/her from the facility until the end of the investigation. Record review of the facility's In-service and Education Record form dated 11/21/2023 revealed staff were provided in-service training on 11/21/2023. The form documented the curriculum for the training was the facility's Abuse policy dated 1/1/2023. The in-service was signed by multiple disciplines including CNA's, MA's LVN's RN's, housekeeping, staffing, and PT. Record review of the facility's POR revealed head-to-toe assessments would be completed for any non-verbal residents. The facility provided a total of nine skin assessments completed on 2/7/2024 for the non-verbal residents. The skin assessments were for Resident #'s 11, 13, 14, 28, 33, 35, 37, 62, and 63. Resident #11's skin assessment documented he had discoloration to his sacrum, a bunion on both large toes, yellow discoloration to the right side of his chest with a healing light pink scab. Resident #13's skin assessment revealed her skin was intact, but that she had a colostomy bag and G-Tube. Per Resident #14's skin assessment, he had a healing stage II pressure wound, dry skin, discoloration of the left knee, redness of his left second toe, and a scratch on his right second toe. Resident #28's skin assessment documented a fistula on his left arm and intact skin. Resident #33's skin assessment revealed both of her legs and arms had contractions, both feet had drop, and she had dry skin on the lower extremities. Per resident #35's skin assessment, her skin was intact and she had abdominal scarring from a former g-tube site. Resident #37's skin assessment documented his left arm was contracted, he had a G-Tube, pink scarring to both legs, and a scar on his left outer knee. Resident #62's skin assessment revealed she utilized a G-Tube, had dry scabs on her right legs, discoloration of both legs, pink circular discoloration on the upper back, and a light pink discoloration under the right breast. Per Resident #62's skin assessment, she had been treated for shingles in January 2024. Resident #63's skin assessment documented he received wound care to both feet daily. Resident #63's skin assessment revealed he had scarring to the scrum and buttocks, both hands and legs were had been contracted, and discoloration to both arms near the elbows. Record review of the facility's Focused Care Partner Rounds checklist revealed the facility had completed rounds for each resident on 2/7/2024, 2/8/2024, and 2/9/2024. The checklists included the following areas for review: odor in rooms, clean floors, dishes in the room, a full water pitcher within reach, a made and locked bed, the bed crank was down, a working and clean privacy curtain, clean closets, a neat and clean room and restroom, covering and labeling on the urinal and bed pan, no taped and/or handwritten signage, oxygen tubing labeled and off the floor, clean walls free of holes, appropriate resident positioning, appropriate resident grooming, proper covering and labeling of a urine bag, call light placement, IV Pole cleanliness and placement, proper labeling and storage of toiletries, gloves available, soap and paper towels available, nasal cannulas and tubing dated within a week, bedside table and bedrail cleanliness, no medications in the rooms, air conditioner and/or heater functioning, toilet and sink free of leaks and/or cracks, and proper linen storage. Record review of the facility's daily incident report log dated 2/8/2024 revealed one incident was reviewed. The report documented Resident #3 had an incident on 2/7/2024. Per the report, the incident was number 1228. Record review of the facility's daily incident report log dated 2/9/2024 revealed two incidents were reviewed. Incident number 1229 for Resident #3 and incident number 1230 for Resident #10. Record review of the facility's daily incident report review dated 2/10/2024 revealed three incidents, incident numbers 1231, 1232, and 1233, were reviewed by both the DON and Admin. Record review of Resident #10's nurse's note dated 2/8/2024 revealed she was found sitting on the floor mat on the left side of the bed. The note documented her back was against the bed and her knees were brought up to her chest. Per the note, Resident #10 said she had slid down the bed when she was eating her lunch. The note revealed a head-to-toe assessment was completed and she was found to have redness to her upper back. The note documented Resident #10 was able to move both her upper and lower extremities, she denied hitting her head, and she was transferred back to the bed by two staff. Per the note, neurological assessments were initiated. Record review of the facility's incident report #1228 revealed Resident #3 had an unwitnessed fall on 2/7/2023. The report documented a nurse was informed by another resident she was found on the floor in her restroom. Per the report, Resident #3 said she had attempted to stand and wash her hands and fell . The Report revealed Resident #3 was assessed for injuries with none noted and neurological assessments were conducted by a nurse. Record review of the facility's incident report #1229 revealed Resident #3 had an unwitnessed fall on 2/8/2024. The report documented she was found on the floor in the middle of her room. Per the report, Resident #3 reported she had fallen trying to stand and reach a pair of pants. The note revealed she had been assessed for injuries with none noted, she denied any pain, and she was not sent to the hospital. Record review of the facility's incident report #1230 revealed Resident #10 had an unwitnessed fall on 2/8/2024. The report documented she was found sitting on her fall mat on the left side of her bed. Per the report, Resident #10 was found with her back against the bed and her knees pulled up to her chest. The report revealed she reported she had been eating her lunch on her bed, that was placed on the bedside table, and she slid to the floor. The report documented a head-to-toe assessment was completed and she had redness to the upper back. Per the report, Resident #10 reported no pain, denied hitting her head, and was able to move her upper and lower extremities with no discomfort. The note revealed neurological assessments were initiated and she was transferred to her bed with the assistance of two staff. Record review of the facility's incident report #1231 dated 2/9/2024 revealed Resident #175 had reported he had fallen getting out of bed. The report documented Resident #175 had complained he fell on his left side hurting his shoulder and leg. Per the report, resident was assessed for injuries and no visible injuries were observed. The report revealed he was provided with as-needed pain medication. Record review of the facility's incident report #1232 dated 2/9/2024 revealed Resident #66 had a skin tear on her leg and blood on her sheets. The report documented Resident #66 was found in her room, sitting on her bed, with her feet in the seat of her wheelchair. Per the report, Resident #66 had a skin tear of the lower left leg. The report revealed she could not provide any information on what occurred. The note documented Resident #66 had asked how she had been injured. Per the note, Resident #66's skin tear was cleansed and covered with gauze. Record review of the facility's incident report #1233 dated 2/9/2024 revealed Resident #57's family member called the facility and reported Resident #57 was sliding out of bed. The report documented two nurses entered her room and found her on the floor, sitting on the fall mat, with her left side leaning against the bed. Per the report, Resident #57 was unable to provide an explanation of what occurred. The Report revealed she was transferred back to bed, the nurses conducted a head-to-toe assessment, an no injuries or pain was noted. The Admin was notified on 2/10/2024 at 9:57 AM, the Immediate Jeopardy was removed. While the IJ was removed on 2/10/24, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing education to facility staff.

Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent accidents for 1 (Resident #18) of 6 residents reviewed for accidents hazards/supervision. The facility failed to prevent Resident #18 from eloping from the facility without the staff's knowledge despite the resident wearing a wander guard. The facility failed to ensure the facility exit doors were secured/locked to prevent resident elopement. An Immediate Jeopardy was identified on 02/08/24. The Immediate Jeopardy was lowered on 02/11/24; however, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents at risk of serious injuries due to lack of supervision. Findings include: Record review of Resident #18's face sheet dated 2/8/24 revealed a [AGE] year-old man admitted on [DATE]. The face sheet documented his diagnoses included encephalopathy (medical term used to describe a disease that affects brain structure or function. It causes altered mental state and confusion), psychotic disorder (are severe mental disorders that cause abnormal thinking and perceptions) with delusions (fixed, false conviction in something that is not real or shared by other people), cerebral infarction (stroke), history of falling, unspecified lack of coordination, aphasia(an impairment of language, affecting the production or comprehension of speech and the ability to read or write), insomnia (inability to fall and/or stay asleep), recurrent depressive disorders (mental disorder characterized by sustained depression of mood, anhedonia, sleep and appetite disturbances, and feelings of worthlessness, guilt, and hopelessness), anxiety (group of mental illnesses that cause constant fear and worry), ataxic gait (clumsy, staggering movements with a wide-based gait), difficulty in walking, paranoid schizophrenia (mental disorder in which people interpret reality abnormally), and convulsions (a type of seizure consisting of a series of involuntary contractions of the voluntary muscles). Record review of Resident #18's case notes revealed that the resident resided with a family member in the same room. On 1/29/24 he was transferred to a different room due to a Covid positive test which was one room away from the facility exit door. Record review of Resident #18's quarterly MDS dated [DATE] revealed a BIMS score of 4 indicating a severe cognitive impairment. The MDS documented he had no potential indicators of psychosis, behaviors affecting others, rejection of care, or wandering behaviors. Per the MDS, Resident #18 had an impairment to one side of his upper and lower extremities, and he used a wheelchair for mobility. The MDS revealed he was administered antipsychotic and antidepressant medications. The MDS documented he received OT services. Record review of Resident #18's care plan dated 2/6/24 revealed a focus on his history of falls with interventions including the use of assistance bars, placing his bed in the lowest position, ensuring fall mats were in place, medication review, use of a scoop mattress, and ensuring the call light was in place. The care plan documented a focus on his behavior plans with interventions including intervention as needed to ensure his and other residents' safety and rights were protected. The care plan included a focus on Resident #18's wander guard elopement device with interventions including frequently monitoring his location, attempts to divert his behaviors, and provision of structured activities. The care plan revealed a focus on his actual falls with interventions including fall cause determinations, education, ensuring the bed was in a low position, and ensuring the room was free of clutter. The care plan documented a focus on his communication problem with interventions including allowing adequate time to respond, referral to speech therapy, and repeating his responses. The care plan included a focus on Resident #18's elopement risk with interventions including fall risk assessment, distraction, provision of structured activities, use of a wander guard elopement reducing device, and completing rounds to ensure his presence. The care plan revealed a focus on his impaired cognitive impairment with interventions including medication administration, use of yes/no questions, cuing and reorienting, and provision of a consistent routine. The care plan revealed a focus on Resident #18's history of seizures with interventions including monitoring for seizures, padded side rails if needed, remaining with the resident during a seizure, and following the facility's seizure protocol. Record review of Resident #18's LVN X's note dated 2/6/24 at 1:30 AM revealed he had left the facility through the back door and was returned to the facility by law enforcement. The note documented that the officer reported Resident #18 was found across the street from the facility. Per the note, Resident #18 reported he had been looking for a man he knew, had left the facility with ketchup to eat, and had left the facility in a jacket and shoes with a blanket. Record review of resident #18's elopement assessments found in the Electronic Health Record (EHR) revealed assessments were completed on 1/7/21, 3/16/22, 4/24/22, 6/14/22, 8/16/22, 11/16/22, 1/26/23, 4/26/23. 7/1/23, 12/15/23, and 2/6/23. All the assessments reported Resident #18 had risk of elopement with the 6/14/22, 8/16/22, 11/16/22, 4/26/23, 7/1/23, 12/15/23, and 2/6/24 indicating he was at a high risk of elopement. Record review of Resident #18's February TAR dated 2/8/24 revealed an order to assess his wander guard for placement and function every shift. The TAR documented this was done every morning shift from 2/1/24 through 2/8/24, and on the night shift on 2/1/24, 2/2/24, 2/4/24, 2/5/24, 2/6/24, and 2/7/24. Per the TAR, Resident #18's wander guard was assessed on 2/5/24 during the night shift by LVN J. Observation and interview on 2/6/24 at 9:10 am, there were no staff in front of Resident #18's door. There was one staff member assisting other residents with their breakfast trays. Resident #18 was lying in bed, he said he did not think he had covid. Observation and interview on 2/7/24 at 12:20 pm, the Receptionist was sitting in the hallway in front of Resident #18's room. She said she was assigned to sit outside Resident #18's room for the day. She said Resident #18 eloped but was not sure what day that happened. Interview on 2/7/24 at 1:22 pm with Resident #18's family member, he said he got a phone call from the facility at 1:06 am on 2/6/24. The facility informed him Resident #18 eloped from the facility and police brought him back. The family said he did not think the facility was doing anything to keep Resident #18 from escaping the facility. The family said the codes for the front door to get in and out of the facility have not changed in years. The family member said the facility wanted to move Resident #18 to a secure unit. The family member would like Resident #18 to stay because his current roommate is a family member. Interview with the DON on 2/7/24 at 1:45 pm, she said Resident #18 was supposed to be on 1:1 monitoring until Resident #18 can be transferred to a secure unit. She said they did not have enough staff to watch him, so she had staff conduct hourly checks instead. Interview with LVN J on 2/8/24 at 8:31 am, she said on the evening of 2/5/24 she checked Resident #18's wander guard for placement but not for function. LVN J said she did not check for function because Resident #18 was in bed sleeping. Interview with the Director of Plant Operations on 2/8/24 at 8:52 am, he said the front door is the only door that has an alarm for the wander guard, the rest of the exit doors were delayed egress emergency doors (the exit door had to be pushed for 15 seconds before emergency door opened). Observation and interview on 2/8/24 beginning at 9:00 am revealed the Director of Plant Operations tested the alarm for the exit doors on the 100 hall, 200 hall, 300 hall, and 400 hall. All alarms sounded when he pushed on the doors for 15 seconds and opened them. The Director of Plant Operations said once the exit door has been opened, staff must reset the alarm on the keypad by the door, the light on the keypad will turn green when the alarm has been set. The Director of Plant Operations was responsible for ensuring the exit doors were secured. Observation on 2/8/24 at 10:14 am, Resident #18 was in the hallway of the Covid unit, he was trying to get staff's attention because he wanted something to drink, he said his throat was hurting. CNA V was at the end of the hallway moving boxes in a room. CNA U was in a room helping a resident, she shouted at CNA V to make sure Resident #18 was in his room. CNA V approached Resident #18 and told him to go back into his room. Observation a nd interview with Resident #18 on 2/8/24 at 10:16 am, Resident #18 pulled down his sock on his left ankle and revealed a wander guard. Resident #18 said he remembered leaving the facility earlier this week. He said the professor gave him some papers to read for a test. Interview with CNA V on 2/8/24 at 10:19 am, she said she did 1:1 monitoring for Resident #18 on Tuesday morning for her entire shift. CNA V said she did not have any information on Resident #18 when he eloped Tuesday morning. Interview with the Administrator on 2/8/24 at 11:32 am, she said Resident #18 went out the back door in the Covid unit. The Administrator said Resident #18 had a history of eloping. The Administrator said she did not think Resident #18 left the property and she needed to get more details from staff that worked that night. On 02/08/24 at 3:03 p.m., the administrator was informed that an Immediate Jeopardy situation was identified due to the above failures. Interview with CNA U on 2/9/24 at 11:10 am she said Resident #18 was on 1:1 checks as of last night. Resident #18 has moved back to the 400 hall, so this may have changed. She said the wander guard is supposed to be checked for placement every shift and the resident must be brought to the front door to check for function. Interview with CNA C on 2/9/24 11:14 am, she said Resident #18 is now on hourly checks and the wander guard had to be checked for placement and function. Interview with LVN S on 2/9/24 at 11:20 am, she said Resident #18 is on hourly checks. The wander guard should be checked by walking him to the front door and checked for placement. Interview with the DON, on 2/9/24 at 11:25 am she said the facility did not have a system in place to check the wander guard for function when residents were placed in the Covid unit. She said the policy should be updated by the charge nurse and either she or the ADON would verify the policy. She said the risk to the resident would be the resident could be harmed if they eloped. Interview with the ADON on 2/9/24 at 11:30 am, she said Resident #18 was back on the hourly checks, she said the wander guard would have to be checked for placement and to checked for function. She said to check for function she would sure the green light is on. Interview with CNA W on 2/9/24 at 12:25 pm, she said Resident #18 left out the side door of Hall 200, she said the door was unlocked that night and she was not sure why. She was not sure what time he left the building and said they did not notice until it was time to take his medications which was around 11:00 pm. She said the police found him across the street and brought him back. Interview with LVN X on 2/9/24 at 1:49 pm she said on 2/5/24 between 11:15 pm and 11:30 pm she saw Resident #18 sitting in his room in his wheelchair . LVN X said Resident #18 was asking for some more pull ups. LVN said she was finishing up taking vitals with other residents in the 200 hall and then went to a different area to get the pull ups. LVN X said when she came back around 11:50 pm, Resident #18 was not in his room. LVN checked Resident #18's bathroom and he was not in there. LVN said she checked the other resident's rooms in the 200 hallway and could not find him. She then went to the Nurse's station located in the center of the building and asked the other staff members if they had seen Resident #18 walk by and they did not see him. LVN X and other staff proceeded to check all the rooms and the restrooms in the building, then went outside to look for him. LVN X said they checked inside and outside the building at least 3 times and then decided to call the police. By the time they got back in the building to call the police, a police officer from the local police department escorted Resident #18 back into the building. LVN X said the police officer found Resident #18 across the street in the hospital parking lot. LVN X said a police report was not filed and she did not get the policeman's name. LVN X said she did not hear a door alarm go off when Resident #18 left the building. LVN X said she went back to check the exit doors for the 200 hallway, and she said the alarms went off when she pushed on the back exit door and the side exit door. LVN X said if staff use any of the exit doors located in the resident hallways, they need to type in a code to exit and enter the building. LVN X said she did not think that Resident #18 knew the code to exit the building. The facility's Plan of Removal was accepted on 02/09/24 at 5:38 p.m., and included: Action: o Conducted audit of all residents who are an elopement risk to ensure appropriate interventions are in place: Completed on 2/9/2024 by DCO. Intervention in place o Reviewed procedure for moving residents to the COVID hall by Admin and DON 2/9/2024 to include identifying placement for residents that are high risk for elopement. o No exit codes are posted next to the exit doors. Confirmed with State Investigator and she removed that statement from her report. Completed on 2/8/2024. o All staff were in-serviced on elopement policy to include checking of wander guard system, interventions to prevent elopement and checking security of emergency exit doors by DCO 2/9/2024 Elopement drills initiated for all staff. Scenario used of a missing resident at the facility by DCO 2/8/2024. o Elopement binder updated completed on 2/8/2024 o All wander guards were checked and working properly 2/6/2024, 2/7/2024 and 2/8/2024 o All exit doors were checked and were working properly 2/6/2024, 2/7/2024 and 2/8/2024 o Head to toe assessment completed on Resident #18 no injuries or adverse effects noted from elopement incident. 2/6/2024 o Reviewed resident care plans. 2/9/24 o Resident remains on one on one until discharged to a secure unit 2/6/2024. o Maintenance Director and/or designee to complete Daily Monitoring of exit doors and wander guard system started on 2/8/2024 o Nursing and/or designee will test wander guard device q shift to ensure that they are properly alarming started on 2/8/2024. o The Medical Director has been notified of the Elopement and reviewed current policy and procedures to keep residents safe from Elopement. Plan of action reviewed with Medical Director with no changes to the current policy. This practice will be reviewed monthly with the QA committee to ensure we are in compliance with Elopement Policy and Procedures completed on 2/8/2024. o All new hires will be trained on Elopement policy and procedure prior to working shift. Started on 2/8/2024. Start Date: 2/8/2024. Completion Date: 2/9/2024 Responsible: EDO and DCO On 02/10/24 and 02/11/24, the surveyor confirmed the plan of removal had been implemented sufficiently to remove the Immediate Jeopardy by: Observation on 2/10/2024 at 9:03 AM of Resident #18 revealed there was no staff in Resident 18's room or outside his door. Staff was observed entering his room to pick up the breakfast trays for him and his roommate. The staff member brought the breakfast trays from the room and exited to other rooms on the hall. Interview on 2/10/2024 at 9:04 AM with LVN S, she said Resident 18 should have a CNA assigned as a one-to-one monitor. LVN S said Resident #18 had a one-to-one monitor during the night shift and a new monitor was assigned that morning. LVN S said the monitor was not in the room. LVN S said the monitor may have gone to the restroom. LVN S said if the monitor had gone to the restroom, she should have informed other staff to ensure continuous coverage for the one-to-one monitoring for Resident #18. LVN S said Resident #18 did not have one-to-one coverage at that moment. LVN S moved to stand in Resident #18's room to provide one-to-one coverage. Interview on 2/10/24 at 9:06 AM with the DON, she said she was aware there was not one-to-one monitoring occurring for Resident #18 at that time. The DON said she had called the monitor's supervisor to locate the monitor. The DON said if the monitor had gone to the restroom, she should have informed other staff to ensure Resident #18 always remained on one-to-one monitoring. The DON said because Resident #18 did not have one-to-one coverage for any amount of time he could have eloped from the facility again. The DON said the staff assigned to provide Resident #18 one-to-one monitoring knew she was assigned to provide him with that monitoring. Record review of Resident #18's Nurse's note dated 2/10/2024 at 9:52 AM revealed he had stayed in his bed for most of the night shift and an elopement monitor was positioned bedside. The note documented Resident #18 would remain on one-to-one elopement monitoring. Record review of Resident #18's Nurse's note dated 2/10/2024 at 10:10 AM revealed he had been in bed and in his wheelchair in his room. The note documented he remained on one-to-one elopement monitoring. Record review of Resident #18's Nurse's note dated 2/9/2024 at 10:59 PM revealed he returned to his original room as he had completed his COVID isolation. The note documented he was on one-to-one elopement monitoring. Observation on 2/10/2024 at 12:31 PM revealed two staff were in Resident #18's room. One staff was standing near the door and the other was seated near his bed. Record review of the facility's elopement binder on 2/10/24 at 12:40 pm revealed it contained information for a total of six residents. The binder included the name, age, sex, weight, race, hair color, eye color, identifying marks or tattoos, mobility devices utilized, physical impairments, language, diagnoses, behavior concerns, and a list of known friends and relatives. The binder contained an area for completion if a resident was determined to be missing with information including the time the resident was discovered missing, the last known location of the resident, a description of the resident's clothing at the time she/he went missing, and medications. The binder included the face sheet for each resident, with a photograph, on the reverse of the missing resident profile. The binder included the information for Resident #'s 18, 25, 45, 53, 66, and 68. Record review of in-service dated 2/8/24 conducted by the DON was about Elopement and Elopement Drill. Record review of in-service dated 2/10/24 conducted by the DON was about one-on-one sitter. Record review of the wander guard daily testing log for February 2024 revealed daily testing on 2/1/24, 2/2/24, 2/3/24, 2/4/24, 2/5/24, 2/6/24, 2/7/24, 2/8/24, 2/9/24, and 2/10/24. Record review of the Elopement Policy dated 11/01/19 read in part .check all offices and any locked doors to ensure none were left unlocked . Interview with LVN K on 2/11/24 at 11:14 AM she said she was in-serviced on restraints and elopement with missing resident drill. Interview with LVN S on 2/11/24 at 11:23 am she said she was in-serviced on resident rights and elopement. She said she was not supposed to put a resident who was at risk of elopement next to exit door. Interview with MA M on 2/11/24 at 11:43 PM she said she was in-serviced on abuse and neglect, pain, medication, and elopement. Interview with MA H on 2/11/24 at 11:50 PM she said she was in-serviced on pain management and medication, abuse and neglect, elopement. She said when you arrived for your shift, conduct a walk around to make sure all residents are accounted for. She said if a resident was missing, the nurse needed to be notified and the facility needed to be checked. If the resident was not found inside the facility, expand the search outside. She said staff needed to work together to search different areas to find the resident as quickly as possible and adhere to timeline to notify family, doctor, and state. Interview on 2/11/24 at 1:26pm with HK AA, she said 1 on 1 supervision meant that the resident must be supervised 24 hours a day. She said that she was in-serviced on elopement and sitting. She said that she understood if she was monitoring a resident and needed to step away, then she should call someone else to supervise until she returned. The Admin was notified on 2/11/2024 at 1:28 pm, the Immediate Jeopardy was removed. While the IJ was lowered on 2/11/24, 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 that is not immediate jeopardy due to the facility continuing education to facility staff.

Based on interview and record review, the facility failed to implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care for 1 of 10 residents (Resident #129) reviewed for care plans, in that: -A baseline care plan was not completed for Resident #129 within 48 hours of admission. This failure could affect all newly admitted residents to the facility by placing them at risk of not receiving the care and services for health promotion and continuity of care. Findings included: Resident #129 Record review of Resident #129's Admission Record revealed he was a [AGE] year-old male who admitted to the facility on [DATE]. His diagnoses included: metabolic encephalopathy (problem in the brain caused by chemical imbalance in the blood), type 2 diabetes mellitus (the body's impaired used of blood sugar), stroke (impaired blood flow to the brain), chronic gout (a painful condition in which uric acid builds in the blood and causes inflammation in the joints). No MDS to review [new admit]. No baseline or comprehensive care plan to review. Interview on 2/7/24 at 1:02 PM with MDS LVN. She said the purpose of the baseline care plan was to provide guidance on how to care for resident until the comprehensive care plan was completed. She said the baseline care plan ensures the resident receives continuity of care, so they can be as happy and comfortable as they can while transitioning into the facility. She said the admitting nurse should complete the baseline care plan and an RN would sign off on it. She said the baseline care plan should be completed withing 48 hours of admission. She said failure to complete a baseline care plan could mean disruption in the resident's routines and the resident may not get the necessary care. Record review and interview with the DON on 2/7/ 2024 at 1:25 PM of Resident #129's Admission Baseline care plan dated 2/4/2024, revealed that all areas were highlighted yellow, did not have any signatures, dates, and no data to print. The DON said this meant the baseline care plan was not completed. She said failure to complete the baseline care plan could mean the resident may not receive the care they should receive. Interview on 2/8/24 at 9:50 AM with the Administrator. She said the purpose of the baseline care plan was to get an understanding of resident's goals at admission and provides baseline instruction on how to care for the resident. She said here expectation was for nurses to complete the baseline care plan within 48 hours of admission. She said failure to do so can result in improper care of the resident. Record review of the facility's policy titled Resident Assessment: Baseline Care plan dated 11/01/2019 revealed in part: A baseline care plan is required to be completed within 48 hours of admission. The baseline care plan must include: o Initial goals based on admission orders o Physician Orders o Dietary Orders o Therapy Services o Social Services o PASARR (if applicable) The facility must provide the resident and their representative with a summary of the baseline care plan to include as a minimum: o Resident's initial goals o A summary of medications and dietary instructions o Any services and treatments administered by the facility and personnel acting on behalf of the facility such as therapy or psych services. o Information to properly care for the resident upon admission. o Address specific health and safety concerns The BPOC will be amended with any changes in care needs and those changes will be communicated to the resident and/or the resident's representative and noted on the BPOC and in the clinical record. The BPOC will continue until the comprehensive plan of care is completed. The comprehensive plan needs to reflect on pervious goals. When the BPOC is no longer needed, it will be scanned into PCC . Include discharge plan as voiced by resident or representative.

Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan consistent with the resident rights and that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and failed to describe services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required for 1 of 12 residents (Resident #57) reviewed for care plans. -The facility failed to document the care plan with the use of Resident #57's scoop mattress usage. This failure could place residents at risk of attaining/maintaining their highest practicable physical, mental, and psychosocial well-being. Findings included: Record review of Resident #57's face sheet dated 2/9/2024 revealed a [AGE] year-old woman admitted on [DATE]. The face sheet documented her diagnoses included encephalopathy ( medical term used to describe a disease that affects brain structure or function), cirrhosis of the liver (degenerative disease of the liver resulting in scarring and liver failure), cerebral infarction (stroke), Parkinson's Disease (brain condition that causes problems with movement, mental health, sleep, pain and other health issues), hypertension (high blood pressure), aphasia (comprehension and communication including reading, speaking, and/or writing disorder resulting from damage or injury to the specific area in the brain), dysarthria (difficulty in speech due to weakness of speech muscles), muscle weakness, difficulty walking, lack of coordination, cognitive communication deficit, and a displaced avulsion fracture of the left hip. Record review of Resident #57's admission MDS dated [DATE] with an ARD of 1/1/2024 revealed a BIMS score of 99 indicating she was unable to complete the interview. The BIMS documented she had both long and short-term memory problems, and could not recall the current season, the location of her room, staff names or faces, or that she was in a nursing home bed. Per the MDS, Resident #57 had no potential indicators of psychosis, behaviors affecting others, rejection of care, or wandering behaviors. The MDS documented Resident #57 she required assistance with bathing, dressing, and toileting prior to her admission. Per the MDS, Resident #57 required she had an impairment to one side of her upper and lower extremities, and she required a cane and or crutch to ambulate. The MDS revealed she was dependent on staff for all ADL's. The MDS documented she had not received OT services, but she was scheduled to begin them on 1/1/2024. Per the MDS, the facility had utilized no restraints or alarms for Resident #57's care. Record review of Resident #57's care plan dated 1/3/2024 revealed a focus on her actual falls on 1/15/2024 and 1/18/2024 with interventions including a fall mat, monitoring for changes in mental status, and neurological assessments after a fall for seventy-two hours. The care plan documented a focus on her impaired cognitive function with interventions including medication administration, use of yes/no questions, cuing and reorienting, and monitoring for any changes in cognitive function. The care plan included a focus on Resident #57's ADL self-care deficit with interventions including her dependence on staff for all ADL care and an OT/PT evaluation and treatment as ordered. The care plan revealed a focus on her potential for impaired mobility, communication, and cognition with interventions including medication administration, monitoring for side effects of medications, and monitoring for tremors, rigidity, and limited range of motion. The care plan did not include any focus or intervention related to a scoop mattress or any other restraint devices. Record review of Resident #57's care plan dated 1/3/2024, observed on 2/9/2024 at 11:12 AM, revealed a focus on her actual falls with interventions including use of fall mats, monitoring for changes in mental status, neurological assessments after a fall for seventy-two hours following a fall, and the use of a scoop style mattress. Record review of resident #57's nurse's note dated 1/7/2024 revealed she was found sliding from the bed to the ground. The note documented the fall mats were in place and the bed was in its lowest position. Per the note, Resident #57 sustained no injuries. The note documented the staff should ensure her fall mats were in place at all times. Record review of Resident #57's incident note dated 1/18/2024 revealed a CNA had found her on the floor and informed the nurse. The note documented she was found lying face down on the fall mat. Per the note, Resident #57 was transferred back to her bed, no injuries were observed, and her vital signs were within normal limits. The note revealed her bed was in the lowest position and the fall mats were in place. Record review of Resident #57's nurse's note dated 1/22/2024 revealed she had rolled out of her bed onto the fall mat. The note documented she sustained no injuries. Per the note, Resident #57's family member believed she may have had a seizure and fallen from the bed. The note revealed her vital signs were within normal limits. Record review of Resident #57's nurse's note dated 1/30/2024 revealed she had been found on the floor. The note documented she was lying on the floor on the fall mat. Per the note, Resident #57 had no injuries and her vital signs were obtained. Record review of Resident #57's nurse's note dated 2/1/2024 revealed the facility was informed by the resident's family member that she was seen on the floor via video monitoring. The note documented she was found on her right side on the fall mat. Per the note, Resident #57 did not sustain any injuries. Record review of Resident #57's incident note dated 2/6/2024 revealed she was found on the fall mat sitting. Per the note, she sustained no injuries. Record review of the facility's Electronic Health Record (EHR) dated 2/9/2024 revealed the facility had completed Morse Fall Scale assessments on Resident #57 on 12/30/2023, 1/11/2024, 1/15/2024, 1/18/2024, 1/30/2024, 2/1/2024, and 2/6/2024. The EHR documented all the assessments rated Resident #57 as having a high risk of falling except for the assessment completed 12/30/2023 which indicated a low risk of falling. Record review of Resident #57's Morse Fall Scale assessment dated [DATE] revealed a score of 55 indicating a high risk of falling. The assessment documented she had a history of falls, she did not ambulate, she was either on bedrest or used a wheelchair, and forgot her limits in ambulation. Observation on 2/9/2024 at 10:29 AM of Resident #57 revealed she was lying in her bed with her head elevated. Resident #57 was utilizing a G-Tube for nutrition. Resident #57's bed was in a low position and fall mats were placed on both sides of the bed. Resident #57 was lying on a scoop style air mattress. Observation on 2/9/2024 at 10:46 AM of Resident #57 revealed she was in a sitting position on the bed with her feet off the mattress near the fall mat. The ADON was informed immediately and intervened returning Resident #57 to bed. Interview on 2/9/2024 at 10:47 AM with the ADON, she said she did not know how long Resident #57 had been in a scoop mattress. The ADON said the scoop mattress was used to prevent a resident from falling from the bed or minimize the likelihood of falls. The ADON said a physician's order was not necessary for a scoop mattress. The ADON said a resident's use of a scoop mattress should be addressed in his/her care plan. Interview on 2/9/2024 at 11:00 AM with the MDS LVN, she said either she as the regional MDS coordinator or the facility's MDS coordinator was responsible for ensuring care plans were up to date. The MDS LVN said a resident who utilized a scoop mattress should have an intervention for falls noting the use of the scoop mattress. The MDS LVN said Resident #57 did not have an intervention related to falls indicating the use of a scoop mattress on her care plan. The MDS LVN said she would add that intervention to the care plan at that time. The MDS LVN said a scoop mattress was typically not utilized for a resident until other interventions such as fall mats and/or lowered bed position had been utilized. The MDS LVN said the care plan should be updated so all staff are aware of the interventions needed for a resident's care. The MDS LVN said if a resident's care plan was not updated regarding the use of a scoop mattress, if a resident was put to bed and the scoop mattress was not present the staff may not know to obtain a scoop mattress prior to assisting the resident into bed. Interview on 2/9/2024 at 11:28 AM with LVN S, she said she had been employed for almost two years. LVN S said her primary duties included obtaining resident blood glucose levels, obtaining vital signs, tracheostomy care, calling physicians and families, and documentation. LVN S said she was unsure how long Resident #57 had been using a scoop mattress. LVN S said Resident #57 was initially admitted to another hall but was moved to her hall recently. LVN S said she believed that Resident #57 had not had a scoop mattress when her room was on the other hall. LVN S said if a resident used a scoop mattress, that information should be found in the resident's care plan. Interview on 2/9/2024 at 11:34 AM with PTA N, he said he did not know how long Resident #57 had been utilizing a scoop mattress. Interview on 2/10/2024 at 9:06 AM with the DON, she said she was unsure how long Resident #57 had been using a scoop mattress. The DON said a resident who utilized a scoop mattress should have a care plan related to that use. The DON said a care plan provided specific instruction on care required for a specific resident. The DON said the care plan provides specified information related to a resident's diet, care services, and interventions. The DON said if Resident #57 did not have a care plan with an intervention related to her scoop mattress use, the care provided to her would not match the care called for in the care plan. Record review of the facility's Resident Assessment policy dated 1/20/2021 revealed a policy statement which read in part .completing and conducting Comprehensive Care Plan Meeting and Reviews by day 21 after Admission. The Care Plan is revised every quarter, significant change of condition, Annual or as the resident condition changes on an individualized basis. The Care Plan process is an ongoing review process. The resident's Care Plan will include participation from residents' representatives, external partners PASRR, Hospice, Therapy, Clinicians . The policy documented the care plan would be completed within twenty-one days of admission with the input of the IDT. Per the policy, the care plan would meet the residents' immediate care needs including fall prevention needs.

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 2 of 10 residents (Resident #3 and Resident #4) reviewed for pressure ulcers. The facility failed to ensure Resident #4 had a low loss air mattress after he was readmitted to the facility resulting in the development and/or worsening of multiple PU's. The treatment nurse failed to properly document the progression of a new FA St III right buttock PU and the progression of a FA unstageable sacral DTI on the weekly PU report and weekly skin assessments for Resident #4. The facility failed to ensure Resident #4's wound dressings were properly labeled with the date and initials. The facility failed to ensure Resident #3 wore heel protectors as ordered by his physician. These failures could affect residents with pressure ulcers and placed them at risk of wound deterioration, decline in health or possible hospitalization . Findings include: Resident #4 Record review of Resident #4's face sheet revealed, a [AGE] year-old-male originally admitted on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #4's Comprehensive MDS dated [DATE] revealed documentation in the section for Skin Condition showing 2 stage IV PUs, 1 unstageable PU, and 1 venous ulcer. There was no documentation of a St III PU. The Section for Skin and Ulcer/Injury Treatment documentation showing; A. Pressure reducing device for bed was checked. Record review of Resident #4's Skin/Wound progress notes dated 4/24/20 read in part, .Writer stated resident has wounds to bilateral heels, left hip, and should, s/t to right forearm, dry exudate to left anterior leg and redness to sacrum . Record review of Resident #4's Care plan dated 04/29/20 read in part, Focus: The resident has (Stage 4) pressure injury (Right Heel) r/t immobility 4/23/2020 N/O Santyl and Calcium Alginate Date, Goal: The resident Pressure Ulcer will show signs of healing and remain free from infection by/through review date, Interventions: .Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate . Record review of Resident #4's physician orders [REDACTED]. Record review of Resident #4's physician orders [REDACTED]. Record review of Resident #4's Weekly Wound assessment dated [DATE] revealed a new facility acquired St III right buttock PU measuring 3 x 2 x 0.1cm, with a pink, red and yellow wound bed, moderate bloody drainage, with the surrounding skin macerated and red. On the Interventions section of the assessment, Low air loss mattress and pillows for positioning/off-loading was checked. Further record review of Resident #4's Weekly Wound Assessments dated May and June 2020 revealed no further documentation of the progression of the St III Right buttock PU and no documentation of an unstageable sacral PU. Record review of Resident #4's physician orders [REDACTED]. Record review of Resident #4's physician orders [REDACTED]. Record review of the facility's weekly Pressure Injury QAPI Log dated 05/28/20 revealed, Resident #4's facility acquired a St IV Lt Heel PU measuring 6 x 7 x 0.2cm identified on 3/26/20, a facility acquired St IV Rt Heel PU measuring 5 x 7 x 0.3cm identified on 4/11/20, and an unstageable Lt Hip PU identified on 4/22/20 present on admission measuring 6 x 4 x UTD cm. There was no documentation of a FA St III right buttock PU or FA unstageable sacral DTI PU on the report. Record review of Resident #4's physician orders [REDACTED]. Record review of the facility's weekly Pressure Injury QAPI Log dated 06/04/20 revealed, no further documentation of a St III right buttock PU or unstageable sacral wound on the report. Record review of Resident #4's Skin/Wound progress notes for the months of 5/26/20 through 06/03/20 revealed, no documentation of a new FA St III right buttock PU identified on 5/23. There was no documentation of wound care completed, measurements, or wound progression until surveyor intervention on 6/09. Further record review of Resident #4's Skin/Wound progress notes dated 6/9/20 revealed, documentation stating the sacral wound was improving. There was no further documentation showing sacral wound measurements, wound care treatment completed, or the development of an unstageable sacral DTI identified on 5/23/20. Record review of Resident #4's Care plan revealed it was not updated to address his St III Right buttock PU, Sacral DTI, and Left hip unstageable PU. Record review of Resident #4's physician orders [REDACTED]. Observation and interview on 6/09/20 at 9:51am of wound care on Resident #4 with the Wound nurse, she stated she would be completing wound care on the residents' left heel, right heel, left hip, and sacrum. When asked what stage the sacral PU wound was, she stated it was unstageable, further stating it was a DTI and the resident had a Foley catheter to allow the sacral wound to heal. She further stated the resident had steri strips to his left arm and orders are to monitor. When asked if the resident was lying on a low loss air mattress, she stated no, further stating he is supposed to be on an air mattress. She said all mattresses at the facility are pressure relieving mattresses, but the resident was recently placed on hospice, further stating the hospice nurse saw the resident on Friday and she requested the low loss air mattress, but she was not sure what happened. Further wound care observation and interview on 6/09/20 at 9:51 am with Resident #4 and the Wound nurse, the resident had a total of six steri strips on his left upper and lower arm, [MEDICATION NAME] dressing to his bilateral heels with his heels off-loaded using pillow support, a dressing to his right buttock, left hip/ischium, and left lateral lower extremity. The Wound nurse completed wound care on the left ischium first. He was repositioned to the right side to complete wound care to the left hip. The old dressing was removed, the dressing was not initialed or dated. The Wound nurse stated whoever completed wound care should have labeled the dressing with the date and his/her initials. The left hip PU measure approximately 4.9 x 4.6 x 0.7cm. The resident was repositioned supine and wound care was completed on the St IV right heel PU, it measured approximately 6 x 7 x 0.1cm. She stated the wound deteriorated, further stating the wound was clean before, but it changed because it now has necrotic tissue which wasn't there before. She then completed wound care to the St IV left heel PU. The wound measured approximately 6 x 7 x 0.1cm with yellow slough in the wound bed and a small amount of red drainage and necrotic tissue. Further wound care observation and interview on 6/09/20 at 9:51 am with Resident #4 and the Wound nurse revealed, wound care was completed to the residents vascular wound on the left LE, the resident was repositioned to his left side to complete wound care to the right buttock. The Wound nurse stated the right buttock wound had deteriorated further stating it was because the resident doesn't eat a lot or get out of bed. She stated the wound had a new area of necrotic tissue. The wound measured approximately 5.1 x 3.7 x UTD cm. When asked how often the Wound MD was seeing the resident, she stated the Wound MD had not been to the facility for the last two weeks because he was waiting to be tested for COVID. When asked who was performing wound measurements if the wound MD was not entering the facility, she stated she does the measurements. Further interview and observation of wound care on 6/09/20 at 9:51 am with Resident #4 with the Wound nurse: the sacral wound care was completed last. The sacral wound measured approximately 9.6 x 5.3 x 0.1cm and had multiple areas of redness and excoriations on the surrounding skin primarily to the right and left buttock. The redness extended to the back of the residents' upper thigh area. Interview on 6/09/20 at 10:50 am with the Wound nurse, when asked how wound measurements and wound progression was communicated to the Wound MD if he was not entering the facility, she stated after completing wound care and measurements she contacts the residents' PCP to inform him of the wound changes and if the wound deteriorated. She said he would give her new wound care orders at that time. She stated the PCP and wound MD were contacted either by phone or via tele medicine if the wound deteriorates. When asked when the last time was the Wound MD saw Resident #4's wounds, she stated his last visit was on 5/07/20. She said right now the PCP was doing all wound orders and the Wound MD was updated via telephone and would agree or disagree with the PCPs orders. Interview on 6/12/20 at 10:43am with the Wound MD, when asked if the facility was contacting him regarding Resident #4's wounds and their progression, he said he could not see the resident physically, stating the resident was dying and on Hospice. He said the resident was dying but not actively dying and that was why the resident had those wounds. He said he relied on the facility to send pictures or to do some type of tele medicine stating he could not enter the facility and do rounds because he did not have his COVID test results. He said there was a gap of about 3-4 weeks and that he did not receive any information because there may have been issues at the facility related to COVID or staffing. He stated he would tell the facility if something changes don't wait until he does rounds on the day his is scheduled to come out, further stating he wants to know right away about the changes so it can be addressed before he comes out. He further stated if he needed to come out another day he would do so. Further interview on 6/12/20 at 10:43am with the Wound MD, when asked if there was another Wound MD who could have come out to manage Resident #4's wounds, he stated there were other physicians in the group, but they wanted to stick with the facility's they were already going to prevent or try to limit possible spread and cross infection. When asked if a low loss air mattress would have helped to prevent the development and/or deterioration of Resident #4's wounds, he stated it would have helped, but the biggest issue was the resident had severe [MEDICAL CONDITION] from the waist down which contributed to his wounds developing. He stated they were determining if they wanted to refer him to a specialist or stop escalation of care. He again stated the mattress would have been better than nothing. Interview on 6/09/20 at 11:04am with LVN #3, when asked what the facility's policy was regarding the use of a low loss air mattress, she stated a resident must have multiple St II PUs or a St III or higher to get an air mattress. She stated the wounds can be anywhere on the residents' body to have a low loss air mattress. Further interview on 6/09/20 at 11:04am with LVN #3, when asked what the facility's policy was regarding labeling wound dressing, she stated the dressing should have the date and initials of the nurse who completed the dressing change. Interview on 6/09/20 at 1:30 pm with the DON, when asked if Resident #4 should have been on a low loss air mattress when he had multiple St IV PUs, a St III PU right buttock PU, and an unstageable sacral PU, she stated the resident was in and out of the hospital and it did not happen because he needed an order in the system. The surveyor informed the DON, there was an order placed on 6/8, but the resident was readmitted to the facility on ,[DATE] and has not had the low loss air mattress since being readmitted . When asked if he was previously on a low loss air mattress prior to his most recent hospitalization , she stated the resident was on a low loss air mattress, further stating she had the receipt of the delivery of the air mattress. Interview on 6/09/20 at 2:29 pm with the DON, when asked why the St III right buttock PU and unstageable sacral PU were not documented on the weekly PU reports and weekly wound assessments, she stated it was a lack of communication between the weekend treatment nurse and the Wound nurse. When informed the Wound nurse is currently performing wound treatments on both wounds, but there still is no documentation showing the wound measurements or progression, she stated it should have been documented on the reports. She stated the treatment was being done because it was documented on the TAR, it just was not documented on the reports. Interview on 6/09/20 at 3:12 pm with the DON, she stated Resident #4 was previously on a low loss air mattress on 4/30 through 5/8, stating he was transferred to the hospital on 5/8. She further stated he should have had an air mattress when he was readmitted to the facility. Interview on 6/09/20 at 3:55 pm with the Wound nurse, when asked where she documented wound care and wound progression, she stated it was documented on the weekly PU report, weekly wound assessments and in the skin/wound care progress notes. When asked why the St III right buttock PU and the unstageable sacral wounds were not documented on the weekly PU reports or skin assessments for dates of 5/28/20, and 6/04/20, she stated she forgot to document the wounds. Further interview on 6/09/20 at 3:55pm with the Wound nurse, when asked if Resident #4 was on a low loss air mattress prior to his most recent hospitalization she stated yes, at some point he was on the air mattress and he should have been on the air mattress when he was readmitted . Interview on 6/12/20 at 8:52am with the Wound nurse, she stated she was trying to fix a broken system in which treatments were not consistently being done. She stated she would come in on weekends to do wound care if the weekend treatment nurse did not come in, further stating if the treatments were not done, then all her work would be undone. She stated has had to do multiple in-services on floating heels ADL care, and refusals. She stated the Wound MD has since seen Resident #4, further stating his St IV PU were reclassified to arterial wounds and that he now has additional wounds. Further interview on 6/12/20 at 8:52am with the Wound nurse, she stated she had Resident #4's St III right buttock wound and sacral DTI were not on the weekly PU report because she had them on her f drive and it did not carry over to the weekly PU report for 5/28/20 or 6/4/20. She stated she creates reports on excel then once it is all updated she must update it on the f drive or it won't carry over to the weekly report. When asked how the other wounds made it to the report for those two weeks, and why she previously stated she forgot to document these wounds, she could not state. When the surveyor requested the wound note documentation on the f drive to review, she stated she could not provide the documentation, stating she did not have access to the drive. Record review of the facility's Skin/Wound QI log dated 6/11/20 for Resident #4 revealed, two new PUs, a right hip DTI measuring 5.1 x 3.7 x UTD cm and a St III left ischium PU measuring 2.7 x 2.1 x 0.1cm; a cluster unstageable sacral PU measuring 9.6 cm x 5.3 x 0.1cm, and one improving St IV left hip PU measuring 4.9 x 4.6 x 0.7cm. The right hip DTI, St III left ischium PU, and cluster sacral wounds were not documented on previous Skin/Wound QI showing wound measurements and/or wound progression. Record review of the facility's Non-PU Skin/Wound QI log dated 6/11/20 for Resident #4 revealed, a total of eight Non-pressure wounds. The resident previously had a total of one non-pressure wound documented on the Non-pressure report dated 6/4/20. The resident had three new arterial wounds; a left lateral anterior leg venous wound measuring 2.6 x0.9 x UTD cm, a right lateral leg arterial ulcer measuring 5.1 x 2.7 x 0.1cm, a left medial planter arterial wound measuring 1.2 x 2.2 x UTDcm, and a new dry exudate right dorsal foot arterial wound measuring 1.2 x 1.2 x UTD cm. Further record review of the facility's Non-PU Skin/Wound QI log dated 6/11/20 for Resident #4 revealed, the resident's right heel and left heel PU wounds were reclassed as arterial wounds, the left heel arterial wound measured 6.2 x 7.1 0.2cm, the right heel arterial wound measured 6.1 x 6.2 x 0.3cm, an existing left cluster anterior leg [MEDICAL CONDITION] wound measuring 5.1 x 2.1 x 0.2cm, and a new arterial left great toe wound measuring 3.1 x 1.6 x 0.1cm. Interview on 6/12/20 at 2:26pm with the DON, when asked if the Wound MD was notified of Resident #4's Right Buttock and sacral wound since it was not documented on the weekly PU report, progress notes, or weekly wound report, she stated she could tell exactly when he was notified. She then stated the PCP was notified because there were orders, she could not provide any documentation showing the wound MD was notified. She stated the facility was supposed to do telehealth but for some reasons they could not do it, so the wound nurse just sent a text message. She stated they did not have to notify the Wound MD because he was only a consulting physician and the PCP provided orders for wound care. She stated as far as the documentation of the wounds, yes it should have been documented, we missed it and can only correct what's going on now. She further stated with the low loss air mattress, they just screwed up and it should have been ordered when he was readmitted . Interview on 6/15/20 at 9:29am with the DON, she stated she was not sure where the disconnect was with the wound care documentation, stating that she and the Wound nurse came into a broken system. She stated she thinks because the Wound MD was not making rounds at the facility for two weeks she felt like measurements were not being done. She stated they now have a tele health app, so the Wound MD or PCP can visualize the wounds if they can't come into the facility and the Wound MD has been educated on proper documentation, including measurements. Resident #3 Record review of Resident #3's face sheet revealed he was an [AGE] year old male that was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Record review of Resident #3's Care Plan dated 03/05/20 revealed Resident #3 had a stage 3 pressure injury to right lateral heel. Resident #3 had an arterial injury to left and right heel, and lateral malleolus related to disease process [MEDICAL CONDITION], and immobility. Staff are to administer medications as ordered. Monitor/document for side effects and effectiveness. Administer treatments as ordered and monitor for effectiveness. Follow facility policies/protocols for the prevention/treatment of [REDACTED]. Record review of Resident #3's MDS dated [DATE] revealed Resident #3 had a BIMS of 12, indicating moderate cognitive impairment. Resident #3 had 3 venous and arterial ulcers present. Resident #3 was at risk for developing pressure ulcers/injuries. Record review of Resident #3's Physician order [REDACTED]. Record review of Resident #3's Weekly Wound assessment dated [DATE] revealed Resident #3 had an arterial right heel wound 2.0 x 2.5 x 0.5cm. Record review of Resident #3's Weekly Wound assessment dated [DATE] revealed Resident #3 had an arterial left heel wound 3.0 x 3.0 x 0.6cm. Record review of the facility non-pressure wound list dated 06/04/20 revealed Resident #3 had a facility acquired arterial ulcer to the right lateral heel starting on 01/16/20, 2.0 x 2.5 x 0.2cm with yellow slough. Record review of the facility non-pressure wound list dated 06/04/20 revealed Resident #3 had a facility acquired arterial ulcer to the left heel starting on 02/03/20, 3.5 x 2.0 x 0.3cm with yellow slough. Observation on 06/03/20 at 10:14 AM revealed Resident #3 was sitting in a wheelchair in his bedroom. There was a bandage on his bilateral foot dated 6/2/20. There were no heel protectors on feet, and his heels were resting on the floor. Observation on 06/09/20 at 12:19 PM revealed Resident #3 was sitting in his wheelchair, his bilateral feet were wrapped annd the dressing was dated 6/8/20. Resident's legs were extended and a pillow was under his lower legs, heels resting on black wedge cushion being held up by two trashcans. Observation on 06/09/20 at 12:57 PM revealed Resident #3's heel protectors were in his closet. Observation on 6/09/20 at 2:47 pm of wound care with Resident #3 and the Wound nurse revealed, the resident's heels were off-loaded with pillows, he was wearing heel protectors bilaterally. Both heels were covered with dry [MEDICATION NAME] dressing, dated and initialed. The Wound nurse removed the old [MEDICATION NAME] wrap and dressing to the right lateral heel, the wound measured approximately 2 x 2.5 x 0.2cm, the wound bed had yellow slough, no odor or drainage noted, the surrounding skin was intact. The Site was cleansed with NS, patted dry, calcium alginate applied and covered with a clean dressing/bandage and secured with a dry [MEDICATION NAME] wrap. The Wound nurse removed the [MEDICATION NAME] dressing to the left lateral heel, the wound measured approximately 3.5 x 2 x 0.2cm, the wound bed was covered with yellow slough, no odor, or drainage noted, surrounding skin was intact. The Wound nurse cleansed the site with NS, Dakin's' solution, patted dry, Santyl and calcium alginate applied to wound bed, site covered with a clean dry dressing and secured a dry [MEDICATION NAME] bandage. Observation on 6/12/20 at 8:33 am of Resident #3 revealed, the resident sitting up in bed with a wedge under his legs, he was not wearing his heel protectors. The heel protectors were sitting on a chair in the residents' room. Interview on 6/12/20 at 9:21 am with the Wound nurse, when asked if Resident #3 had an order to keep the heel protectors on during the day and off an HS, should he have the protectors on in the morning, she stated yes. When informed by the surveyor the resident was not wearing the heel protectors as ordered, she stated they were supposed to be on, but if he refused, there should be documentation in the nursing progress notes. When informed there was no documentation showing the resident refused to wear the heel protectors, she stated it should be documented. Record review of Resident #3's nursing progress notes dated 6/12/20 revealed, no documentation showing the resident refused to wear the heel protectors. Record review of the facility's Routine Skin Care policy no date read in part, .7. All stage III & IV pressure ulcers will be placed on a specialty mattress. Record review of the facility's Skin Management System policy no date read in part, .A. Pressure Ulcers, Venous Ulcers and Arterial Ulcers, and surgical sites will be documented on the Weekly Wound Observation. Use one form per wound. Wound progress is to be documented each week with measurements and wound descriptions .2. Routine weekly checks will be completed on the Skin Observation Tool on every resident if skin is intact it will be noted as such. If a new pressure sore is noted, Weekly Wound Observation Form will be started .9. the skin report will be reviewed weekly Standard of Care Meeting. The weekly skin report is housed on your desktop .12. All dressing are to be dated and initialed upon completion .

Based on record review and interview the facility failed to consult with the resident's physician of a significant change in the resident's physical and psychosocial status for 1 of 11 residents (CR #1) reviewed for physician consultation in that: - The facility failed to consult with CR #1's physician when she had increased pain during ADL care. CR #1 was in severe pain for 3 days until she was diagnosed with [REDACTED]. An Immediate Jeopardy (IJ) was identified on 10/04/2019. While the IJ was lowered on 10/06/2019, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated because the facility continued to train staff and monitor the effectiveness of the Plan of Removal. This failure affected 1 former resident and placed her at risk of their physicians not managing their health care needs which could lead to delayed medical treatment, unmanaged pain and decline in health. Findings include: Record review of CR#1's face sheet revealed she was a [AGE] year-old female that was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. CR#1 was discharged from the facility on 09/24/19. Record review of hospital records dated 08/30/19 revealed Examinations: XR hip 2-3 views left XR knee hip 2-3 views left XR knee 3 views left .Impression: 1. The alignment of the left hip and left knee is anatomic without fracture or dislocation. 2. There is moderate bilateral hip joint [MEDICAL CONDITION]. Predominant tricompartmental left knee [MEDICAL CONDITION]. There is no left knee effusion. 3. Dense arterial vascular calcifications are present. Additionally several calcified structures posterior to the knee likely represent renal cysts in the setting of prior trauma . Record review of baseline plan on care, dated 9/5/19, revealed that CR#1 had presence of a dull, achy pain upon admission located on the left knee. No pain scale noted. Record review of CR#1's progress notes dated 9/5/19 revealed that resident was admitted into facility with, ROM to upper extremities. Resident pain level 8/10 (Level 8 on a scale of 1-10) to left leg. Assessed resident abrasion and discoloration below left knee. Discoloration to left hip, redness to sacrum, R knee discolored and scar behind knee. Record review of CR#1's physician orders dated 9/5/19 revealed she was prescribed [MEDICATION NAME] HCl Tablet 50 mg (opioid pain medication), 1 tablet by mouth every 6 hours as needed for Pain. She had no other medications for pain. Record review of physician progress notes [REDACTED]. Here for rehabilitation Extremities: left knee abrasion and [DIAGNOSES REDACTED] .Skin: left knee abrasion Plan Left hip xray negative for fractures. Pain management. Fall precautions Pain Assessment - documented as positive and a follow-up is documented (08/30/2019) Record review of physician progress notes [REDACTED].Patient now complaints of left knee pain at 10/10 on the pain scale . Pain assessment - documented as positive and a follow-up plan is documented (08/30/2019) . Record review of CR#1's Pain Interview (3.0) Assessment, dated 9/10/19, the resident revealed that she had pain in the last 5 days at an occasional frequency that did not limit her day-to day activities. No indicators of pain or possible pain were observed at time of assessment and pain management intervention of [MEDICATION NAME] 50mg 1 tab q 6hrs. was noted as effective. Record review of CR #1's clinical record revealed no other pain interview assessments following 9/10/19 were performed on CR#1. Record review of CR#1's MDS dated [DATE] revealed CR#1 had a BIMS of 9, indicating moderate cognitive impairment. CR#1 required extensive assistance of two people for bed mobility. CR#1 required total assistance of two people for transfers. CR#1 had presence of pain which frequency was documented at 3 meaning Occasionally. CR#1's highest Pain Intensity was documented as a '6' on a scale of 1 to 10 during the 5 day look back period. Record review of CR#1's Care Plan dated 9/12/19 revealed, revealed a focus on CR#1's ADL self-care performance deficit related to activity intolerance, limited mobility and pain, with a goal to improve current level of function in ADL self-care by requiring 1-2 person assist with transfers, showering bed mobility and turning and repositioning. Further record review of CR#1's care plan dated 9/12/19 revealed CR#1 had potential for pain and risk of injury from decreased ADL's due to hip pain, and arthritis. Interventions included assessing for characteristics of pain, discussing with resident factors that precipitate pain and what may reduce it, administering pain medications as ordered and discussing with resident the need to request pain medication. Record review of CR#1's MAR indicated [REDACTED]. CR #1's pain level was between 1-9 on a scale of 1-10 each time the medication was administered. Record review of CR #1's nurses notes dated 9/6/19 to 9/23/19 noted all follow-up pain assessments after the administration of the PRN [MEDICATION NAME] indicated effective pain management. Record review of CR#1's physical therapy discharge summary, dated 9/24/19, stated that resident's reported pain with movement on 9/6/19, 9/19/19, 9/18/19 and 9/24/19. On 9/18/19, a summary of daily skilled services PTA noted, pain = unable to determine at this time (Pt (complaint of) pain in her back and (left) knee. Pt did not describe or report levels on a scale.) In an interview with the PTA on 10/3/19 at 2:28PM, the PTA said that CR#1 did exercises while being seated or standing up and grasping onto a bar. Whenever he transferred the resident from her bed to her wheelchair, he would stand her up and pivot her to her seat. The PTA stated that the resident had a difficult time verbalizing the source of her pain and the only pain the resident made him aware of was pain that she felt in her left knee and lower back. The resident never made a complaint about her hip. Record review CR#1's clinical record dated (MONTH) 2019 revealed no ROM assessments, nor evaluation to determine cause, location and type of pain. Record review of CR#1's clinical record dated (MONTH) 2019 revealed no evidence her physician was consulted regarding change in condition or continued/increased pain. Review of Incidents in (MONTH) 2019 revealed no documentation of incident/fall for CR#1. In a telephone interview with CR #1's family member on 10/4/19 at 9:40AM, the family member mentioned that CR#1's pain was never discussed in any of the care plan meetings that he had with staff. Prior to admitting resident into the facility, she was cleared by the hospital to not have any fractures resulting from the fall she had at her home on 8/30/19. He stated that on Friday, 9/20/19, he was with CR#1 as the resident was being transferred to her wheelchair by unspecified CNAs in preparation for her physical therapy session. He heard the resident screaming and in response told the staff to stop flopping her around like a rag doll. He got to talk with PTA during resident's physical therapy session and stated that PTA was good and gentle with her. Prior to leaving the facility on 9/20/19, after end of therapy session and care plan meeting, he told the MDS nurse, in passing, that something ain't right about the resident and she seems to be in more pain than usual. The family member reported that the resident was denied surgery to treat fracture and is currently located at another skilled nursing facility. Record review of CR #1's progress notes reveal family member had met with social worker and DON on 9/20/19 and did not discuss pain management. In an interview with the MDS nurse on 10/4/19 at 4:43PM, she stated that she did a pain interview on CR#1 upon admission and the highest pain level that the resident ever reported was a 6 out of 10. She was aware of resident's knee pain but was only made aware of the additional pain the resident felt from other staff after discharge. The MDS nurse met with CR#1's family member during a care plan meeting, in which pain was never mentioned. The few days prior to resident's discharge, she never ran into the family member and he never mentioned the pain to her. In an interview with Resident #2 on 10/2/19 at 9:47AM, she said she was CR #1's roommate. She heard CR #1 screaming for help on Sunday morning, 9/22/19 starting at 1:50 AM while CNA R and LVN P were changing her brief. She said CNA R kept telling her you're okay, you're okay, and LVN P provided a pain pill for the resident only after Resident #2 suggested her need for pain relief. LVN P required CR#1 to clearly state what medication she needed and for what purpose. Resident #2 said CR#1 kept saying bad pill because she may not have been in the right mind to effectively communicate her needs, however, LVN P did not accept her answer of bad pill at first, but eventually gave her the medication when she stated she was hurting. In a second interview with Resident #2 on 10/2/19 at 1:17 PM, Resident #2 stated that CR#1 was fine and didn't express pain on Friday, 9/20/2019. She requested for RN A to assess CR#1 following the episode of pain on 9/22/19 but RN A responded that it must be due to her arthritis. She said RN A could not do that because she was not allowed to discuss her roommate's plan of care or [DIAGNOSES REDACTED].#1 to the social worker. Resident #2 added that CNA T and CNA S have both asked her, after they changed the resident, if CR#1 usually yelled like this while being changed, and she answered them saying, no, this is so much worse. In an interview with CNA N on 10/3/19 at 12:29PM, CNA N revealed that CR#1 had been hollering in pain since she first came in to facility and that the resident was the way she was a few days prior saying that, every time you rolled her to change her she would holler a little. She said at first, she thought that it was due to her [MEDICAL CONDITION], based on what the nurses, including RN A, were telling her when she asked for the reason for resident's pain. The resident's roommate, Resident #2, notified her that she was hollering more than normal and believed that it was due to her pain. CNA N stated that as the days went on, the resident was hollering more and more, so at that point she started getting another CNA to assist her with CR#1's incontinent care. In an interview with CNA S on 10/5/19 at 12:55PM, CNA S said that she usually took care of CR#1 during the day shift and she was in bed most of the time until she was taken to therapy. She said when she first met the resident, every time she touched her or rolled her over, the resident felt pain. CR#1 would state, it hurts, repeatedly. She said she would request CNA N to help her with incontinent care. When resident was experiencing pain, she remembered reporting it to LVN U. She said LVN U checked on her, but CNA S did not receive any feedback from her about the resident after that. In an interview with LVN U on 10/3/19 at 1:34PM, LVN U stated that when working with CR#1, she would stay in bed. The resident was an effective communicator and would usually ask for pain medication usually in the morning. She believed that the resident's pain was generalized because when she was would ask the resident where she hurts, and the resident would tell her it hurts all over. LVN U said she never heard the resident yell before and CNAs never reported resident's pain to her. In an interview with CNA R on 10/3/19 at 2:01PM, CNA R stated that the last time she worked with CR#1, she complained that she was hurting during incontinent care. She said when she pulled the dryer sheet to roll her towards the window, that was when the resident started yelling in pain. CNA R said that she had changed the resident before and had never had the resident complain the way she did during that shift. CR#1 used to be capable of rolling herself on command during incontinent care. She reported it to LVN P who then came to help CNA R finish incontinent care on the resident. When they finished changing her, they made sure she was comfortable again. She heard LVN P ask the resident at the time if she was hurting and the resident would respond, I'm just hurting, repeatedly. LVN P asked her if she wanted something for her pain and the resident said yes. CNA R did not know what happened afterwards, because she left shortly after. In an interview with LVN P on 10/3/19 at 2:40PM, LVN P stated when the resident was first admitted to the facility, she was able to turn and position herself during incontinent care. During the night shift on 9/21-22/19, the aide that she was working with, CNA R, asked her for help to change CR#1's briefs. She said CR #1 was not screaming when they changed her, the resident just kept stating, they're hurting me repeatedly while holding on the side rail of her bed even though no one was touching her at the time. When she asked the resident where she was hurting, she could not express to her when she felt the pain. LVN P stated that she did not call the doctor or write a progress note for CR#1 after that encounter with the resident. She said she gave CR#1 a pain pill at that time but added that it seemed like her roommate, Resident #2, would only ask that they give CR#1 a pain pill just so that Resident #2 could go back to sleep. LVN P notified the next nurse, unspecified, during the shift change. Record review of CR#1's MAR, dated (MONTH) 2019, revealed that LVN P administered [MEDICATION NAME] 50mg to resident on 9/22/19 at 2:17 AM with a reported pain rating of 4 on a scale of 1-10. In an interview with CNA T on 10/3/19 at 2:55PM, CNA T stated that CR#1 was effective in making her needs known. She said she had worked with the resident up to four times by changing resident's briefs and transferring her from her wheelchair to her bed. She said the resident would complain of pain whenever she moved her around in the bed. During the 2-10p shift on 9/22/19, she was complaining of pain. She asked CR#1's roommate, Resident #2, if she usually screamed like that and Resident #2 said yes. CNA T reported the complaints of pain to RN A who told her that she would go in and check on her later. In an interview with RN A on 10/5/19 at 12:32PM, RN said that she had never heard CR #1 scream out in pain and she did not seem distressed at the times she checked on her throughout the day on 9/22/19. She said CR#1 had asked RN A for a pain pill before and as soon as it was administered, the resident fell asleep. She said she assessed the resident at the times resident was in pain by looking at her back and her knees and didn't see any bruising or anything indicative of injury. She said she also checked the resident's vital signs on that day but did not document them on the progress notes. She said the CNAs on duty never told her that the resident was yelling in pain, only that the resident's roommate wanted to speak with her. She said when she met with Resident #2, she wanted to discuss CR#1's care with her because she was screaming in pain. She said Resident #2 started to play recordings of CR#1's crying that occurred during the night shift and she stopped the resident from continuing to play the recordings because she believed it was a HIPAA violation and there was no way to prove if that was really her yelling on the recording. RN A also stated that she was not allowed to discuss CR#1's care with her. She told Resident #2 that if she were to hear the screaming herself that she would make a referral to the social worker or her doctor. Record review of CR#1's MAR, dated (MONTH) 2019, revealed that RN A administered [MEDICATION NAME] 50mg to resident on 9/18/19 at 1:41 PM with a reported pain rating of 5/10 and on 9/22/19 at 7:30 PM with a reported pain rating of 5 on a scale of 1-10. In an interview with LVN M on 10/3/19 at 1:01PM, LVN M stated that her first time tending to CR#1 was on 9/23/19. She said Resident #2 had revealed to her recordings of the resident crying in pain during the night shift of 9/21-22/19 and told her that the resident had been in pain for that past week. She said she brought up the voice recordings Resident #2 kept of CR#1 at the morning meeting on 9/23/19. She said the meeting was attended by the DON, ADON, MDS nurse, social worker, administrator, and a corporate nurse. She said when she went to look at CR#1, the resident was transferred into her wheelchair by CNA D and CNA N ready for therapy, and the resident did not look distressed and was not screaming so she opted out of doing an assessment at that moment to avoid bothering the resident. She added, without reference as to when assessment took place, that by looking at the resident sitting in her wheelchair, she suspected a broken hip due to swelling on one side and one leg being longer than the other. She said she left the facility at the end of her shift thinking that staff members would follow up on the information she gave them during the morning meeting. LVN M stated that she did not call the doctor or do any charting on the resident until 9/24/19, the day the resident was discharged after finding the fracture. Record review of CR#1's MAR, dated (MONTH) 2019, revealed that LVN M administered 1 tablet of [MEDICATION NAME] 50mg to resident on 9/23/19 at 11:41 AM PM with a reported pain rating of 6 on a scale of 1-10. In an interview with the Social Worker on 10/3/19 at 3:30PM, she stated that she was made aware that Resident #2 had a recording of CR#1 yelling in pain at the morning meeting on 9/23/19 but she never got to hear the recordings. She said she just visited Resident #2 to tell her that it was a HIPAA violation to voice record other residents. In an interview with the ADON on 10/3/19 at 3:44PM, she stated that she heard of the voice recordings being mentioned in the morning meeting but did not get to listen to them. She said she knew that CR#1 had issues with pain but did not know it was getting progressively worse. She stated that CNAs were to figure out the source of residents' pain and if pain could not be resolved via prescribed medications, then the doctor should be notified to place a new order for resident. Nurses were responsible for doing a pain scale assessment and documenting in the progress notes on residents' change in condition. In an interview with the DON on 10/3/19 at 3:52PM, the DON stated that she was aware that CR#1 was experiencing pain and was taking [MEDICATION NAME] for it, but she was never alerted by any staff that she was hollering in pain. Whenever she saw the resident she was always smiling and did not seem to be in pain, even while being discharged from the facility. She heard about the recordings that Resident #2 had, not at the morning meeting, but during lunch time, date unspecified. She said she did not want to believe Resident #2's word because she tended to be over the top. The DON said she only wanted to believe what the nurses said to have observed, and no nurse called to notify her about any changes in CR#1. In an interview with the Administrator on 10/3/19 at 4:10PM, he said that he was made aware of Resident #2 voice recordings of CR#1 crying in pain after resident was discharged . He said he was in and out of the morning meeting that took place on 9/23/19 and did not hear about the resident's pain getting worse. He said he was first aware of the resident's pain on 9/24/19 when he heard the resident screaming from down the hall midmorning. He said it was then that they notified the doctor who ordered the x-rays. In an interview on 10/04/19 at 4:39 PM the DON stated the Physician saw CR#1 several times during the time CR#1 was at the facility. She said if the physician wanted to increase the medication he would have given her something else. She said after the [MEDICATION NAME] was administered, she said her pain went back to zero. The DON never heard CR#1 moaning or crying in pain. She said when CR#1 was discharged to the hospital the resident was calm. Record review of CR#1's Progress notes dated 09/24/19 at 10:25 AM read in part, Received resident awake and alert to self, made Physician aware that resident screams and cries when ADL's are being performed, N.O received X-Ray Left Hip 3 Views, confirmation number # 40, vitals stable, will continue to closely monitor . Record review of Radiology Report dated 09/24/19 reported at 3:15PM read in part, Examination: Radiographs of the left hip and pelvis. History: Pain Findings: There is mild arthritic changes of the hip with circumferential collar osteophytes and joint space narrowing. Possible impacted fracture neck of femur. Bony mineralization is reduce for age. No evidence of osteo[DIAGNOSES REDACTED]. Remainder the pelvis is grossly intact. Surgical staple seen on medial aspect of thigh. Impression: Mild Arthritic changes of the hip. Possible impacted fracture neck of femur ([MEDICAL CONDITION]), need clinical correlation Record review of CR#1's Progress notes dated 09/24/19 at 5:00pm read in part, . Received X-Ray results noted finding of fracture to left hip, Physician Made aware of results, N.O. to send to (ER) for eval. 5:10pm RP .made aware. 5:15pm (EMS) notified of transport. 6:25pm Resident transported to (ER) at this time via Crossroads EMS . Record review of CR #1's MAR indicated [REDACTED]. Record review of CR#1's hospital records revealed she was admitted to hospital on [DATE] with a pain level of 10 and noted she had complaints of pain for 2 days. CR#1 had a [DIAGNOSES REDACTED]. In an interview on 10/04/19 at 8:53 AM the Physician stated he was not aware of CR#1's having change of condition regarding her pain. When the facility notified him of the resident's pain he ordered an X-ray. He said the facility was usually good at contacting him when a resident had a change. CR#1 had an X-ray prior to her leaving the hospital and did not show a fracture. He said CR#1 was a difficult case for the staff. He said the staff at the facility probably thought the pain was related to her arthritic knee. He said sometimes, when the swelling goes down and another X-ray was performed it will show sometime different. The staff at the facility probably went off the first x-ray and thought her pain was from CR#1's knee. Record review of the facility policy Change in a Resident's Condition or Status dated 05/2017 revealed .Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.) .1. The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): a. accident or incident involving the resident; b. discovery of injuries of an unknown source; .d. significant change in the resident's physical/emotional/mental condition; e. need to alter the resident's medical treatment significantly; .i. specific instruction to notify the Physician of changes in the resident's condition . The Administrator and DON were notified of Immediate Jeopardy (IJ) on 10/04/19 at 5:15 PM due to the above failures. A Plan of removal was requested. The final plan of removal was accepted on 10/05/2019 at 12:40 PM after revisions were made. The Plan of Removal included the following: Plan of Removal Plan of IJ Removal for Focused Care at Cedar Bayou 10/4/19- 10/5/2019 Plan of Action o Pain Interviews completed by DON/ADON/MDS/Charge Nurse on all building residents by 10/5/2019. o Pain assessment initiated on all residents that were triggered from the pain interview completed 10/5/19 By DON/ADON/Charge Nurse. o In-service initiated for pain assessment, and management, and physician notification to be completed by 10/5/19 by the DON/ADON. o In-service provided to the CNAs on using Stop and Watch to notify the Nurses on pain complaint by the residents by DON/ADON completed by 10/5/2019. o In-service provided to Direct Care Staff by DON/ ADON on pain treatment alternatives (i.e. repositioning, exercise, therapy modalities and pain cream) 10/5/2019. o In-service provided to all facility employees on Abuse and Neglect prohibition, and resident's right completed 10/5/19 by the Administrator/DON. o All residents identified with pain will have plan of action reviewed with the attending physician by the DON/ADON on 10/5/2019. o Care plan will be updated indicating pain concern and management by the MDS Nurse to be completed by 10/5/2019. o CNAs educated on utilizing the resident's Kardex to obtain information on how to provide care for resident with pain by DON/ADON to be completed by 10/5/19. o Facility Kardex audit completed 10/4/2019 by Director of Clinical Education. Kardex reflects the correct staff participation for individual transfer. o DON/ ADON monitor usage of residents as needed pain medication 10/5/2019 and reviewed with Medical Director. Orders will change to scheduled at physician's discretion. o Regional Director of Clinical Operations educated DON on notifying physician when resident requesting PRN pain medication consistently for 3 days, and if pain is not relieved with PRN medication administration. New Pain assessment should be completed before notifying attending physician. DON/ADON to educate Nursing staff on notification starting 10/5/2019. o DON/ADON/ MDS initiated pain competency assessment for resident examination and assessment on each Nurse (LVN and RN) 10/5/2019. o DON/ADON/ MDS to review and update resident pain care plan after completion of resident pain assessment 10/5/2019. o DON/ADON In-serviced C.N.[NAME] on use of Kardex in Point Click Care on Individual residents. 10/5/2019 o Staff not in-service will not allow to work until they receive training and competency check off. o No direct staff to work before they have been in-service on identified areas. Ongoing Monitoring Resident's condition will be reviewed in daily clinical meeting to identify pain concerns, transfer concerns or change in condition Validation/Monitoring tool o Stop and Watch o Standard of care o QAPI process o Kardex Monitoring of Plan of Removal Monitoring of the facility plan of removal began on 10/05/19 at 1:40 PM. Facility staff from the morning, evening and night shift were interviewed about identifying changes in condition, pain assessments, stop and watch tool, Kardex, point click care, notifying the physician, abuse, neglect, resident rights, documentation, and pain interventions. The staff interviewed included 5 nurses, 1 MA and 10 CNA's. The staff interviewed were able to confidently demonstrate knowledge in the areas of in-services completed in the plan of removal. Record review of In-services dated 10/4/19 revealed nursing staff were in-serviced on topics including Stop and Watch tool for pain, change of condition, physician and family notifications, resident rights, abuse and neglect, pain assessments, pain management and notifications and documentation regarding pain. Observation of 5 of 5 residents between (10/05/19 - 10/06/19) for pain management revealed no concerns with pain management. The sample size was expanded to include 5 additional residents that were monitored for pain management. The expanded sample included residents on pain management program. The resident records were reviewed, and they were observed and interviewed if able to. Expanded sample residents displayed no current practice concerns and revealed facility staff were following their plan of removal. The Administrator, DON, and MDS Nurse were notified IJ was lowered on 10/06/19 at 11:32 AM. However, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated due to the facility continued to monitor the plan of correction for effectiveness.

Based on record review and interview the facility failed to ensure pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents goals and preferences for 1 of 11 residents (CR #1) reviewed for pain management. -The facility failed to recognize and assess CR #1's increased pain when she yelled out in pain during ADL care. CR #1 was in severe pain for three days when she was diagnosed with [REDACTED]. -The facility failed to accurately assess the effectiveness of CR #1's pain management program and consult with the physician when it was ineffective. An Immediate Jeopardy (IJ) was identified on 10/04/2019. While the IJ was lowered on 10/06/2019, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated because the facility continued to train staff and monitor the effectiveness of the Plan of Removal. This failure affected 1 former resident, causing to severe pain and a delay in treatment for [REDACTED]. Findings include: Record review of CR#1's face sheet revealed she was a [AGE] year-old female that was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. CR#1 was discharged from the facility on 09/24/19. Record review of hospital records dated 08/30/19 revealed Examinations: XR hip 2-3 views left XR knee hip 2-3 views left XR knee 3 views left .Impression: 1. The alignment of the left hip and left knee is anatomic without fracture or dislocation. 2. There is moderate bilateral hip joint [MEDICAL CONDITION]. Predominant tricompartmental left knee [MEDICAL CONDITION]. There is no left knee effusion. 3. Dense arterial vascular calcifications are present. Additionally several calcified structures posterior to the knee likely represent renal cysts in the setting of prior trauma . Record review of baseline plan on care, dated 9/5/19, revealed that CR#1 had presence of a dull, achy pain upon admission located on the left knee. No pain scale noted. Record review of CR#1's progress notes dated 9/5/19 revealed that resident was admitted into facility with, ROM to upper extremities. Resident pain level 8/10 (Level 8 on a scale of 1-10) to left leg. Assessed resident abrasion and discoloration below left knee. Discoloration to left hip, redness to sacrum, R knee discolored and scar behind knee. Record review of CR#1's physician orders [REDACTED]. She had no other medications for pain. Record review of physician progress notes [REDACTED]. Here for rehabilitation Extremities: left knee abrasion and [DIAGNOSES REDACTED] .Skin: left knee abrasion Plan Left hip xray negative for fractures. Pain management. Fall precautions Pain Assessment - documented as positive and a follow-up is documented (08/30/2019) Record review of physician progress notes [REDACTED].Patient now complaints of left knee pain at 10/10 on the pain scale . Pain assessment - documented as positive and a follow-up plan is documented (08/30/2019) . Record review of CR#1's Pain Interview (3.0) Assessment, dated 9/10/19, the resident revealed that she had pain in the last 5 days at an occasional frequency that did not limit her day-to day activities. No indicators of pain or possible pain were observed at time of assessment and pain management intervention of [MEDICATION NAME] 50mg 1 tab q 6hrs. was noted as effective. Record review of CR #1's clinical record revealed no other pain interview assessments following 9/10/19 were performed on CR#1. Record review of CR#1's MDS dated [DATE] revealed CR#1 had a BIMS of 9, indicating moderate cognitive impairment. CR#1 required extensive assistance of two people for bed mobility. CR#1 required total assistance of two people for transfers. CR#1 had presence of pain which frequency was documented at 3 meaning Occasionally. CR#1's highest Pain Intensity was documented as a '6' on a scale of 1 to 10 during the 5 day look back period. Record review of CR#1's Care Plan dated 9/12/19 revealed, revealed a focus on CR#1's ADL self-care performance deficit related to activity intolerance, limited mobility and pain, with a goal to improve current level of function in ADL self-care by requiring 1-2 person assist with transfers, showering bed mobility and turning and repositioning. Further record review of CR#1's care plan dated 9/12/19 revealed CR#1 had potential for pain and risk of injury from decreased ADL's due to hip pain, and arthritis. Interventions included assessing for characteristics of pain, discussing with resident factors that precipitate pain and what may reduce it, administering pain medications as ordered and discussing with resident the need to request pain medication. Record review of CR#1's MAR indicated [REDACTED]. CR #1's pain level was between 1-9 on a scale of 1-10 each time the medication was administered. Record review of CR #1's nurses notes dated 9/6/19 to 9/23/19 noted all follow-up pain assessments after the administration of the PRN [MEDICATION NAME] indicated effective pain management. Record review of CR#1's physical therapy discharge summary, dated 9/24/19, stated that resident's reported pain with movement on 9/6/19, 9/19/19, 9/18/19 and 9/24/19. On 9/18/19, a summary of daily skilled services PTA noted, pain = unable to determine at this time (Pt (complaint of) pain in her back and (left) knee. Pt did not describe or report levels on a scale.) In an interview with the PTA on 10/3/19 at 2:28PM, the PTA said that CR#1 did exercises while being seated or standing up and grasping onto a bar. Whenever he transferred the resident from her bed to her wheelchair, he would stand her up and pivot her to her seat. The PTA stated that the resident had a difficult time verbalizing the source of her pain and the only pain the resident made him aware of was pain that she felt in her left knee and lower back. The resident never made a complaint about her hip. Record review CR#1's clinical record dated (MONTH) 2019 revealed no ROM assessments, nor evaluation to determine cause, location and type of pain. Record review of CR#1's clinical record dated (MONTH) 2019 revealed no evidence her physician was consulted regarding change in condition or continued/increased pain. Review of Incidents in (MONTH) 2019 revealed no documentation of incident/fall for CR#1. In a telephone interview with CR #1's family member on 10/4/19 at 9:40AM, the family member mentioned that CR#1's pain was never discussed in any of the care plan meetings that he had with staff. Prior to admitting resident into the facility, she was cleared by the hospital to not have any fractures resulting from the fall she had at her home on 8/30/19. He stated that on Friday, 9/20/19, he was with CR#1 as the resident was being transferred to her wheelchair by unspecified CNAs in preparation for her physical therapy session. He heard the resident screaming and in response told the staff to stop flopping her around like a rag doll. He got to talk with PTA during resident's physical therapy session and stated that PTA was good and gentle with her. Prior to leaving the facility on 9/20/19, after end of therapy session and care plan meeting, he told the MDS nurse, in passing, that something ain't right about the resident and she seems to be in more pain than usual. The family member reported that the resident was denied surgery to treat fracture and is currently located at another skilled nursing facility. Record review of CR #1's progress notes reveal family member had met with social worker and DON on 9/20/19 and did not discuss pain management. In an interview with the MDS nurse on 10/4/19 at 4:43PM, she stated that she did a pain interview on CR#1 upon admission and the highest pain level that the resident ever reported was a 6 out of 10. She was aware of resident's knee pain but was only made aware of the additional pain the resident felt from other staff after discharge. The MDS nurse met with CR#1's family member during a care plan meeting, in which pain was never mentioned. The few days prior to resident's discharge, she never ran into the family member and he never mentioned the pain to her. In an interview with Resident #2 on 10/2/19 at 9:47AM, she said she was CR #1's roommate. She heard CR #1 screaming for help on Sunday morning, 9/22/19 starting at 1:50 AM while CNA R and LVN P were changing her brief. She said CNA R kept telling her you're okay, you're okay, and LVN P provided a pain pill for the resident only after Resident #2 suggested her need for pain relief. LVN P required CR#1 to clearly state what medication she needed and for what purpose. Resident #2 said CR#1 kept saying bad pill because she may not have been in the right mind to effectively communicate her needs, however, LVN P did not accept her answer of bad pill at first, but eventually gave her the medication when she stated she was hurting. In a second interview with Resident #2 on 10/2/19 at 1:17 PM, Resident #2 stated that CR#1 was fine and didn't express pain on Friday, 9/20/2019. She requested for RN A to assess CR#1 following the episode of pain on 9/22/19 but RN A responded that it must be due to her arthritis. She said RN A could not do that because she was not allowed to discuss her roommate's plan of care or [DIAGNOSES REDACTED].#1 to the social worker. Resident #2 added that CNA T and CNA S have both asked her, after they changed the resident, if CR#1 usually yelled like this while being changed, and she answered them saying, no, this is so much worse. In an interview with CNA N on 10/3/19 at 12:29PM, CNA N revealed that CR#1 had been hollering in pain since she first came in to facility and that the resident was the way she was a few days prior saying that, every time you rolled her to change her she would holler a little. She said at first, she thought that it was due to her [MEDICAL CONDITION], based on what the nurses, including RN A, were telling her when she asked for the reason for resident's pain. The resident's roommate, Resident #2, notified her that she was hollering more than normal and believed that it was due to her pain. CNA N stated that as the days went on, the resident was hollering more and more, so at that point she started getting another CNA to assist her with CR#1's incontinent care. In an interview with CNA S on 10/5/19 at 12:55PM, CNA S said that she usually took care of CR#1 during the day shift and she was in bed most of the time until she was taken to therapy. She said when she first met the resident, every time she touched her or rolled her over, the resident felt pain. CR#1 would state, it hurts, repeatedly. She said she would request CNA N to help her with incontinent care. When resident was experiencing pain, she remembered reporting it to LVN U. She said LVN U checked on her, but CNA S did not receive any feedback from her about the resident after that. In an interview with LVN U on 10/3/19 at 1:34PM, LVN U stated that when working with CR#1, she would stay in bed. The resident was an effective communicator and would usually ask for pain medication usually in the morning. She believed that the resident's pain was generalized because when she was would ask the resident where she hurts, and the resident would tell her it hurts all over. LVN U said she never heard the resident yell before and CNAs never reported resident's pain to her. In an interview with CNA R on 10/3/19 at 2:01PM, CNA R stated that the last time she worked with CR#1, she complained that she was hurting during incontinent care. She said when she pulled the dryer sheet to roll her towards the window, that was when the resident started yelling in pain. CNA R said that she had changed the resident before and had never had the resident complain the way she did during that shift. CR#1 used to be capable of rolling herself on command during incontinent care. She reported it to LVN P who then came to help CNA R finish incontinent care on the resident. When they finished changing her, they made sure she was comfortable again. She heard LVN P ask the resident at the time if she was hurting and the resident would respond, I'm just hurting, repeatedly. LVN P asked her if she wanted something for her pain and the resident said yes. CNA R did not know what happened afterwards, because she left shortly after. In an interview with LVN P on 10/3/19 at 2:40PM, LVN P stated when the resident was first admitted to the facility, she was able to turn and position herself during incontinent care. During the night shift on 9/21-22/19, the aide that she was working with, CNA R, asked her for help to change CR#1's briefs. She said CR #1 was not screaming when they changed her, the resident just kept stating, they're hurting me repeatedly while holding on the side rail of her bed even though no one was touching her at the time. When she asked the resident where she was hurting, she could not express to her when she felt the pain. LVN P stated that she did not call the doctor or write a progress note for CR#1 after that encounter with the resident. She said she gave CR#1 a pain pill at that time but added that it seemed like her roommate, Resident #2, would only ask that they give CR#1 a pain pill just so that Resident #2 could go back to sleep. LVN P notified the next nurse, unspecified, during the shift change. Record review of CR#1's MAR, dated (MONTH) 2019, revealed that LVN P administered [MEDICATION NAME] 50mg to resident on 9/22/19 at 2:17 AM with a reported pain rating of 4 on a scale of 1-10. In an interview with CNA T on 10/3/19 at 2:55PM, CNA T stated that CR#1 was effective in making her needs known. She said she had worked with the resident up to four times by changing resident's briefs and transferring her from her wheelchair to her bed. She said the resident would complain of pain whenever she moved her around in the bed. During the 2-10p shift on 9/22/19, she was complaining of pain. She asked CR#1's roommate, Resident #2, if she usually screamed like that and Resident #2 said yes. CNA T reported the complaints of pain to RN A who told her that she would go in and check on her later. In an interview with RN A on 10/5/19 at 12:32PM, RN said that she had never heard CR #1 scream out in pain and she did not seem distressed at the times she checked on her throughout the day on 9/22/19. She said CR#1 had asked RN A for a pain pill before and as soon as it was administered, the resident fell asleep. She said she assessed the resident at the times resident was in pain by looking at her back and her knees and didn't see any bruising or anything indicative of injury. She said she also checked the resident's vital signs on that day but did not document them on the progress notes. She said the CNAs on duty never told her that the resident was yelling in pain, only that the resident's roommate wanted to speak with her. She said when she met with Resident #2, she wanted to discuss CR#1's care with her because she was screaming in pain. She said Resident #2 started to play recordings of CR#1's crying that occurred during the night shift and she stopped the resident from continuing to play the recordings because she believed it was a HIPAA violation and there was no way to prove if that was really her yelling on the recording. RN A also stated that she was not allowed to discuss CR#1's care with her. She told Resident #2 that if she were to hear the screaming herself that she would make a referral to the social worker or her doctor. Record review of CR#1's MAR, dated (MONTH) 2019, revealed that RN A administered [MEDICATION NAME] 50mg to resident on 9/18/19 at 1:41 PM with a reported pain rating of 5/10 and on 9/22/19 at 7:30 PM with a reported pain rating of 5 on a scale of 1-10. In an interview with LVN M on 10/3/19 at 1:01PM, LVN M stated that her first time tending to CR#1 was on 9/23/19. She said Resident #2 had revealed to her recordings of the resident crying in pain during the night shift of 9/21-22/19 and told her that the resident had been in pain for that past week. She said she brought up the voice recordings Resident #2 kept of CR#1 at the morning meeting on 9/23/19. She said the meeting was attended by the DON, ADON, MDS nurse, social worker, administrator, and a corporate nurse. She said when she went to look at CR#1, the resident was transferred into her wheelchair by CNA D and CNA N ready for therapy, and the resident did not look distressed and was not screaming so she opted out of doing an assessment at that moment to avoid bothering the resident. She added, without reference as to when assessment took place, that by looking at the resident sitting in her wheelchair, she suspected a broken hip due to swelling on one side and one leg being longer than the other. She said she left the facility at the end of her shift thinking that staff members would follow up on the information she gave them during the morning meeting. LVN M stated that she did not call the doctor or do any charting on the resident until 9/24/19, the day the resident was discharged after finding the fracture. Record review of CR#1's MAR, dated (MONTH) 2019, revealed that LVN M administered 1 tablet of [MEDICATION NAME] 50mg to resident on 9/23/19 at 11:41 AM PM with a reported pain rating of 6 on a scale of 1-10. In an interview with the Social Worker on 10/3/19 at 3:30PM, she stated that she was made aware that Resident #2 had a recording of CR#1 yelling in pain at the morning meeting on 9/23/19 but she never got to hear the recordings. She said she just visited Resident #2 to tell her that it was a HIPAA violation to voice record other residents. In an interview with the ADON on 10/3/19 at 3:44PM, she stated that she heard of the voice recordings being mentioned in the morning meeting but did not get to listen to them. She said she knew that CR#1 had issues with pain but did not know it was getting progressively worse. She stated that CNAs were to figure out the source of residents' pain and if pain could not be resolved via prescribed medications, then the doctor should be notified to place a new order for resident. Nurses were responsible for doing a pain scale assessment and documenting in the progress notes on residents' change in condition. In an interview with the DON on 10/3/19 at 3:52PM, the DON stated that she was aware that CR#1 was experiencing pain and was taking [MEDICATION NAME] for it, but she was never alerted by any staff that she was hollering in pain. Whenever she saw the resident she was always smiling and did not seem to be in pain, even while being discharged from the facility. She heard about the recordings that Resident #2 had, not at the morning meeting, but during lunch time, date unspecified. She said she did not want to believe Resident #2's word because she tended to be over the top. The DON said she only wanted to believe what the nurses said to have observed, and no nurse called to notify her about any changes in CR#1. In an interview with the Administrator on 10/3/19 at 4:10PM, he said that he was made aware of Resident #2 voice recordings of CR#1 crying in pain after resident was discharged . He said he was in and out of the morning meeting that took place on 9/23/19 and did not hear about the resident's pain getting worse. He said he was first aware of the resident's pain on 9/24/19 when he heard the resident screaming from down the hall midmorning. He said it was then that they notified the doctor who ordered the x-rays. In an interview on 10/04/19 at 4:39 PM the DON stated the Physician saw CR#1 several times during the time CR#1 was at the facility. She said if the physician wanted to increase the medication he would have given her something else. She said after the [MEDICATION NAME] was administered, she said her pain went back to zero. The DON never heard CR#1 moaning or crying in pain. She said when CR#1 was discharged to the hospital the resident was calm. Record review of CR#1's Progress notes dated 09/24/19 at 10:25 AM read in part, Received resident awake and alert to self, made Physician aware that resident screams and cries when ADL's are being performed, N.O received X-Ray Left Hip 3 Views, confirmation number # 40, vitals stable, will continue to closely monitor . Record review of Radiology Report dated 09/24/19 reported at 3:15PM read in part, Examination: Radiographs of the left hip and pelvis. History: Pain Findings: There is mild arthritic changes of the hip with circumferential collar osteophytes and joint space narrowing. Possible impacted fracture neck of femur. Bony mineralization is reduce for age. No evidence of osteo[DIAGNOSES REDACTED]. Remainder the pelvis is grossly intact. Surgical staple seen on medial aspect of thigh. Impression: Mild Arthritic changes of the hip. Possible impacted fracture neck of femur ([MEDICAL CONDITION]), need clinical correlation Record review of CR#1's Progress notes dated 09/24/19 at 5:00pm read in part, . Received X-Ray results noted finding of fracture to left hip, Physician Made aware of results, N.O. to send to (ER) for eval. 5:10pm RP .made aware. 5:15pm (EMS) notified of transport. 6:25pm Resident transported to (ER) at this time via Crossroads EMS . Record review of CR #1's MAR indicated [REDACTED]. Record review of CR#1's hospital records revealed she was admitted to hospital on [DATE] with a pain level of 10 and noted she had complaints of pain for 2 days. CR#1 had a [DIAGNOSES REDACTED]. In an interview on 10/04/19 at 8:53 AM the Physician stated he was not aware of CR#1's having change of condition regarding her pain. When the facility notified him of the resident's pain he ordered an X-ray. He said the facility was usually good at contacting him when a resident had a change. CR#1 had an X-ray prior to her leaving the hospital and did not show a fracture. He said CR#1 was a difficult case for the staff. He said the staff at the facility probably thought the pain was related to her arthritic knee. He said sometimes, when the swelling goes down and another X-ray was performed it will show sometime different. The staff at the facility probably went off the first x-ray and thought her pain was from CR#1's knee. Record review of the facility Pain Management Policy dated 09/14 revealed . Effective pain recognition and management requires an ongoing facility-wide commitment to resident comfort, to identifying and addressing barriers to managing pain, and addressing any misconceptions that residents, families, and staff may have about managing pain. Nursing home residents are at high risk for having pain that may affect function, impaired mobility, impaired mood, or disturb sleep, and diminish quality of life .The onset of acute pain may indicate a new injury or a potentially life-threatening condition or illness. It is important, therefore, that a resident's reports of pain, or nonverbal signs suggesting pain, be evaluated . 3. Patients/Residents are routinely evaluated for level of pain (0-10) each shift and is designated by initials on the nurse MAR. If resident is expressing pain, the pain is to be addressed. 4. A pain evaluation will be completed upon admission, readmission, and any new episode of pain or exacerbation of pain. Residents with dementia will be evaluated using the (PAIN AD) 6. Non-Pharmacological Interventions should also be used to relive pain 7. Behaviors are often the result of pain and if the resident has dementia it is often worthwhile to trial an NSAID or Tylenol and see if it helps with behavior .8. If Patient/Resident is assessed for unrelieved pain, the nurse will notify the attending physician to obtain an order for [REDACTED]. The Administrator and DON were notified of Immediate Jeopardy (IJ) on 10/04/19 at 5:15 PM due to the above failures. A Plan of removal was requested. The final plan of removal was accepted on 10/05/2019 at 12:40 PM after revisions were made. The Plan of Removal included the following: Plan of Removal Plan of IJ Removal for Focused Care at Cedar Bayou 10/4/19- 10/5/2019 Plan of Action o Pain Interviews completed by DON/ADON/MDS/Charge Nurse on all building residents by 10/5/2019. o Pain assessment initiated on all residents that were triggered from the pain interview completed 10/5/19 By DON/ADON/Charge Nurse. o In-service initiated for pain assessment, and management, and physician notification to be completed by 10/5/19 by the DON/ADON. o In-service provided to the CNAs on using Stop and Watch to notify the Nurses on pain complaint by the residents by DON/ADON completed by 10/5/2019. o In-service provided to Direct Care Staff by DON/ ADON on pain treatment alternatives (i.e. repositioning, exercise, therapy modalities and pain cream) 10/5/2019. o In-service provided to all facility employees on Abuse and Neglect prohibition, and resident's right completed 10/5/19 by the Administrator/DON. o All residents identified with pain will have plan of action reviewed with the attending physician by the DON/ADON on 10/5/2019. o Care plan will be updated indicating pain concern and management by the MDS Nurse to be completed by 10/5/2019. o CNAs educated on utilizing the resident's Kardex to obtain information on how to provide care for resident with pain by DON/ADON to be completed by 10/5/19. o Facility Kardex audit completed 10/4/2019 by Director of Clinical Education. Kardex reflects the correct staff participation for individual transfer. o DON/ ADON monitor usage of residents as needed pain medication 10/5/2019 and reviewed with Medical Director. Orders will change to scheduled at physician's discretion. o Regional Director of Clinical Operations educated DON on notifying physician when resident requesting PRN pain medication consistently for 3 days, and if pain is not relieved with PRN medication administration. New Pain assessment should be completed before notifying attending physician. DON/ADON to educate Nursing staff on notification starting 10/5/2019. o DON/ADON/ MDS initiated pain competency assessment for resident examination and assessment on each Nurse (LVN and RN) 10/5/2019. o DON/ADON/ MDS to review and update resident pain care plan after completion of resident pain assessment 10/5/2019. o DON/ADON In-serviced C.N.[NAME] on use of Kardex in Point Click Care on Individual residents. 10/5/2019 o Staff not in-service will not allow to work until they receive training and competency check off. o No direct staff to work before they have been in-service on identified areas. Ongoing Monitoring Resident's condition will be reviewed in daily clinical meeting to identify pain concerns, transfer concerns or change in condition Validation/Monitoring tool o Stop and Watch o Standard of care o QAPI process o Kardex Monitoring of Plan of Removal Monitoring of the facility plan of removal began on 10/05/19 at 1:40 PM. Facility staff from the morning, evening and night shift were interviewed about identifying changes in condition, pain assessments, stop and watch tool, Kardex, point click care, notifying the physician, abuse, neglect, resident rights, documentation, and pain interventions. The staff interviewed included 5 nurses, 1 MA and 10 CNA's. The staff interviewed were able to confidently demonstrate knowledge in the areas of in-services completed in the plan of removal. Record review of In-services dated 10/4/19 revealed nursing staff were in-serviced on topics including Stop and Watch tool for pain, change of condition, physician and family notifications, resident rights, abuse and neglect, pain assessments, pain management and notifications and documentation regarding pain. Observation of 5 of 5 residents between (10/05/19 - 10/06/19) for pain management revealed no concerns with pain management. The sample size was expanded to include 5 additional residents that were monitored for pain management. The expanded sample included residents on pain management program. The resident records were reviewed, and they were observed and interviewed if able to. Expanded sample residents displayed no current practice concerns and revealed facility staff were following their plan of removal. The Administrator, DON, and MDS Nurse were notified IJ was lowered on 10/06/19 at 11:32 AM. However, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated due to the facility continued to monitor the plan of correction for effectiveness.

Based on observation, interview and record review, the facility failed to provide necessary treatment and services, based on the comprehensive assessment and consistent with professional standards of practice, to promote healing and prevent new pressure ulcers from developing for 1 of 3 residents reviewed for pressure ulcers (CR # 1) in that: --The facility failed to provide interventions to address CR #1's refusals to reposition and have wound care. CR # 1 developed (3) unstageable pressure ulcers while in the facility. He was discharged to a local hospital after a change of condition. This failure affected 1 resident and placed 6 other residents with pressure ulcers at risk of new development or worsening of exisiting pressure ulcers. Findings include: Intake # 8 CR # 1 Record review of the face sheet for CR # 1 revealed a [AGE] year old male with admission date of [DATE] and discharge to the hospital on [DATE] for a change of condition. [DIAGNOSES REDACTED]. Record review of the Nursing Admission assessment dated [DATE] revealed CR # 1 had a pressure ulcer to the sacrum, [MEDICAL CONDITION] to right lower leg, and left below knee amputation on admission. Record review of the Interim care plan dated 2/24/18 revealed: Problem: resident is at risk for pressure ulcer. Intervention: assess resident for risk; monitor resident nutritional intake; provide preventative equipment if indicated; refer to dietician; skin assessment upon admission and at a minimum weekly therafter; turn and reposition per facility protocol. Record review of the Admission Minimum Data set ((MDS) dated [DATE] revealed CR # 1 had 1 unhealed Stage 3 pressure ulcer that was present upon admission. CR # 1's BIMS score was 14. There were no signs or symptoms of behaviors on assessment. Record review of CR # 1's Acute Care Plan for pressure ulcers (undated) revealed: Site # 1: Sacrum Stage 3; Site # 2: Left Ischium Stage 4; Site # 3: Right Hip, Unstageable; Site # 4: Right Ischium Unstageable: Interventions included: Treatment per protocol or current order. Reassess treatment at a minimum of every 2 weeks to evaluate for changes in treatment if improvement not noted. Treatment nurse or designee will assess wounds and measure on a weekly basis. Dietary supplements per nutritional protocols for wound healing. Low air loss mattress ordered. Pillows between pressure areas and for proper body alignment while in bed or up in chair. Record review of CR# 1's undated care plan for resistance to care revealed: refusals to be changed at times, receive wound treatments and will not lie in any position but on his back, and refuses to turn for peri care. Interventions included: allow him to make decisions about treatment regime, to provide sense of control. Encourage as much participation by him as possible during care. Give clear explanation of all care activities prior to and as they occur. If he resists , ressure resident, leave and return 5-10 minutes later and try gain. Provide consistency in care to promote comfort with ADL's. Record review of the Significant Change MDS date 4/20/18 revealed a BIMS score of 15. Behavioral symptoms exhibited were rejection of care which occured 1 to 3 days. Unhealed pressure ulcers revealed one Stage 3 pressure ulcer that was present on admission, one Stage 4 pressure ulcer which was not present upon admission, and 2 unstageable pressure ulcers that were not present on admission. In an interview with Wound Care Nurse on 4/27/18 at 11:00 am, she stated CR # 1 was admitted with a sacral wound, and later aquired 3 more wounds (left and right ischeum, and thigh). She said the wound care was to be done every day, and he allowed her to do wound care initially, but he started refusing to be turned for wound treatments in approximately the last 2 weeks because he was sore, and often refused baths and incontient care within the same time frame. Wound Care Nurse stated she and other staff would talk to him about the risks of infection if he didn't allow them to treat the wounds, but often he would still refuse. She stated the wound care specialist came to the facility and assessed the wounds every week. Interview with DON on 4/27/18 at 11:10 am revealed that when CR # 1 refused turning and wound care, they would document that he refused and update the care plan. Record review of the facility weekly wound progress notes revealed the following : 3/13/18: unstageable pressure wound to the right ischium measuring 4 x 7 cm, and a Stage 3 to the sacrum measuring 2.5 x 3 x 0.3 cm. 3/28/18: unstageable pressure wound to the right ischium measuring 4 x 7 cm; Stage 3 to the sacrum measuring 2.5 x 3 x 0.3 cm; and a new Stage 2 pressure wound to the right hip measuring 4 x 4 x 0.2 cm. 4/11/18: Stage 4 (previously unstageable) pressure wound to the right ischium measuring 3.5 x 8 x 3 cm; Stage 3 to the sacrum measuring 4 x 3 x 0.3 cm; unstageable (due to necrosis) of the right hip measuring 7 x 4.5 cm; and a new unstageable pressure ulcer to the left ischium measuring 2 x 2 cm. Additional notes revealed resident is non compliant with turning and getting off his back, being changed by CNA's, and wound care. Record review of the Wound Care Specialist evaluations revealed the following: 3/13/18: (1) Stage 3 pressure wound on his sacrum with moderate serous drainage, measuring 2.5 x 3 x 0.3 cm., apply Santyl once daily; (2) an unstageable (due to necrosis) pressure wound of the right ischium with light serous drainange, measuring 4 x 7 x not measurable cm, apply silver alginate once daily. 3/28/18: (1) Stage 3 pressure wound to the sacrum with moderate serous drainage, measuring 2.5 x 3 x 0.3 cm, same dressing; (2) unstageable (due to necrosis) pressure wound of the right ischium with light serous drainage, measuring 4 x 7 x not measurable cm, apply wet to moist dressing with Dakins solution once daily ; (3) a new pressure wound of the right hip with moderate serous drainage, measuring 4 x 4 x 0.2 cm, apply silver alginate once daily. 4/11/18: (1) Stage 3 pressure wound to the sacrum with moderate serous drainage, measuring 4 x 3 0.3 cm, same dressing; (2) Stage 4 pressure wound of the right ischium (previously unstageable) with moderate serous drainage, measuring 3.5 x 8 x 3 cm, same dressing ; (3) unstageable (due to necrosis) pressure wound of the right hip with ligth serous drainage, measuring 7 x 4.5 x not measurble cm, apply wet to moist dressing with Dakins solution once daily ; (4) a new unstageable (due to necrosis) of the left ischium with light serous drainage, measuring 2 x 2 x not measurable cm, apply santyl once daily 4/25/18: (1) Stage 3 pressure wound to the sacrum with moderate serous drainage, measuring 4 x 4 x 0.3 cm, apply silver alginate once daily; (2) Stage 4 pressure wound of right ischium with moderate serous drainage, measuring 6 x 7 x 3 cm, wet to moist dressing with Dakins solution once daily; (3) unstageable (due to necrosis) of the right hip with moderate serous drainage, measuring 7 x 5.5 x not measurable cm, wet to moist dressing with Dakins solution once daily ; (4) and unstageable (due to necrosis) of the left ischium with moderate serous drainage, measuring 2 x 2 x not measurable cm, apply wet to moist dressing with Dakins solution once daily. --Dressing to the Stage 4 pressure ulcer to right ischium was changed from silver alginate to Dakins solution and wet to moist dressing on 3/28/18; dressings to Stage 3 to sacrum, unstageable to right hip, and unstageable to left ischium were changed from santyl to Dakins solution on 4/25/18. Record review of CR #1's consolidated physician's orders [REDACTED]. 2/23/18 - 2/28/18: apply Silver Alginate daily to Stage 3 sacral wound and right lower leg [MEDICAL CONDITION]. 3/01/18 - 3/31/18: apply Silver Alginate to Stage 3 sacral wound, apply Santyl to Stage 2 right hip (3/29), and right ischium (3/14); Liquid protein 2 times a day, low air loss mattress ordered 3/2/18, Multi Vitamin Mineral tablet, Vitamin C tablet 2 times a day for wound healing (all ordered 3/2/18) 4/01/18 - 4/30/18: apply Dakins solution with wet to moist dressing to Stage 3 sacral wound, right ischium, left ischium, and right hip pressure sores. Record review of CR #1's facility progress notes revealed : 3/29/18: resident complained of pain level 5 on his buttock pressure ulcer, MD notified, ordered Tylenol 650 mg every 6 hours PRN for pain. Resident was informed, and stated: what good is that gonna do I want it healed 3/30/18: resident did not want anything for pain, did not allow re-positioning. 4/3/18: resident complained of pain on his buttocks, but wanted nothing for it. 4/10/18: refused to be weighed, stated I do not want to have to go through all of that 4/11/18: refused to be weighed, stated It hurts my butt to be moved around 4/12/18: refused shower, said he did not like to get out of bed. 4/13/18: refuses to allow staff to turn him, refusing to stay on side to get weight off his backside. MD aware. 4/18/18: right hip xray with great difficulty, wants to be left alone, refused to be weighed 4/23/18: refusing to have wound care, stated too tired and sore. MD and DON aware of daily refusals. 4/24/18: refusing wound care, says too sore and too tired. Further review of CR #1's progress notes dated Febuary (YEAR) to (MONTH) (YEAR) revealed the physician was not notified of CR #1's pain or refusals unless noted above. Record review of the hospital records revealed CR # 1 was admitted on [DATE] due to altered mental status since the afternoon. He had a [DIAGNOSES REDACTED]. Interview with CR # 1 on 4/27/18 at 12:00 pm (in the hospital) revealed he was alert and oriented, but kept drifting off to sleep and then wake up to talk. He stated they did wound care at the facility, but sometimes it would hurt to turn so he would tell them not to do it. In an interview with RN B on 4/27/18 at 1:30 pm, she stated CR # 1 recently had a new pain medication prescribed, that seemed to be working, and they were able to turn him and give him a bed bath on 4/25/18. She stated his wounds were open and draining at that time. In an interview with MA E on 4/27/18 at 1:35 pm, she stated she assisted in the bed bath for CR # 1 on 4/25/18, and stated the wounds were open and stated they looked bad. In further interview, she stated he had refused to be turned a lot, and she would usually go back to ask again, talk to him about the risks of not allowing them to turn or do care, and he would still refuse. At that point, she would document his refusal. In an interview with PTA G on 4/27/18 at 1:38 pm, he stated in the last couple of weeks CR # 1 would often refuse to do therapy, but sometimes they could do light range of motion. He stated the therapy would be very limited due to CR # 1's pain, breathing, and tremors, and when he reached his pain threshold, he would stop them from doing more. In an interview with LVN F on 4/27/18 at 2:45 pm, she stated she did the wound care on weekends. She stated CR # 1 refused care last weekend (4/21, 4/22) and she knew he didn't want to turn because he was hurting. The last time she did weekend wound care was on 4/15/18, and at that time the wounds were draining. In an interview with the DON on 5/1/18 at 9:00 am, she stated CR # 1 would not say why he didn't want to turn, and that he would usually just say no. She further stated she thought the wounds got worse because he refused to turn. In an interview with the Wound Care Nurse on 5/1/18 at 9:30 am, she stated she did not know why the wounds kept popping up, except that he kept refusing to turn. He would say that he hurt, he just had therapy, or he just didn't want to turn. She said he started refusing wound care the last week or so he was in the facility. In an interview with LVN J on 5/1/18 at 10:15 am, she stated CR # 1 recently refused to be turned on the 2pm - 10pm shift, and staff would usually go back to see if he would allow turning, but most often in the last week or two he would refuse. They would document whenever he refused. In an interview with the Wound Care Specialist on 5/1/18 at 10: 40 am, he stated CR # 1 was large, and heavy and was admitted with the sacral wound, and had an unstageable to right hip, left ischium, and right ischium. He stated it was challenging to treat them because of the resident's pain, and he debrided the necrotic tissue to make them improve somewhat. He stated CR # 1 was pre-medicated for pain before he came, but still complained of pain while he was there to assess the wounds. Wound Care Specialist stated he thought the wounds were improving the last time he saw them, there was more granulation tissue and less drainage. Record review of CR #1's facility Treatment Records revealed the following: 3/01/18 - 3/31/18: wound care for Stage 3 sacrum was not completed on 3/1/18, 3/11/18, 3/22/18 and 3/26/18; Stage 2 right hip was not missed. 4/01/18 - 4/30/18: wound care orders for Stage 3 sacrum was not completed on 4/7/18 and 4/8/18; left ischium was not completed on 4/24/18; right ischium was not completed on 4/7/18 and 4/8/18; right hip was not completed on 4/7/18, 4/8/18 and 4/24/18. A facility policy on pressure sores was requested from the DON and was not obtained by the time of exit. The CMS 672 dated 4/27/18 listed a census of 92 residents, with 7 residents with pressure ulcers.

Based on observation, interview, and record review the facility failed to provide pain management consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 7 residents reviewed for pain management. (CR #1) --The facility failed to assess, treat and manage CR #1's pain from four stage 3 and stage 4 wounds.He was admitted to a local hospital after a change in condition. -- The facility failed to implement pain management techniques to address CR #1's pain. This failure affected 1 resident and placed 47 other residents at risk of further decline in their mental or physical functioning and untreated pain. Findings include: Intake # 8 CR # 1 Record review of the face sheet for Resident # 1 revealed a [AGE] year old male with admission date of [DATE] and discharge to the hospital on [DATE] for change of condition. [DIAGNOSES REDACTED]. Record review of the Nursing Admission assessment dated [DATE] revealed CR # 1 had a pressure ulcer to the sacrum, [MEDICAL CONDITION] to right lower leg, and left below knee amputation on admission. Record review of the Interim care plan dated 2/24/18 revealed: Problem: resident is at risk for pressure ulcer. Intervention: assess resident for risk; monitor resident nutritional intake; provide preventative equipment if indicated; refer to dietician; skin assessment upon admission and at a minimum weekly therafter; turn and reposition per facility protocol. Record review of the Admission Minimum Data set ((MDS) dated [DATE] revealed CR # 1 had 1 unhealed Stage 3 pressure ulcer that was present upon admission. CR # 1's BIMS score was 14. The Pain Assessment Interview revealed occasional pain or hurting in the last 5 days, with the worst pain at level 6 in the past 5 days. Record review of CR # 1's Acute Care Plan for pain related to wounds (undated) revealed: Interventions included administer pain meds as ordered by physician, assess for pain on admission and as needed thereafter; assess pain for source, duration and severity; notify physician of concerns or if pain persist; reposition for comfort. Record review of CR # 1's undated care plan for resistance to care revealed: refusals to be changed at times, receive wound treatments and will not lie in any position but on his back, and refuses to turn for peri care. Interventions included: allow him to make decisions about treatment regime, to provide sense of control. Encourage as much participation by him as possible during care. Give clear explanation of all care activities prior to and as they occur. If he resists , ressure resident, leave and return 5-10 minutes later and try gain. Provide consistency in care to promote comfort with ADL's. Record review of the Significant Change MDS dated [DATE] revealed a BIMS score of 15. Pain Assessment interview revealed occasional pain or hurting in the last 5 days, with the worst pain at level 3 in the past 5 days. Record review of CR #1's facility progress notes revealed : 3/29/18: resident complained of pain level 5 on his buttock pressure ulcer, MD notified, ordered Tylenol 650 mg every 6 hours PRN for pain. Resident was informed, and stated: what good is that gonna do I want it healed 3/30/18: resident did not want anything for pain, did not allow re-positioning. 4/3/18: resident complained of pain on his buttocks, but wanted nothing for it. 4/10/18: refused to be weighed, stated I do not want to have to go through all of that 4/11/18: refused to be weighed, stated It hurts my butt to be moved around 4/12/18: refused shower, said he did not like to get out of bed. 4/13/18: refuses to allow staff to turn him, refusing to stay on side to get weight off his backside. MD aware. 4/18/18: right hip xray with great difficulty, wants to be left alone, refused to be weighed 4/23/18: refusing to have wound care, stated too tired and sore. MD and DON aware of daily refusals. 4/24/18: refusing wound care, says too sore and too tired. Further review of CR #1's progress notes dated Febuary (YEAR) to (MONTH) (YEAR) revealed the physician was not notified of CR #1's pain or refusals unless noted above. Record review of consolidated physician's orders [REDACTED]. 2/23/18 - 2/28/18: Tylenol tablet 325 mg (Acetominophen) Give 1 tablet by mouth every 6 hours as needed for pain for 1 day (started 2/23/18, end date 2/24/18) 3/01/18 - 3/31/18: Tylenol tablet 325 mg (Acetominophen) Give 2 tablet by mouth every 6 hours for as needed pain (started 3/2/18) 4/01/18 - 4/30/18: Tylenol with [MEDICATION NAME] # 3 tablet (Acetominophen/[MEDICATION NAME]) Give 1 tablet by mouth three times a day for pain (started 4/17/18); [MEDICATION NAME] tablet 15 mg Give 1 tablet by mouth every 2 hours as needed for pain (ordered 4/24/18); [MEDICATION NAME] tablet 15 mg Give 1 tablet by mouth four times a day for pain (started 4/24/18). Monitor for pain every shift use 0-10 scale, if pain is noted, chart in nurses notes the interventions/treatments used and the effectiveness. Record review of CR #1's MAR indicated [REDACTED] Record review of CR #1's MAR indicated [REDACTED]. 4/8/18 at 7:29pm and 4/9/18 at 3:49pm. Tylenol #3, one tablet by mouth ever 6 hours as needed for pain was administered on the following dates: 4/11/18 at 10:18am, 4/11/18 at 5:23pm, 4/12/18 at 4:55pm, 4/13/18 at 2:51pm, 4/14/18 at 12:35pm, 4/15/18 at 3:00pm, 4/17/18 at 11:28am, 4/21/18 at 1:00am, 4/22/18 at 8:00am and 4/22/18 at 2:00pm. In an interview with Wound Care Nurse on 4/27/18 at 11:00 am, she stated CR # 1 was admitted with a sacral wound, and later aquired 3 more wounds (left and right ischeum, and thigh). She said the wound care was to be done every day, and he allowed her to do wound care initially, but he started refusing to be turned for wound treatments in approximately the last 2 weeks because he was sore, and often refused baths and incontient care within the same time frame. Wound Care Nurse stated she and other staff would talk to him about the risks of infection if he didn't allow them to treat the wounds, but often he would still refuse. She stated the wound care specialist came to the facility and assessed the wounds every week. Interview with DON on 4/27/18 at 11:10 am revealed that when CR # 1 refused turning and wound care, they would document that he refused and update the care plan. Record review of the facility weekly wound progress notes revealed the following : 3/13/18: unstageable pressure wound to the right ischium measuring 4 x 7 cm, and a Stage 3 to the sacrum measuring 2.5 x 3 x 0.3 cm. 3/28/18: ustageable pressure wound to the right ischium measuring 4 x 7 cm; Stage 3 to the sacrum measuring 2.5 x 3 x 0.3 cm; and a new Stage 2 pressure wound to the right hip measuring 4 x 4 x 0.2 cm. 4/11/18: Stage 4 (previously unstageable) pressure wound to the right ischium measuring 3.5 x 8 x 3 cm; Stage 3 to the sacrum measuring 4 x 3 x 0.3 cm; unstageable (due to necrosis) of the right hip measuring 7 x 4.5 cm; and a new unstageable pressure ulcer to the left ischium measuring 2 x 2 cm. Record review of the Wound Care Specialist evaluations revealed the following: 3/13/18: (1) Stage 3 pressure wound on his sacrum with moderate serous drainage, measuring 2.5 x 3 x 0.3 cm., (2) an unstageable (due to necrosis) pressure wound of the right ischium with light serous drainange, measuring 4 x 7 x not measurable cm. 3/28/18: (1) Stage 3 pressure wound to the sacrum with moderate serous drainage, measuring 2.5 x 3 x 0.3 cm; (2) unstageable (due to necrosis) pressure wound of the right ischium with light serous drainage, measuring 4 x 7 x not measurable cm; (3) a new pressure wound of the right hip with moderate serous drainage, measuring 4 x 4 x 0.2 cm. 4/11/18: (1) Stage 3 pressure wound to the sacrum with moderate serous drainage, measuring 4 x 3 0.3 cm; (2) Stage 4 pressure wound of the right ischium (previously unstageable) with moderate serous drainage, measuring 3.5 x 8 x 3 cm; (3) unstageable (due to necrosis) pressure wound of the right hip with ligth serous drainage, measuring 7 x 4.5 x not measurble cm; (4) a new unstageable (due to necrosis) of the left ischium with light serous drainage, measuring 2 x 2 x not measurable cm. 4/25/18: (1) Stage 3 pressure wound to the sacrum with moderate serous drainage, measuring 4 x 4 x 0.3 cm; (2) Stage 4 pressure wound of right ischium with moderate serous drainage, measuring 6 x 7 x 3 cm; (3) unstageable (due to necrosis) of the right hip with moderate serous drainage, measuring 7 x 5.5 x not measurable cm; (4) unstageable (due to necrosis) of the left ischium with moderate serous drainage, measuring 2 x 2 x not measurable cm. Record review of the hospital records revealed CR # 1 was admitted on [DATE] due to altered mental status since the afternoon. He was diagnosed with [REDACTED]. Interview with CR # 1 on 4/27/18 at 12:00 pm (in the hospital) revealed he was alert and oriented, but kept drifting off to sleep and then wake up to talk. He stated they did wound care at the facility, but sometimes it would hurt to turn so he would tell them not to do it. In an interview with RN B on 4/27/18 at 1:30 pm, she stated CR # 1 recently had a new pain medication prescribed, that seemed to be working, and they were able to turn him and give him a bed bath on 4/25/18. She stated his wounds were open and draining at that time. In an interview with MA E on 4/27/18 at 1:35 pm, she stated she assisted in the bed bath for CR # 1 on 4/25/18, and stated the wounds were open and stated they looked bad. In further interview, she stated he had refused to be turned a lot, and she would usually go back to ask again, talk to him about the risks of not allowing them to turn or do care, and he would still refuse. At that point, she would document his refusal. In an interview with PTA G on 4/27/18 at 1:38 pm, he stated in the last couple of weeks CR # 1 would often refuse to do therapy, but sometimes they could do light range of motion. He stated the therapy would be very limited due to CR # 1's pain, breathing, and tremors, and when he reached his pain threshold, he would stop them from doing more. In an interview with LVN F on 4/27/18 at 2:45 pm, she stated she did the wound care on weekends. She stated CR # 1 refused care last weekend (4/21, 4/22) and she knew he didn't want to turn because he was hurting. The last time she did weekend wound care was on 4/15/18, and at that time the wounds were draining. In an interview with the DON on 5/1/18 at 9:00 am, she stated CR # 1 would not say why he didn't want to turn, and that he would usually just say no. She further stated she thought the wounds got worse because he refused to turn. In an interview with the Wound Care Nurse on 5/1/18 at 9:30 am, she stated she did not know why the wounds kept popping up, except that he kept refusing to turn. He would say that he hurt, he just had therapy, or he just didn't want to turn. She said he started refusing wound care the last week or so he was in the facility. In an interview with LVN J on 5/1/18 at 10:15 am, she stated CR # 1 recently refused to be turned on the 2pm - 10pm shift, and staff would usually go back to see if he would allow turning, but most often in the last week or 2 he would refuse. They would document whenever he refused. In an interview with the Wound Care Specialist on 5/1/18 at 10: 40 am, he stated CR # 1 was large, and heavy and was admitted with the sacral wound, and had unstageable to right hip, left ischium, and right ischium. He stated it was challenging to treat them because of the resident's pain, and he debrided the necrotic tissue to make them improve somewhat. He stated CR # 1 was pre-medicated for pain before he came, but still complained of pain while he was there to assess the wounds. Wound Care Specialist stated he thought the wounds were improving the last time he saw them, there was more granulation tissue and less drainage. In an interview with Medical Director on 5/1/18 at 10:00 am, he stated that CR # 1 was on Tylenol when he was admitted since the resident said it was working for him, but when he started refusing care recently, he was changed to Tylenol # 3 and [MEDICATION NAME] 15 mg. Medical Director further stated the other wounds probably appeared because he was sitting on them most of the time. He also had heart failure and had to sit up to breathe. He was not aware of CR #1 refusing care because of pain before a few weeks ago. Record review of Daily Skilled Nurses (Pain Assessment) notes dated 03/01/18 - 04/25/18 revealed: 3/27/18: pain level 4, no verbal descriptor, inexpressive facial expression, relaxed body language, and no need to console ; 3/29/18: pain level 4, no verbal descriptor, inexpressive facial expression, relaxed body language, and no need to console; 04/05/18: pain level 3, no verbal descriptor, inexpressive facial expression, relaxed body language, and no need to console; 04/13/18: pain level 4, no verbal descriptor, inexpressive facial expression, relaxed body language, and no need to console; 04/23/18: pain level 2, no verbal descriptor, inexpressive facial expression, relaxed body language, and no need to console. A facility policy on pain management requested from the DON and was not obtained by the time of exit. The CMS 672 dated 4/27/18 listed 47 residents on a pain management program.

Based on observation, interview, and record review, the facility failed to maintain an effective infection control program to help prevent the development and transmission of disease and infection . This was evidenced by: These failures affected 2 residents and placed 85 residents at risk for transmission of disease. Findings included: Observation on 06/10/15 at 3:50 revealed CNA J was in one room assisting a resident then walked to the room next door to answer the call light and then went to the next room and retrieved dirty laundry without washing her hands. She then carried the dirty laundry down the hallway withut washing her hands. In an interview with CNA J on 06/10/15 at 4:00pm she said she could not remember most of what they instructed her to do during the in-service. CMS 672 reports a census of 107 residents.

Based on observation, interview, and record review, the facility failed to implement written policies and procedures that prohibit neglect for one of 23 residents (Resident #1) reviewed for abuse and neglect. CNA D transferred Resident #1 from the bed to the Geri-chair without assistance from another staff and bumped Resident #1's leg. An x-ray was performed and it was found the Resident had a fractured fibula and tibia. This failure affected 1 resident and placed an additional 114 residents at risk of injury. Incident # 6 Findings include: Record review of the face sheet for Resident # 1 revealed the [AGE] year old Resident was admitted to the facility on 7/18/13 with a readmission date of [DATE]. [DIAGNOSES REDACTED]. Record review of the Provider Investigation report dated 1/15/15 revealed CNA D transferred Resident # 1 without additional staff assistance, resulting in an injury on 01/09/15. The investigation note read in part...Resident #1 functional ability was she needed extensive and total assistance... Resident #1 was transferred by CNA D without additional help and it resulted in a tibia/fibula fracture... Assessment was performed on 01/09/15 at 10:30am: leg was swollen and resident expressed that she was in pain... The summary of the investigation read, CNA D transferred the resident by herself and had "bumped her leg on the geri-chair during the transfer...we prefer that two people transfer Resident #1 due to her [DIAGNOSES REDACTED]." Record review of the self report document dated January 10, 2015 revealed Resident #1's medical condition was she had a recent [MEDICAL CONDITION] (no date) that occurred when she was walking to therapy and had a [DIAGNOSES REDACTED]." Record review of Resident #1's Minimum Data Set assessments dated 06/18/14 and 11/08/14 revealed the Resident had severe cognitive impairment, impaired vision, high risk for falls and required extensive assistance of two staff for transfers. Record review of Resident #1's care plan revealed extensive to total staff assistance required for Activity of Daily Living (ADLs) to include transfers. Notation on the care plan revealed 2 person transfer via mechanical lift. Record review of x-ray report dated 1/9/15 read by the Radiologist revealed impression: acute fractures of the shaft of the tibia and fibula. Observation and interview on 01/16/15 at 1:40pm revealed Resident #1 in her bed positioned on her back. She had an immobilizer in place on her left leg. Resident #1 could not remember how she hurt her leg but did say had to stay in bed now and she was bored. In an interview with the DON on 1/16/15 at 2:30 pm she stated that employee training on transfers included using 2 persons for all mechanical lift transfers, but CNA D attempted to transfer Resident # 1 by herself. Resident # 1's leg was red and swollen after the transfer, and an x-ray showed a [MEDICAL CONDITION] and tibia: the type of fracture caused by a twisting motion. Attempts to interview CNA D by phone were made and messages were left but CNA D did not return the messages. CNA D was no longer employed at the facility. In an interview with Resident # 1's roomate on 1/16/15 at 3:00 pm, she stated she was in the room when Resident # 1 was transferred by CNA D, and said she did not witness the transfer itself, but heard Resident # 1 exclaim "ouch" after she was transferred. Record review of facility inservice records on Transfer Techniques, revised April 2011, revealed "never operate a lift alone". Record review of in-services revealed an in-service conducted on 03/24/14, 05/16/14 and 05/19/14 regarding proper transfer techniques. Record review of facility inservices dated 1/9/15 and 1/14/15 revealed "if a resident is 2 person transfer, you must transfer with 2 people". Record review of the facility's abuse and neglect policy dated December 2006 read...Neglect is defined as failure to provide goods and services necessary to avoid physical harm... The CMS 672 listed a census of 115.

Based on observation, interview, and record review, the facility failed to provide services in accordance with the plan of care for one of 23 residents (Resident #1) reviewed for written plan of care. CNA D transferred Resident #1 from the bed to the Geri-chair without assistance from another staff and bumped Resident #1's leg. An x-ray was performed and it was found the Resident had a fractured fibula and tibia. This failure affected 1 resident and placed an additional 114 residents at risk of injury. Incident # 6 Findings include: Record review of the face sheet for Resident # 1 revealed the [AGE] year old Resident was admitted to the facility on 7/18/13 with a readmission date of [DATE]. [DIAGNOSES REDACTED]. Record review of the Provider Investigation report dated 1/15/15 revealed CNA D transferred Resident # 1 without additional staff assistance, resulting in an injury on 01/09/15. The investigation note read in part...Resident #1 functional ability was she needed extensive and total assistance... Resident #1 was transferred by CNA D without additional help and it resulted in a tibia/fibula fracture... Assessment was performed on 01/09/15 at 10:30am: leg was swollen and resident expressed that she was in pain... The summary of the investigation read, CNA D transferred the resident by herself and had "bumped her leg on the geri-chair during the transfer...we prefer that two people transfer Resident #1 due to her [DIAGNOSES REDACTED]." Record review of the self report document dated January 10, 2015 revealed Resident #1's medical condition was she had a recent [MEDICAL CONDITION] (no date) that occurred when she was walking to therapy and had a [DIAGNOSES REDACTED]." Record review of Resident #1's Minimum Data Set assessments dated 06/18/14 and 11/08/14 revealed the Resident had severe cognitive impairment, impaired vision, high risk for falls and required extensive assistance of two staff for transfers. Record review of Resident #1's care plan revealed extensive to total staff assistance required for Activity of Daily Living (ADLs) to include transfers. Notation on the care plan revealed 2 person transfer via mechanical lift. Record review of x-ray report dated 1/9/15 read by the Radiologist revealed impression: acute fractures of the shaft of the tibia and fibula. Observation and interview on 01/16/15 at 1:40pm revealed Resident #1 in her bed positioned on her back. She had an immobilizer in place on her left leg. Resident #1 could not remember how she hurt her leg but did say had to stay in bed now and she was bored. In an interview with the DON on 1/16/15 at 2:30 pm she stated that employee training on transfers included using 2 persons for all mechanical lift transfers, but CNA D attempted to transfer Resident # 1 by herself. Resident # 1's leg was red and swollen after the transfer, and an x-ray showed a [MEDICAL CONDITION] and tibia: the type of fracture caused by a twisting motion. Attempts to interview CNA D by phone were made and messages were left but CNA D did not return the messages. CNA D was no longer employed at the facility. In an interview with Resident # 1's roomate on 1/16/15 at 3:00 pm, she stated she was in the room when Resident # 1 was transferred by CNA D, and said she did not witness the transfer itself, but heard Resident # 1 exclaim "ouch" after she was transferred. Record review of facility inservice records on Transfer Techniques, revised April 2011, revealed "never operate a lift alone". Record review of in-services revealed an in-service conducted on 03/24/14, 05/16/14 and 05/19/14 regarding proper transfer techniques. Record review of facility inservices dated 1/9/15 and 1/14/15 revealed "if a resident is 2 person transfer, you must transfer with 2 people". The CMS 672 listed a census of 115.