Every finding on record at Focused Care at Linden

Based on interview and record review the facility failed to allow the resident the right to obtain a copy of the records or any portions thereof, including in an electronic from or format when such records were maintained electronically, upon request and 2 working days advance notice to the facility for 1 of 1 resident (Resident #1) reviewed for the right to access copies of records. The facility failed to provide medical records for Resident #1 to the legal representative of Resident #1's family member within two working days of a request on [DATE] and [DATE].This failure could place residents at risk by causing a negative health impact due to not having continuity of care.Findings include:Record review of a face sheet, dated [DATE], indicated Resident #1 was originally admitted on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses which included dementia (a decline in mental ability severe enough to interfere with daily life), peripheral vascular disease (a disease of the blood vessels that restricts circulation to the legs and feet), and need for assistance with personal care. The face sheet indicated Resident #1 was discharged from the facility on [DATE].Record review of a Significant Change MDS, dated [DATE], indicated Resident #1 was understood and understood others. The MDS indicated Resident #1's BIMS was a 9, which indicated moderate cognitive impairment.Record review of a nurses note, dated [DATE] at 4:34 p.m., indicated Resident #1 expired in the facility on [DATE].Record review of an Authorization Form for Release of Protected Health Information for Resident #1 indicated, I, (Family Member A), hereby authorize the following named physician(s) or health care providers to obtain and disclose.the protected health information and associated billing records described below.The health information and billing records in the custody of the physicians or health care providers who have examined, evaluated, or treated (Resident #1). The facility and the medical director were listed as the names of the health care providers. The form was signed by Family Member A and Resident #1 on [DATE]. The form indicated Family Member A was Resident #1's power of attorney.Record review of a certified mail receipt post marker [DATE] and addressed to the facility indicated a received signature of the Business Office Manager. The sender was the legal representative of Family Member A.Record review of a formal letter from the office of the legal representative of Family Member A, dated [DATE], indicated the Authorization Form for Release of Protected Health Information for Resident #1, dated [DATE], was attached. The letter also indicated, Please provide, (Resident #1's) records electronically within 48 hours of receiving this notice.During an interview on [DATE] at 9:35 a.m., the Administrative Assistant for the legal representative of Family Member A said Resident #1's records were requested almost a year ago. She said the full record for Resident #1 had been requested. She said they had not received a response and had not received the records.During an interview on [DATE] at 12:18 p.m., the Executive Director of Operations said she vaguely remembered an attorney sending a release for the records of Resident #1. She said typical procedure was to send the request on to the main corporate office and then they released the records. She said she would have to do some checking because it had been a while. She said the signature on the certified mail receipt postmarked [DATE] appeared to be the signature of the Business Office Manager. She said the Business Office Manager was not present in the facility.During an interview on [DATE] at 2:18 p.m., the Executive Director of Operations said she found the request in an email she sent to the main corporate office. She said she called the corporate office, and no one could provide confirmation the records for Resident #1 were released. She said the records were now being processed and would be sent out. She said records should be released when they were requested because the family had the right to the resident's information.Record review of an Access to Medical Records facility policy, last revised on [DATE], indicated, .Each resident has the right to access and or obtain copies of his or her personal and medical records upon request.A resident/responsible party may submit his/her request either orally or in writing for access to personal or medical records pertaining to him/her .Request will be sent to the Chief Clinical Officer and Director of Regulatory/Risk Management.The resident/responsible party may obtain a copy of his or her personal or medical record within two business days of an oral or written request.

Based on interview and record review, the facility failed to send a copy of the transfer or discharge notice to a representative of the Office of the State Long-Term Care Ombudsman for 2 of 2 residents (Resident #1 and Resident #2) reviewed for discharge notices. The facility did not ensure Ombudsman A was provided with a copy of the 30-day discharge notices for Resident #1 and Resident #2. This failure places residents at risk of not having access to an advocate who could have informed them of their options and rights and being inappropriately discharged from the facility. The findings included: 1. Record review of the face sheet, dated 06/24/26, reflected Resident #1 was a [AGE] year-old female who admitted to the facility on [DATE] with a diagnosis of unspecified dementia without behaviors (loss of cognitive functioning that interferes with daily life). Record review of the quarterly MDS assessment, dated 06/05/26, reflected Resident #1 had clear speech, was understood by others, and was able to understand others. Resident #1 had a BIMS score of 12, which reflected moderately impaired cognition. The MDS reflected no active discharge planning was occurring for the resident to return to the community. Record review of Resident #1's comprehensive care plan, dated 07/22/25, reflected that she required 24-hour supervision and treatment, and the discharge plan was to remain in the facility for long-term care. Record review of Resident #1's Notice of Intent to Discharge letter, dated 06/11/26, reflected a formal notification of discharge from the facility was being provided to Resident #1's family member because Medicaid pending supporting documents were not received. Ombudsman A's contact information was provided in the letter, and the bottom of the letter reflected a copy of the letter should have been sent to Ombudsman A through first class mail. 2. Record review of the face sheet, dated 06/24/26, reflected Resident #2 was an [AGE] year-old male who admitted to the facility on [DATE] with a diagnosis of unspecified dementia with other behavioral disturbance (loss of cognitive functioning that interferes with daily life). Record review of the quarterly MDS assessment, dated 05/06/26, reflected Resident #2 had clear speech, was understood by others, and was able to understand others. Resident #2 had a BIMS score of 10, which reflected moderately impaired cognition. The MDS reflected no active discharge planning was occurring for the resident to return to the community. Record review of Resident #2's comprehensive care plan, dated 02/05/26, reflected no care plan was in place to address discharge goals. Record review of Resident #2's Notice of Intent to Discharge letter, dated 06/11/26, reflected a formal notification of discharge from the facility was being provided to Resident #2's family member because Medicaid pending supporting documents were not received. Ombudsman A's contact information was provided in the letter, and the bottom of the letter reflected a copy of the letter should have been sent to Ombudsman A through first class mail. During an interview on 06/24/26 at 1:25 p.m., Ombudsman A stated she was unaware that Resident #1 and Resident #2 had been issued a 30-day discharge notice from the facility. She stated the facility were supposed to provide her with a copy of the notices so she could have contacted the family and appealed the decision if it was wanted. Ombudsman A stated she liked to know when discharge letters were issued so she could have informed the resident or the resident's family of their rights. During an interview on 06/24/26 at 2:04 p.m., the BOM stated she was responsible for writing the 30-day discharge notices and mailing them, after the Administrator reviewed and signed them. She stated 30-day discharge notices were not common and she did not issue them regularly. The BOM stated she typed Resident #1 and Resident #2's letters on 06/11/26 but did not mail them to Resident #1 and Resident #2's family member until 06/15/26. She said she did not mail a copy of the letters to Ombudsman A. She stated Ombudsman A's contact information was provided on the letter and the family could have contacted Ombudsman A if they chose to. The BOM stated she was unaware that a copy of the letter needed to be provided to Ombudsman A. During an interview on 06/24/26 at 2:54 p.m., the Administrator stated she only issued a 30-day discharge notice from the facility as a last resort. She stated Resident #1 and Resident #2's family members had been asked on multiple occasions over multiple months to provide financial documents required to be sent with the Medicaid application process. The Administrator stated the requested documents were never received. She stated the 30-day discharge letters were sent on 06/15/26 and Ombudsman A was not provided with a copy of the letter. She stated Ombudsman A's contact information was provided to the family in the letters. She stated Ombudsman A was notified today on 06/24/26 after the surveyor intervention. She said it was important to ensure Ombudsman A was provided with a copy of the 30-day discharge notices so she could have communicated with the family and made an appeal as needed. Record review of the Transfer or Discharge Notice policy, dated December 2016, reflected . A copy of the notice will be sent to the Office of the State Long-Term Care Ombudsman.

Based on observations, interviews, and record review, the facility failed to ensure that residents received adequate supervision and assistance devices to prevent accidents for 1 (Resident #20) of 6 residents reviewed for accidents and supervision. The facility failed to ensure adequate supervision and implementation of safety interventions for a resident assessed to be at risk for elopement. This resulted in Resident #20 exiting the building on 03/19/2026 without staff knowledge or supervision, placing the resident at risk for harm. The noncompliance was identified as PNC. The Immediate Jeopardy (IJ) began on 03/19/2026 and ended on 03/20/2026. The facility had corrected the noncompliance before the survey began. This failure could result in residents leaving the facility without supervision, placing them at risk for injury, harm, or death.Findings included: Record review of a face sheet dated 04/14/2026 indicated Resident #20 was a [AGE] year-old male that admitted to the facility on [DATE] with diagnoses of CVA (medical emergency caused by blocked or ruptured blood vessels restricting blood flow to the brain), hemiplegia (the severe or complete paralysis of one side of the body, usually caused by brain damage [such as stroke, tumor, or trauma] on the opposite side), and bipolar disorder (a chronic mental health condition characterized by extreme mood swings, including emotional highs [mania or hypomania] and lows [depression]). Record review of a quarterly MDS assessment dated [DATE] revealed Resident #20 had a BIMS of 07 which indicated moderate cognitive impairment. The MDS also revealed Resident #20 was mobile per walker and required partial (helper does less than half) assistance with toileting. Resident #20 required stand by assistance for transfer and bed mobility. Resident #20 was coded as having wandering behaviors 1-3 days. Record review of a care plan dated 03/19/2026 revealed Resident #20 was at high risk for elopement and had a wander guard on his left wrist as of 03/19/2026. There was no care plan for elopement prior to 03/19/2026. Record review of an elopement risk assessment dated [DATE] revealed Resident #20 was a moderate risk for elopement with a numerical score of 5. Record review of an elopement risk assessment dated [DATE] revealed Resident #20 was a high risk for elopement with a numerical score of 6. The assessment revealed Resident #20 voiced desire to leave the facility.Record review of a progress note written by LVN A on 03/19/2026 at 11:47 a.m., revealed Resident #20 was noted to be outside of the facility by the side of the road and was found by LVN B when she was returning to work from break. Resident #20 was assisted back inside the facility and assessed for injury with none found. A Wanderguard was placed on the resident, and his care plan was updated. Family, MD, Administrative nurses were notified.During an observation and interview on 04/14/2026 at 10:00 a.m., the Administrator revealed the area of the facility grounds where Resident #20 was located by LVN B on 03/19/2026 was flat grassy terrain approximately 10 feet from the entrance of the facility and 4 feet from the residential street running adjacent to the building. The speed limit sign read 20 miles per hour. Resident #20 was approximately 40 yards from the road running parallel to the facility and the posted speed limit was 35 miles per hour. She stated Resident #20 had not made it to the road when he was noted outside and returned to the facility.During an interview on 04/14/2026 at 1:00 p.m., LVN A stated she was the nurse that was on duty the day Resident #20 eloped. She stated she last saw Resident #20 at around 11:15 a.m.- 11:20 a.m. She stated he was at the nurse's station attempting to call family member and was unsuccessful. She stated he headed back down towards his room with his walker, and she went on to assist the next resident. She stated at 11:30 a.m., she received a phone call from LVN B stating Resident #20 was out by the road next to the facility. She stated not wanting to leave the other residents unattended, she alerted the Activity Director, and the Activity Director went out to assist LVN B to bring Resident #20 back inside the facility. She stated when he came in, she immediately assessed him, and he had no injuries, and she applied a Wanderguard. She stated she thought he must have exited the front door because the front door only locked when someone wearing a Wanderguard got within a few feet of it. She stated it alarmed if someone with a Wanderguard attempted to exit or actually exited and no alarm ever sounded. LVN A stated once Resident #20 was assessed and safe, she notified the DON, Administrator, MD, and Resident #20's family member. She stated when she questioned Resident #20, he stated he wanted to go home. LVN A stated she was the nurse that completed Resident #20's quarterly elopement risk assessment the day before on 03/18/2026 and she was aware he went from a moderate risk for elopement to a high risk for elopement. She stated he had recently started saying I got to go. She stated he never exited any door or even went up to the doors prior to his elopement. LVN A stated she was not aware that she needed to immediately put intervention in place for Resident #20. She stated on 03/20/2026 the Administrator provided education to her about the process of implementing an intervention for any assessment that changes a resident to a high risk resident and contacting an administrative nurse for guidance if you are unsure what intervention to put in place. LVN A stated Resident #20 has had no further attempts at elopement. He sat near the nurse's station for the remainder of the day. She stated she was instructed to test the Wanderguard at the door and she did. During an interview on 04/14/2026 at 2:10 p.m., LVN B stated on 03/19/2026 she was returning from her lunch break around 11:30 a.m. and noted a resident walking through the yard of the facility toward the residential road that runs alongside the building. She stated when she got closer, she saw that it was Resident #20 and pulled over on the side of the residential road to assist him back to the facility. She stated she called LVN A and told her about Resident #20 being in the yard headed to the road. She stated within 2 minutes the Activity Director came out and assisted her to get Resident #20 back into the building. She stated Resident #20 was in no distress and the weather was between 65-70 degrees with no rain. She stated Resident #20 was difficult to understand but she made out he was headed home. During an interview on 04/14/2026 at 2:30 p.m., the Activity Director stated she was in the hallway on 03/19/2026 around 11:30 a.m. when LVN A asked her to go outside and assist LVN B with Resident #20. She stated she found LVN B walking with Resident #20 back towards the building when she went out the front door. She stated they were about 10 feet from the side of the residential road that ran beside the facility. The Activity Director stated she met them in the yard and assisted Resident #20 back to the facility while LVN B moved her car. She stated Resident #20 was not in any distress when returned to the facility. During an interview on 04/14/2026 at 2:40 p.m., the Director of Plant Operations (DPO) stated he was notified of Resident #20's elopement and was instructed to check all exit doors to confirm proper function. He stated he did so immediately. The DPO stated he checked all exit doors on a routine basis as part of his facility inspection. He stated all exit doors functioned properly. During an interview on 04/14/2026 at 2:48 p.m., the MDS Coordinator stated she was instructed to complete elopement assessments on all residents in the facility and compare them with the previous assessment to ensure all residents had the proper elopement risk with interventions. She stated she audited all 40 residents and checked their care plans for interventions, and no resident's status changed. During an interview on 04/14/2026 at 2:58 p.m., the DON stated she was called about the incident on 03/19/2026 as soon as it happened and directed LVN A to apply the Wanderguard after she assessed Resident #20 and to complete another elopement assessment and update his care plan. She stated she was working night shift and was not in the facility on 03/19/2026 during the time of the incident. The DON stated she or her designee began monitoring all new admits and high-risk individuals for accuracy of assessments and interventions each day for 2 months. She stated she or designee also audited all elopement risk assessment and care plans to ensure that all staff had resident information stayed up to date in the EHR. During an interview on 04/14/2026 at 3:10 p.m., the Administrator stated she was called about the incident on 03/19/2026 with Resident #20 around 11:40 a.m., she was out of the facility at the time. She stated she instructed LVN A to ensure the functioning of the Wanderguard and place Resident #20 on increased supervision. She stated she called the DPO and asked him to check the grounds and test all Wanderguards and exit doors for proper functioning. Upon her return to the facility, she obtained statements from all employees on duty to determine how Resident #20 exited the facility. No statement indicated any alarm was sounded prior to Resident #20 being located outside of the facility. She stated it was her belief Resident #20 exited the facility through the front door as it was the only door that would not have alarmed since Resident #20 was not wearing a Wanderguard at the time. She stated she began the inservice training on the facility's Elopement Policy and Procedure to include where to find additional information on all residents deemed to be high risk for elopement. All nurses received training on identifying residents that were high risk for elopement and promptly putting interventions in place when high risk residents were identified and updating the care plan, so the rest of the facility becomes aware of the change. The Administrator stated she directed the MDS nurse to complete an elopement assessment audit for all residents to validate that all assessments were current and accurate. She stated the audit did not find any new high risk elopement residents. She stated she directed the social worker to validate that each resident deemed a high risk for elopement had the information updated in their chart to alert all staff of the resident's high-risk status. She stated she conducted a root cause analysis to pinpoint the area of breakdown and counseled LVN A. She stated an Ad Hoc QA meeting was held to discuss elopement and develop a plan to prevent elopements such as this occur again. She stated they planned to discuss the performance improvement plan monthly for the next 2 months to ensure it worked. Review of facility policy titled 'Elopement' dated 11/01/2019 revealed, if a resident triggers for high elopement risk, staff is to immediately notify the charge team and interdisciplinary team to review the care plan and implement necessary interventions. The facility had corrected the noncompliance on 03/20/2026 by the following:- Returning Resident #20 to the facility with no injury- Reassessing Resident #20's elopement status and providing a Wanderguard to ensure his safety.- Updating Resident #20's care plan to ensure all staff were aware of his elopement status- Education with LVN A on accurate elopement assessment and prompt interventions for high-risk residents on 03/19/2026.- 100% nursing staff on all shifts received education on wandering/elopement and resident safety and included new process of checking all assessments scored as high risk for accuracy and intervention each day in morning meeting.- All Wanderguard systems and door alarms were checked for proper functioning.- DON and/or designee were monitoring new admissions and high-risk residents to ensure interventions were in place daily for 2 months.- DON and/or designee were auditing elopement risk assessments weekly for 2 months to ensure care plans reflect the needs and concerns in the assessments.- The ad hoc Quality Assurance and Performance Improvement committee that was completed with the medical director and interdisciplinary team will be discussed at QAA meetings for a minimum of 3 months or until a pattern of compliance is maintained. Record review of an Ad Hoc Quality Assurance (QA) Meeting Sign-in Sheet dated 03/20/2026 indicated the facility had an QA meeting addressing the incident. The QA Meeting Sign-in Sheet indicated the DON, ADON, Medical Director, LVN A, Director of Plan Operations, Activity Director, MDS Coordinator, Medical Records staff member, Director of Therapy, Director of Plant Operations and the Administrator attended. Record review and interview of the sampled residents from 04/13/2026 to 04/14/2026 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #7, Resident #8, Resident #15, Resident #17, Resident #19, Resident #21, Resident #36, Resident #37 and Resident #48) revealed they had not eloped. They stated they had not attempted to elope. All staff interviewed (LVN A, LVN B, CNA C, CNA D, RN E, [NAME] F, CNA J, CNA K, LVN L, CNA M, Housekeeper N, Housekeeper O, the Social Worker, the Activity Director, the Dietary Manager, and ADON) on 04/14/2026 and 04/15/2026 verbalized they had been in-serviced on risk management related to elopement, the facilities policy on elopement, how to respond when an elopement occurred and how to prevent elopement. Each staff member was able to verbalize the definition of elopement, how to recognize each resident's elopement risk and interventions, and how to respond to an elopement situation. The nurses were able to verbalize the importance of accurate elopement assessments and providing immediate intervention for new high-risk residents. Record review of an 'Inservice Training Report' dated 03/19/2026 indicated all staff were in-serviced on the facility Elopement policy and the process of ensuring high risk residents have interventions in place. The training was conducted by the Administrator. Record review of an 'Inservice Training Report' dated 03/20/2026 indicated LVN A was inserviced on accurate risk assessments and providing immediate intervention for newly identified high risk residents. Record review of 'Door Locks and Alarm Checks' dated 03/19/2026 to 04/15/2026 indicated all doors, locks and alarms had been tested daily since 03/19/2026. Record review of 'New admission and High-Risk Monitoring List' dated 03/20/2026 indicated review occurred daily since 03/20/2026. Record review of 'Elopement Risk Assessment Audit' dated 03/20/2026 indicated elopement risk assessments were reviewed weekly since 03/20/2026. During an observation and interview on 04/14/2026 at 1:10 p.m., Resident #20 was observed wearing a Wanderguard to his left wrist. Resident # 20 was walked up to the door and said It won't let me out. It is going to lock. The door locked and alarm sounded when surveyor attempted to open door with Resident #20 within 3 feet of the door. The noncompliance was identified as PNC. The Immediate Jeopardy (IJ) began on 03/19/2026 and ended on 03/20/2026. The facility had corrected the noncompliance before the survey began.

Based on observation, interview and record review, the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 2 of 17 residents (Resident #3 and Resident #21) reviewed for pharmacy services.1.The facility failed to administer (7) doses of Multivitamin with minerals, (9) doses of Pepcid (famotidine-medication to reduce stomach acid), and (10) doses of Stress B Complex (dietary supplement designed to support energy and immune system function during times of stress) for Resident #3.2. The facility failed to administer (12) doses of Multivitamin with minerals, (14) does of famotidine, and (10) doses of GlycoLax (medication for constipation) for Resident #21 from 3/01/2026 to 4/13/2026.These failures could place residents at risk for not receiving the intended therapeutic benefit of prescribed medications. 1. Record review of a face sheet dated 4/15/2026 indicated Resident #3 was [AGE] year-old male originally admitted on [DATE] and readmitted on [DATE] with diagnoses including hypoglycemia (a condition in which your blood sugar (glucose) level is lower than the standard range), CVA (stroke), and convulsions (involuntary, rapid, and rhythmic shaking of the body caused by erratic electrical activity in the brain). Record review of a significant change MDS assessment dated [DATE] indicated Resident #3 required dependent assistance with ADLs such as transfer, toileting, and dressing. The MDS indicated Resident #3 had a BIMS score of 99, which indicated severely impaired cognition. Record review of MD orders dated March 2026 revealed the following orders for Resident #3: Multivitamin with minerals give one per PEG (percutaneous endoscopic gastrostomy- feeding tube) daily- start date 3/04/2026 and no stop date. Pepcid 40mg give one per PEG daily-start date 3/04/2026 and no stop date. Stress B-Complex 500mg give one per PEG daily-start date 3/04/2026 and no stop date. Record review of the MAR dated March 2026 revealed the following missed doses of medication for Resident #3: Multivitamin with minerals was missed on 3/24/26, 3/27/2026, 3/28/2026, and 3/29/2026. Pepcid 40mg tablet was missed on 3/26/2026, 3/27/2026, 3/28/2026, and 3/29/2026. Stress B-Complex was missed on 3/04/2026 through 3/13/2026. Record review of the MAR dated April 2026 revealed the following missed doses of medication for Resident #3: Multivitamin with minerals was missed on 4/01/2026 through 4/03/2026. Pepcid 40mg tablet was missed on 4/01/2026 through 4/03/2026. Stress B-Complex was missed on 4/01/2026 through 4/03/2026. During an interview on 4/14/2026 at 11:40 a.m., RN E stated she had not given Multivitamin with minerals, Pepcid, and Stress B- Complex to Resident #3 on the dates marked as not administered on the MAR in both March and April because the medications were not available in the facility. She stated she checked the medication rooms and the other medication carts and when she could not find them, put them on the list of items that needed to be reordered. She stated she did not think to call the MD and inform him the facility was out of the medication. RN E stated she was unsure who reordered over the counter medications. She stated she had been instructed to make a list that was kept in the medication room with all over-the counter medications that needed to be reordered. 2. Record review of Resident #21's face sheet dated 4/13/2026 revealed he was [AGE] years old and admitted to the facility initially on 2/17/2014 and readmitted on [DATE]. Resident #21 had diagnoses including cerebral palsy (permanent movement and posture disorders caused by abnormal brain development or damage, typically occurring before birth), gastroparesis (delayed emptying of stomach contents), gastrostomy (also call PEG tube-device inserted through the abdominal wall directly into the stomach to deliver nutrition, fluids, and medications when oral intake was insufficient), quadriplegia (unable to move body, typically caused from damage of the spinal cord in the neck). Record review of Resident #21's quarterly MDS assessment dated [DATE] revealed he had no speech and was rarely/never understood and sometimes understood others. Resident #21 was unable to complete the BIMS because he was rarely/never understood. Resident #21 was dependent on staff assistance for all ADLs. Record review of MD orders dated April 2026 revealed the following orders for Resident #21: Multivitamin-minerals give one tablet per PEG tube one time a day for supplement- start date 2/28/2024 and no stop date. Famotidine 20mg give one tablet two times daily for acid indigestion-start date 5/28/2026 and no stop date. GlycoLax powder (polyethylene Glycol 3350) give 17 grams by PEG two times a day for constipation with 4-8 ounces of water-start date 5/19/2025 and no stop date. Record review of the MAR dated March 2026 revealed the following missed doses of medication for Resident #21: Multivitamin-minerals were missed on 3/13/26, 3/14/2026, 3/15/2026, 3/18/2026, 3/19/2026, 3/23/2026, 3/24/2026, 3/27/2026, 3/28/2026, 3/29/2026, and 3/31/2026. Famotidine 20 mg tablet was missed on 3/09/2026, 3/11/2026, 3/12/2026, 3/13/2026, 3/14/2026, 3/23/2026, 3/24/2026, 3/27/2026, 3/28/2026, 3/29/2026 and 3/31/2026. GlycoLax powder was missed on 3/31/2026. Record review of the MAR dated April 2026 revealed the following missed doses of medication for Resident #21: Multivitamin-minerals tablets were missed on 4/02/2026. Famotidine 20 mg tablets were missed on 4/01/2026, 4/02/2026 and 4/03/2026. GlycoLax powder was missed on 4/01/2026, 4/02/2026, 4/03/2026, 4/06/2026, 4/07/2026, 4/09/2026, 4/10/2026, 4/12/2026 and 4/13/2026. Record review of Resident #21's Administration notes indicated: 3/09/2026 LVN A documented Famotidine tablet 20 mg - OUT OF STOCK 3/11/2026 RN E documented Famotidine tablet 20 mg - on order 3/12/2026 RN E documented Famotidine tablet 20 mg - on order 3/13/2026 LVN A documented Famotidine tablet 20 mg - OUT OF STOCK 3/13/2026 LVN A documented Multiple Vitamins-Mineral - OUT OF STOCK 3/14/2026 LVN A documented Famotidine tablet 20 mg - OUT OF STOCK 3/14/2026 LVN A documented Multiple Vitamins-Mineral - OUT OF STOCK 3/15/2026 LVN A documented Multiple Vitamins-Mineral - OUT OF STOCK 3/18/2026 LVN A documented Multiple Vitamins-Mineral - OUT OF STOCK 3/19/2026 LVN A documented Multiple Vitamins-Mineral - OUT OF STOCK 3/23/2026 LVN A documented Multiple Vitamins-Mineral - OUT OF STOCK 3/23/2026 LVN A documented Famotidine tablet 20 mg - OUT OF STOCK 3/24/2026 LVN A documented Multiple Vitamins-Mineral - OUT OF STOCK 3/24/2026 LVN A documented Famotidine tablet 20 mg - OUT OF STOCK 3/27/2026 LVN A documented Famotidine tablet 20 mg - OUT OF STOCK 3/27/2026 LVN A documented Multiple Vitamins-Mineral - OUT OF STOCK 3/28/2026 LVN A documented Multiple Vitamins-Mineral - OUT OF STOCK 3/28/2026 LVN A documented Famotidine tablet 20 mg - OUT OF STOCK 3/29/2026 LVN A documented Famotidine tablet 20 mg - OUT OF STOCK 3/29/2026 LVN A documented Multiple Vitamins-Mineral - OUT OF STOCK 3/31/2026 RN E documented Multiple Vitamins-Mineral - on order 3/31/2026 RN E documented Famotidine tablet 20 mg - on order 3/31/2026 RN E documented GlycoLax Powder - on order 4/01/2026 LVN A documented Famotidine tablet 20 mg - OUT OF STOCK 4/01/2026 LVN A documented GlycoLax Powder - OUT OF STOCK 4/02/2026 LVN A documented GlycoLax Powder - OUT OF STOCK 4/02/2026 LVN A documented Multiple Vitamins-Mineral - OUT OF STOCK 4/02/2026 LVN A documented Famotidine tablet 20 mg - OUT OF STOCK 4/03/2026 LVN A documented Famotidine tablet 20 mg - OUT OF STOCK 4/03/2026 RN E documented GlycoLax Powder - on order 4/06/2026 LVN A documented GlycoLax Powder - OUT OF STOCK 4/07/2026 LVN A documented GlycoLax Powder - OUT OF STOCK 4/09/2026 ADCO documented GlycoLax Powder - ordered 4/10/2026 LVN A documented GlycoLax Powder - OUT OF STOCK 4/12/2026 LVN A documented GlycoLax Powder - OUT OF STOCK 4/13/2026 RN E documented GlycoLax Powder - on order During an observation on 4/14/2026 at 3:20 PM, RN E showed she had MVI with minerals, famotidine, and GlycoLax in her medication cart for Resident #21. During an observation and interview on 4/14/26 at 3:35 PM, Resident #21 was lying in bed. Resident #21 was non-verbal. Resident #21 blinked twice, indicating he was not having any stomach pain at that time. Resident #21 blinked once indicating staff took good care of him. During an interview on 4/15/2026 at 9:34 AM, LVN A said she had worked at the facility for six months as nurse after graduating nursing school. LVN A said they had a clip board in the supply closet to write down any OTC medications or supplies that were needed. LVN A said the central supply person who was doing the ordering, no longer worked at the facility. LVN A said she thought Activity Director and the DCO were doing the ordering now. LVN A said she documented in Resident #21's chart the medications were not given because the Pepcid and the MVI with minerals were not available in the building at time of administration. LVN A said she was not sure why they were not available, but she did not have them. LVN A said she had written on the clip board in the supply room several times and told the Central Supply person. LVN A said she knew they had hired a new person and were trying to get things straightened out. LVN said she did not notify the MD that the medications were not available because she did not know she needed to. LVN A said she was still learning the processes. LVN A said the nurse was responsible for ensuring the resident received their medications as ordered by the MD, but if the medications were not available, she could not give them. LVN A said the Pepcid (famotidine) and GlycoLax not being available for Resident #21 could be real bad because he was a quadriplegic. During an interview on 4/15/2026 at 10:20 AM, MD P said he would expect his orders to be followed. Md P said it was general nursing for nursing staff to let him know if the resident was not getting medications as he prescribed. MD P said he didn't think missing doses of the MVI with minerals, GlycoLax, or famotidine affected Resident #21. During an interview on 4/15/2026 at 1:10 PM, the DCO stated she was temporarily responsible for ordering and reordering supplies and medications. She stated in the past it had been the responsibility of the medical records designee to order supplies and over the counter medications. She stated the medical records staff member was terminated and the assignment of ordering supplies and medications was reassigned to the activity's director temporarily until a new medical records staff member could be hired and trained. The DCO stated there had been a gap in time when supplies were not ordered timely, because of the lack of communication between the floor staff and herself on how low the over-the-counter medication supplies were. She stated there were a few items that the facility ran out of. She stated had she known the facility was completely out she would have run to the local stores and obtained the medications for the residents. The DCO stated she expected all orders to be followed and the staff to inform her if the facility is out of particular medication and if they are unable to obtain it the MD should be called for further direction. The DCO stated did not feel there was a significant adverse effect on the residents for missing over the counter medications. During an interview on 4/15/2026 at 1:13 PM, RN E said she had worked at the facility since January 2026 full-time. RN E said she believed the last order for the MVI with minerals was made by the previous ordering person and the MVI with minerals was ordered wrong, but she did not know why the famotidine was not available. RN E said not receiving the famotidine could have caused Resident #21 to have increased abdominal pain. RN E said if medications or supplies were not available in the facility the MD should be notified to see if alternative interventions or medications were needed. During an interview on 04/15/2026 at 2:30 PM, the Administrator said she expected the nurses to communicate with DCO and herself any problems they have getting anything they need for the residents from clothing to medications and equipment. The Administrator said the facility would have sent the van driver to the store for the medications had they known the facility was out. During an interview 4/15/2026 at 3:28 PM, the ADCO said the person who was supposed to be ordering those OTC medications and supplies was not doing their job and they fired her about two weeks ago. The ADCO said in all reality, they could have bought those OTC medications at the store down the street. During an interview on 4/15/2026 at 3:59 PM, the DCO said Resident #21 not receiving the Pepcid (famotidine) could have led to Resident #21 having increased discomfort. The DCO said if a medication was not available the nurse should have notified the MD for a replacement or let her know if it was something she could just run and get from the store. Record review of the facility's policy titled Administering Medications, dated revised on April 2019 stated . medications were administered in a safe and timely manner, and as prescribed . medications were administered in accordance with the prescribers orders, including any required time frame . the individual administering medication checks the label THREE times to verify the right resident, right medication, right dosage, right time, and right method/route of administration before giving the medication . Mediations must be administered within one (1) hour of their prescribed time, unless otherwise specified .

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety requirements.The facility failed to ensure there was minimal carbon buildup on 3 skillets.The facility failed to ensure the stove was clean from debris and black carbon buildup on the stove top.The facility failed to ensure there was no grease buildup on the fryer.The facility failed to ensure the toaster was clear of debris on 4/14/2026.These failures could place residents at risk of foodborne illness and food contamination. Findings included:During initial tour observations in the kitchen on 4/13/2026 at 9:08 AM and accompanied by Dietary Manager, there was yellow to amber colored film build up behind the [NAME] and along the right side of the [NAME] with a baking sheet screwed into wall to divide the [NAME] from the oven. The baking sheet observed to have black area with debris and yellow substance scattered on the baking sheet. The toaster was observed to have crumb debris inside the toast with debris located in the base and corners of the toaster. There were 4 frying pans located on the shelf next to the stove with black carbon build up on the base of the frying pans and one frying pan with thick black buildup on the inside of the pan.During an observation on 4/14/2026 at 11:46 AM, observed black carbon buildup on pots/pans stored next to the stove. The [NAME] also observed to have yellow to amber colored film buildup behind the [NAME] and along the side of the [NAME] with a baking sheet screwed to the wall. The skillets remain stored on shelf next to the stove with observed black carbon buildup.During an interview on 4/15/2026 at 1:08 PM, [NAME] F said all the kitchen staff pitch in to clean the equipment in the kitchens such as pots, pans, surfaces. The manager cleans the [NAME], stove, and big stuff in the kitchen. She said the maintenance man cleans the gas lines. [NAME] F said the kitchen staff clean the industrial equipment monthly. She said they would remove the pots/pans from services if the pan was scorched, burned, or bowed out. She said the black substance on the pots and pans looked like soot. She said the kitchen staff sign off on the checklist cleaning schedule log when the task was completed. The [NAME] said if the pots and pans were in use it could cause a fire. The [NAME] said the manager and kitchen staff were responsible for ensuring the equipment was clean and there was no black build up. During an interview on 4/15/2026 at 1:15 PM, [NAME] G said she was responsible for ensuring the kitchen was clean. She said the kitchen staff changed the oil in the [NAME]. [NAME] G said she cleaned the kitchen stove every couple of days, but she did wipe up spills daily. She said if the [NAME] was not cleaned, it could cause a fire. She said the pots and pans should not have black carbon buildup and stated it could cause a fire. [NAME] G said the aide helper should clean the toaster after every use. She said the debris could cause a fire. [NAME] G said if the pots and pans could not be cleaned up, then they need to be replaced. The [NAME] said she always sweeps and mops at night when she works. She said she usually tries to clean the stove 1 x weekly, but she does not always get it done. She said she puts the stove parts in the sink and puts degreaser and cleaned them off. She said the buildup could cause a fire. [NAME] G said the [NAME] should be cleaned because the grease could cause a fire. [NAME] G said everyone should clean a little each day. During an interview on 4/15/2026 at 1:28 PM, The Director of Food Service said she expected the kitchen staff to clean the kitchen daily. She said the deep [NAME] was cleaned every Friday. She said she expected the kitchen staff to clean as they go throughout their day. The Director of Food Service said if the deep [NAME] was cleaned on Friday, it should not have the grease buildup on it when surveyor entered on Monday. She said sometimes the kitchen staff falls short on tasks. She said the kitchen staff try to clean the oven and stove when there is a mess on it. She said she felt she needed a stronger chemical to clean the stove and the staff used a degreaser. She said the buildup of grease on the [NAME], and the stove carbon buildup could cause a fire. She said before the previous Director left; she was going to bring a cleaning tool for the stove. The Director of Food Service said the toaster should be cleaned after each use and she expected it to be cleaned daily. She said the debris could also cause a fire. She said the pots and pans should not have the black carbon buildup on them as it could also cause a fire. The Director of Food service said the facility just ordered new skillets and we should have thrown the other ones away. The Director said she does go behind the kitchen staff, but they do not always get things done. She said she was responsible for the kitchen. During an interview on 4/15/2026 at 2:12 PM, the DCO said she expected the kitchen to be cleaned and including the stove, oven, [NAME] and toaster. She said it could be a fire hazard. The DCO said the Dietary Manager was responsible for ensuring the kitchen/equipment was cleaned. During an interview on 4/15/2026 at 2:25 PM, the EDO said she expected the pots and pans to be removed/cleaned depending on the condition. The EDO said the food service employees were responsible for ensuring equipment was clean. She said it depended on buildup on the equipment that it could be frameable or insects could be attracted to food particles causing an issue with pest. Record review of daily cleaning schedule dated 4/13/2026-4/19/2026 indicated the cooks were responsible for cleaning the oven, stove, grill and were signed off completed on 4/13/2026, 4/14/2026 by [NAME] G.Record review of a facility policy titled Kitchen Sanitation dated 3/2026 indicated .Equipment should be maintained in a clean, sanitary condition and free from spills, to minimize the risk of cross contamination. Procedure .1. Clean and sanitize food preparation areas and equipment after use. 2. Clean grills, griddles, vent hoods, microwave ovens, and similar cooking devices after use and as needed. 3. A certified company to maintain the vent hood exhaust system, every 6 months. 4. Store equipment to prevent contamination. 9. Utilize stainless steel cleaner as needed.

Based on observations, interviews, and record review, the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 2 of 6 residents (Resident #27 and Resident #8) and 1 of 2 medication carts (100/300 hall medication cart) reviewed for drugs and biologicals.1. The facility failed to ensure RN E locked the 100/300 hall medication cart when she went into Resident #27's room on 4/14/2026.2. The facility failed to ensure RN E did not leave Resident #8's medication cards of furosemide (used to increase urine production to decrease fluid levels), carvedilol (used to treat high blood pressure), hydralazine (used to treat high blood pressure), glipizide (used to treat high blood sugar), gabapentin (used to treat nerve pain), Jardiance (used to treat high blood sugar), and clonidine (used to treat high blood pressure) on top of the medication cart unsupervised on 4/14/2026. 3. The facility failed to ensure RN E locked the 100/300 hall medication cart when she went into the medication room on 4/14/2026.These failures could place residents at risk of medication misuse and drug diversion.Findings included:During an observation on 4/14/2026 at 8:51 AM, RN E went into Resident #27's room which was two doors down from where the medication cart was parked against the wall with the drawers facing toward the hallway and left the medication cart unlocked and unsupervised.During an observation beginning at 4/14/26 at 8:53 AM, RN E prepared medications for administration for Resident # 8. RN E placed the medications in a medication cup and then handed the medication card to the surveyor to write down the medications, then the surveyor handed the medication cards back to RN E upside down on top of her medication cart. This process continued for each medication until RN E started to gather supplies to administer Resident #8's Lantus (insulin-used to treat high blood sugar) and RN E then said there was not enough Lantus in the pen, and she needed to go get another pen. RN E placed the medication cup with Resident #8's medications in the medication cart and locked the cart. RN E left the medication cart at 9:07 AM and returned at 9:19 AM and left the following seven medication cards with medications on top of the medication cart: furosemide, carvedilol, hydralazine, glipizide, gabapentin, Jardiance, and clonidine. During an observation on 4/14/2026 beginning at 3:55 PM, RN E was sitting in the 100 hall nurse's station, and the medication cart was sitting in front of the nurse's station with the drawers facing the hallway and it was not locked. Then, the medication room was reviewed with RN E that was located just off the nurse's station in a closed room. RN E left the medication cart unlocked and unsupervised while in the medication room for approximately five minutes. Upon exiting the medication room, there were three staff members standing in front of the unlocked medication cart. RN E then walked from around the nurse's station to medication cart and saw it was unlocked and locked it.During an interview 4/15/2026 at 1:13 PM, RN E said she had worked at the facility since January 2026 full-time. She said the medication cart should be locked at all times when not in her eyesight. RN E she said she was doing some things different than her normal because the surveyor was there and it messed up her routine. RN E said they have residents with dementia who wandered and it was a safety hazard to leave it unlocked and unsupervised. RN E said she was responsible for ensuring the medication cart and the medications were secured in the locked cart. RN E said she normally did not remove the cards from the medication cart but did for the surveyor to review and it messed up her routine. During an interview on 4/15/2026 at 3:59 PM, the DCO said the medication carts should not be left unlocked and medications should not be left out on top of the medication cart. The DCO said it was a rookie mistake and the nurse's first time with the state. The DCO said it was a safety issue leaving the medications on top of the medication cart and leaving the medication cart unlocked and unsupervised.During an interview on 4/15/2026 at 4:24 PM, the EDO said the medication cart should be locked when the nurse walks away. The EDO said someone could have walked away with the medications that was not supposed to have it.Record review of the facility's policy titled Administering Medications, dated revised on April 2019 stated . medications were administered in a safe and timely manner, and as prescribed . During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. It may be kept in the doorway of the resident's room, with open drawers facing inward and all other sides closed. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by .Record review of the facility's policy titled Storage of Medications, dated revised on April 2007 stated . The facility shall store all drugs and biologicals in a safe, secure, and orderly manner . the nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner . Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use . carts used to transport such items shall not be left unattended if open or otherwise potentially available to others .

Based on interviews and records reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #8) of 15 residents reviewed for care plans. The facility failed to ensure Resident #8 had a comprehensive care plan for pain. This failure could place residents at risk of not having their individualized needs met and a decline in their quality of care and life. Findings included: Record review of the face sheet, dated 04/14/2026, reflected Resident #8 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of heart failure (a chronic condition where the heart cannot pump enough blood to meet the body's needs), morbid obesity (complex chronic disease in which you have a body mass index (BMI) of 40 or higher), and pain. Record review of the quarterly MDS assessment, dated 01/21/2026, reflected Resident #8 had a BIMS of 12, which indicated moderate memory impairment. Resident #8 had required substantial (helper does more than half the work) assistance with ADLs such as transfer, dressing, and toileting. Resident #8 received opioids for pain. Record review of the consolidated physician order for April 2026, reflected Resident #8 had an order for Tramadol 50mg one tablet every 8 hours as needed for pain dated 12/11/2025. Record review of the MAR for April 2026 reflected. Resident #8 was administered tramadol 8 times from 04/01/2026 to 04/15/2026 for pain. Record review of Resident #8's comprehensive care plan, dated 03/17/2026, reflected no care plan for pain. During an interview on 04/15/2026 at 12:40 p.m., the MDS Coordinator stated the care plans included all things that were coded on the MDS. She stated the care plan should be reviewed by the nursing staff to know the individual care instructions for each resident. The MDS Coordinator stated items such as falls, high risk medication usage, hospice services, and diagnoses should be care planned for resident safety. She stated not care planning an important item with the interventions could result in the staff not knowing what is needed for the management of the individual resident condition. She stated she overlooked Resident #8's pain care plan, but it should have been care planned to ensure a full picture of his needs in his care plan. During an interview on 04/15/2026 at 1:00 p.m., the DON stated it was the responsibility of the MDS nurse to create the comprehensive care plan and all nurses' responsibility to ensure that acute changes be updated on the care plan. She stated all major diagnoses, conditions, medications, and falls should be care planned with interventions to alert the staff of the potential of these situations recurring and to give instructions on what to do in those cases. The DON stated she did not feel care planning had a negative impact on the residents. During an interview on 04/15/2026 at 1:30 p.m., the Administrator stated she expected the MDS nurse and administrative nurses to ensure the care plans were complete and accurate for each individual. She stated care plans were meant to be a blue print to individual resident care and were important to individualized care. Record review of the Care Plans, Comprehensive Person-Centered policy, dated April 2021, reflected A comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident.the interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.the care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.the comprehensive, person-centered care plan includes measurable objectives and timeframes, describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment;.and which professional services are responsible for each element of care; includes the resident's stated goals upon admission and desired outcomes; builds on the resident's strengths; and reflects currently recognized standards of practice for problem areas and conditions.the interdisciplinary team reviews and updates the care plan. at least quarterly.

Based on interviews and record review, the facility failed to notify the resident's representative when there were changes in the resident's physical, mental, or psychosocial status for 1 of 3 residents (Resident #50) reviewed for notification of changes.The facility failed to notify Resident #50's RP after resident- to- resident incident resulting in a scratch to right forearm on 3/30/2026.This failure could place residents at risk of not having their preferred responsible party represent them in care decisions.Findings Included: Record review of Resident #50's face sheet dated 4/14/2026 indicated an [AGE] year old male who was readmitted on [DATE] with diagnoses including Atherosclerotic heart disease (a type of heart disease when the coronary arteries become narrowed or blocked due to the buildup of plaque which reduces blood flow to the heart muscle), muscle wasting and atrophy (a loss of muscle mass, strength, and function), ataxic (poor muscle control that causes clumsy movements affecting walking, balance, hand coordination, speech and swallowing, and eye movement), dementia (a syndrome characterized by a decline in cognitive function, affecting memory, thinking, behavior and ability to perform everyday activities) and cognitive communication disorder (difficulty communicating due to impaired cognitive processes rather than primary speech or language problem). The face sheet identified RP was the emergency contact and responsible party.Record review of Resident #50's Quarterly MDS, dated [DATE], indicated Resident #50 understood and was understood by others. The quarterly MDS also indicated his BIMS score was 3 which meant he was severely cognitively impaired.Record review of Resident #50's Care plan, initiated 3/30/2026 indicated he was involved in Resident-to-Resident altercation. The interventions included monitoring resident for any after effects of the incident and skin assessment to be performed on resident. Resident #50's care plan also his choices and preferences would be identified through interview process with interventions for Resident and/or resident representative would be involved in care planning process.Record review of Progress note dated 3/30/2026 at 1:54 PM indicated Resident #50 was in the bathroom when another Resident came in and grabbed him by the collar of his shirt. Resident #50 put his hands up and another resident grabbed his wrist and forcefully pushed him out of the bathroom to his bed. The progress note indicated Resident #50 had a scratch to right forearm measuring 4.5 cm x 0.3 cm x 0 cm. The progress note did not indicate the RP was notified.During an interview on 4/14/2026 at 4:11 PM, the RP said she believed Resident #50 was cared for but not perfect. She said she was not aware of an incident that occurred on 3/30/2026 and she said she would want to be aware of the incident and the scratch to his arm.During an interview on 4/15/2026 at 1:52 PM, Resident #50 said he did not recall the incident on 3/30/2026. Resident #50 said he would want his RP notified of any changes or concerns with his condition.During an interview on 4/15/2026 at 1:59 PM, RN E said the facility wanted staff to notify the family of any verbal or physical altercations and to also report to the DCO/EDO/Provider. RN E said the nurse would document notification in the progress note.During an interview on 4/15/2026 at 2:12 PM, the DCO said notification depended on the situation. She said notification of RP would be documented in the progress note. She said it would also be documented on the incident report. The DCO said the RP should be contacted if the incident was verbal, physical or if the resident was wandering. She said Resident #50 had a scratch, not a wound. The DCO said the RP did not need to be contacted because it was a scratch, but the RP had the right to be involved in care. She said everyone was responsible for ensuring RP was contacted.During an interview on 4/15/2026 at 2:25 PM, the ADM said she expected the staff to notify the family of any incidents or accidents. The EDO said Resident #50's RP was difficult to reach. The EDO said the staff would document the notification of the RP on the incident report and progress note. The EDO said if the staff could not reach the RP, they should pass the information on the oncoming staff. She said there was no impact on the resident, but the RP had a right to know. The incident report did not indicate the RP was contacted. The incident report did not indicate the RP was notified.Requested a facility policy related to notification of RP provided to DCO and there was no policy related. The facility did not have a policy for Notification of Resident Representative.Record review of policy titled Abuse last revised on 1/1/2023 indicated .In addition, the facility will notify resident/resident responsible party and inform them of any misappropriations and to whom they report concerns, incidents, and grievances without fear of retribution; and will receive feedback regarding their expressed concerns. These items were listed in the facility admission agreement and were posted within the facility. This list also contains the telephone number at the corporate office if any concerns continue to go unresolved.

Based on interview and record review, the facility failed to ensure an encoded, accurate, and complete MDS discharge assessment was electronically completed and transmitted to the CMS System within 14 days after completion for 1 of 1 resident (Resident #10) reviewed for discharge MDS assessments. The facility did not ensure Resident #10's discharge MDS assessment was transmitted within 14 days of completion. This failure could place residents at risk of not having records completed and submitted in a timely manner as required. Findings included: Record review of Resident #10's, undated face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. Resident #10 had diagnoses which included hypertension (high blood pressure) and arthritis. The face sheet indicated Resident #10 was discharged on 11/01/2025. Record review of Resident #10's admission MDS dated [DATE] revealed he had a BIMS of 14, which indicated no cognitive impairment. Resident #10 required supervision with all ADLs. Record review of Resident #10's EHR on 04/15/2026 indicated no discharge MDS was transmitted prior to survey intervention. During an interview on 04/15/2026 at 12:38 p.m., the MDS Coordinator said she was responsible for completing and submitting MDS assessments. She said Resident #10's discharge assessment was completed but not transmitted within 14 days of his discharge. She said the corporate MDS coordinator monitors the MDS assessments she completed. She said it was important to complete and submit discharge assessments because it ensured that proper documentation was collected prior to discharge. She stated Resident #10's discharge assessment was not transmitted because of a software issue. During an interview on 04/15/2026 at 1:30 p.m., the Administrator said she expected the MDS coordinator to follow the MDS Completion and Submission policy. She said the MDS Coordinator was responsible for submitting discharge assessment timely. She said the corporate MDS Coordinator should be ensuring the facility's MDS Coordinator completed and submitted assessments timely. She said timely assessment submission was important ensure the facility was following CMS guidelines. Record review of a facility's MDS Completion and Submission Timeframes policy revised 07/2021 indicated .our facility will conduct and submit resident assessments in accordance with currency federal and state submission timeframes .the assessment coordinator or designee is responsible for ensuring that resident assessment are submitted to CMS QIES assessment submission and processing system in accordance with current federal and state guidelines .timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual . Record Review of the CMS RAI Version 3.0 Manual, dated October 2025, indicated, in Chapter 2, page 2-39 09. Discharge Assessment-Return Not Anticipated (A0310F), Must be completed (item Z0500B) within 14 days after the discharge date (A2000 + 14 calendar days). The RAI Manual further revealed the discharge assessment-return not anticipated must be submitted within 14 days after the MDS completion date (Z0500B +14 calendar days) .

Based on observation, interviews, and record review, the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 1 of 17 residents (Resident #21) reviewed for resident rights.1. The facility failed to ensure RN E closed the window blinds, opening to the parking lot in front of the building, while performing medication administration and tube feeding through Resident #21's PEG tube (tube inserted through the abdominal wall directly into the stomach to deliver nutrition, fluids, and medications when oral intake was insufficient) on 4/14/2026.2. The facility failed to ensure RN E did not discuss Resident #21's family, by saying his family is very demanding and particular about his care and his family doesn't like it when we use too much water, while setting up supplies, providing medication administration and tube feeding through his PEG tube on 4/14/2026.These failures could place residents at risk of humiliation, diminished quality of life, loss of dignity and self-worth.Findings included:Record review of Resident #21's face sheet dated 4/13/2026 revealed he was [AGE] years old and admitted to the facility initially on 2/17/2014 and readmitted on [DATE]. Resident #21 had diagnoses including cerebral palsy (permanent movement and posture disorders caused by abnormal brain development or damage, typically occurring before birth), gastroparesis (delayed emptying of stomach contents), gastrostomy (also called PEG tube), quadriplegia (unable to move body, typically caused from damage to the spinal cord in the neck).Record review of Resident #21's quarterly MDS assessment dated [DATE] revealed he had no speech and was rarely/never understood and sometimes understood others. Resident #21 was unable to complete the BIMS because he was rarely/never understood. Resident #21 was dependent on staff assistance for all ADLs.Record review of Resident #21's Care Plan indicated he required tube feedings related to Cerebral Palsy. The Care Plan indicated Resident #21 had a communication problem related to aphasia (unable to speak) but he understood and could blink his eyes once for yes and twice for no. Resident #21 was dependent on staff for all his ADLs.During an observation and interview on 4/14/2026 beginning at 3:20 PM, RN E raised Resident #21's shirt exposing his bare abdomen and PEG tube. RN E said, while setting up supplies on Resident #21's bedside table, his family is very demanding and particular about his care. RN E said his family doesn't like it when we use to much water as she poured distilled water into a cup on the bedside table. RN E then administered 2 medications to Resident #21 and his bolus feeding (method of delivering nutrition directly into the stomach through a feeding tube using a syringe). RN E said his family doesn't like it when we use to much water again while leaning over the resident to administer medications then flushed the PEG tube with water between each medication and before/after his bolus feeding. The resident's window blinds were left open during the care, with his feeding tube and abdomen exposed. The window by Resident #21's bed opened to the parking lot in front of the building. RN E said Resident #21 could blink once for yes and twice for no if asked questions.During an interview and observation on 4/14/2026 at 3:35 PM after RN E left the room, Resident #21 blinked once, indicating yes, it bothered him to have the window blinds open when the nurse provided care to his PEG tube. Resident #21 blinked once, indicating he would prefer the window blinds to be closed during his PEG tube care. During an interview on 04/15/2026 at 1:13 PM, RN E said she had worked at the facility since January 2026 full-time. RN E said she normally worked on Unit 1 which was all of hall 100 and most of hall 300. RN E said the window blinds of Resident #21's room should have been closed during care for his privacy. RN E said they always closed the blinds during his incontinent care. RN said she thought Resident #21 knew his family was difficult. RN E said she did not feel she was being insulting because Resident #21 knew his family was demanding. RN E said she had a good relationship with Resident #21's family and did not mean anything negative about it. She said she could see where it could be considered a dignity issue with leaving his window blinds open during his PEG tube care, but she did not mean anything bad with what was said about his family.During an interview on 4/15/2026 at 3:59 PM, the DCO said the nurse should have closed the window blinds during Resident #21's PEG care and she should not have discussed any issues related to the residents' family in front of the resident. The DCO said it was a dignity and resident rights issue.During an interview on 4/15/2026 at 4:24 PM, the EDO said residents should be provided privacy during care and staff should not talk about the resident's family in the room. The EDO said it could be a dignity issue.Record review of the facility's policy titled Resident Rights dated revised December 2016, indicated . employees shall treat all residents with kindness, respect, and dignity . federal and state laws guarantee certain basic rights to all residents of this facility . these rights include the resident's right to . a dignified existence . be treated with respect, kindness, and dignity . be supported by the facility in exercising his or her rights . privacy and confidentiality .

Based on observation, interview, and record review the facility failed to post the daily nurse staffing information with the current date, resident census, and numbers of staff actual hours worked at the beginning of each shift in a place readily accessible to residents and visitors for 2 of 3 days, in that: The facility failed to update and post the daily nurse staffing information on 04/14/2026 and 04/15/2026. This failure could affect residents, their families, and facility visitors by placing them at risk of not having access to information regarding staffing data and facility census. The findings included: An observation on 04/14/2026 at 9:30 a.m. revealed the daily nurse staffing pattern posted was from 04/13/2026. An observation on 04/15/2026 at 10:45 a.m. revealed the daily nurse staffing pattern posted was from 04/13/2026. An observation on 04/15/2026 at 2:00 p.m. revealed the daily nurse staffing pattern posted was from 0413/2026. During an interview on 04/15/2026 at 2:45 p.m., the DON stated the night nurse was responsible for changing the staffing posting each day and she would take over checking to ensure it was done. She stated not changing it each day was an oversight on the part of the night nurses. She stated failure to post the staffing numbers could give the public inaccurate information on the staffing of the building that was caring for their loved ones. During an interview on 04/15/2026 at 3:00 p.m., the Administrator stated, it was the responsibility of the night nurse to ensure the staffing numbers were posted daily. She stated it was to be checked by the DON during the week and the weekend supervisor on weekends. The Administrator stated not posting the information would give the public inaccurate information. Record review of a policy titled Posting Direct Care Daily Staffing Numbers, revealed within two (2) hours of the beginning of each shift, the shift supervisor shall compute the number of direct care staff and complete the Nursing Staff Directly Responsible for Resident Care form. The shift supervisor shall date the form, record the census and post the staffing information in the location designated by the Administrator.

Based on observation, interviews and record review the facility failed to provide or obtain radiology and other diagnostic services to meet the needs of its residents for 1 of 4 (Resident #1) residents reviewed for radiology services. The facility failed to ensure Resident #1's STAT x-ray results were obtained and reported to the physician in a timely manner. Resident #1's x-ray results were not reviewed by the facility until 10/20/25, which was 4 days after the STAT x-ray was performed. This failure could result in a delay in treatment of broken bones, increased pain, and a decreased quality of life. The findings included: Record review of the face sheet, dated 10/30/25, reflected Resident #1 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of dementia (memory loss) without behaviors, pressure ulcer of sacral region, stage 4 (wound that exposes muscle, bone, or tendon to the sacrum [triangular bone in the lower back formed from fused vertebrae and situated between the two hip bones of the pelvis] caused from pressure), Multiple Sclerosis (a progressive disease that damages the protective cover around nerves called myelin in your central nervous system, which can cause muscle weakness, vision changes, numbness and memory issues), and Arnold Chiari Syndrome (a condition in which brain tissue extends into the spinal canal). Record review of the quarterly MDS assessment, dated 05/03/25, reflected Resident #1 had clear speech, was understood by others, and was able to understand others. Resident #1 had a BIMS score of 8, which indicated moderately impaired cognition. Resident #1 had no behaviors or refusal of care. The MDS reflected Resident #1 had an impairment to both sides of her lower extremities that interfered with daily functions or placed resident at risk of injury. Record review of the comprehensive care plan, initiated on 10/15/25, reflected Resident #1 complained of pain to her right knee. Resident #1 denied falling or injuries. Resident #1 had a nondisplaced lateral plateau fracture (break or crack in the shin bone or tibia). The interventions were as follows:1. On 10/15/25 - Obtain x-ray to right knee per the physician's orders.2. On 10/15/25 - Mechanical lift when transferred.3. On 10/22/25 - Administer pain medication per physician orders.4. On 10/22/25 - Check skin every shift under brace for redness, irritation, or breakdown.5. On 10/22/25 - May remove brace for showers.6. On 10/22/25 - Referral to the orthopedic (specialist bone doctor).7. On 10/22/25 - Straight leg brace to right lower extremity as the resident allows. Record review of Resident #1's progress notes, dated 10/15/25 at 10:32 PM, RN A documented While moving [Resident #1] from room [ROOM NUMBER] to 116, [Resident #1] complained of knee pain and swelling. Upon assessment, [Resident #1's] knee was very swollen. No redness or warmth noted. Contacted NP about getting [x-ray] for right knee. Awaiting response. [Resident #1] in bed at this time. [Call light] and [by mouth] fluids at bedside. Record review of the SBAR Communication Form, dated 10/16/25, reflected Resident #1 had new onset pain, swelling, and warmth of the right knee. Orders were obtained for a STAT x-ray for the right lower extremity. Record review of Resident #1's order details, dated 10/16/25, reflected the Nurse Practitioner ordered the following x-rays with an urgency of STAT:1. Left femur (upper leg), 2 views2. Right knee, 2 views3. Right Tibia and fibula (lower leg), 2 viewsThe order details reflected it was sent to the radiology provider. Record review of Resident #1's radiology report reflected the right knee x-ray was completed on 10/16/25 at 12:24 PM and was read by the radiologist and reported to the facility on [DATE] at 5:25 PM. The impression was findings concerning for a nondisplaced lateral plateau fracture [break or crack in the shin bone or tibia] Record review of Resident #1's radiology report reflected the right tibia and fibula x-ray was completed on 10/16/25 at 12:22 PM and was read by the radiologist and reported to the facility on [DATE] at 5:26 PM. The impression was findings of an age-indeterminate distal fibular fracture [fracture of the fibula bone near the ankle, unable to determine the age of the injury] . Record review of Resident #1's radiology report reflected the right femur x-ray was completed on 10/16/25 at 12:26 PM and was read by the radiologist and reported to the facility on [DATE] at 5:27 PM. The impression was no acute osseous abnormality [bone structure changes]. Record review of the follow-up note, dated 10/19/25, reflected Resident #1 had pain in her right knee with swelling and pain during movement. The follow-up note did not reflect any information on the x-ray results. Record review of Resident #1's radiology report reflected a right ankle x-ray was completed on 10/20/25 at 1:09 PM and was read by the radiologist and reported to the facility on [DATE] at 2:18 AM. The impression was osteopenia (bones are weaker than normal) and no fracture noted. Record review of the in-service education record, dated 10/20/25, reflected education was provided on osteopenia for nurses only. There were 4 nurse signatures. Record review of the in-service education record, dated 10/20/25, reflected education was provided on the pain management policy and procedures for nurses only. There were 3 nurse signatures. Record review of the witness statement, signed and dated 10/20/25 at 2:00 PM by CNA B, reflected the following: [Resident #1] was transferred to shower chair by 2 staff, given a shower then transferred back to bed in 116. I never heard anything pop and she never said anything hurt. Record review of the witness statement, signed and dated 10/21/25 at 12:00 PM by RN A, reflected the following: On 10/15/25 [Resident #1] was being transferred to shower chair prior to room change. [Resident #1] informed staff her right knee was swollen. Upon assessment right knee was swollen but no redness, warmth, or pain noted. [Resident #1] was transferred without incident to shower chair then after shower transferred to bed in 116. [NP] notified of swelling and pain management regimen continued per [Resident #1's] baseline. I never heard anything pop and she never complained of increased pain. Record review of Resident #1's progress notes, dated 10/21/25 at 1:14 PM, the DON documented Spoke with [Resident #1's family member] regarding fracture of right leg in 2 places, [new order] for straight leg brace, [non-weight bearing] to right leg and [orthopedic] referral. Record review of the 24-hour report sheets, dated 10/15/25 to 10/25/25, reflected the following:1. On 10/15/25, Resident #1 moved to 304. The 24 report sheet did not address Resident #1's right knee.2. On 10/16/25, Resident #1 moved to 116 and STAT [right lower extremity] x-ray for swelling/pain/warmth.3. On 10/17/25, Resident #1 pending x-ray results.4. On 10/18/25, Resident #1 was not listed.5. On 10/19/25, Resident #1 was not listed.6. On 10/20/25, the 24 hour report sheet did not address Resident #1's right knee or x-ray. During an observation and interview on 10/30/25 at 9:33 AM, Resident #1 was lying in the bed with the head of her bed elevated slightly. Resident #1's hair was pulled back, and she appeared neat and clean. Resident #1 was pleasant and calm during the interview. Resident #1 stated she was having some pain this morning, but the nurse had just given her some pain medication. Resident #1 stated she took pain medication regularly and her pain was well-controlled. Resident #1 stated her pain was from her right knee and leg. Resident #1 said she recently found out she had a fracture. Resident #1 stated it was an accident and happened during a transfer. Resident #1 stated she did not remember everything about the incident because her memory was not that good. Resident #1 stated she had no complications or increased pain from the fracture in her leg. During an interview on 10/30/25 at 10:56 AM, LVN C stated Resident #1 had first complained about pain in her right knee during the night of 10/15/25 when they were moving her room. LVN C stated RN A had contacted her when she was driving to work and informed her the NP had ordered an x-ray for Resident #1's right leg. LVN C stated when she arrived at work, she placed the x-ray order into the computer system as STAT and it was automatically sent over to the radiology company. LVN C stated she was unable to remember when the x-ray was performed or if she received the results. LVN C stated she was unsure what the time frames were for STAT orders on radiology. LVN C stated when STAT orders were ordered by the doctor, she normally received the results the same day. LVN C stated Resident #1 had pain medications scheduled, which were effective at controlling her pain. LVN C stated she did not work at the facility again until 10/20/25 but had to leave early for a family emergency. LVN C stated 10/20/25 was her last day working at the facility. During an interview on 10/30/25 at 11:24 AM, the DON stated Resident #1 had diagnoses of multiple sclerosis and osteopenia. She stated on 10/15/25 prior to the transfer and room change, Resident #1 had reported to the staff her right knee was swollen but denied any pain. She stated the staff transferred Resident #1 to the shower chair, provided a shower, then transferred her back to bed. The DON stated Resident #1 was a stand and pivot transfer with a gait belt and 2 staff assistance. She stated Resident #1 was usually weak but was able to bear some weight. She said the next morning, on 10/16/25, LVN C noticed Resident #1 had new onset of pain, swelling, and warmth to her right knee. The DON stated LVN C completed the change of condition assessment and notified the NP. She stated the x-rays were ordered and completed the same day. She stated on 10/17/25 she received a text message from the radiology representative that the order was missing diagnosis codes. The DON stated she was out of town and was not going to be able to provide the diagnosis codes until she returned. The DON stated she did not hear back from the radiology representative, so she assumed he got in touch with the staff at the facility. She stated the facility did not obtain the radiology results until 10/20/25 when she checked the portal. The DON stated she notified the doctor, family, and obtained new orders for a brace and orthopedic consult. The DON said she initiated in- service education on osteopenia and pain management. She stated she expected the facility staff to ensure STAT orders were followed up on. She stated all the nurses had access to the radiology results portal. The DON stated the radiology company did not call the facility to notify them that Resident #1 had a fracture. She said the radiology representative only mentioned the diagnosis code when he called on 10/17/25 but did not mention Resident #1 had a fracture. During an interview on 10/30/25 at 11:58 AM the ADON stated he has been the ADON for the last week and prior to that he worked the floor. The ADON stated he was working the floor on 10/17/25 and 10/18/25. The ADON stated he got a stomach bug the evening of 10/18/25, went home early, and called in 10/19/25. He said normally when STAT x-rays were ordered, the order was placed in the computer and submitted to the radiology company. He stated the company would have come out, completed the x-ray, and posted the imaging results under diagnostic results. He stated the company would have posted the results online and did not usually fax them. He said he was not made aware the x-rays were ordered and obtained on Resident #1 on the 17th or 18th when he worked. He said Resident #1 had no complaints of pain or discomfort during that weekend and was always in a good mood. He stated he was in Resident #1's room daily because he had to perform wound care. He stated if he was aware Resident #1 had x-rays completed, he would have looked for the results or followed up with x-ray company for the results. He stated he had no issues with the radiology company prior to the incident. He stated he was under the impression a STAT radiology or lab order could be completed within 24 hours. He stated it was important to ensure x-ray results were obtained timely to prevent further injuries to the resident. He stated it was important to ensure issues or concerns or pending results were passed on in report so follow up could happen timely with no delays in treatment. During an interview on 10/30/25 at 12:25 PM, CNA B stated nothing significant happened during the transfer with Resident #1 on 10/15/25. She said Resident #1 was complaining of pain to her right knee before they moved or transferred her. She stated when she placed Resident #1 back in bed she was still complaining of pain, so she notified the nurse. CNA B stated her knees were always big and nothing looked abnormal. She said she heard no popping noises or anything that would have indicated Resident #1 had an injury. She stated she transferred Resident #1 using a gait belt. She stated Resident #1 was able to bear weight. During an interview on 10/30/25 at 2:50 PM, The Administrator stated she was first notified of Resident #1's fracture on 10/20/25 during the stand-up clinical meeting. She said that was when the facility obtained the results for her x-rays. The Administrator stated the IDT met to try and determine the cause of the injury, but she had no falls or injuries reported. The Administrator stated she submitted the report to HHSC and completed her investigation. She stated she had no reason to believe her injuries were intentionally caused by the facility staff. The Administrator stated during her investigation it was determined that Resident #1 had been complaining of pain during the evening of 10/15/25 prior to any transfers. She said Resident #1 reported she heard a popping noise during the transfer, but the staff denied any popping noises. The Administrator stated it was discovered she had osteopenia and was at risk for fractures. She said she was unsure if there had been any issues or concerns with the radiology company. The Administrator stated she expected the nursing staff to follow up with STAT orders. She stated they should have been looking for the results and noting them on the 24 hour report sheet. She stated it was important to ensure radiology results were received timely to prevent a delay in treatment or decreased quality of care. She stated Resident #1 was well-managed while the results were pending and developed no complications. During an interview on 10/30/25 at 2:38 PM, the NP stated she expected the facility to ensure results were obtained from STAT x-ray orders. The NP stated if the facility did not have the results from a STAT order, they should have followed up with the radiology company for the results. She said at the minimum it should have been passed on during report for continued follow up. The NP stated it was important to ensure that radiology results were received timely to ensure treatment and services were implemented to prevent further injuries. The NP stated Resident #1 was stable and developed no complications. She stated Resident #1 was bed bound and her pain was managed with her current pain regimen. During an interview on 10/30/25 at 2:57 PM, the Director of Radiology stated the technicians tried to perform STAT orders within 4 hours of receiving the orders. He stated the time in which the STAT order was completed, depended on the territory and where the technicians were in relation to where the test was ordered. He stated the average time it took for the radiologist to read the x-rays was 1 hour, but it depended on the day and what was going on. He stated the x-ray results were submitted to the facilities in real time, as the results were sent straight into the portal and into their electronic charting system. He stated the facility should have access to the results as soon as it was read by the radiologist. During an interview on 10/31/25 at 2:01 PM, the Radiology Compliance Officer stated Resident #1's x-ray orders were completed on 10/16/25 at 12:06 PM, which was the same day they were ordered. He stated the radiologist read them on 10/17/25. He stated the orders were not put into the system as a STAT order. Record review of the imaging services agreement, dated 01/06/25, reflected .Company will use reasonable efforts to dispatch STAT x-ray services as soon as possible after receipt of the STAT order. STAT (emergency) service is provided for life-threatening and/or critical situations requiring rapid images. Record review of the Lab/Radiology Management policy, revised 04/21/21, reflected .provide or obtain laboratory services to meet the needs of its residents.the community is responsible for the timeliness of the services.the community must notify the attending physician of the lab results.ensure all labs ordered have been collected with results communicated to doctor and family in a timely manner.

Based on interview, and record review, the facility failed to provide the necessary services to maintain personal hygiene for 1 of 10 residents reviewed for ADLs. (Resident #2)The facility failed to provide Resident #2 with his scheduled showers.This failure could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in poor care, risk for skin breakdown, feelings of poor self-esteem, lack of dignity and health.Findings included:Record review of a face sheet dated 07/14/25 revealed Resident #2 was a [AGE] year-old male and was initially admitted to the facility on [DATE] with diagnoses including cerebral palsy (a group of disorders that affect movement and posture, impacting motor skills and muscle tone), personal history of traumatic brain injury (a brain injury that occurs when a sudden trauma to the head disrupts normal brain function), and reduced mobility. Record review of a quarterly MDS dated [DATE] revealed Resident #2 had no speech. The MDS indicated Resident #2 was rarely to never understood and sometimes understood others. The MDS did not indicate a BIMS score. The MDS indicated Resident #2 was dependent on staff for all ADLs, including bathing. Record review of a care plan dated 04/22/25 revealed Resident #2 had a diagnosis of depression. The care plan indicated Resident #2 had an ADL self-care performance deficit related to disease process. The care plan indicated Resident #2 had limited mobility, range of motion, inability to sit unsupported related to cerebral palsy and was dependent on staff for ADLs. There was an intervention that Resident #2 was totally dependent on 2 staff members to provide bath/shower per facility policy and as necessary. Record review of Resident #2's electronic medical record accessed on 07/14/25 - 07/16/25 indicated Resident #2 preferred showers on Monday and Thursday on day shift. Record review of ADL - Bathing documentation for Resident #2 from 06/19/25 - 07/16/25 revealed no documentation for a bath or a shower on Thursday - 06/26/25, Thursday - 07/03/25, Monday - 07/07/25, and Monday - 07/14/25. During an interview on 07/15/25 at 8:22 a.m., Family Member A said Resident #2 had recently missed some of his showers due to the facility not having the appropriate lift pad for the mechanical lift. During an interview on 07/16/2025 at 8:15 a.m., the Activity Director said she helped out on the floor as an RCP. She said she had known Resident #2 to have missed one shower because they did not have a lift pad. She said the facility had ordered new lift pads. She said family told her about him missing other showers.During an interview on 07/16/25 at 9:29 a.m., Family Member B said Resident #2 was supposed to be bathed three times a week. Family Member B said he was only showered on Mondays and Thursdays. She said they had to bath him once themselves because he had missed his shower because the facility did not have a shower lift pad. Family Member B said they ended up bringing one from home. Family Member B said this was approximately 3 weeks ago. Family Member B said the wound care doctor had wanted Resident #2 bathed three times a week. Family Member B said it depended on what staff was working if he got his showers. During an interview 07/16/25 at 12:58 p.m., RCP D said Resident #2 had never missed a shower on her shift. She said she could not speak for other aides. She said all of the showers were charted in the resident's electronic medical record. She it was her understanding the family wanted him showered two days a week. She felt some aides were maybe not charting the showers. She said if the family wanted him to be bathed three times a week, he should be bathed three times a week. She said it had always been 2 times a week.During an interview on 07/16/25 at 1:40 p.m., LVN E said she had known Resident #2 to have missed his showers because of not having shower pads. She said he had missed maybe 5 showers. She said his showers had always been two days a week. She said she thought that was what the family wanted. She said when he had missed his showers, she felt like he at least got a bed bath. She said bed baths or showers should have been charted in the Resident's electronic medical record. She said if there was no documentation, he did not receive a bath or shower. She said she felt like it was a charting issue. She said a resident not receiving their baths could lead to poor hygiene and infection. She said it was a dignity issue too.During an interview on 07/16/25 at 12:06 p.m., the ADOC said it was never presented to her that family wanted Resident #2 bathed three times a week. She said she felt he did not miss any showers. She felt it was just failure of the staff to document. She said this was an on-going education with the aides. During an interview on 07/16/25 at 2:09 p.m., the DCO said the family had wanted Resident #2 to be bathed only two times a week. She said this was the first she heard of them wanting him bathed three times a week. She said it had not been brought up in care plan meetings. She said she would expect all showers to be documented in the electronic medical record. She said she felt Resident #2 got showers and they were just not documented. During an interview on 07/16/25 at 2:55 p.m., the EDO said she did not have the shower schedule, but she would expect for Resident #2 to be showered on his scheduled shower days. She said she would expect the aide to document each shower or bath in Resident #2's electronic medical record. She said there had been a few times the family had been concerned about him not getting his showers. She said they have had to discard lift pads for resident safety. She said they were now building up their inventory. She said there had been times there was not one available and it would be available later in the day. She said even if it was not available in the morning it should have been available later in the day and Resident #2 should have been showered. She said cleanliness is important, and not being showered could be a dignity issue depending on the resident. During an interview on 07/16/25 at 4:20 p.m., the EDO said the facility did not have an ADL or bathing policy.

Based on interview and record review, the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect, exploitation, or mistreatment of residents for 1 of 7 residents reviewed for abuse and neglect.The facility failed to prevent Resident #1 from being abused when RCP A told Resident #1 You better get out of my face and get back in your room. on 07/05/25 as witnessed by LVN B and LVN C.The facility failed to immediately suspend RCP A. The facility staff failed to immediately interview Resident #1 concerning the allegations. These failures could place residents at risk for continued abuse and neglect due to inappropriate interventions and failure to report the allegations of abuse timely. Findings included:Record review of a face sheet dated 07/14/25 revealed Resident #1 was [AGE] years old and was initially admitted on [DATE] with diagnoses including congestive heart failure (chronic condition where the heart cannot pump enough blood to meet the body's needs), bipolar disorder (a mental illness that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks), and anxiety disorder. Record review of an annual MDS dated [DATE] revealed Resident #1 had a BIMS score of 15 which indicated intact cognition. The MDS indicated Resident #1 required supervision to moderate assistance with most ADLs. Record review of a care plan last reviewed on 07/14/25 revealed Resident #1 had a behavior problem related to low frustration tolerance. The care plan indicated Resident #1 got angry with other residents and would yell at them or staff. The care plan indicated Resident #1 made false allegations against staff and other residents. There was an intervention for caregivers to provide opportunity for positive interaction and attention. Record review of a typed statement indicated Resident #1 was interviewed by the DCO and the EDO on 07/07/25. The statement indicated the date of the incident was 07/05/25. The statement indicated, .A while after lunch I had gone to my room and found my roommate, in bed with the lift pad pulled over her face and her left fingers in the straps on the side and she was pulling on them. I went to (RCP A) who was standing in the hallway and told her, and she said that she would come fix it. After a few minutes, I went to see where she was, and she was still standing in the hall. I went to the nurses' station and was telling (LVN B), but I was so upset I couldn't get my words out, so she pushed me down to my room. When we got back to my room, (RCP A) was in there. (LVN B) went into the room, and I stayed in the hallway. They both came out and started walking back towards the nurses station. (RCP A) got about halfway up the hall and turned around and smiled at me. I said loudly (RCP A) its not funny. And she said (Resident #1, that's why we don't get along. You need to shut up and let me do my job. (LVN B) came to my room later and told me that she reported (RCP A) to the DCO because she can't talk to me that way and that it was abuse. The statement was not signed. Record review of a typed statement indicated RCP A was interviewed by the DCO and ADCO on 07/07/25. The statement indicated the date of the incident was 07/05/25. The statement indicated, .After lunch I had put (Resident #1's roommate) in bed from her geri-chair and then walked out of the room to go get my resident out of the dining room and tend to their needs. (Resident #1) came to me while I was pushing another resident to her room and asked me to move (Resident #1's roommate's) chair and told me that (the roommate) had pulled her lift pad over her face and that her hand was tangled up in straps, so I went in there and took care of that then went and changed a couple more residents that were asking for help then came back to (the roommate's) room to change her. As I was finishing with her, (LVN B) came into the room and asked what was going on, being rude to me. So, I told her what happened, and she said I was rude, so I just walked out of the room. I stopped to get my linen barrel, and (Resident #1) was behind me talking about me and saying things under her breath and being confrontational, so I said, (Resident #1) go in your room and leave me alone. The statement was not signed. Record review of a typed statement indicated LVN B was interviewed by the DCO and ADCO on 07/07/25. The statement indicated the date of the incident was 07/05/25. The statement indicated, .After lunch I was sitting at the nurses' station with the other nurse and (Resident #1) came up to the nurses' station and told the other nurse she needed to report something. The other nurse told her that was sitting right there, and (Resident #1) said she wanted (LVN C) to be witness in case something didn't get done about it. She then started telling me that her roommate was in bed with a lift pad over her face. When we got there the door was closed and she said, Well I guess she is in there fixing it now. I entered the room, and (RCP A) was in there finishing her incontinent care. I asked her what was going on and she started telling me that the resident had pulled the lift pad over her face and that her hand was kind of tangle up in it but it was fixed now. As we walked out of the room, (RCP A) was behind me and I heard her say You need to get out of my face and go back to your room. I informed (RCP A) that she can not talk to residents like that. (RCP A) walked away and I spoke with (Resident #1) who was not in any distress afterwards and told her that I would report the incident to the DCO, which I did but I never said anything about it being abuse. If I felt like it was abuse, I would have reported it right away to (the EDO). The statement was not signed.Record review of a typed statement by the Business Office Manager dated 07/07/25 indicated, (Resident #1) approached me.at my office door around 10:10 a.m. She then asked me if I heard about her and (RCP A). I replied, No ma'am. She then told me that (Resident #1's roommate) was in the lift pad with it over her head and her arms were through the hole in the pad. She then told (RCP A) Why did you leave (Resident #1's roommate) like that? She said (RCP A) smiled at her, and (Resident #1) went down to the nurses station to tell (LVN B). She stated she was upset and couldn't get her words out, and (LVN B) pushed her down the room to see what she was upset about. (RCP A) was in there and everything was then normal with the lift pad. (Resident #1) said (RCP A) laughed at her, and (Resident #1) said something to her (unsure of what exact words were) and (RCP A) then told her to Shut up and let me do my job. (Resident #1) said (LVN B) approached her after this statement and told her that was abuse and she was going to report it. The statement was signed by the Business Office Manager.Record review of an In-Service and Education Record dated 07/07/25 indicated the ADCO educated 23 staff members on Types of Verbal Abuse and the Effects It Can Have on our Residents and Families. RCP A was not in attendance. The in-service indicated, .Verbal abuse is the use of spoken words to cause emotional harm or anguish to the victim. It includes both the words that are spoken and the way they are spoken.Includes any use of speech that is meant to accomplish any of the following against an individual.scare.undermine.belittle.humiliate.discredit.Perpetrators may us manipulation to convince victims they deserve the abuse.Judging - The use of you statements for the purpose of casting judgement on the victim's character or person.Blaming - Statements that claim the victim is a fault for negative occurrences that are beyond the victim's control.Record review of a Disciplinary Action Record dated 07/07/25 indicated RCP A was suspended after an occurrence that happened on 07/05/25. The occurrence was an allegation of verbal abuse made by a resident. The record indicated RCP A was suspended pending an investigation. The record indicated RCP A was suspended via telephone at 11:50 a.m. The record was signed by the DCO and the ADCO. Record review of a Disciplinary Action Record dated 07/10/25 indicated RCP A was given a Final warning. The facts regarding the incident indicated, Rudeness to resident and coworkers. Unprofessional behavior towards charge nurses when asked to complete task. Expectations for team member behavior indicated, Employee will remain professional towards residents and co-workers. Employee will treat everyone with dignity and respect. Corrective action to be taken indicated, Final write up. Further customer service issues will lead to termination. The record indicated RCP A refused to sign. The record was signed by the DCO and EDO.Record review of an undated Provider Response indicated, (Resident #1) made an allegation that the CNA providing care to her roommate told her to shut up and let me do my job. The CNA named in the allegation was asked to provide and statement and suspended pending the outcome of the investigation. The CNA said she told (Resident #1) go in your room and leave me alone. The investigation did not confirm the allegation of abuse. The investigation did confirm an incident of very poor customer service. The employee received disciplinary action for this incident as her statement to the resident was unprofessional and represented poor customer service. The employee will no longer be assigned to provide care to that resident. During an interview on 07/14/25 at 3:03 p.m., Resident #1 said on 07/05/25 she had come back to her room after lunch. She said her roommate had her arm tangled into her lift pad. She said she left out of her room to tell RCP A that her roommate needed help. She said RCP A was just down the hall near the linen cart. Resident #1 said she told RCP A that her roommate needed help and RCP A did not respond. She said she waited awhile, and RCP A never came. She said she peeped out the door and RCP A was still by the linen cart. She said she headed to the nurse's station to get LVN B. She said she had a hard time telling LVN B what was going on. She said LVN B came back to her room with her. Resident #1 said when they got back to the room, RCP A was in the room and had her roommate back like she was supposed to be. She said LVN B went in the room and closed the door. She said she did not know what was said between them. She said when they came out of the room RCP A looked at her and laughed at her. Resident #1 said she raised her voice and told RCP A it was not funny. The resident said RCP A told her, That's why we can't get along because you won't mind your own business and let me do my job. She said RCP A then told her, Shut up and go back to your room. She said LVN B told her RCP A could not talk to her that way because it was verbal abuse. She said later LVN B came to her and told her that she had reported the way RCP A talked to her. She said she had not seen RCP A since the incident. When Resident #1 was asked about what RCP A had said to her, Resident #1 said, absolutely it was abusive. Resident #1 said, I don't want her on this hall.During an attempted interview on 07/15/25 at 9:50 a.m., a call was placed to RCP A. There was a recording, The subscriber you have dialed is not in service.During an interview on 07/15/25 at 10:56 a.m., LVN B said on 07/05/25 Resident #1 came to the nurse's station. Resident #1 said her roommate was in the bed with the lift pad stuck over her head and her hand was stuck in the pad. LVN B said she went to the room with Resident #1. LVN B said when she got there the door was closed. She said RCP A was in the room. LVN B said RCP A had an attitude with her. She said when she walked out, Resident #1 said something to RCP A. She said she could not hear what Resident #1 said. LVN B said she was walking up the hall when she heard RCP A say, you better get out of my face and get back in your room. She said she was approximately four doors away. LVN B said she told RCP A she could not talk to Resident #1 like that. LVN B said RCP A said, did you not hear what she said to me?. LVN B said she told RCP A, I don't care what she said to you this her home and you cannot talk to her like that. LVN B said she never told Resident #1 it was verbal abuse. LVN B said she just told Resident #1 that RCP A could not talk to her like that and it had been reported to the DCO. LVN B said what RCP A said was rude and she felt like it was abuse. LVN B said RCP A's tone was hateful. She said she would not want RCP A to talk to her grandmother like that. She said if RCP A had talked to her grandmother that way, she would have a mugshot. She said the incident happened around 1:40 p.m. She said she reported it immediately to the DCO. She said she called the DCO to talk to her about the incident. She said the DCO told her she would call the EDO. She said she waited for the DCO to call her back, but she never did. She said the incident happened at the end of RCP A's shift and she left right after the incident.During an attempted interview on 07/15/25 at 11:40 a.m., RCP A was called at a different number provided by the Business Office Manager. There was no answer. The surveyor was unable to leave a message.During an interview on 07/15/25 at 12:15 p.m., the DCO said the incident between Resident #1 and RCP A was reported to her immediately. She said the incident happened on 7/5/25 at the end of RCP A's shift. She said RCP A was suspended on the morning of 07/07/25 and it was reported to the state on the 07/07/25. She said there were several versions of what happened and all that was told to her on the 07/05/25 was that RCP A told Resident #1, just let me do my job. She said she felt this was a customer service issue. She said Resident #1 did not say she felt abused until 07/07/25. She said RCP A did not return to work until 7/10/25. She said this was the only shift RCP A had worked since the incident on 07/05/25. The DCO said she attempted to call RCP A and there was no answer.During an interview on 07/15/25 at 12:54 p.m., LVN B said on 07/05/25, RCP A's tone was very strong. LVN B said staff had to respect their residents. She said the typed statement dated 07/07/25 was given over the telephone. LVN B said the statement was correct except for the last sentence. LVN B said she never stated, If I felt like it was abuse, I would have reported it right away to (the EDO).During an interview on 07/15/25 at 1:10 p.m., the EDO said she was contacted on the afternoon of 07/05/25. She said the DCO reported to her that Resident #1 was upset and RCP A had said something to the effect of let me do my job. She felt it was rude but not an abuse allegation. The EDO said she was not in the building on the 07/05/25. She said she did not interview the resident on 07/05/25. She said the DCO was in the building. She said things changed on the morning of 07/07/25 when Resident #1 reported the incident to the Business Office Manager. She said that was when it was reported to the state because of what was reported to the Business Office Manager was an allegation of abuse, because she said something different to her than what LVN B said on Saturday, 07/05/25.During an interview on 07/15/25 at 3:18 p.m., LVN C said Resident #1 came to the nurse's station on 07/05/25. She said LVN B went down to the room to check on the roommate. She said when they were coming back out into the hallway Resident #1 said something to RCP A, but she could not hear what she said. She said she then heard RCP A say, get out of my face and go back to your room. She said her tone was harsh. LVN C said Resident #1 did not seem afraid or anxious. She said as a charge nurse they do have the authority to send someone home. She said LVN B called the DCO to clarify what she should do. She said she was present when LVN B called the DCO. She said LVN B explained in detail what had happened. She said she told the DCO that RCP A said, get out of my face and go back to your room. LVN C said LVN B was upset.During an interview on 07/16/25 at 8:15 a.m., the Activity Director said she had seen RCP A have an attitude with other staff but never to any residents. She said since the incident on 07/05/25 between RCP A and Resident #1, Resident #1 had still been attending activities. She said she had not been anxious or afraid. She said, She has not changed a bit.During an interview on 07/16/25 at 8:58 a.m., the Business Office Manager said Resident #1 came into her office on 07/07/25 and asked if she had heard what happened between her and RCP A. She said Resident #1 told her on 07/05/25 her roommate was tangled in her lift pad. She said Resident #1 told her she went to RCP A to ask for assistance and RCP A just brushed her off and continued doing her work. She said Resident #1 told her she went to LVN B. She said Resident #1 told her that LVN B went down to the room and RCP A was in the room. She said Resident #1 told her she said, (RCP A) you know what you did. She said Resident #1 told her RCP A said, Shut up and let me do my job. The Business Office Manager said she gave a statement on what Resident #1 had told her. She said that was not an appropriate thing to say to a resident. She said Resident #1 told her that LVN B heard what was said and told Resident #1 it was verbal abuse, and she would be reporting it. She said she reported what Resident #1 told her to the EDO. She said she felt like what Resident #1 told her was verbal abuse. She said Resident #1 said she did not want RCP A to be her aide anymore. She said since 07/07/25 Resident #1 had gone about her normal activities and had not been upset. She said she had not seen RCP A again since the incident. She said RCP A was very stand offish, not friendly, and can be rude. She said she had never seen her be rude to residents.During an interview on 07/16/25 at 12:06 p.m., the ADCO said she did not witness the incident between RCP A and Resident #1. She said it happened before she came into work on 07/05/25. She said she saw Resident #1 on 07/07/25. She said Resident #1 told her RCP A had said to her, That's why we can't get along because you won't mind your own business and let me do my job. She said RCP A then told her, To shut up and go back to her room. The ADCO said she was also on the phone with the DCO when RCP A gave her statement over the phone. The ADCO said RCP A said she was in the next room changing a resident and Resident #1 had come to tell her what happened. She said RCP A admitted to telling Resident #1 to go back to her room. She said if RCP A said Get out of my face and go back to your room in a hateful or harsh tone it was verbal abuse. She said she started in-services on Customer Service and Verbal Abuse on 07/07/25. The ADCO said RCP A could be difficult with other staff.During an interview on 07/16/25 at 2:09 p.m., the DCO said when LVN B called her on 7/5/25 she tried to clarify exactly what words RCP A used toward Resident #1 and it was told to her that RCP A said, leave me alone and let me do my job. She said at the time she did not feel it was abuse. She said that was different than telling the resident to shut up and go to their room. She said she did not interview the resident on 07/05/25. She said she was going to deal with it as a customer service issue until the morning of 07/07/25 when the story had changed and sounded more like abuse. She said that was when Resident #1 made the statement that RCP A had told her to shut up and go back to her room. She said RCP A was suspended on 07/07/25. She said since the incident Resident #1 has been absolutely fine. She said there had been no adverse psychological effects. She said she preferred not to speculate on a negative outcome for the resident. She said RCP A has been reassigned and would not be providing care to Resident #1. During an interview on 07/16/2025 at 2:55 p.m., the EDO said on 07/05/25 she was notified about the incident between RCP A and Resident #1. She said she felt one thing was told to herself and the DCO on 07/05/25 and then something different was reported on Monday, 07/07/25. She said then she felt like what was said on 07/07/25 was reportable. She said if the nurses were saying it was abuse now, they should have been saying in was abuse at the time and it would have been handled differently. She said the situation was not reported to her as abuse. She said as the EDO you can only make a decision on the facts that have been presented to you. She said RCP A was not suspended until Monday because of what was presented to her on Saturday. She used what was presented to her on Saturday to make the judgement call. She said she talked to Resident #1 almost every day. She said she had not said anything else to her about the incident. She said she has not been upset or distraught. She said DCO was in the building on 7/5/25 during the time the two charge nurses were on duty and nothing additional was shared with her. She said Resident #1 had a history of making her concerns and needs known to the DCO and she did not say anything to her on 07/05/25. She said RCP A has been reassigned and would not provide care to the Resident #1.Record review of a facility Abuse Policy last revised on 01/27/20 indicated, .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 facility staff will adhere to the policies and procedures and will follow the guidelines in the written policy and procedure.Residents will not be subjected to abuse by anyone, including, but not limited to community staff.This includes physical, verbal, sexual, physical/chemical restraint.The administrator and/or designee are responsible for maintaining ALL facility policies that prohibit abuse, neglect, and misappropriation of funds/personal belongings, involuntary seclusion, or corporation punishment.Identification of possible problems that need investigation.Investigating allegations.Reporting incidents, investigations, and facility response to results of investigation within mandated time frames.Protecting residents during investigation.Upon notification of an allegation of physical or mental abuse, neglect or involuntary seclusion, the facility will conduct interviews that include documented statement summaries from the alleged perpetrator, the alleged victim, .and any staff who worked prior to and during the time of the incident.Investigations will focus on determining if the abuse occurred, the extent of the abuse, and potential cause(s).All events that involve an allegation of abuse.must be reported immediately or not later than 2 hours of alleged violation.Protection: It is utmost important that resident(s) suspected of being abused, and all other resident must be protected during the initial identification, and investigation process. The facility will initiate immediate procedures to ensure that these residents are protected fully from any further harm or potential harm. Upon notification of allegation, the Abuse Coordinator or designee will perform the following.Identify the perpetrator that is identified by eyewitness or during the investigation and remove the perpetrator from further contact with the resident pending outcome of the investigation.When there is no resolution to the suspected abuse, but there is indication that the abuse occurred, the facility will immediately conduct an in-service on abuse, and will notify staff that there is strong suspicion of abuse occurring, and it will not be tolerated.

Based on interview and record review, the facility failed to ensure the right to be free from abuse was provided for 1 of 7 reviewed for abuse. (Resident #1) The facility failed to ensure Resident #1 was free from abuse when RCP A told Resident #1, You better get out of my face and get back in your room. on 07/05/25 as witnessed by LVN B and LVN C. This failure could place residents at risk for verbal abuse and emotional harm.Findings included:Record review of a face sheet dated 07/14/25 revealed Resident #1 was [AGE] years old and was initially admitted on [DATE] with diagnoses including congestive heart failure (chronic condition where the heart cannot pump enough blood to meet the body's needs), bipolar disorder (a mental illness that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks), and anxiety disorder. Record review of an annual MDS dated [DATE] revealed Resident #1 had a BIMS score of 15 which indicated intact cognition. The MDS indicated Resident #1 required supervision to moderate assistance with most ADLs. Record review of a care plan last reviewed on 07/14/25 revealed Resident #1 had a behavior problem related to low frustration tolerance. The care plan indicated Resident #1 got angry with other residents and would yell at them or staff. The care plan indicated Resident #1 made false allegations against staff and other residents. There was an intervention for caregivers to provide opportunity for positive interaction and attention. Record review of a typed statement indicated Resident #1 was interviewed by the DCO and the EDO on 07/07/25. The statement indicated the date of the incident was 07/05/25. The statement indicated, .A while after lunch I had gone to my room and found my roommate, in bed with the lift pad pulled over her face and her left fingers in the straps on the side and she was pulling on them. I went to (RCP A) who was standing in the hallway and told her, and she said that she would come fix it. After a few minutes, I went to see where she was, and she was still standing in the hall. I went to the nurses' station and was telling (LVN B), but I was so upset I couldn't get my words out, so she pushed me down to my room. When we got back to my room, (RCP A) was in there. (LVN B) went into the room, and I stayed in the hallway. They both came out and started walking back towards the nurses station. (RCP A) got about halfway up the hall and turned around and smiled at me. I said loudly (RCP A) its not funny. And she said (Resident #1, that's why we don't get along. You need to shut up and let me do my job. (LVN B) came to my room later and told me that she reported (RCP A) to the DCO because she can't talk to me that way and that it was abuse. The statement was not signed. Record review of a typed statement indicated RCP A was interviewed by the DCO and ADCO on 07/07/25. The statement indicated the date of the incident was 07/05/25. The statement indicated, .After lunch I had put (Resident #1's roommate) in bed from her geri-chair and then walked out of the room to go get my resident out of the dining room and tend to their needs. (Resident #1) came to me while I was pushing another resident to her room and asked me to move (Resident #1's roommate's) chair and told me that (the roommate) had pulled her lift pad over her face and that her hand was tangled up in straps, so I went in there and took care of that then went and changed a couple more residents that were asking for help then came back to (the roommate's) room to change her. As I was finishing with her, (LVN B) came into the room and asked what was going on, being rude to me. So, I told her what happened, and she said I was rude, so I just walked out of the room. I stopped to get my linen barrel, and (Resident #1) was behind me talking about me and saying things under her breath and being confrontational, so I said, (Resident #1) go in your room and leave me alone. The statement was not signed. Record review of a typed statement indicated LVN B was interviewed by the DCO and ADCO on 07/07/25. The statement indicated the date of the incident was 07/05/25. The statement indicated, .After lunch I was sitting at the nurses' station with the other nurse and (Resident #1) came up to the nurses' station and told the other nurse she needed to report something. The other nurse told her that was sitting right there, and (Resident #1) said she wanted (LVN C) to be witness in case something didn't get done about it. She then started telling me that her roommate was in bed with a lift pad over her face. When we got there the door was closed and she said, Well I guess she is in there fixing it now. I entered the room, and (RCP A) was in there finishing her incontinent care. I asked her what was going on and she started telling me that the resident had pulled the lift pad over her face and that her hand was kind of tangle up in it but it was fixed now. As we walked out of the room, (RCP A) was behind me and I heard her say You need to get out of my face and go back to your room. I informed (RCP A) that she can not talk to residents like that. (RCP A) walked away and I spoke with (Resident #1) who was not in any distress afterwards and told her that I would report the incident to the DCO, which I did but I never said anything about it being abuse. If I felt like it was abuse, I would have reported it right away to (the EDO). The statement was not signed.Record review of a typed statement by the Business Office Manager dated 07/07/25 indicated, (Resident #1) approached me.at my office door around 10:10 a.m. She then asked me if I heard about her and (RCP A). I replied, No ma'am. She then told me that (Resident #1's roommate) was in the lift pad with it over her head and her arms were through the hole in the pad. She then told (RCP A) Why did you leave (Resident #1's roommate) like that? She said (RCP A) smiled at her, and (Resident #1) went down to the nurses station to tell (LVN B). She stated she was upset and couldn't get her words out, and (LVN B) pushed her down the room to see what she was upset about. (RCP A) was in there and everything was then normal with the lift pad. (Resident #1) said (RCP A) laughed at her, and (Resident #1) said something to her (unsure of what exact words were) and (RCP A) then told her to Shut up and let me do my job. (Resident #1) said (LVN B) approached her after this statement and told her that was abuse and she was going to report it. The statement was signed by the Business Office Manager.Record review of an In-Service and Education Record dated 07/07/25 indicated the ADCO educated 23 staff members on Types of Verbal Abuse and the Effects It Can Have on our Residents and Families. RCP A was not in attendance. The in-service indicated, .Verbal abuse is the use of spoken words to cause emotional harm or anguish to the victim. It includes both the words that are spoken and the way they are spoken.Includes any use of speech that is meant to accomplish any of the following against an individual.scare.undermine.belittle.humiliate.discredit.Perpetrators may us manipulation to convince victims they deserve the abuse.Judging - The use of you statements for the purpose of casting judgement on the victim's character or person.Blaming - Statements that claim the victim is a fault for negative occurrences that are beyond the victim's control.Record review of a Disciplinary Action Record dated 07/10/25 indicated RCP A was given a Final warning. The facts regarding the incident indicated, Rudeness to resident and coworkers. Unprofessional behavior towards charge nurses when asked to complete task. Expectations for team member behavior indicated, Employee will remain professional towards residents and co-workers. Employee will treat everyone with dignity and respect. Corrective action to be taken indicated, Final write up. Further customer service issues will lead to termination. The record indicated RCP A refused to sign. The record was signed by the DCO and EDO. Record review of an undated Provider Response indicated, (Resident #1) made an allegation that the CNA providing care to her roommate told her to shut up and let me do my job. The CNA named in the allegation was asked to provide and statement and suspended pending the outcome of the investigation. The CNA said she told (Resident #1) go in your room and leave me alone. The investigation did not confirm the allegation of abuse. The investigation did confirm an incident of very poor customer service. The employee received disciplinary action for this incident as her statement to the resident was unprofessional and represented poor customer service. The employee will no longer be assigned to provide care to that resident.During an interview on 07/14/25 at 3:03 p.m., Resident #1 said on 07/05/25 she had come back to her room after lunch. She said her roommate had her arm tangled into her lift pad. She said she left out of her room to tell RCP A that her roommate needed help. She said RCP A was just down the hall near the linen cart. Resident #1 said she told RCP A that her roommate needed help and RCP A did not respond. She said she waited awhile, and RCP A never came. She said she peeped out the door and RCP A was still by the linen cart. She said she headed to the nurse's station to get LVN B. She said she had a hard time telling LVN B what was going on. She said LVN B came back to her room with her. Resident #1 said when they got back to the room, RCP A was in the room and had her roommate back like she was supposed to be. She said LVN B went in the room and closed the door. She said she did not know what was said between them. She said when they came out of the room RCP A looked at her and laughed at her. Resident #1 said she raised her voice and told RCP A it was not funny. The resident said RCP A told her, That's why we can't get along because you won't mind your own business and let me do my job. She said RCP A then told her, Shut up and go back to your room. She said LVN B told her RCP A could not talk to her that way because it was verbal abuse. She said later LVN B came to her and told her that she had reported the way RCP A talked to her. She said she had not seen RCP A since the incident. When Resident #1 was asked about what RCP A had said to her, Resident #1 said, absolutely it was abusive. Resident #1 said, I don't want her on this hall. During an attempted interview on 07/15/25 at 9:50 a.m., a call was placed to RCP A. There was a recording, The subscriber you have dialed is not in service.During an interview on 07/15/25 at 10:56 a.m., LVN B said on 07/05/25 Resident #1 came to the nurse's station. Resident #1 said her roommate was in the bed with the lift pad stuck over her head and her hand was stuck in the pad. LVN B said she went to the room with Resident #1. LVN B said when she got there the door was closed. She said RCP A was in the room. LVN B said RCP A had an attitude with her. She said when she walked out, Resident #1 said something to RCP A. She said she could not hear what Resident #1 said. LVN B said she was walking up the hall when she heard RCP A say, you better get out of my face and get back in your room. She said she was approximately four doors away. LVN B said she told RCP A she could not talk to Resident #1 like that. LVN B said RCP A said, did you not hear what she said to me?. LVN B said she told RCP A, I don't care what she said to you, this her home and you cannot talk to her like that. LVN B said she never told Resident #1 it was verbal abuse. LVN B said she just told Resident #1 that RCP A could not talk to her like that and it had been reported to the DCO. LVN B said what RCP A said was rude and she felt like it was abuse. LVN B said RCP A's tone was hateful. She said she would not want RCP A to talk to her grandmother like that. She said if RCP A had talked to her grandmother that way, she would have a mugshot. During an attempted interview on 07/15/25 at 11:40 a.m., RCP A was called at a different number provided by the Business Office Manager. There was no answer. The surveyor was unable to leave a message. During an interview 07/15/25 at 12:15 p.m., the DCO said the incident between Resident #1 and RCP A was reported to her immediately. She said the incident happened on 07/05/25 at the end of RCP A's shift. She said RCP A was suspended on the morning of 07/07/25 and it was reported to the state on the 07/07/25. She said there were several versions of what happened and all that was told to her on the 07/05/25 was that RCP A told Resident #1, just let me do my job. She said she felt this was a customer service issue. She said Resident #1 did not say she felt abused until 07/07/25. She said RCP A did not return to work until 7/10/25. She said this was the only shift RCP A had worked since the incident on 07/05/25. The DCO said she had attempted to call RCP A and there was no answer.During an interview on 07/15/25 at 12:54 p.m., LVN B said on 07/05/25, RCP A's tone was very strong. LVN B said staff had to respect their residents. She said the typed statement dated 07/07/25 was given over the telephone. LVN B said the statement was correct except for the last sentence. LVN B said she never stated, If I felt like it was abuse, I would have reported it right away to (the EDO). During an interview on 07/15/25 at 1:10 p.m., the EDO said she was contacted on the afternoon of 07/05/25. She said the DCO reported to her that Resident #1 was upset and RCP A had said something to the effect of let me do my job. She felt it was rude but not an abuse allegation. The EDO said she was not in the building on the 07/05/25. She said the DCO was in the building. She said things changed on the morning of 07/07/25 when Resident #1 reported the incident to the Business Office Manager. She said that was when it was reported to the state because of what was reported to the Business Office Manager was an allegation of abuse, because she said something different to her than what LVN B said on Saturday, 07/05/25.During an interview on 07/15/25 at 3:12 p.m., Resident #1 said she had not seen RCP A again since the incident on 07/05/25. Resident #1 said she was not afraid of being out of her room. She said if she saw RCP A, she would not be afraid of her, but it would cause her some anxiety.During an interview on 07/15/25 at 3:18 p.m., LVN C said Resident #1 came to the nurse's station on 07/05/25. She said LVN B went down to the room to check on the roommate. She said when they were coming back out into the hallway Resident #1 said something to RCP A, but she could not hear what she said. She said she then heard RCP A say, get out of my face and go back to your room. She said her tone was harsh. LVN C said Resident #1 did not seem afraid or anxious. She said she was present when LVN B called the DCO. She said LVN B explained in detail what had happened. She said she told the DCO that RCP A said, get out of my face and go back to your room. LVN C said LVN B was upset. During an interview on 07/16/25 at 8:15 a.m., the Activity Director said she had seen RCP A have an attitude with other staff but never to any residents. She said since the incident on 07/05/25 between RCP A and Resident #1, Resident #1 had still been attending activities. She said she had not been anxious or afraid. She said, She has not changed a bit.During an interview on 07/16/25 at 8:58 a.m., the Business Office Manager said Resident #1 came into her office on 07/07/25 and asked if she had heard what happened between her and RCP A. She said Resident #1 told her on 07/05/25 her roommate was tangled in her lift pad. She said Resident #1 told her she went to RCP A to ask for assistance and RCP A just brushed her off and continued doing her work. She said Resident #1 told her she went to LVN B. She said Resident #1 told her that LVN B went down to the room and RCP A was in the room. She said Resident #1 told her she said, (RCP A) you know what you did. She said Resident #1 told her RCP A said, Shut up and let me do my job. The Business Office Manager said she gave a statement on what Resident #1 had told her. She said that was not an appropriate thing to say to a resident. She said Resident #1 told her that LVN B heard what was said and told Resident #1 it was verbal abuse, and she would be reporting it. She said she reported what Resident #1 told her to the EDO. She said she felt like what Resident #1 told her was verbal abuse. She said Resident #1 said she did not want RCP A to be her aide anymore. She said since 07/07/25 Resident #1 had gone about her normal activities and had not been upset. She said she had not seen RCP A again since the incident. She said RCP A was very stand offish, not friendly, and can be rude. She said she had never seen her be rude to residents.During an interview on 07/16/25 at 12:06 p.m., the ADCO said she did not witness the incident between RCP A and Resident #1. She said it happened before she came into work on 07/05/25. She said she saw Resident #1 on 07/07/25. She said Resident #1 told her RCP A had said to her, That's why we can't get along because you won't mind your own business and let me do my job. She said RCP A then told her, To shut up and go back to her room. The ADCO said she was also on the phone with the DCO when RCP A gave her statement over the phone. The ADCO said RCP A said she was in the next room changing a resident and Resident #1 had come to tell her what happened. She said RCP A admitted to telling Resident #1 to go back to her room. She said if RCP A said Get out of my face and go back to your room in a hateful or harsh tone it was verbal abuse. She said she started in-services on Customer Service and Verbal Abuse on 07/07/25. The ADCO said RCP A could be difficult with other staff. During an interview on 07/16/25 at 2:09 p.m., the DCO said when LVN B called her on 7/5/25 she tried to clarify exactly what words RCP A used toward Resident #1 and it was told to her that RCP A said, leave me alone and let me do my job. She said at the time she did not feel it was abuse. She said that was different than telling the resident to shut up and go to their room. She said she was going to deal with it as a customer service issue until the morning of 07/07/25 when the story had changed and sounded more like abuse. She said that was when Resident #1 made the statement that RCP A had told her to shut up and go back to her room. She said since the incident Resident #1 has been absolutely fine. She said there has been no adverse psychological effects. She said she preferred not to speculate on a negative outcome for the resident. She said RCP A has been reassigned and would not be providing care to Resident #1.During an interview on 07/16/2025 at 2:55 p.m., the EDO said on 07/05/25 she was notified about the incident between RCP A and Resident #1. She said she felt one thing was told to herself and the DCO on 07/05/25 and then something different was reported on Monday, 07/07/25. She said then she felt like what was said on 07/07/25 was reportable. She said if the nurses were saying it was abuse now, they should have been saying in was abuse at the time and it would have been handled differently. She said the situation was not reported to her as abuse. She said as the EDO you can only make a decision on the facts that have been presented to you. She said RCP A was not suspended until Monday because of what was presented to her on Saturday. She used what was presented to her on Saturday to make the judgement call. She said she talked to Resident #1 almost every day. She said she had not said anything else to her about the incident. She said she has not been upset or distraught. She said DCO was in the building on 7/5/25 during the time the two charge nurses were on duty and nothing additional was shared with her. She said Resident #1 had a history of making her concerns and needs known to the DCO and she did not say anything to her on 07/05/25. She said RCP A has been reassigned and would not provide care to the Resident #1.Record review of a facility Abuse Policy last revised on 01/27/20 indicated, .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 facility staff will adhere to the policies and procedures and will follow the guidelines in the written policy and procedure.Residents will not be subjected to abuse by anyone, including, but not limited to community staff.This includes physical, verbal, sexual, physical/chemical restraint.

Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as possible and provide supervision to prevent avoidable accidents for 1 of 6 residents reviewed for accidents. (Residents #2) The facility failed to keep Resident #2 free of injury after her bed rolled, hitting a wall, while LVN C provided incontinent care. This failure could place residents at risk of injury from accident and hazards. Findings included: Record review of the face sheet dated 04/09/25 revealed Resident #2 was [AGE] years old and admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (lung disease), peripheral vascular disease (a condition where blood vessels outside the heart and brain become narrowed or blocked, restricting blood flow, often to the legs and feet), and acquired absence of right leg above the knee. Record review of the quarterly MDS dated [DATE] revealed Resident #2 was understood and understood other. The MDS indicated Resident #2 had a BIMS of 8 which indicated moderate cognitive impairment. The MDS indicated Resident #2 dependent on staff for toileting hygiene and required moderate assistance with personal hygiene. The MDS indicated Resident #2 required substantial/maximal assistance with rolling left and right. Record review of the care plan last revised on 01/28/25 indicated Resident #2 had an ADL self-care performance deficit related to an acquired absence of right leg above the knee requiring extensive assistance. The care plan indicated the resident was able to turn with extensive assistance. The care plan indicated during incontinent care, nurse was assisting Resident #2 to turn to right side. While rolling the bed rolled into the wall causing resident to roll too far and hit the wall with foot, head, and left hand. The care plan indicated the resident had 2 metatarsal fractures. There was an intervention to send the resident to the emergency room for evaluation and for the resident to be a 2 person assist during incontinent care. The interventions were initiated on 03/24/25. Record review of an incident report dated 03/23/25 at 5:50 a.m. indicated, .During incontinent care, nurse was assisting resident to turn to right side. While rolling, the bed rolled into wall causing resident to roll too far and hit the wall with foot, head, and left hand. Resident states that when she was rolling she hit her foot on the food board and her knuckles on both hands on the wall .No injuries observed at time of the incident .Level of Pain: 0 . The incident report was completed by LVN C. Record review of a Nurses Note for Resident #2 dated 03/23/25 at 5:58 a.m. by LVN C indicated, During resident care was turning resident to change pull up and bed was not locked. When bed rolled to the wall resident ended up rolling over to fall hitting the wall. Assessed and not noted bruising at this time. Resident has no complaints of pain . Record review of a report of an X-Ray of Resident #2's left hand dated 03/23/25 indicated, .Lucency (an area where the X-ray beam passes through more easily, appearing darker or less dense on the image) involving the distal (situated away from the center of the body) aspect of the ulna (one of the two bones in the forearm, located on the pinky side of the hand, and is the longer of the two), which may reflect a nondisplaced fracture . Record review of a report of an X-ray of Resident #2's left foot dated 03/23/25 indicated, Acute fractures involving the second and third metatarsal (bones of the toe) necks, relatively nondisplaced .Mineralization is decreased . Record review of hospital records for Resident #2 dated 03/23/25 indicated, Patient presents with .an injury to head while turning her in the bed .she is here for complaints of pain in both hands and pain in the left foot and toe area . Patient complaint of discomfort to palpation of both hands. Bruising and small abrasions to the hands are noted .examination of the left foot reveal tenderness along the foot into the toes . Patient's workup returned with fractures of the second and third metatarsals (bones of the toe. Degenerative changes are noted throughout the other x-ray .She will need orthopedic referral for treatment of her foot . Record review of a Nurses Note for Resident #2 dated 03/24/25 at 2:47 p.m. by the ADCO indicated, Resident up in w/c (wheelchair) .Resident has no complaint of pain or discomfort at this time. Continues with bruising to the top of bilateral hands with small skin tears to the left. Redness and light bruising noted to left side of forehead .continues ace wrap to left foot for comfort. Resident has two fractured toes . Record review of a Weekly Skin Assessment for Resident #2 dated 03/24/25 indicated bruising bilateral hands. The report indicated skin tears to left hand, right hand, and right elbow. The skin assessment was signed by the DCO. Record review of Orthopedic Surgeon notes dated 04/09/25 indicated second and third metatarsal (bones of the toes) neck fractures left foot and distal ulna (lower arm bone nearest the 5 finger) left wrist. There were orders to ace wrap left foot and for a Velcro splint to the left wrist. The notes were signed by the Orthopedic Surgeon. During an interview on 04/09/25 at 12:48 p.m., a family member said when they left Resident #2 on 03/22/2025 and she was fine. She said Resident #2 called on 03/23/25 and told them she fell out of bed. The family member said they were told about the incident with the bed rolling and Resident #2 hitting the wall. The family member said they talked to LVN C, and he did seem very genuine about what happened. She said LVN C told her that he did not know the bed was not locked down and when he went to change Resident #2 the bed rolled, and the resident hit the wall. The family member said they did not feel like LVN C did anything intentionally. During an observation and interview on 04/09/25 at 12:55 p.m., Resident #2 was resting in bed. There was bruising to her left forehead, a brace on her left wrist, a healing abrasion to the back of her left hand, and an ace wrap to her left foot. The resident said there was nothing wrong with her head. A family member was at bedside and said all the bruising, abrasions, and injury to her left foot was from the incident when her bed rolled during incontinent care. Resident #2 said LVN C rolled her, and she hit the wall. She said she hit the wall hard. She said LVN C was not being rough with her. She said he was trying to assist her, and the bed rolled. She said she was not afraid of LVN C. She felt safe in the facility. During an interview on 04/09/25 at 1:18 p.m., LVN C said he went in Resident #2's room. LVN C said Resident #2 said she was wet and needed to be changed. He said the resident said he could change her. LVN C said he raised the bed up so he would not hurt his back. He said when he rolled Resident #2, he leaned against the bed and the bed rolled. He said the bed had appeared to be locked but the bed still rolled. He said Resident #2 hit the bed pretty hard. He said the bed was actually out from the wall and it hit the wall hard when it rolled. He said there was no bruising at the time of the incident and the resident had no complaints. He said he then finished changing Resident #2. He said all of this happened at the end of shift. He said he did an incident report and initiated neuro checks on the resident because she hit the wall so hard. He said the resident never complained of foot pain to him. He said there were no other staff in the room at the time of the incident. During an interview on 04/09/2025 at 2:03 p.m., the Director of Plant Operations said after the incident concerning Resident #2, he was called to check Resident #2's bed. He said the bed had six different brakes. He said one brake was loose but the other 5 were in good working order. He said there was not a mechanical reason the bed should have moved if the brakes were locked. During an interview on 04/09/2025 at 2:51 p.m., the DCO said LVN C told her he was performing incontinent care for Resident #2. LVN C told her he rolled Resident #2 onto her right side. He told her he thought the bed was locked but the brakes were not working. The DCO said his weight went against the bed and the bed rolled. She said Resident #2 was holding onto the assist bar with her hands. She said the resident had bruising to left side of her forehead. She said they were not sure what Resident #2's foot hit. She said it could have hit the foot board or even the hooks from the air mattress pump. She said she would have expected for LVN C to have made sure the bed was locked. She said a bed not being locked could cause injuries such as this. She said she was not sure where the wrist injury came from. She said the resident had not been complaining of wrist pain. During an interview on 04/09/25 at 3:28 p.m., the EDO said it was reported to her that the nurse went in to provide incontinent care for Resident #2 and when he went to roll her over the bed moved and the resident hit the wall. She said he was the only person in the room providing care. She said after this incident Resident #2 would require 2-person assistance. She said the resident did have osteoporosis. She said she had bruising to her forehead, she had a broken bones in her foot, she had a broken bone in her wrist. She said Resident #2 had abrasions to her hand and skin tears. She said they felt she was holding on to the handrail and hitting the wall caused the abrasions and skin tears. She said when Resident #2 returned from her orthopedic doctor visit on 04/09/25 the fracture to the wrist was listed. She said this was the first they had heard about the wrist fracture. She said she expected staff to make sure beds were locked while providing care to ensure safety of the resident. She said they completed audits on all of the beds to make sure they were in working order. Record review of an undated Addressing Resident Safety in the Community facility policy did not address ensuring resident's beds were locked during incontinent care. Record review of a Bed Safety facility policy dated 04/2021 did not address ensuring resident's beds were locked during incontinent care.

Based on observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, or mistreatment are reported immediately or not later than 2 hours for 1 of 6 residents reviewed for abuse and neglect. (Resident #1) The facility staff (RCP A, LVN B, and the Social Worker) failed to report an allegation of abuse immediately to the Abuse Coordinator after Resident #1 alleged that RCP D threw a blanket on her face and told her to shut the hell up. This failure could place residents at risk for abuse and neglect. Findings included: Record review of a face sheet dated 04/09/25 revealed Resident #1 was a [AGE] year-old female and was admitted on [DATE] with diagnoses including schizoaffective disorder bipolar type (combines symptoms of both schizophrenia (like hallucinations and delusions) and bipolar disorder (like mania and depression), diabetes, and high blood pressure. Record review of a quarterly MDS dated [DATE] revealed Resident #1 was understood and understood others. The MDS revealed a BIMS score of 9, indicating moderate cognitive impairment. The MDS indicated Resident #1 required substantial to maximal assistance with most ADLs. Record review of a care plan last revised on 04/10/25 revealed Resident #1 was verbally aggressive related to schizoaffective disorder and mental/emotional illness, ineffective coping skill and poor impulse control with past history of verbal disruption, screaming, cursing, making accusations, telling family untruths about staff and other residents. This focus area of the care plan was last revised on 04/17/23. Record review of an undated and untimed written statement of LVN B indicated, On 4/1/25 the 6-2 RCP (RCP A) told me that (Resident #1) had a complaint against (RCP D), the 10-6 rcp from the previous night. I went to speak with (Resident #1), and she stated that the night before (RCP D) threw a blanket at her head and told her to shut the hell up. I asked he if she was okay, and she said yes. She did not have any notable injuries. I asked her why (RCP D) would have done that, and she said she did not know. I informed her that I would tell the administrative team, and someone would come speak to her. I then went to the social worker's office and reported what the resident had told me. The statement indicated it was obtained by the DCO and the ADCO. The statement was signed by the DCO and the ADCO. Record review of an undated and untimed statement by the Social Worker indicated, Resident (Resident #1) state that she wanted to tell me about (RCP D) last night. (RCP D) got mad at her because she told her to pick up the bowls and stuff. (RCP D) threw a blanket at her, and it hit the top of her, and she didn't say she was sorry. The statement was signed by the Social Worker. Record review of a Disciplinary Action Record dated 04/01/25 indicated RCP D was suspended pending investigation of physical abuse allegation made by a resident. The record indicated RCP D was notified of the suspension by phone on 04/01/25 at 2:41 p.m. The record was signed by the ADCO and the DCO. Record review of a police Incident Report dated 04/01/25 at 3:19 p.m. indicated .On April 1, 2025, (police officer) was dispatched to (the facility). Upon arrival, I was met by the Administrator (EDO) .(the EDO) stated that there was an incident where a resident (Resident #1) accused a worker of hitting her in the face with a blanket .(Resident #1) state that a nurse, (RCP D) got mad at her because she asked her to clean her room and take her food tray. (Resident #1) stated that at this point, (RCP D) who was standing in the hallway, threw a blanket and hit her in the face with it .(RCP 1) said in her statement that she was doing rounds and that she would come back to pick up trays after she was finished .(RCP D) said in her statement .she overheard (Resident #1) calling to someone to bring her a blanket and that is when (RCP D) got the blanket and went into the room. (RCP D) said that when she unfolded the blanket, she fanned it up and the edge of it brushed against (Resident #1's) face. (RCP D) said that she was sorry for that immediately and said it was an accident. (Resident #1) was not in any pain or discomfort when (RCP D) left the room according to her statement. Based on my interviews and observations, I believe that this was an unintentional accident and that (RCP D) did fan the blanket, but there was no intention to harm (Resident #1). Record review of an undated Investigation Summary indicated, .Based upon the outcome of the investigation, it was determined that several facility employees failed to follow policy and procedure of notifying the Abuse Coordinator immediately when a suspected/actual resident abuse allegation occurs. The employees received individualized education from the EDO. The social services director was sent home once this was discovered and allowed to return after the investigation was complete. The EDO provided 1:1 education to this employee upon return. Record review of an In-service & Education Record dated 04/02/25 at 9:45 a.m. indicated the EDO educated the Social Worker on .All allegations of abuse, neglect or misappropriation must be reported timely to the Abuse Coordinator EDO is the Abuse Coordinator. The DCO will serve in this capacity in the absence of the EDO .Failure to comply with this requirement will result in disciplinary action to include possible immediate termination . Record review of an In-service & Education record dated 04/01/25 indicated the DCO educated LVN B on Any allegations of abuse/neglect/misappropriation must be reported to Abuse Prevention Coordinator . During an observation and interview on 04/09/25 at 10:20 a.m., Resident #1 was resting in bed. There was no bruising or signs of abuse. She said on 3/31/25 she asked RCP D if she would pick up her meal tray. She said when RCP D came in the room she then asked for a blanket. She said RCP D threw the blanket on her and did not spread it out. She said RCP D did not say anything to her. She said she was not injured in any way. She said she reported the incident the next morning to RCP A and RCP A reported it to LVN B. She said RCP D no longer provided care to her and she was ok with it. She said she was not afraid to live in the facility. She said she had no other issues with any staff members. During an interview on 04/09/25 at 10:59 a.m., LVN B said she did not know the specific date of the incident concerning Resident #1. She said RCP A came to her and told her what Resident #1 had reported to her. LVN B said RCP A told her that Resident #1 said RCP D threw a blanket over her head and told her to shut the hell up. She said Resident #1 did not like RCP D. She said she went in to talk to Resident #1. She said Resident #1 told her that RCP D threw a blanket at her head and told her to shut the hell up. She said Resident #1 told her she did not like RCP D, and she was going to try to get another aide in trouble because she did not like her either. She said the EDO (the Abuse Coordinator) was not in the facility at the time, so she did not report the allegation to her. She said she reported the incident immediately to the social worker. She said she was told later that she should have reported the incident to the EDO. During an interview on 04/09/25 at 11:33 a.m., the Social Worker said she interviewed Resident #1 on the morning of 4/1/25 after the incident was reported to her by LVN B. She said LVN B told her Resident #1 was upset with RCP D. The Social Worker said Resident #1 told RCP D threw a blanket on her head. She said the only other thing she told her was that RCP D did not apologize. She said Resident #1 never told her that RCP D said to shut the hell up. The Social Worker said Resident #1 always upset with someone. She said the resident made false accusations against staff. She said she knew the allegation was reported to her before the morning meeting. She said she was disciplined for not reporting the allegation to the EDO. She said she never reported the allegation to the Administrator and did not know how she found out. She just brought me into the office. During an interview on 04/09/2025 at 12:40 p.m., the Social Worker said she said she just did not pay enough attention to what LVN B was telling her. She said she thought LVN B was reporting the behavior of Resident #1 and not that RCP D may have done something abusive. She said she did not realize that it was an abuse allegation until after she was called into the EDO's office. She said she interviewed the resident after leaving the EDO's office and that was when Resident #1 told her that RCP D had thrown the blanket. During an attempted interview on 04/09/2025 at 1:55 p.m., a call was made to interview RCP A. There was no answer. Left a detailed message requesting a return call. A return call was not received. During an interview on 04/09/2025 at 2:27 p.m., RCP D said she did not know anything about the allegation made by Resident #1 until she was questioned about it. She said she never threw a blanket. She said she never told the resident to shut up. She Resident #1 was upset with her because she did not pick up the evening meal tray as fast as she wanted her too. She said she did bring Resident #1 a blanket and when she spread the blanket out it did cover her face. She said she immediately removed the blanket and told her she did not mean for that to happen. She said she apologized to the resident. She said she had been reassigned and would not be providing care to Resident #1. During an interview on 04/09/2025 at 2:41 p.m., LVN B said RCP A reported the allegation made by Resident #1 at approximately 10:00 a.m. She said she reported the incident immediately to the Social Worker. She said she did not report it to the EDO because she was not at the facility at the time. She said she was told later that she still should have notified the EDO. She said she really was not thinking about abuse. She said she was thinking more about the resident's behaviors and had been told to report any behaviors to the social worker. She said she then told the DCO at approximately 12:45 p.m. During an interview on 04/09/25 at 2:51 p.m., the DCO said the allegation of abuse made by Resident #1 was reported to the state on 04/01/25 but happened on 03/31/25. She said Resident #1 had asked to speak to her. She said Resident #1 told her RCP D got a blanket and threw it on her from the hallway. She said there were no witnesses to the incident. She said RCP D told her she fanned the blanket out and it went in the resident's face accidently. She said she pulled the blanket down immediately. She said when she first started interviewing RCP D, she did not know what she was talking about. The DCO said she found out about the allegation at approximately 1:00 p.m. on 04/01/25. She said she talked to LVN B. She said LVN B told her she was following instructions from a previous DCO to report any behaviors of Resident #1 to the Social Worker. She said Resident 1's version differed depending on who she told the allegation to. She said she was the one who reported the incident to the EDO. She said she would have expected for the Social Worker to have reported the incident to the EDO immediately after it was reported to her by LVN B. She said allegations of abuse not being reported timely could lead to abuse possibly continuing if it was actually occurring. During an interview on 04/09/25 at 3:28 p.m., the EDO said Resident #1 alleged that evening (03/31/25) RCP D threw a blanket from the hallway that landed on her head and told her to shut the hell up. She said RCP D said she got the resident a blanket. Unfolded the blanket, fluffed it out and touched the resident on the face. RCP D said she removed the blanket and said she was sorry. She said Resident #1 then reported the allegation of abuse to RCP A. The EDO said she was not in the building at the moment. She said RCP A told LVN B about the allegation made by Resident #1. She said LVN B ended up reporting the allegation to the Social Worker. She said once she found out about the allegation, she sent the Social Worker home and did a one on one with her after she returned to worked. She said LVN B and RCP A was given one on one education also. She said it was about three hours from the time the allegation was made to RCP A and LVN B and the time she found out about the allegation. She said the DCO was who reported it to her around 1:00 p.m. She said she would have expected RCP A, LVN B, and the Social Worker to have reported the allegation to her sooner. She said she was out of the facility, but her number was at the desk, and they could have called her. She said she expected all allegations of abuse to be reported to her immediately. She said allegations not being reported timely limited her options to intervene and take action. Record review of an Abuse facility policy last revised on 01/01/23 indicated, .The facility staff will adhere to the policies and procedures and will follow the guidelines in the written policy and procedure .All events that involve an allegation of abuse or involve a suspicious serious bodily injury of unknown origin must be reported immediately or not later than 2 hours of alleged violation .

Based on observation, interview, and record review, the facility failed to ensure treatment and services was provided, consistent with professional standards of practice, to promote healing and prevent new ulcers from developing for 3 of 7 residents reviewed for quality of care. (Resident #93, Resident #11, and Resident #15) The facility failed to initiate wound care treatment after Resident #93 admitted on [DATE], with multiple areas of shearing. The facility failed to perform a weekly skin assessment on Resident #93 that was due on 02/08/25. The facility failed to initiate Resident #93's wound care orders noted in the wound care doctor's progress notes on 02/08/25 until 02/10/25. The facility failed to implement a specialty mattress (use in the treatment and prevention of pressure ulcers) for Resident #93, per their policy, due to multiple stage 3 pressure injuries on 02/01/25. The facility failed to float Resident #93's heels on 02/10/25 and 02/11/25. The facility failed to offload and/or reposition Resident #93 every 2 hours on 02/10/25 and 02/11/25. An IJ was identified on 02/11/25. The IJ template was provided to the facility on [DATE] at 5:00 p.m. While the IJ was removed on 02/12/25, the facility remained out of compliance at a scope of pattern and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because all staff had not been trained on the process of carrying out orders for residents admitted with wounds or obtaining orders if no orders accompanied the resident, completion of weekly skin assessments, wound care orders, skin management policy, and pressure ulcer prevention and interventions for residents with pressure ulcers. 2.The facility failed to document wound care was performed on Resident #11, on 02/01/25, 02/02/25, 02/03/25, 02/05/25, and 02/10/25. The facility failed to document Resident #11's weekly skin assessments on 01/02/25, 01/15/25, 01/22/25, 01/29/25, and 02/04/25. 3.The facility failed to document wound care was performed on Resident #15's right upper thigh wound on 01/17/25, 01/20/25, and 01/29/25. The facility failed to document Resident #15's weekly skin assessments on 01/19/25, 01/26/25, 02/02/25, and 02/09/25. Theses failures could place residents at risk for wound deteriorations and more wound development. Findings included: 1. Record review of Resident #93's face sheet dated 02/11/25 indicated Resident #93 was a [AGE] year-old female admitted to the facility on [DATE]. Resident #93 had diagnoses including acute kidney failure (when the kidneys suddenly can't filter waste products from the blood), urinary tract infection (is an infection in any part of your urinary system: kidneys, bladder, ureters, and urethra), morbid obesity (is a medical condition characterized by excessive body weight that significantly impacts health and well-being), and pressure ulcer of right hip, left hip, and other sites, stage 3 (a full-thickness tissue loss where the subcutaneous fat layer is visible within the wound, but the bone, tendon, or muscle is not exposed). Record review of the MDS, on 02/10/25, indicated Resident #93 was admitted to the facility less than 21 days ago. No MDS for Resident #93 was completed prior to exit. Record review of Resident #93's care plan dated 02/03/25 indicated: *Resident #93 was admitted with stage 3 pressure ulcer to right thigh. Interventions included assess and document skin condition every week, pressure relieving appliances as ordered, reposition residents as indicated to relieve pressure and for comfort, and wound care per MD orders. *Resident #93 was admitted with Stage 3 pressure ulcer to right hip. Interventions included assess and document skin condition every week, monitor nutritional intake, weight, lab values and report significant changes to MD, pressure relieving appliances as ordered, reposition residents as indicated to relieve pressure and for comfort, and wound care per MD orders. *Resident #93 was admitted with stage 3 pressure ulcer to left thigh. Intervention included administer treatments as ordered and monitor for effectiveness, monitor nutritional status, and obtain and monitor lab/diagnostic work as ordered. Record review of Resident #93's consolidated physician orders dated active as of 02/11/25 indicated the following: *Left thigh- cleanse with house wound cleanser. Apply Medi honey and collagen sheet. Cover with foam and border gauze dressing everyday shift. Start 02/11/25. *Nursing to perform weekly skin assessment. Ordered 02/09/25. *Right hip- cleanse with house wound cleanser and pat dry. Apply Medi honey and cover with collagen sheet and foam then secure with border dressing everyday shift. Start 02/11/25. *Right thigh- cleanse with house wound cleanser and pat dry. Apply Medi honey and collagen sheet. Cover with foam and secure with border dressing everyday shift. Start 02/11/25. The consolidated physician order did not reflect wound care orders for Resident #93's left thigh, right hip, and right thigh pressure ulcer on admission (02/01/25). Record review of Resident #93's MAR dated 02/01/25-02/28/25 indicated the following: *Left thigh- cleanse with house wound cleanser. Apply Medi honey and collagen sheet. Cover with foam and border gauze dressing everyday shift. Start 02/11/25. *Nursing to perform weekly skin assessment. Ordered 02/02/25. Discontinued 02/09/25. No documentation was noted on 02/02/25 and 02/09/25. *Right hip- cleanse with house wound cleanser and pat dry. Apply Medi honey and cover with collagen sheet and foam then secure with border dressing everyday shift. Start 02/11/25. *Right thigh- cleanse with house wound cleanser and pat dry. Apply Medi honey and collagen sheet. Cover with foam and secure with border dressing everyday shift. Start 02/11/25. Record review of Resident #93's progress note dated 01/12/25-02/12/25 indicated: *02/01/25 at 7:47 p.m. by the ADCO, .new admission skin assessment .the following areas were all noted upon admission to the facility . Right Lateral thigh shearing 2cm x 5cm x0.1cm open area without exudate with surrounding scaring . Right gluteal area shearing 0.4cm x 0.4cm x 0.1 cm no exudate noted . Right lateral hip shearing with surrounding scaring 5.5cm x 1.4cm x 0.1cm no exudate noted . Right Posterior hip shearing 1.3cm x 0.9cm x 0.1cm no exudate noted . Right posterior thigh near gluteal fold 1.2cm x 0.1cm. Area is a hard area that appears to be healing . Left posterior thigh shearing 1.2cm x 1cm x 0.1cm area noted to have slight bleeding when dressing was removed . right medial posterior thigh near gluteal fold 1cm x 1cm. area is a hard area that appears to be healing . *02/08/25 at 7:33 p.m. by DNP S, .date of service: 02/07/25 .wound initial .Resident #93 . The following wounds were evaluated during today's visit . Wound 1 Right Hip, Pressure Injury, Stage 3 . Wound 2 Right Thigh, Pressure Injury, Stage 3 . Wound 3 Left Thigh, Pressure Injury, Stage 3 . Patient is admitted with multiple wounds . Per report from DON . WOUND ASSESSMENT: .Wound: 1 . Status: Present on Admission Location: Right Hip . Primary Etiology: Pressure Injury Severity: Stage 3 . Size: 6 cm x 1.5 cm x 0.1 cm. Actual area is 9 cm2. Actual volume is 0.9 cm3 Wound Base: , 100% granulation . Wound Edges: Attached . Periwound: Fragile, No erythema, No edema Exudate: Light Serous .Wound Odor: None . Signs of Wound Infection: No signs of infection Wound Pain at Rest: 0 . Wound: 2 . Status: Present on Admission Location: Right Thigh . Primary Etiology: Pressure Injury .Severity: Stage 3 . Size: 4 cm x 2 cm x 0.1 cm. Actual area is 8 cm2. Actual volume is 0.8 cm3 Wound Base: , 100% granulation . Wound Edges: Attached . Periwound: Fragile, No erythema, No edema, No maceration Exudate: Light Serous . Wound Odor: None . Signs of Wound Infection: No signs of infection Wound Pain at Rest: 0 . Wound: 3 . Status: Present on Admission Location: Left Thigh . Primary Etiology: Pressure Injury .Severity: Stage 3 . Size: 1.5 cm x 1 cm x 0.1 cm. Actual area is 1.5 cm2. Actual volume is 0.15 cm3 Wound Base: , 100% granulation . Wound Edges: Attached . Periwound: Fragile, No erythema, No edema, No maceration Exudate: Light Serous . Wound Odor: None .Signs of Wound Infection: No signs of infection Wound Pain at Rest: 0 . Recommendations consisting of: .We will re-evaluate this patient on our next visit (anticipated 1-2 weeks), Implement pressure relieving measures, offloading, and repositioning, as tolerated . Establish turning frequency based on the characteristics of the support surface and the patient's response . Protect skin from exposure to excessive moisture (periwound) with a barrier product. Use skin emollients to hydrate dry skin . Repositioning should be undertaken using the 30-degree tilted side-lying position (alternating right side, back, left side) . Plan of care discussed with facility staff .Wound# 1 Right Hip Pressure Injury Treatment Recommendations: .clean with Wound Cleanser . apply Collagen particles, Honey and Bordered foam dressing . change Daily and as needed if dislodged, saturated, or soiled Wound # 2 Right Thigh Pressure Injury .Treatment Recommendations: . clean with Wound Cleanser . apply Collagen particles, Honey and Bordered foam dressing . change Daily and as needed if dislodged, saturated, or soiled Wound # 3 Left Thigh Pressure Injury .Treatment Recommendations: . clean with Wound Cleanser . apply Collagen particles, Honey and Bordered foam dressing . change Daily and as needed if dislodged, saturated, or soiled . Record review of Resident #93's memorandum of transfer and physician certification dated 02/01/25 indicated emergency department diagnoses included pressure injury of contiguous region involving back, right buttock, and right hip, stage 2. Record review of Resident #93's hospital discharge summary dated 02/01/25 did not reflect wound care orders. Record review of Resident #93's Braden scale for predicting pressure sore risk dated 02/01/25 indicated score of 16 which was at risk. Record review of Resident #93's weekly skin assessment dated [DATE] indicated .does the resident have a pressure, venous, arterial, diabetic, or surgical wound .yes .stage 2 PU, multiple shearing sites to right lateral thigh, right posterior thigh multiple, left posterior thigh, right buttocks, left posterior thigh . The facility's electronic medical record did not reflect a skin assessment on 02/08/25 or 02/09/25. Record review of Resident #93's wound assessment report dated 02/07/25 indicated .left thigh .Length: 1.50 cm .Width: 1.00 cm .Depth: 0.10 cm .left thigh .pressure injury .stage 3 .treatment: daily .wound cleanser .collagen particles and honey .bordered foam dressing . Record review of Resident #93's wound assessment report dated 02/07/25 indicated .right thigh .length: 4 cm .width: 2 cm .depth: 0.10 cm .right thigh .pressure injury .stage 3 . treatment: daily .wound cleanser .collagen particles and honey .bordered foam dressing . Record review of Resident #93's wound assessment report dated 02/07/25 indicated .right thigh .length: 6 cm .width: 1.5 cm .depth: 0.10cm .right hip .pressure injury .stage 3 . treatment: daily .wound cleanser .collagen particles and honey .bordered foam dressing . Record review of the facility's Skin Management: Prevention and Treatment of Wounds policy revised 10/06/22 indicated .specialty mattress will be implemented for residents with multiple stage 2 areas, stage 3, or stage 4 pressure injuries . During an observation and interview on 02/10/25 at 10:51 a.m., Resident #93 was lying in the bed on her back. Resident #93 was not on a specialty mattress. Resident #93 did not have any pressure relieving devices noted in her bed. Resident #93's legs were not offloaded. Resident #93 said staff did not turn her every 2 hours or prop her heels with pillows. She said she could turn herself with the assist rails but staff did not place pillows behind her back, underneath her buttocks or between her legs. During an observation and interview on 02/10/25 at 3:05 p.m., Resident #93 was lying in the bed on her back. Resident #93 was not on a specialty mattress. Resident #93 did not have any pressure relieving positioning devices noted in her bed. Resident #93's legs were not offloaded. Resident #93 said staff did not turn her every 2 hours or propped her heels with pillows. During an observation on 02/11/25 at 10:02 a.m., Resident #93 was lying in the bed on her back. Resident #93 was not on a specialty mattress. Resident #93 did not have any pressure relieving positioning devices noted in her bed. Resident #93's legs were not offloaded. During an observation and interview on 02/11/25 at 11:32 a.m., Resident #93 was lying in the bed on her back. Resident #93 was not on a specialty mattress. Resident #93 did not have any pressure relieving positioning devices noted in her bed. Resident #93's legs were not offloaded. Resident #93 said staff had not turn her every 2 hours or propped her heels with pillows. She said she had wounds on thighs, buttock, and hip. She said when she came from the hospital, there were dressings on two of the wounds. She said the facility did not do dressing changes every day. She said it depended on the staff as to what was done to her wounds. She said some staff did nothing and others would put cream on the wounds if they were closed. During an observation on 02/11/25 at 1:25 p.m., Resident #93 was lying in the bed on her back. Resident #93 was not on a specialty mattress. Resident #93 did not have any pressure relieving positioning devices noted in her bed. Resident #93's legs were not offloaded. During an interview on 02/11/25 at 1:30 p.m., the ADCO said she was working the floor when Resident #93 was admitted . She said she was Resident #93's admitting nurse. She said if the admitting nurse was not a RN, then the nurse was only responsible for measuring and describing the wound. She said a RN, the DCO, or MD staged pressure wounds at the facility. She said upon admission the resident's MD should be notified and general wound care orders obtained. She said when the wound care doctor rounded on Fridays, the facility received specialized wound care orders. She said the wound care doctor came every Friday and the DCO notified him of who needed to be seen. She said after the wound care doctor rounded and made recommendations. She said the wound care doctor placed his recommendations in a progress note. She said the floor nurses or the DCO were responsible to place the recommendations in the facility's electronic medical record as an order. She said the DCO and ADCO were responsible for ensuring the wound care orders were followed through. She said the floor nurses were responsible for the resident's weekly skin assessments. She said the DON and DNP completed the weekly wound assessments when he rounded on Fridays. She said Resident #93 wounds on admission were shearing to her right hip, right buttocks, left thigh, and left buttocks. She said since she was not a RN, she did not stage Resident #93's wounds. She said Resident #93 arrived from the hospital with dressings over the wounds. She said she notified NP R by text or phone and let her know about Resident #93's shearing. She said she did not receive a response from NP R until shift change. She said she could not remember what NP R said about Resident #93's shearing. She said she knew she passed the message from NP R on to RN G when she gave report. She said she did not know what wound care treatment Resident #93 had been receiving since admission on 02/01/25. She said she did not know the facility's policy or criteria on specialty mattress because she just started January 13, 2025. She said she did not know if Resident #93 met the facility's criteria for a specialty mattress but she probably did. She said other interventions for Resident #93's pressure wounds should have been frequent repositioning and incontinent care and a dietary consult. She said the dietician would be at the facility this week. She said since Resident #93 had a skin assessment on 02/01/25, then she should have had one on 02/08/25. She said even though the skin assessment was a day after the wound care doctor came, it should have been done by the floor nurse. She said skin assessments were important to ensure skin issues were not missed and proper wound care orders were in place. She said following doctors' orders were important to prevent the wound from declining and promote healing. She said the facility provided Resident #93 assist rails and trapeze bar to help with her mobility. On 02/11/25 at 2:23 p.m., called NP R and left voicemail. On 02/11/25 at 2:25 p.m., called RN G and left voicemail. During an interview on 02/11/25 at 2:58 p.m., NP R said she received a text message from LVN A that Resident #93 was admitted . She said she was currently driving and could not remember if the ADCO contacted her on admission about Resident #93's wounds. She said normally the facility followed the hospital's wound care orders and did not need them to give any orders. During an interview on 02/11/25 at 4:41 p.m., NP R called back and said LVN A and the ADCO called her on 02/01/25 about Resident #93. She said she told LVN A and the ADCO to resume all hospital orders and she would see Resident #93 on Tuesday, 02/04/25. During an interview on 02/11/25 at 6:01 p.m., RN G said she had worked at the facility for 6 years. She said she had taken care of Resident #93. She said she was texting with NP R on 02/05/05 about another resident lab work and NP R asked about Resident #93. She said NP R mentioned the hospital had not sent Resident #93 with wound care orders when she discharged . She said she told NP R that there were no wound care orders in Resident #93's hospital discharge paperwork. She said she told NP R, she did not know what the facility had been doing either for Resident #93's pressure wounds. She said NP R ordered collagen and a dry dressing and for the wound care doctor to see Resident #93. She said she did the ordered wound care on Resident #93 that night shift (02/05/25). She said she thought she placed the wound care orders NP R gave for Resident #93 in the facility's electronic medical records. She said Resident #93's wound care orders from NP R would be on her MAR if she did. She said it was important to have put in the wound care orders from NP R, so the next person knew what to do for Resident #93's wounds. She said not doing wound care treatments for Resident #93's wounds could cause further break down or increased stages. She said Resident #93's wounds would have been called stage 2's on admission. She said if the admission nurse was not a RN, then the next RN on duty was responsible for staging the pressure ulcer. She said if a wound needed to be staged by a RN, that information needed to be passed down by the next nurse or put on the 24-hour report. She said staging a pressure ulcer was important so the wound could be caught early and treated so it did not decline. She said she was not aware Resident #93's wounds were not staged until DNP S came on 02/07/25. She said a resident had to have pressure breakdown to be on a low air loss mattress. She said Resident #93 was on a bariatric pressure reduction mattress. She said she did not if they made bariatric specialty mattresses. She said if they made bariatric low air loss mattresses, Resident #93 would qualify for one because she had several areas of pressure breakdown. During an interview on 02/12/25 at 1:57 p.m., LVN D said nurses were responsible for resident's skin assessments. She said the skin assessments were due weekly and as needed. She said the weekly skin assessments should be charted in the resident medical records. She said a resident should be on a low air loss mattress if they have pressure ulcers or at the family request. She said heels should be floated for residents after hip surgery, residents who do not turn good, or residents with redness on their heels. She said residents should be repositioned every 2 hours. She said the RCP or LVN could do it but the RCP was primarily responsible. She said if a resident was able to turn themselves in the bed, the RCP should still encourage and help the resident turn every 2 hours. She said the RCP should be propping the resident with pillows to offload them when repositioning. She said the LVN should be ensuring the RCP are repositioning every 2 hours and offloading the residents by observation. She said a RN and LVN certified in wound care could stage pressure wounds. She said primarily RNs. She said if a resident needed a pressure wound staged, she would find a RN or contact the DCO. She said the facility had a telehealth option to stage wounds available now. She said the resident's doctor or the medical director was contacted for wound care orders. She said nursing management was responsible for taking the wound care doctor recommendations and making them orders. She said when the wound care doctor rounded on Fridays, he gave the DCO a copy of his recommendations on a piece of paper before he left. She said the wound care doctor left around 10 am. She said the bedside nurses were responsible for doing wound care treatments. She said the nurses documented on the MAR/TAR when wound care was completed. She said if wound care was not documented on the resident MAR/TAR, it could indicate it was not done. She said some residents did not show on the right screen to be done on the facility's computer system. She said skin assessments, wound care treatments, and repositioning/offloading were important to prevent skin breakdown and worsening of wound and not miss anything. During an interview on 02/12/25 at 5:25 p.m., RCP H said she had worked at the facility for 2 years. She said she found out a resident had wounds when she changed them. She said she was not really made aware by nursing staff or during report which resident had wounds. She said it depended on the severity of the wound what type of treatment the resident required. She said some resident needed cream and other had dressing changes by the nursing staff. She said RCPs were responsible for repositioning the residents every 2 hours with rounds. She said the residents should be alternated side to side and propped with pillows. She said residents stuck in the bed should have their heels offloaded. She said Resident #93 was stuck in the bed unless PT got her up. She said when she had Resident #93, she went in her room every once in a while, to remind her to turn but not every 2 hours. She said turning and offloading were important to prevent skin breakdown. She said constant pressure caused skin breakdown. During an interview on 02/12/25 at 5:49 p.m., the ADCO said wound care was documented on the resident's TAR in the facility's charting system. She said if wound care was not documented in the facility's charting system, it could indicate it was not done. She said the charge nurses were responsible for the resident's wound care. She said the DCO and ADCO should ensure the charge nurses were doing the ordered wound care treatments and documenting wound care on the resident's MAR/TARs. She said doing the resident's ordered wound care treatment was important to prevent decline of the wound, infection, prevent pain and more wounds. She said it was also important to do wound care to monitor the wound and follow doctor's orders. She said completion of the resident's skin assessment was documented on the TAR/MAR and a skin assessment form was also done. She said when she first started, she did not know that a skin assessment form had to be done even if the resident had no skin changes. She said she documented she completed Resident #15's skin assessment on the MAR/TAR but she did not do a new skin assessment form. She said she and the DCO Q were in the process, of putting a process in place to do chart audits to monitor skin assessments and wound care orders. During an interview on 02/12/25 at 6:57 p.m., DCO P, who was covering for DCO Q, said she expected nursing staff to follow physician orders. She said she expected nursing staff to document wound care on the MAR/TAR and/or progress note in the facility's charting system. She said if the wound care was not documented on the MAR/TAR and/or progress note, it could indicate it was not done. She said she expected nursing staff to order skin assessment on admission. She said she expected nursing staff to complete skin assessment weekly and with skin changes. She said the DCO ordered the resident's specialty mattresses and the charge nurse should ensure it was on the correct settings. She said all resident benefited from having their heels floated. She said but immobile residents especially needed their heels floated. She said she expected residents to be repositioned and offloaded at least every 2 hours by the RCPs. She said she preferred staging pressure wounds be done by the telehealth system. She said a RN or DCO should stage the resident pressure wounds. She said the ADCO and DCO should be ensuring nursing staff were doing wound care and skin assessments. She said all of these were important for wound prevention and management. During an interview on 02/12/25 at 7:34 p.m., the EDO said skin assessment were to be completed every 7 days in the facility's charting system. She said Resident #93 met the criteria for a low air loss mattress. She said the facility had a few specialty mattresses in house and she also could order one if needed. She said the DCO or the nursing staff who rounded with the wound care doctor was responsible for inputting his orders. She said it was important to document wound care and skin assessments to have an adequate clinical record. She said it was important to do wound care and skin assessments to promote wound healing. She said nursing management was responsible for ensuring nursing staff completed skin assessment and wound care. She said nursing management should be doing chart audits to ensure it was happening. Record review of a facility's Skin Management: Prevention and Treatment of Wounds policy revised 10/06/22 indicated .the purpose of this procedure is for prevention and treatment of skin breakdown such as pressure injuries, diabetic ulcers, arterial ulcers, and skin wounds Skin assessments will be documented at a minimum of every 7 days on a Weekly Skin Assessment . Staging of wounds will be performed by a registered nurse or licensed nurse certified in wound care . Dependent residents will have heels floated while in bed and be turned and repositioned at a minimum of every 2 hours . A licensed nurse will obtain orders from physician for new skin wounds and transcribe onto resident's treatment record for follow up . Specialty mattresses will be implemented for residents with multiple stage II areas, stage Ill, or stage IV pressure injuries . Weekly skin assessments will be documented on the Weekly Skin Assessment every 7 days or less . Licensed nurse will initiate the schedule for the wound form in Point Click Care which automatically triggers every 7 days from day of completion . The EDO and DCE were notified of an IJ on 02/11/25 on 5:00 p.m., were given a copy of the IJ template, and a Plan of Removal (POR) was requested. The Plan of Removal was accepted on 02/12/25 at 9:40 a.m. and included the following: F686- Skin Integrity/Pressure Ulcer Plan of Action: Resident #93 had wound care orders written on 02/11/25. A weekly wound assessment was completed on 02/11/25. A specialty mattress was placed on Resident #93's bed on 02/11/25. Resident #93's heels were floated effective 02/11/25. Skin sweep competed on 02/11/25 to ensure all skin issues were identified and had current orders and interventions in place. Completed 02/11/25 by Director of Clinical Education and designees. Director of Clinical Education will educate Director of Clinical Services and Assistant Director of Clinical Services on the process of reviewing new resident admissions electronic health records for completion of order transcription as it relates to wound orders as well as carrying out those orders. Completed 2/11/25 If a RN or wound care certified LVN is not on duty at the time a resident admits, the admitting nurse on duty will utilize Advanced Wound Care Telehealth for a consult. Completed 02/12/25. All licensed nurses will be educated by the ADCO or designee on the process of carrying out orders for residents admitted with wounds or obtaining orders if no order accompanies the resident when admitted . Education will also include the completion of weekly skin assessments per schedule. Completion 02/12/25 10:00 a.m. Anyone who is not on duty that we cannot reach by phone will be required to complete the in-service prior to working their next shift. All licensed nurses will receive in-service regarding wound care orders and weekly skin assessments prior to the beginning of their next shift to begin 02/11/25. Any newly hired nurses will receive the above education upon hire during orientation prior to taking a shift on the floor. Ad hoc QAPI meeting will be held with the Medical Director on 02/12/25 reviewing the policies and procedures for wound care. All licensed nurses will be educated on the Skin Management policy regarding general guidelines, prevention, notification, treatment, and documentation the Director of Clinical Education or designee. Completed 2/12/2025 2:00 p.m. Anyone who is not on duty that we cannot reach by phone will be required to complete the in-service prior to working their next shift. All C.N.A.'s will be educated by the Director of Clinical Education or designee regarding pressure ulcer prevention and interventions for residents with pressure ulcers. Completed 2/12/2025 3:00 p.m. Anyone who is not on duty or cannot come in or be reached by phone will be required to complete the in-service prior to working their next shift.? Validation/Monitoring Tools? Director of Clinical Operations or Assistant Director of Clinical Operations will review all orders for new admissions every day in the morning clinical meeting to ensure orders have been written and carried out for residents admitted with wounds. ?Beginning 02/12/25. Director of Clinical Operations or designee will review weekly skin assessments daily to ensure timely completion. Beginning 02/12/25. Director of Clinical Operations or designee will review wound physician documentation weekly to ensure any orders are carried out timely. Beginning 02/12/25. Director of Clinical Operations and/or designee will review all wound care patients orders, interventions, and skin assessments during Standards of Care Meeting weekly, Beginning 02/12/25.?? The Administrator, Director of Clinical Operations and/or designee will review the action plan developed related to obtaining wound care orders, implementing wound care interventions, and weekly skin assessments in QAPI meeting monthly during the next six months. Beginning 02-12-25.? This surveyor and team verification of the Plan of Removal from 02/12/25 was as follows: Record review of Resident #93's MAR dated 02/01/25-02/28/25 indicated wound care written on 02/11/25. Record review of Resident #93's skin assessment dated [DATE] completed by DCO P, indicated, .stage 3 pressure injuries x3 (right lateral hip, right thigh and left inner thigh) seen by AWC MD . Record review of Resident #93's wound assessment dated [DATE] completed by DCO P, indicated, .right thigh .2.2cmx3cmx0.2cm . Record review of Resident #93's wound assessment dated [DATE] completed by DCO P, indicated, .left inner thigh .1cmx0.1cmx0.2cm . Record review of Resident #93's wound assessment dated [DATE] completed by DCO P, indicated, .right lateral hip .4.5cmx1.3cmx0.2cm . Record review of [TRUNCATED]

Based on observation, interview, and record review the facility failed to ensure, at the time each resident was admitted , there were physician orders for the resident's immediate care for 1 of 7 residents reviewed for admission physician orders. (Resident #93) The facility failed to initiate wound care treatment after Resident #93 admitted on [DATE], with multiple areas of shearing. The facility failed to initiate Resident #93's wound care orders noted in the wound care doctor's progress notes on 02/08/25 until 02/10/25. An IJ was identified on 02/11/25. The IJ template was provided to the facility on [DATE] at 5:00 p.m. While the IJ was removed on 02/12/25, the facility remained out of compliance at a scope of pattern and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because all staff had not been trained on the process of carrying out orders for residents admitted with wounds or obtaining orders if no orders accompanied the resident, completion of weekly skin assessments, wound care orders, skin management policy, and pressure ulcer prevention and interventions for residents with pressure ulcers. These failures could place residents at risk of not receiving appropriate care and treatment services. Findings included: 1. Record review of Resident #93's face sheet dated 02/11/25 indicated Resident #93 was a [AGE] year-old female admitted to the facility on [DATE]. Resident #93 had diagnoses including acute kidney failure (when the kidneys suddenly can't filter waste products from the blood), urinary tract infection (is an infection in any part of your urinary system: kidneys, bladder, ureters, and urethra), morbid obesity (is a medical condition characterized by excessive body weight that significantly impacts health and well-being), and pressure ulcer of right hip, left hip, and other sites, stage 3 (a full-thickness tissue loss where the subcutaneous fat layer is visible within the wound, but the bone, tendon, or muscle is not exposed). Record review of the MDS, on 02/10/25, indicated Resident #93 was admitted to the facility less than 21 days ago. No MDS for Resident #93 was completed prior to exit. Record review of Resident #93's care plan dated 02/03/25 indicated: *Resident #93 was admitted with stage 3 pressure ulcer to right thigh. Interventions included assess and document skin condition every week, pressure relieving appliances as ordered, reposition residents as indicated to relieve pressure and for comfort, and wound care per MD orders. *Resident #93 was admitted with Stage 3 pressure ulcer to right hip. Interventions included assess and document skin condition every week, monitor nutritional intake, weight, lab values and report significant changes to MD, pressure relieving appliances as ordered, reposition residents as indicated to relieve pressure and for comfort, and wound care per MD orders. *Resident #93 was admitted with stage 3 pressure ulcer to left thigh. Intervention included administer treatments as ordered and monitor for effectiveness, monitor nutritional status, and obtain and monitor lab/diagnostic work as ordered. Record review of Resident #93's consolidated physician orders dated active as of 02/11/25 indicated the following: *Left thigh- cleanse with house wound cleanser. Apply Medi honey and collagen sheet. Cover with foam and border gauze dressing everyday shift. Start 02/11/25. *Nursing to perform weekly skin assessment. Ordered 02/09/25. *Right hip- cleanse with house wound cleanser and pat dry. Apply Medi honey and cover with collagen sheet and foam then secure with border dressing everyday shift. Start 02/11/25. *Right thigh- cleanse with house wound cleanser and pat dry. Apply Medi honey and collagen sheet. Cover with foam and secure with border dressing everyday shift. Start 02/11/25. The consolidated physician order did not reflect wound care orders for Resident #93's left thigh, right hip, and right thigh pressure ulcer on admission (02/01/25). Record review of Resident #93's MAR dated 02/01/25-02/28/25 indicated the following: *Left thigh- cleanse with house wound cleanser. Apply Medi honey and collagen sheet. Cover with foam and border gauze dressing everyday shift. Start 02/11/25. *Nursing to perform weekly skin assessment. Ordered 02/02/25. Discontinued 02/09/25. No documentation was noted on 02/02/25 and 02/09/25. *Right hip- cleanse with house wound cleanser and pat dry. Apply Medi honey and cover with collagen sheet and foam then secure with border dressing everyday shift. Start 02/11/25. *Right thigh- cleanse with house wound cleanser and pat dry. Apply Medi honey and collagen sheet. Cover with foam and secure with border dressing everyday shift. Start 02/11/25. Record review of Resident #93's progress note dated 01/12/25-02/12/25 indicated: *02/01/25 at 7:47 p.m. by the ADCO, .new admission skin assessment .the following areas were all noted upon admission to the facility . Right Lateral thigh shearing 2cm x 5cm x0.1cm open area without exudate with surrounding scaring . Right gluteal area shearing 0.4cm x 0.4cm x 0.1 cm no exudate noted . Right lateral hip shearing with surrounding scaring 5.5cm x 1.4cm x 0.1cm no exudate noted . Right Posterior hip shearing 1.3cm x 0.9cm x 0.1cm no exudate noted . Right posterior thigh near gluteal fold 1.2cm x 0.1cm. Area is a hard area that appears to be healing . Left posterior thigh shearing 1.2cm x 1cm x 0.1cm area noted to have slight bleeding when dressing was removed . right medial posterior thigh near gluteal fold 1cm x 1cm. area is a hard area that appears to be healing . *02/08/25 at 7:33 p.m. by DNP S, .date of service: 02/07/25 .wound initial .Resident #93 . The following wounds were evaluated during today's visit . Wound 1 Right Hip, Pressure Injury, Stage 3 . Wound 2 Right Thigh, Pressure Injury, Stage 3 . Wound 3 Left Thigh, Pressure Injury, Stage 3 . Patient is admitted with multiple wounds . Per report from DON . WOUND ASSESSMENT: .Wound: 1 . Status: Present on Admission Location: Right Hip . Primary Etiology: Pressure Injury Severity: Stage 3 . Size: 6 cm x 1.5 cm x 0.1 cm. Actual area is 9 cm2. Actual volume is 0.9 cm3 Wound Base: , 100% granulation . Wound Edges: Attached . Periwound: Fragile, No erythema, No edema Exudate: Light Serous .Wound Odor: None . Signs of Wound Infection: No signs of infection Wound Pain at Rest: 0 . Wound: 2 . Status: Present on Admission Location: Right Thigh . Primary Etiology: Pressure Injury .Severity: Stage 3 . Size: 4 cm x 2 cm x 0.1 cm. Actual area is 8 cm2. Actual volume is 0.8 cm3 Wound Base: , 100% granulation . Wound Edges: Attached . Periwound: Fragile, No erythema, No edema, No maceration Exudate: Light Serous . Wound Odor: None . Signs of Wound Infection: No signs of infection Wound Pain at Rest: 0 . Wound: 3 . Status: Present on Admission Location: Left Thigh . Primary Etiology: Pressure Injury .Severity: Stage 3 . Size: 1.5 cm x 1 cm x 0.1 cm. Actual area is 1.5 cm2. Actual volume is 0.15 cm3 Wound Base: , 100% granulation . Wound Edges: Attached . Periwound: Fragile, No erythema, No edema, No maceration Exudate: Light Serous . Wound Odor: None .Signs of Wound Infection: No signs of infection Wound Pain at Rest: 0 . Recommendations consisting of: .We will re-evaluate this patient on our next visit (anticipated 1-2 weeks), Implement pressure relieving measures, offloading, and repositioning, as tolerated . Establish turning frequency based on the characteristics of the support surface and the patient's response . Protect skin from exposure to excessive moisture (periwound) with a barrier product. Use skin emollients to hydrate dry skin . Repositioning should be undertaken using the 30-degree tilted side-lying position (alternating right side, back, left side) . Plan of care discussed with facility staff .Wound# 1 Right Hip Pressure Injury Treatment Recommendations: .clean with Wound Cleanser . apply Collagen particles, Honey and Bordered foam dressing . change Daily and as needed if dislodged, saturated, or soiled Wound # 2 Right Thigh Pressure Injury .Treatment Recommendations: . clean with Wound Cleanser . apply Collagen particles, Honey and Bordered foam dressing . change Daily and as needed if dislodged, saturated, or soiled Wound # 3 Left Thigh Pressure Injury .Treatment Recommendations: . clean with Wound Cleanser . apply Collagen particles, Honey and Bordered foam dressing . change Daily and as needed if dislodged, saturated, or soiled . Record review of Resident #93's memorandum of transfer and physician certification dated 02/01/25 indicated emergency department diagnoses included pressure injury of contiguous region involving back, right buttock, and right hip, stage 2. Record review of Resident #93's hospital discharge summary dated 02/01/25 did not reflect wound care orders. Record review of Resident #93's Braden scale for predicting pressure sore risk dated 02/01/25 indicated score of 16 which was at risk. Record review of Resident #93's weekly skin assessment dated [DATE] indicated .does the resident have a pressure, venous, arterial, diabetic, or surgical wound .yes .stage 2 PU, multiple shearing sites to right lateral thigh, right posterior thigh multiple, left posterior thigh, right buttocks, left posterior thigh . The facility's electronic medical record did not reflect a skin assessment on 02/08/25 or 02/09/25. Record review of Resident #93's wound assessment report dated 02/07/25 indicated .left thigh .Length: 1.50 cm .Width: 1.00 cm .Depth: 0.10 cm .left thigh .pressure injury .stage 3 .treatment: daily .wound cleanser .collagen particles and honey .bordered foam dressing . Record review of Resident #93's wound assessment report dated 02/07/25 indicated .right thigh .length: 4 cm .width: 2 cm .depth: 0.10 cm .right thigh .pressure injury .stage 3 . treatment: daily .wound cleanser .collagen particles and honey .bordered foam dressing . Record review of Resident #93's wound assessment report dated 02/07/25 indicated .right thigh .length: 6 cm .width: 1.5 cm .depth: 0.10cm .right hip .pressure injury .stage 3 . treatment: daily .wound cleanser .collagen particles and honey .bordered foam dressing . Record review of the facility's Skin Management: Prevention and Treatment of Wounds policy revised 10/06/22 indicated .specialty mattress will be implemented for residents with multiple stage 2 areas, stage 3, or stage 4 pressure injuries . During an observation and interview on 02/10/25 at 10:51 a.m., Resident #93 was lying in the bed on her back. Resident #93 was not on a specialty mattress. Resident #93 did not have any pressure relieving devices noted in her bed. Resident #93's legs were not offloaded. Resident #93 said staff did not turn her every 2 hours or prop her heels with pillows. She said she could turn herself with the assist rails but staff did not place pillows behind her back, underneath her buttocks or between her legs. During an observation and interview on 02/10/25 at 3:05 p.m., Resident #93 was lying in the bed on her back. Resident #93 was not on a specialty mattress. Resident #93 did not have any pressure relieving positioning devices noted in her bed. Resident #93's legs were not offloaded. Resident #93 said staff did not turn her every 2 hours or propped her heels with pillows. During an observation on 02/11/25 at 10:02 a.m., Resident #93 was lying in the bed on her back. Resident #93 was not on a specialty mattress. Resident #93 did not have any pressure relieving positioning devices noted in her bed. Resident #93's legs were not offloaded. During an observation and interview on 02/11/25 at 11:32 a.m., Resident #93 was lying in the bed on her back. Resident #93 was not on a specialty mattress. Resident #93 did not have any pressure relieving positioning devices noted in her bed. Resident #93's legs were not offloaded. Resident #93 said staff had not turn her every 2 hours or propped her heels with pillows. She said she had wounds on thighs, buttock, and hip. She said when she came from the hospital, there were dressings on two of the wounds. She said the facility did not do dressing changes every day. She said it depended on the staff as to what was done to her wounds. She said some staff did nothing and others would put cream on the wounds if they were closed. During an observation on 02/11/25 at 1:25 p.m., Resident #93 was lying in the bed on her back. Resident #93 was not on a specialty mattress. Resident #93 did not have any pressure relieving positioning devices noted in her bed. Resident #93's legs were not offloaded. During an interview on 02/11/25 at 1:30 p.m., the ADCO said she was working the floor when Resident #93 was admitted . She said she was Resident #93's admitting nurse. She said if the admitting nurse was not a RN, then the nurse was only responsible for measuring and describing the wound. She said a RN, the DCO, or MD staged pressure wounds at the facility. She said upon admission the resident's MD should be notified and general wound care orders obtained. She said when the wound care doctor rounded on Fridays, the facility received specialized wound care orders. She said the wound care doctor came every Friday and the DCO notified him of who needed to be seen. She said after the wound care doctor rounded and made recommendations. She said the wound care doctor placed his recommendations in a progress note. She said the floor nurses or the DCO were responsible to place the recommendations in the facility's electronic medical record as an order. She said the DCO and ADCO were responsible for ensuring the wound care orders were followed through. She said the floor nurses were responsible for the resident's weekly skin assessments. She said the DON and DNP completed the weekly wound assessments when he rounded on Fridays. She said Resident #93 wounds on admission were shearing to her right hip, right buttocks, left thigh, and left buttocks. She said since she was not a RN, she did not stage Resident #93's wounds. She said Resident #93 arrived from the hospital with dressings over the wounds. She said she notified NP R by text or phone and let her know about Resident #93's shearing. She said she did not receive a response from NP R until shift change. She said she could not remember what NP R said about Resident #93's shearing. She said she knew she passed the message from NP R on to RN G when she gave report. She said she did not know what wound care treatment Resident #93 had been receiving since admission on 02/01/25. She said she did not know the facility's policy or criteria on specialty mattress because she just started January 13, 2025. She said she did not know if Resident #93 met the facility's criteria for a specialty mattress but she probably did. She said other interventions for Resident #93's pressure wounds should have been frequent repositioning and incontinent care and a dietary consult. She said the dietician would be at the facility this week. She said since Resident #93 had a skin assessment on 02/01/25, then she should have had one on 02/08/25. She said even though the skin assessment was a day after the wound care doctor came, it should have been done by the floor nurse. She said skin assessments were important to ensure skin issues were not missed and proper wound care orders were in place. She said following doctors' orders were important to prevent the wound from declining and promote healing. She said the facility provided Resident #93 assist rails and trapeze bar to help with her mobility. On 02/11/25 at 2:23 p.m., called NP R and left voicemail. On 02/11/25 at 2:25 p.m., called RN G and left voicemail. During an interview on 02/11/25 at 2:58 p.m., NP R said she received a text message from LVN A that Resident #93 was admitted . She said she was currently driving and could not remember if the ADCO contacted her on admission about Resident #93's wounds. She said normally the facility followed the hospital's wound care orders and did not need them to give any orders. During an interview on 02/11/25 at 4:41 p.m., NP R called back and said LVN A and the ADCO called her on 02/01/25 about Resident #93. She said she told LVN A and the ADCO to resume all hospital orders and she would see Resident #93 on Tuesday, 02/04/25. During an interview on 02/11/25 at 6:01 p.m., RN G said she had worked at the facility for 6 years. She said she had taken care of Resident #93. She said she was texting with NP R on 02/05/05 about another resident lab work and NP R asked about Resident #93. She said NP R mentioned the hospital had not sent Resident #93 with wound care orders when she discharged . She said she told NP R that there were no wound care orders in Resident #93's hospital discharge paperwork. She said she told NP R, she did not know what the facility had been doing either for Resident #93's pressure wounds. She said NP R ordered collagen and a dry dressing and for the wound care doctor to see Resident #93. She said she did the ordered wound care on Resident #93 that night shift (02/05/25). She said she thought she placed the wound care orders NP R gave for Resident #93 in the facility's electronic medical records. She said Resident #93's wound care orders from NP R would be on her MAR if she did. She said it was important to have put in the wound care orders from NP R, so the next person knew what to do for Resident #93's wounds. She said not doing wound care treatments for Resident #93's wounds could cause further break down or increased stages. She said Resident #93's wounds would have been called stage 2's on admission. She said if the admission nurse was not a RN, then the next RN on duty was responsible for staging the pressure ulcer. She said if a wound needed to be staged by a RN, that information needed to be passed down by the next nurse or put on the 24-hour report. She said staging a pressure ulcer was important so the wound could be caught early and treated so it did not decline. She said she was not aware Resident #93's wounds were not staged until DNP S came on 02/07/25. She said a resident had to have pressure breakdown to be on a low air loss mattress. She said Resident #93 was on a bariatric pressure reduction mattress. She said she did not if they made bariatric specialty mattresses. She said if they made bariatric low air loss mattresses, Resident #93 would qualify for one because she had several areas of pressure breakdown. During an interview on 02/12/25 at 1:57 p.m., LVN D said nurses were responsible for resident's skin assessments. She said the skin assessments were due weekly and as needed. She said the weekly skin assessments should be charted in the resident medical records. She said a resident should be on a low air loss mattress if they have pressure ulcers or at the family request. She said heels should be floated for residents after hip surgery, residents who do not turn good, or residents with redness on their heels. She said residents should be repositioned every 2 hours. She said the RCP or LVN could do it but the RCP was primarily responsible. She said if a resident was able to turn themselves in the bed, the RCP should still encourage and help the resident turn every 2 hours. She said the RCP should be propping the resident with pillows to offload them when repositioning. She said the LVN should be ensuring the RCP are repositioning every 2 hours and offloading the residents by observation. She said a RN and LVN certified in wound care could stage pressure wounds. She said primarily RNs. She said if a resident needed a pressure wound staged, she would find a RN or contact the DCO. She said the facility had a telehealth option to stage wounds available now. She said the resident's doctor or the medical director was contacted for wound care orders. She said nursing management was responsible for taking the wound care doctor recommendations and making them orders. She said when the wound care doctor rounded on Fridays, he gave the DCO a copy of his recommendations on a piece of paper before he left. She said the wound care doctor left around 10 am. She said the bedside nurses were responsible for doing wound care treatments. She said the nurses documented on the MAR/TAR when wound care was completed. She said if wound care was not documented on the resident MAR/TAR, it could indicate it was not done. She said some residents did not show on the right screen to be done on the facility's computer system. She said skin assessments, wound care treatments, and repositioning/offloading were important to prevent skin breakdown and worsening of wound and not miss anything. During an interview on 02/12/25 at 5:25 p.m., RCP H said she had worked at the facility for 2 years. She said she found out a resident had wounds when she changed them. She said she was not really made aware by nursing staff or during report which resident had wounds. She said it depended on the severity of the wound what type of treatment the resident required. She said some resident needed cream and other had dressing changes by the nursing staff. She said RCPs were responsible for repositioning the residents every 2 hours with rounds. She said the residents should be alternated side to side and propped with pillows. She said residents stuck in the bed should have their heels offloaded. She said Resident #93 was stuck in the bed unless PT got her up. She said when she had Resident #93, she went in her room every once in a while, to remind her to turn but not every 2 hours. She said turning and offloading were important to prevent skin breakdown. She said constant pressure caused skin breakdown. During an interview on 02/12/25 at 5:49 p.m., the ADCO said wound care was documented on the resident's TAR in the facility's charting system. She said if wound care was not documented in the facility's charting system, it could indicate it was not done. She said the charge nurses were responsible for the resident's wound care. She said the DCO and ADCO should ensure the charge nurses were doing the ordered wound care treatments and documenting wound care on the resident's MAR/TARs. She said doing the resident's ordered wound care treatment was important to prevent decline of the wound, infection, prevent pain and more wounds. She said it was also important to do wound care to monitor the wound and follow doctor's orders. She said completion of the resident's skin assessment was documented on the TAR/MAR and a skin assessment form was also done. She said when she first started, she did not know that a skin assessment form had to be done even if the resident had no skin changes. She said she documented she completed Resident #15's skin assessment on the MAR/TAR but she did not do a new skin assessment form. She said she and the DCO Q were in the process, of putting a process in place to do chart audits to monitor skin assessments and wound care orders. During an interview on 02/12/25 at 6:57 p.m., DCO P, who was covering for DCO Q, said she expected nursing staff to follow physician orders. She said she expected nursing staff to document wound care on the MAR/TAR and/or progress note in the facility's charting system. She said if the wound care was not documented on the MAR/TAR and/or progress note, it could indicate it was not done. She said she expected nursing staff to order skin assessment on admission. She said she expected nursing staff to complete skin assessment weekly and with skin changes. She said the DCO ordered the resident's specialty mattresses and the charge nurse should ensure it was on the correct settings. She said all resident benefited from having their heels floated. She said but immobile residents especially needed their heels floated. She said she expected residents to be repositioned and offloaded at least every 2 hours by the RCPs. She said she preferred staging pressure wounds be done by the telehealth system. She said a RN or DCO should stage the resident pressure wounds. She said the ADCO and DCO should be ensuring nursing staff were doing wound care and skin assessments. She said all of these were important for wound prevention and management. During an interview on 02/12/25 at 7:34 p.m., the EDO said skin assessment were to be completed every 7 days in the facility's charting system. She said Resident #93 met the criteria for a low air loss mattress. She said the facility had a few specialty mattresses in house and she also could order one if needed. She said the DCO or the nursing staff who rounded with the wound care doctor was responsible for inputting his orders. She said it was important to document wound care and skin assessments to have an adequate clinical record. She said it was important to do wound care and skin assessments to promote wound healing. She said nursing management was responsible for ensuring nursing staff completed skin assessment and wound care. She said nursing management should be doing chart audits to ensure it was happening. Record review of a facility's Skin Management: Prevention and Treatment of Wounds policy revised 10/06/22 indicated .the purpose of this procedure is for prevention and treatment of skin breakdown such as pressure injuries, diabetic ulcers, arterial ulcers, and skin wounds Skin assessments will be documented at a minimum of every 7 days on a Weekly Skin Assessment . Staging of wounds will be performed by a registered nurse or licensed nurse certified in wound care . Dependent residents will have heels floated while in bed and be turned and repositioned at a minimum of every 2 hours . A licensed nurse will obtain orders from physician for new skin wounds and transcribe onto resident's treatment record for follow up . Specialty mattresses will be implemented for residents with multiple stage II areas, stage Ill, or stage IV pressure injuries . Weekly skin assessments will be documented on the Weekly Skin Assessment every 7 days or less . Licensed nurse will initiate the schedule for the wound form in Point Click Care which automatically triggers every 7 days from day of completion . The EDO and DCE were notified of an IJ on 02/11/25 on 5:00 p.m., were given a copy of the IJ template, and a Plan of Removal (POR) was requested. The Plan of Removal was accepted on 02/12/25 at 9:40 a.m. and included the following: [F635] Plan of Action: Resident #93 had wound care orders written on 02/11/25. A weekly wound assessment was completed on 02/11/25. A specialty mattress was placed on Resident #93's bed on 02/11/25. Resident #93's heels were floated effective 02/11/25. Skin sweep competed on 02/11/25 to ensure all skin issues were identified and had current orders and interventions in place. Completed 02/11/25 by Director of Clinical Education and designees. Director of Clinical Education will educate Director of Clinical Services and Assistant Director of Clinical Services on the process of reviewing new resident admissions electronic health records for completion of order transcription as it relates to wound orders as well as carrying out those orders. Completed 2/11/25 If a RN or wound care certified LVN is not on duty at the time a resident admits, the admitting nurse on duty will utilize Advanced Wound Care Telehealth for a consult. Completed 02/12/25. All licensed nurses will be educated by the ADCO or designee on the process of carrying out orders for residents admitted with wounds or obtaining orders if no order accompanies the resident when admitted . Education will also include the completion of weekly skin assessments per schedule. Completion 02/12/25 10:00 a.m. Anyone who is not on duty that we cannot reach by phone will be required to complete the in-service prior to working their next shift. All licensed nurses will receive in-service regarding wound care orders and weekly skin assessments prior to the beginning of their next shift to begin 02/11/25. Any newly hired nurses will receive the above education upon hire during orientation prior to taking a shift on the floor. Ad hoc QAPI meeting will be held with the Medical Director on 02/12/25 reviewing the policies and procedures for wound care. All licensed nurses will be educated on the Skin Management policy regarding general guidelines, prevention, notification, treatment, and documentation the Director of Clinical Education or designee. Completed 2/12/2025 2:00 p.m. Anyone who is not on duty that we cannot reach by phone will be required to complete the in-service prior to working their next shift. All C.N.A.'s will be educated by the Director of Clinical Education or designee regarding pressure ulcer prevention and interventions for residents with pressure ulcers. Completed 2/12/2025 3:00 p.m. Anyone who is not on duty or cannot come in or be reached by phone will be required to complete the in-service prior to working their next shift.? Validation/Monitoring Tools? Director of Clinical Operations or Assistant Director of Clinical Operations will review all orders for new admissions every day in the morning clinical meeting to ensure orders have been written and carried out for residents admitted with wounds. ?Beginning 02/12/25. Director of Clinical Operations or designee will review weekly skin assessments daily to ensure timely completion. Beginning 02/12/25. Director of Clinical Operations or designee will review wound physician documentation weekly to ensure any orders are carried out timely. Beginning 02/12/25. Director of Clinical Operations and/or designee will review all wound care patients orders, interventions, and skin assessments during Standards of Care Meeting weekly, Beginning 02/12/25. The Administrator, Director of Clinical Operations and/or designee will review the action plan developed related to obtaining wound care orders, implementing wound care interventions, and weekly skin assessments in QAPI meeting monthly during the next six months. Beginning 02-12-25.? This surveyor and team verification of the Plan of Removal from 02/12/25 was as follows: Record review of Resident #93's MAR dated 02/01/25-02/28/25 indicated wound care written on 02/11/25. Record review of Resident #93's skin assessment dated [DATE] completed by DCO P, indicated, .stage 3 pressure injuries x3 (right lateral hip, right thigh and left inner thigh) seen by AWC MD . Record review of Resident #93's wound assessment dated [DATE] completed by DCO P, indicated, .right thigh .2.2cmx3cmx0.2cm . Record review of Resident #93's wound assessment dated [DATE] completed by DCO P, indicated, .left inner thigh .1cmx0.1cmx0.2cm . Record review of Resident #93's wound assessment dated [DATE] completed by DCO P, indicated, .right lateral hip .4.5cmx1.3cmx0.2cm . Record review of the facility's Residents with Pressure Injuries provided by the EDO on 02/11/25 indicated seven residents with pressure injuries. Five residents were included in finalized sample. Resident #11 and Resident #15 had missing documentation of wound care and skin assessments. Record review of the facility's weekly skin assessment dated [DATE] indicated all 40 resident skin assessments were completed. Record review of the QAPI Ad hoc meeting sign in sheet dated 02/12/25 at 8:00 a.m., indicated the EDO, Medical Director, [NAME], DFS, DLE, DCE, DPO, ADCO, and SSDD. During an observation on 02/12/25 at 4:00 p.m., a low air loss mattress, a type of specialty mattress, was noted in Resident #93's room. Several pillows were noted on Resident #93's bed used for offloading. Record review of an In-Service and Education Record for Chart Reviews for Admission and Readmitted d 02/11/25, was conducted by the DCE indicated the DCO Q (via phone) and ADCO were in attendance. Record review of an In-Service and Education Record for Wound Care Orders-Admission and Readmission and Wound Care Orders-Wound

Based on interviews and record review the facility failed to complete a performance review of each Resident Care Provider (RCP) at least once every 12 months, for 5 of 5 (RCP L, RCP O, RCP U, RCP V, and RCP W) reviewed for annual competency evaluations. The facility failed to complete annual RCP (facility titles CNA as RCP) competency evaluations for RCP L, RCP O, RCP U, RCP V, and RCP W based on the personnel file review results. This failure could affect residents and place them at risk of not receiving consistent, appropriate interventions necessary to meet the residents' needs. Findings included: Record review of the Personnel File Review completed on 02/12/25, indicated RCP L, RCP O, RCP U, RCP V, and RCP W did not have a competency evaluation on file. The Personnel File Review indicated RCP L's date of hire was 01/07/25, RCP O 12/5/24, RCP U 12/5/24, RCP V 10/17/24, and RCP W 11/21/24. During an interview on 02/12/25 at 1:44 p.m., the Director of Nurses said that she did not know if the RCP (CNA) competencies had been completed. She said she could not find them. She said that the previous Director of Nurses did not file them or indicate where she placed them if she completed them. She said it was important for Resident Care Providers to have their annual competencies evaluated to ensure they were proficient in the areas of care they provide. During an interview on 02/12/25 at 5:09 p.m., the Administrator said she did not know if the RCP competencies were completed or not. She said she believed they were completed but they did not have documented proof to provide at the time the interview was conducted . Record review of the facility policy titles Competency of Nursing Staff dated 04/2020, indicated All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by State law In addition, licensed nurses and nursing assistants employed (or contracted) by the facility will participate in a facility-specific, competency-based staff development and training program demonstrate specific competencies and skill sets deemed necessary to care for the needs of residents, as identified through resident assessments and described in the plans of care.

Based on interview and record review the facility failed to ensure residents were free of any significant medication errors for 2 of 7 residents reviewed for medications. (Resident #1 and Resident #2) The facility failed to ensure: *Resident #1 (deceased ) was given medications as prescribed. She was given Venlafaxine 75mg two times daily for a total of 6 times over a period of 5 days when the medication was supposed to be on hold. *Resident #1 was given Lisinopril and Metoprolol Succinate ER 12 times in [DATE] and 3 times in February 2024 when the medications were supposed to be held because her blood pressure was below the parameters. *Resident #1's orders were followed due to the possible interactions of Venlafaxine, with Tramadol, Ibuprofen and other medications Resident #1 was receiving. The NP said to monitor for low blood pressure and fever due to Serotonin syndrome. There was no indication this monitoring was provided. *Resident #2 (a current resident) Carvedilol 3.125 mg blood pressure medications given in [DATE] times when her blood pressure was below the parameters. *A system in place to ensure the medications were held and medication parameters were followed. *Their medication administration policy was followed. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 1:05 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These deficient practices could place residents at risk of physical complications, hospitalization , and possible death. Findings included: Record of Resident #1's face sheet dated [DATE] indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Some of her diagnoses were congestive heart failure, bipolar disorder, schizoaffective disorder (mental health disorder including symptoms such as hallucinations, delusions, disorganized thinking, mania, and depression), dementia, and lack of coordination. Record review of Resident #1's admission MDS dated [DATE] indicated moderate cognitive impairment. The resident required supervision or touching assistance with eating. The resident required partial to moderate assistance with hygiene showers, upper body dressing, lower body dressing. The resident required partial to moderate assistance with transferring from chair to bed and toilet. Record review of Resident #1's care plan dated [DATE] indicated a focused area of the resident was at risk for adverse consequences related to receiving antipsychotic medications with a diagnosis of schizoaffective disorder. Some of the interventions were: Monitor resident for side effects of anti-anxiety medication, including but not limited to hypotension, sedation, and increase anxiety. Monitor the resident for side effects of anti-depressant medication's, including but not limited to increased confusion, changes in appetite, and changes in sleep pattern. Monitor the resident for side effects of antipsychotic medication's, such as muscle, rigidity, changes in appetite, sleep, disturbances, tardive, dyskinesia (side effect of antipsychotic medications that cause involuntary movements of the head and body including lip smacking, grimacing, eye blinking, and repetitive movements), seizures, and cardiac changes. Record review of Resident #1's care plan dated [DATE] indicated a focused area of the resident was at risk for adverse consequences related to receiving antipsychotic medications with a diagnosis of schizoaffective disorder. Some of the interventions were:. Monitor resident for side effects of anti-anxiety medication, including but not limited to hypotension, sedation, and increase anxiety. Monitor the resident for side effects of anti-depressant medication's, including but not limited to increased confusion, changes in appetite, and changes in sleep pattern. Monitor the resident for side effects of antipsychotic medication's, such as muscle, rigidity, changes in appetite, sleep, disturbances, tardive, dyskinesia, seizures, and cardiac changes. Record review of Resident #1's physician orders indicated in order dated [DATE] for lisinopril tablet 2.5 mg to given by mouth one time a day for hypertension hold if the systolic blood pressure is under 100 or the diastolic blood pressure is under 60. An order Metoprolol Succinate ER 25mg tablet extended release 25 mg give one tablet by mouth in the morning for hypertension is systolic is less than 110 and diastolic is less than 60 or post is less than 60. Record review of Resident #1's MAR for [DATE] indicated the resident's lisinopril and metoprolol were given on these dates when her blood pressures were below the parameters. On [DATE] A blood pressure of ,d+[DATE] On [DATE], a blood pressure of ,d+[DATE] On [DATE] a blood pressure of ,d+[DATE] On [DATE], a blood pressure of ,d+[DATE] On [DATE], a blood pressure of ,d+[DATE] On [DATE], blood pressure ,d+[DATE] On [DATE], a blood pressure of ,d+[DATE] On [DATE] a blood pressure of ,d+[DATE] On [DATE] a blood pressure of ,d+[DATE] On [DATE] a blood pressure of ,d+[DATE] On [DATE] a blood pressure of ,d+[DATE] On [DATE] a blood pressure of ,d+[DATE]. Record review of Resident #1's February 2024 MAR indicated the resident's lisinopril and metoprolol were given on these dates when her blood pressures were below the parameters. On [DATE] a blood pressure of ,d+[DATE] On [DATE] a blood pressure of ,d+[DATE] On [DATE] a blood pressure of ,d+[DATE] During an interview on [DATE] at 1:02 p.m. the DON said the checks on the MAR meant the medications were given. The DON said according to the documentation all the blood pressure medications were given on the dates when the blood pressure was below the parameters. She said a 5 means hold, 9 means progress notes. She said that was not their procedures or good nursing judgement to give blood pressure medications when the blood pressure was below the parameters. She did not know why they were given but they were all given by RN D. During an interview on [DATE] at 1:15 p.m. RN D said she did not remember if she held Resident #1's the blood pressure medications or not. She said she would have thought she had not given them but could not be sure. She said she knew if she checked that she gave them then she gave them. Record Review of Resident #1's computerized physician order indicated orders for: Depakote 125 mg 4 tablets three times daily for behaviors ordered [DATE]; Risperdal 2mg one tablet at bedtime for bipolar disorder ordered [DATE]; Ibuprofen 800 mg every 8 hours as need for pain ordered [DATE]; Tramadol 50mg give one tablet two times a day for pain ordered [DATE]; Buspirone HCL 5mg 2 tables three times daily for anxiety ordered [DATE]. Resident' #1's February 2024 MAR indicated an order dated [DATE] for Venlafaxine 75 mg two times a day for increased mood discontinued on [DATE]. Record review of Resident #1's nurses notes dated [DATE] indicated: At 10:24 a.m. an order noted the Venlafaxine HCL has triggered the following drug protocol alerts and warnings related to drug-to-drug interaction. The system has identified a possible drug interaction with current medications such as Ibuprofen 800 mg may increase the risk of upper gastrointestinal bleeding. Buspirone 5mg table interaction additive serotonergic affects ( may increase serotonin levels). Tramadol 50 mg at risk for developing serotonin syndrome ( potentially life threating condition associated with activity in the central nervous system. Usually caused by interactions between drugs). At 10:28 a.m. the resident was seen by NP E today and indicated to start Venlafaxine 75 mg by mouth two times a day to increase mood and decrease depression and agitation. At 3:52 p.m. the resident was seen by NP F who said to monitor the resident for acute signs and symptoms of fever and low blood pressure.( There was no indication this recommendation or order was followed. ) signed by the ADON. Record review of Resident #1's [DATE] MAR indicate indicated the resident received Venlafaxine 75 mg on [DATE] at 7p.m. and on [DATE] Venlafaxine 75 mg was given at 7:00 a.m. and at 7:00 p.m . Record review of Resident #1's nursing note dated [DATE] at 1:40 a.m. indicated the resident was resting quietly in bed. At 11:32 a.m. the resident was given venlafaxine per order. Record review of Resident #1's nursing note dated [DATE] at 10:29 a.m. indicated the resident was very sedated sitting up in wheelchair with eyes closed, reaching for things that were not there. NP F was notified and received an order to hold Venlafaxine 75 mg until the resident is back to baseline. Then MD and NP to adjust dosage MAR updated. Record review of Resident #1's nursing note dated [DATE] at 8:40 p.m. indicated Ibuprofen 800 mg given for pain, with complaints of hurting all over . (Record review of Resident #1's orders did not reveal an order to hold the medications, or to restart the medications.) Record review of Resident #1's MAR for February 2024 indicated on [DATE] Venlafaxine 75 mg was given at 7:00 a.m. and at 7:00 p.m. Record review of Resident #1 the facility 24 hour/change in condition report indicated on [DATE] Venlafaxine 75 mg on hold. Record review of Resident #1's MAR for February 2024 indicated on [DATE] Venlafaxine 75 mg was given at 7:00 a.m. It was not given at 7:00 p.m. and indicated it was on hold. Record review of Resident #1's nursing note dated [DATE] at 11:30 a.m. resident up in wheelchair , more alert today, propelling self-short distances, no complaints of discomfort. At 8:34 p.m. Venlafaxine 75 mg on hold. Record review of Resident #1 the facility 24 hour/change in condition report indicated on [DATE] Venlafaxine 75 mg on hold. Record review of Resident #1's MAR for February 2024 indicated on [DATE] Venlafaxine 75 mg was given at 7:00 a.m. and at 7:00 p.m. Record review of Resident #1 the facility 24 hour/change in condition report indicated on [DATE] Venlafaxine 75 mg on hold. Record review of Resident #1's MAR for February 2024 indicated on [DATE] Venlafaxine 75 mg was not given at 7:00 a.m. and not given at 7:00 p.m. the MAR indicated the medication was on hold. Record review of Resident #1's nursing note on [DATE] at 8:32 a.m. indicated Venlafaxine 75 mg remains on hold. At 9:29 a.m. called to the resident room by CNA. The resident noted laying on her abdomen on the floor. She stated she was trying to get out of bed. The resident was assessed for injuries. Vital signs within normal limits the resident was assisted back to bed by two staff members, there were no injury noted. Encourage the resident to wait for assistance to get out of bed. At 1:16 p.m. Resident up at nurses' station, alert and oriented answers questions appropriately denies pain or discomfort, no delayed injuries notes post fall thus far and neuro checks remain within normal limits. At 9:19 p.m. Venlafaxine 75 mg remains on hold. At 10:51 p.m. Ibuprofen 800 mg given for pain with complaints of hurting all over. Record review of Resident #1 the facility 24 hour/change in condition report indicated on [DATE] Venlafaxine 75 mg on day three, and she had an unwitnessed fall with no injury. Record review of Resident #1's MAR for February 2024 indicated on [DATE] Venlafaxine 75 mg was given at 7:00 a.m. and at 7:00 p.m. Record review of Resident #1's nursing note on [DATE] at 1:07 a.m. the resident is resting quietly in bed, easily aroused respirations even and unlabored with no shortness of breath noted. She had reddened areas to the right side of face that reddened. There are no delayed injuries noted from the fall. Record review of Resident #1 the facility 24 hour/change in condition report indicated on [DATE] Venlafaxine 75 mg on hold- day 4 and she received ibuprofen for complaints of pain. Record review of Resident #1's MAR for February 2024 indicated on [DATE] the MAR indicated see progress note. Record review of Resident #1's nursing note on[DATE] at 8:39 a.m. Venlafaxine 75 mg two times a day held until clarified. At 11:02 a.m. received a new order for Venlafaxine 37.5 mg daily the updated pharmacy notified. At 11:02 a.m. NP F gave an order to decrease Venlafaxine to 37.5 mg. MAR updated and pharmacy notified. Record review of Resident #1 the facility 24 hour/change in condition report indicated on [DATE] Venlafaxine 75 mg on hold 6a to 2p nurse to get clarification. Record review of Resident #1's physician orders dated [DATE] indicated an order for Venlafaxine 37.5 give one tablet one time a day for anxiety. It was discontinued on [DATE]. Record review of Resident #1's nursing note dated [DATE] at 1:25 a.m. indicated the resident is awake, naps on and off, talking at random, repeating phrases over and over, speech is clear. To restart Venlafaxine 37.5 for depression. At 5:42 a.m. the resident was awake all night, talking out at random. Record review of Resident # 1's MAR indicated she received Venlafaxine 37.5 mg at 8 AM. The MAR indicated the medication was discontinued on [DATE]. Record review of Resident #1's nursing notes dated [DATE] at 11:18 a.m. Venlafaxine given per order. At 5:18 p.m. resident sitting in wheelchair, unable to stay awake for very long. Lethargic and oriented times one. NP F was notified of residents change in orientation and requested Venlafaxine be discontinued due to medication interaction. At 8:19 p.m. The resident was lethargic and refused to wake up to take medications. The resident was responding appropriately to self. Record review of Resident #1 the facility 24 hour/change in condition report indicated on [DATE] Venlafaxine 37.5 mg. On the night shift resident awake all shift. Record review of Resident #1 the facility 24 hour/change in condition report indicated on [DATE] Venlafaxine discontinued. Record review of Resident #1 the facility 24 hour/change in condition report indicated on [DATE] Venlafaxine discontinued day two. The resident sent to the hospital at 8:49 p.m. due to changing condition. During an interview on [DATE] at 11:44 a.m. NP F said Resident #1 was started on a high dose of Venlafaxine because she appeared to be able to tolerate high doses of medications. She said everyone was different, they held it ,decreased it, watched it, and discontinued the medication. She said she was not aware if anyone called her to restart the medications or when she told the staff to start Resident #1 back on the Venlafaxine. However, from the calls she had received the resident did not tolerate the medications well and she had discontinued it on [DATE] due to reports of continued lethargic behaviors. She said she did want Resident #1 to be monitored for low blood pressure and fever for drug interactions with the Venlafaxine and Resident #1's current medication for possible serotonin overdose. She said the Serotonin Syndrome had a several different symptoms and could cause a resident medical distress. She said that was why she wanted the resident checked for fever and low blood pressure. She did not know that those checks did not appear to be done. She said she had gotten some calls from LVN G and RN D about Resident #1 but no acute calls. During an interview and record review on [DATE] at 2:21 p.m. The ADON said she had not written an order when NP F told indicated Resident #1 needed to be monitored for fever and low blood pressure, she had just put in as nursing note. She said the nurses were supposed to monitor for adverse reactions when giving give new medications anyway. She said that NP recommendation was supposed to be on the 24-hour report. After review of the 24-hour reports, she acknowledged that it was not noted on the reports. The ADON said she was no sure if she talked to the NP F or if she just put a note on her desk. She said they did not have an official system in place for recommendations to be added to the MAR. sShe said she had not placed an order in the computer. The ADON said it was good nursing practice to not give blood pressure medications if the diastolic blood pressure was below 60 even without stated parameters. She did not know why a nurse would give the medications. During an interview and record review on [DATE] at 3:40 p.m. the DON said there was no order to put Venlafaxine on hold. Review of Resident #1 's MAR revealed the Venlafaxine was given when it was supposed to be on hold. She said she did not know why some staff gave the Venlafaxine and some did not. She said normally they put in an order to hold medications for a specific time and did not know why that had not occurred . She said they would put it in the nurses notes and on the 24-hour report to remind nurses of the hold. Review of the nurses' notes indicated some nursesd did document the Venlafaxine was on hold and it was on the 24-hour report however it was still given when it was supposed to be on hold. She said they had a system in place but apparently it did not work for Resident #1. During an interview on [DATE] at 9:34 a.m. the DON said the Venlafaxine should have been put on hold in the computer with a clarification of how long it was on hold. The DON said nurses are to clarify orders if there is are any questions. She said the physician should have been notified more frequently of Resident change in condition. She said they should have put the information into computer system and it should have had a timeframes. She said in order to fix the situation they needed to monitor orders, monitor MARs and provide training for nurses. During an interview on [DATE] at 9:41 a.m. the NP F said she had no knowledge Resident #1 was still getting Venlafaxine when it was supposed to be on hold. She said she had assumed that they her order in the system and they were following it as recommended. She said with the blood pressure medications nursing judgment would be to hold the blood pressure medications according to parameters. Resident #2 Record review of Resident #2's face sheet dated [DATE] indicated she was admitted to the facility on [DATE]. Some of her diagnoses were essential primary high blood pressure, and a history of stroke. Record review of Resident # 2's care plan dated [DATE] indicated a Focused area of complications related to high blood pressure and at risk for side effects of medications. Interventions were to monitor blood pressure for side affects of medications. Record review of resident #2 Physicians orders indicated carvedilol 3.125 mg give one tablet by mouth two times a day for hypertension hold if systolic blood pressure is less than 100 or diastolic is less than 60 or heart rate is 55. Record review of resident #2 MAR for [DATE] indicated: On [DATE] at 8:00 a.m. blood pressure was ,d+[DATE]. On /,d+[DATE] at 8:00 a.m. blood pressure was ,d+[DATE] On [DATE] at 8:00 p.m. blood pressure was ,d+[DATE]. During an interview and record review on [DATE] at 9:15 a.m. Review records with the DON was shown showed Resident #2 record a resident with high blood pressure. The records revealed she received blood pressure medications and had parameters for those medications. Her blood pressure medications were given three times in [DATE] when her blood pressure was below the parameters. The DON said two of those times were by RN D. During an interview on [DATE] at 1:01 p.m. the DON said if a resident is given blood pressure medication and their blood pressure is already low it could cause them to be lightheaded and fall or it could cause the residents blood pressure to bottom out and they go into cardiac arrest and die . Record review of the facilities guidelines for medication administration policy with the revision date of eight 2022 indicated medication's are administered as prescribed in accordance with good nursing practices and practices that only legally authorize to administer medication in preparation always employed the more during medication administration prior to the administration of any medication, the medication and dosage schedule on the residence March are compared with the medication label if the label in the mark are different and the container has not already been flagged, indicating a change in instructions or there is any other reason to question the doses or directions, the physicians orders are checked for the correct dosage schedule when a medication ordered is changed, and the remainder of the current supply can still be used. The complaint container should be flagged right away in order changed communicated to the provider pharmacy. The administration of medication indicates medication's are in administered in accordance with written orders of the prescriber. Monitoring of side effects or medication related problems occurs but particularly after medication is administered and especially after the first few doses of a medication documentation, including electronic indicated if an electronic system is used, specific procedures, required for resident, identification, identification of medication, due to specific times, and documentation of administration, refusal, holding of doses, and dosing parameters, such as vital signs and lab values are described in the systems user manual. These procedures should be followed, and made for slightly from the procedures for using paper mars. Electronic systems. Also describe procedures for secure access, maintaining privacy of resident information, and for electronic signatures. The Administrator was notified on [DATE] at 1:05 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The Administrator was provided the Immediate Jeopardy template on [DATE] at 1:05 p.m. and a Plan of Removal was requested. The facility's Plan of Removal was accepted on [DATE] at 10:09 a.m. and included: [Plan of Removal F-757 Action: The Director of Infection Prevention will provide education on company's policy related to medication administration including following physician-ordered medication parameters were followed to the DCO. [DATE] The DCO or designee will clarify any orders that require clarification upon review. If a medication is noted on the 24 hour report to be on hold, the DCO or designee will ensure that this is reflected in the residents physician orders. The employee that failed to follow the facility policies regarding parameters will receive not only the education outlined below, but will also receive disciplinary action. In-service on company's policy related to medication administration including following physician-ordered medication parameters to all nurses conducted by the DCO/Designee. The inservice will be a reminder for most, but it will be in-depth in reviewing the negative outcomes that a resident could experience as a result of failing to observe the parameters. All nursing staff expected to be in-serviced prior to the next shift worked. All nursing staff expected to be in-serviced by [DATE]. This education will also be included in all new nurse orientation for any newly hired nurses. DCO/Designee to complete chart reviews daily during the clinical meeting to ensure medication administration including following physician-ordered medication parameters are being carried out per policy. [DATE] A random audit was conducted on [DATE] and no additional residents were identified as affected. DCO/Designee to complete med pass competencies on all regularly scheduled nurses by [DATE]. Any part time or PRN staff that are unavailable to complete a competency by [DATE] will be required to do so prior to returning to work. The Medical Director has been notified of the immediate jeopardy and reviewed current policy and procedures for medication administration including following physician-ordered medication parameters. 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 medication administration policy and procedures. [DATE] ] On [DATE] the investigator confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Review of the staff disciplinary actions indicated they were completed. Review of the Chart audits on medications indicated they were completed and all residents on blood pressure medications had parameters in place. Review of the medication competencies on medication pass were completed for the staff that were present. During an interview on [DATE] at 1:45 p.m. RN D said she did a general medication pass and competency on the blood pressure, and plus prior to administering medications. She said when she talked to NP F she just said until she reached baseline, and she did not give dates. The RN said had trouble with computers. She said she thought she put the order in but it did not appear to take. She said with the blood pressures looked like she gave them but she did not think that she had. She said she knew the charting said she did. Record review of a disciplinary action for RN D dated [DATE] indicated the employee failed to put a medication on hold per physician orders. Also the employee administered blood pressure medication to two different residence when it should have been held when the blood pressure was below the parameters. The employee will follow facility administration, policies, and corrective action taken. Any future policy violation will result in termination. The form indicated the employee will sign when she returns to work. Interviews were conducted with facility staff on [DATE] between 12:59 p.m. and 4:59 p.m. At 12:29 p.m. CNA I worked 6a to 2p At 1:07 p.m. CNA J worked 6a to 2p At 1:21p.m. CNA K worked 6a to 2p and 10 p to 6a At 1:45 p.m. RN D worked 6a to 2p At 2:16 p.m. LVN L worked 6a to 2p and 2p to 10 p At 2:28 p.m. CNA M worked 2p to 10 p At 2:41 p.m. CNA N worked 2p to 10 p At 3:05 p.m. CNA O worked from 2p to 10 p At 3:58 p.m. LVN P At 4:12 p.m. LVN Q worked form 10 p to 6 a At 4:20 p.m. LVN R worked form 10 p to 6a At 4:26 p.m. RN C worked 2p to 10 p At 4:37 p.m. worked 6a to 2 p Interviews with nurses indicated they were knowledgeable about the in-services provided regarding residents' medication administration. The nurses indicated they followed the parameters for administering blood pressure medications and were familiar with going into the system and putting medications on hold. They indicated when they go in to administer medications the system informed them when medications were due. If there was no hold order in the computer, they could have given the medications. The nurses also said if they received an order from the NP or the doctors they would read the order back for a clear understanding. If a doctor gave an order to hold the medications, they would ask for time frames and put them the computer. During an interview on [DATE] at 2:47 p.m. the Administrator said she worked at the facility for about two years. She said the incident with Resident #1 was not reported to her. She said they were all surprised the resident had gone to the hospital and passed away but did not think there were any issues at the facility regarding the Resident. She said if a resident admits, discharges, or passed away it was communicated in the morning meetings. She said they were going to train and educate and complete more monitoring of staff actions. She said they will conduct a more in depth review in the clinical meeting, we will tackle problems that they find or that are brought to their attention. During an interview on [DATE] at 4:59 p.m. the DON said nurses should use common nursing judgement in some situations. She said they will make sure these things did not happen going forward. The DON said nurses were in serviced and reminded of things they should already be doing. She said daily she would print out order list to monitor and print out vials daily just to look over. The DON said the aides were also in serviced and reminded of things they should have already been doing. She said the stop and watch alert is not new. She said all staff are aware if there is a change in condition with a resident to report it and if no action is taken go to the next level. She said they are to contact the NP or physician when they have questions about order clarification and change of resident condition in a timely manner. She said she had completed medication administration competency evaluations on nurses that had been in the buildings. The Administrator and DON were informed the IJ was removed on [DATE] at 5:23 p.m.; however, the facility remained out of compliance with a scope of pattern and a severity level of 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 that were put into place.

Based on interview and record review the facility failed to ensure treatment and care was provided to meet professional standards of practice for 1 of 7 residents reviewed for quality of care. (Resident #1) The facility failed to ensure Resident #1 was provided a timely assessment when she experienced a change of condition. LVN A noted Resident #1 had a change in condition on [DATE] around 2:00 p.m. but LVN A did not assess the resident at that time. At 8:00 p.m., Resident #1's oxygen level was 87 percent and she had vomited a black substance. The resident was also lethargic/unresponsive at dinner and unable to eat with assistance. EMS was called and placed a face mask on Resident #1 at 15L of oxygen and transported the resident to the ER where she was diagnosed with sepsis secondary to pneumonia. The resident was intubated and placed in ICU. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 1:05 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These deficient practices could place residents at risk of not being assessed for a change of condition that may require treatment alterations and could lead to additional pain and suffering. Findings included: Record of Resident #1's face sheet dated [DATE] indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Some of her diagnoses were congestive heart failure, bipolar disorder, schizoaffective disorder (mental health disorder including symptoms such as hallucinations, delusions, disorganized thinking, mania, and depression), dementia, and lack of coordination. Record review of Resident #1's admission MDS dated [DATE] indicated moderate cognitive impairment. The resident required supervision or touching assistance with eating. The resident required partial to moderate assistance with hygiene showers, upper body dressing, lower body dressing. The resident required partial to moderate assistance with transferring from chair to bed and toilet. Record review of Resident #1's care plan dated [DATE] indicated a focused area of the resident was at risk for adverse consequences related to receiving antipsychotic medications with a diagnosis of schizoaffective disorder. Some of the interventions were: Monitor resident for side effects of anti-anxiety medication, including but not limited to hypotension, sedation, and increase anxiety. Monitor the resident for side effects of anti-depressant medication's, including but not limited to increased confusion, changes in appetite, and changes in sleep pattern. Monitor the resident for side effects of antipsychotic medication's, such as muscle, rigidity, changes in appetite, sleep, disturbances, tardive, dyskinesia (side effect of antipsychotic medications that cause involuntary movements of the head and body including lip smacking, grimacing, eye blinking, and repetitive movements), seizures, and cardiac changes. Record review of Resident #1's nursing note indicated: On [DATE] at 1:41 p.m. resident continued to be very sleepy, did not wake up to take meds and ate 30 percent of lunch. She was in the wheelchair in the hallway sleeping. Her vital signs were stable. On [DATE] at 5:09 a.m. the resident was in bed with eyes closed easily arouse with respirations even and unlabored. No shortness of breath noted discontinued Venlafaxine HCL day three no adverse reactions. No signs and symptoms of sedations. The residence behavior within normal limits. No pain or discomfort observed. At 8:50 a.m. the resident blood pressure medications metoprolol and lisinopril were held due to blood pressure of ,d+[DATE]. At 8:34 p.m. medications were held due to residence status. At 8:50 p.m. the resident was sent to the hospital due to change in condition. (There were no other notes or assessments.) Signed by LVN A Record review of Resident #1's EMS report dated [DATE] indicated arrived at the scene at 8:33 p.m. Upon arrival at the scene the patient was lying in bed, mumbling, and reaching aimlessly into the air. The patient could tell us her name and the staff (LVN A) stated she was a [AGE] year-old female, and she started acting strangely at approximately 2:00 p.m. The patient was placed on monitor and vitals were obtained her temperature was 100.6 Fahrenheit. blood pressure was ,d+[DATE], respirations were 18 and labored and her oxygen stat was 93 percent. The sounds in her lungs revealed bubbling and gurgling. She was given a nebulizer treatment which improved her lung sounds and was placed on 15 mL of oxygen via facemask. The patient was transported to the ER and arrived at the destination at 9:15 p.m. The chief complaint was, altered consciousness, and lethargy (unusual decreased consciousness) for at least six hours and fever. Record review of Resident #1's emergency hospital records dated [DATE] with the arrival time of 9:20 p.m. indicated the patient was found in respiratory distress, low blood pressure and rapid heartbeat. On arrival the patient was in respiratory distress on a non-breather mask at 15 L oxygen. The nurses at the nursing home stated there was a possible aspiration (when food, liquid, vomit, or foreign object enters the lungs) episode today. Her blood pressure was ,d+[DATE], her pulse was 142, her temp was 103, her oxygen stat was 94%. The diagnosis was sepsis (the body's response to an infection or widespread inflammation) secondary to pneumonia. The patient will be transferred to an ICU for further management due to the complexity of the case and being a full code. Patient received from a nursing home with respiratory distress with a stat of 87 per nursing home. Staff said the condition noted at 2:00 p.m. The patient vomited around that time. She was transferred to the hospital on [DATE] at 2:00 a.m. Record review of Resident #1's hospital records indicated the resident was admitted to their facility on [DATE] on arrival she was on 12 L nasal cannula and unresponsive with blood pressures in the 80 systolic and O2 stats in the 80s. She was emergently intubated (to establish an airway and prevent secondary brain injury). During an interview on [DATE] at 3:36 p.m. the DON said she received a message from LVN A on the night of [DATE]. She said LVN A sent Resident #1 to the ER because she was not acting herself. The DON said LVN A said she contacted NP F and she said to send Resident #1 out. The DON said LVN A said Resident #1 did not eat supper and looked like she vomited something black. The LVN said Resident# 1's O2 stat was at 87 percent. The DON said the facility Interact transfer form was not in the clinical record and there was nothing in the nursing notes about Resident #1's condition prior to hospitalization . The DON said from what she saw in Resident #1's clinical record LVN A did not make the clinical document, she had likely assessed Resident #1 because she told her the blood pressure and oxygen status, but she did not document anything. During an interview on [DATE] at 5:05 p.m. RN C said Resident #1 had a steady decline. She said Resident #1 would repeat things over and over and over and sit in the hallway and yell out. She said the doctor put Resident #1 on Venlafaxine to aide with her behaviors. RN C said Resident#1 had been a lethargic for several days, the medications were reduced and discontinued. She said on [DATE] Resident #1 was sitting at the assisted dining table and refused to eat. The RN said Resident #1 appeared to be lethargic. She said Resident #1 would not wake up, and just blink, that was all. The RN said she was the one who tried to assist Resident #1 to eat and when she tried to put something in her mouth, she would not respond. She said the Resident #1 did not appear to be with it enough to chew. The RN said she was afraid Resident #1 would choke so she refused to feed her. She said she was not her nurse but had observed the resident was not her usual self for several days, and she was just assisting in the dining room. RN C said she thought Resident #1 was just having symptoms from the medications. During an interview on [DATE] at 5:07 p.m. LVN G said Resident #1 had been sleepy for the last couple of days. She said she worked with the Resident #1 the day before she was hospitalized on [DATE] and the Resident seemed fine. She said Resident #1's vitals were within normal limits for Resident #1. She said Resident #1 was not coughing or wheezing and had no rattle. The LVN G said Resident #1's voice was raspy as always but not wet. She said the Resident #1 was put on some new medications because she would sit in the hallway and yell and scream. The LVN said when most residents that are put on the medications, they are usually sleepy the first few days. She said there were some changes with the Venlafaxine and it was discontinued. She said she administered the medication as prescribed. She said Resident #1 would wake up and respond when spoken to. During an interview on [DATE] at 5:11 p.m. CNA B said she worked at the facility for about 1 year. She said when Resident #1 first arrived at the facility she would repeat things over and over. She said Resident #1 had a moderate decline. She said she was at the facility on [DATE] when Resident #1 was sent to the hospital. She said when she arrived that day at 2:00 p.m. Resident #1 could hardly do anything. She said Resident #1 was just sitting in the wheelchair with her head back and appeared to be asleep but was hard to awaken. She said it was like Resident #1 could not hold her head down at all. CNA B said Resident #1 had been kind of out of it (real sleepy and not herself, but she would respond) for the last couple of days, however on that day she would barley respond. She said all the nurses were aware the resident had a decline; Resident #1 would usually be placed right in front of the nurses' station. CNA B said the nurses said Resident #1 was like that because some medication they had put her on made her sleepy. CNA B said Resident #1 would not eat supper on [DATE], she would not open her mouth or hold her head down to take a bite. She had informed LVN A Resident #1 could not eat. She said that night around 8:00 p.m. when she was putting Resident #1 to bed, she had some black stuff coming out of her mouth and she told the nurse. CNA B said it was at that time the LVN A came and looked at Resident #1 and sent her out to the hospital. During an interview on [DATE] at 11:20 a.m. the DON said she saw LVN A but did not talk to her about Resident #1. She said she thought the LVN could not complete a note or an assessment after the Resident #1 was deceased . The DON said it appeared LVN A came in at 2p on [DATE] and failed to assess the resident when a change in condition was noted or to document what was going on with Resident #1. During a telephone interview on [DATE] at 11:25 a.m. LVN A said when she came to work on [DATE] at 2:00 p.m. Resident # 1 was in her wheelchair asleep and had her neck/head back. She said Resident #1 was usually up talking but she was not her normal self. She said when they went to supper the resident did not eat anything. She said around 8:00 p.m. she texted NP F and she told her Resident #1 need to be sent out. She said she texted the physician at the same time around 8:00 p.m. The LVN said she checked her vital signs and everything. She said she did not remember if she had written anything down or not. She said she worked PRN and did not know what was going on with Resident #1. She said she assessed her but did not complete the assessment because she did not have time. She said after they laid Residen t#1 down that night her breathing was shallow and her 02 sat was under 90. She said Resident #1 was laying in the bed reaching in the air. The LVN said Resident #1 did not have a fever and EMS did not say anything about her breathing. During an interview on [DATE] at 11:44 a.m. NP F said she felt the nurses were good about reporting things, and she received mixed messages about Resident #1. She said one nurse would report one thing and one nurse would see something different. She said she had reports that Resident #1 would eat good one day and one day not. She said the reports that she received about Resident #1 were not consistent. She said she was shocked when they reported the resident had died , it was totally unexpected. On [DATE] at 8:04 p.m. she received a text from LVN A. She said the text stated Resident #1 was not acting herself, 02 stat was 87 at the time, bp was ,d+[DATE], and heart rate 67. NP F said Resident #1 was started on a high dose of Venlafaxine because she appeared to be able to tolerate high doses of medications. She said everyone was different, they held it, decreased it, watched it, and discontinued the medication. She said she was not aware if anyone called her to restart the medications or when she told the staff to start Resident #1 back on the Venlafaxine. However, from the calls she had received the resident did not tolerate the medications well and she had discontinued it on [DATE] due to reports of continued lethargic behaviors. She said she did want Resident #1 to be monitored for low blood pressure and fever for drug interactions with the Venlafaxine and Resident #1's current medication for possible serotonin overdose. She said the Serotonin Syndrome had several different symptoms and could cause a resident medical distress. She said that was why she wanted the resident checked for fever and low blood pressure. She did not know that those checks did not appear to be done. She said she had gotten some calls from LVN G and RN D about Resident #1 but no acute calls. During an interview on [DATE] at 12:00 p.m. RN D said she had worked with Resident #1 the day before she had gone to the hospital. She said Resident #1 was sleepy but would respond. She said other than being sleepy she was her normal self. She said the resident did not have a cough and had taken her medications without incident. She had eaten only part of her lunch that day, but she did not note any distress. During an interview on [DATE] at 12:05 p.m. CNA H said when she arrived at the facility on [DATE] at 6:00 a.m. She said Resident #1 was extremely hard to get up that morning. She said Resident #1 seemed overly tired. She said Resident #1 was less coherent. CNA H said normally Resident #1 wanted to go out to smoke or go to the dining room to wait on breakfast but said did not want to do any of those things. She said for the last few days Resident #1 would sleep quite a bit. She said most days she would sleep some because she may have been up the night before. She said on that day she was sleeping and not eating. CNA H said RN D was the nurse on [DATE] and she knew Resident #1 was more tired than usual because she had told her. She had also placed the resident close to the nurse's station. During an interview and record review on [DATE] at 3:40 p.m. the DON said review of the EMS and hospital records indicated LVN A had told the hospital Resident #1 had a change in condition around 2:00 p.m. The DON said she was not made aware of the change until around 8:00 p.m. She could not say why the nurse had waited 6 hours before assessing Resident #1 and sending her out to the hospital. During a telephone interview on [DATE] at 3:50 p.m. LVN A said she told the hospital the Resident #1 had thrown up at about 2:00 p.m. and it was black. They had chocolate cake but she did not know if it was the cake or not. She also told the hospital Resident #1 had a change in condition around 2p. During an interview on [DATE] at 9:41 a.m. the NP F said there were no reports of any changes with Resident #1 until around 8:00 p.m. on [DATE]. During an interview on [DATE] at 10:01 the BOM said the family member texted her the day Resident #1 went to the hospital to say she seemed over medicated they could not get her to wake up. She said she had told the nurse. The family member had texted her again, but she did not recall exactly what the text said. During a telephone interview on [DATE] at 10:30 a.m. a family member said on the day Resident #1 went to the hospital her family member called her crying and upset because Resident #1 could not seem to get her breath to talk. That Family member said they were there on [DATE] about 2 or 3 in the afternoon. The family member said whoever she talked to told her Resident #1 had been like that for two or three days. The family member said Resident #1 was sitting in the wheelchair with her head back and she could not get her to really wake up. The family member said Resident#1 had a bruise on her face that looked like it was a few days old. The aide told her the resident had fallen in her room a few days earlier. The family member said they wheeled Resident #1 out by the nurse's station because they were concerned, she was not doing well. The family member said they talked to the nurse behind the nurse's station and asked what was going on with Resident#1? The family member said she did not really get an answer and was upset and confused when she left the facility. She thought something was wrong, but the staff acted like Resident #1 was fine, but she was not. The family member said the Resident had black stuff coming out of her mouth. She said they could not get her head down so she could clean her mouth, it looked like she had food in her mouth. They said Resident #1's neck was in almost an awkward position held back and she did not appear to be able to lift her head. The family member said when Resident #1 arrived at the hospital food was stuck to the top of her mouth, and it was so bad they had to throw the dentures away. The food looked like it had been there for a long time. The family member said the Resident #1's neck was held in a back position when she was in the hospital even while lying in the bed. It was like her neck was paralyzed in that position. During an interview on [DATE] at 1:21 p.m. CNA K said Resident #1 was not herself at all. She said some nurses they reported to would act and others would not. She said Resident #1 had a tremendous change. She was loud and very vocal. They changed her medications, and she was zonked out, sleeping like she was not in the world. She said they reported their concerns to the nurses, and they would say it was just the medication. CNA K said the last 3- or 4-days Resident #1 was in the facility, it did not matter if Resident #1 was up in the chair or in bed her head was back, her mouth was open, and she was asleep. During an interview on [DATE] at 1:45 p.m. RN D said she was thinking Resident #1's problem was the change in medications. She had seen her in the hallway picking things out of the air and she was still asleep. She said she had not really assessed her but if someone told her black stuff was coming out of her mouth, she would have assessed her for sure. During an interview on [DATE] at 4:26 p.m. RN C said she was not Resident #1's nurse on [DATE]. She said at dinner she tried to feed Resident #1, and she could not eat. The RN said she refused to feed Resident #1 and told the aide not to even try. She said it appeared Resident #1 was unable to hold her head down to eat. She sat with her head back like she was asleep and was not responding appropriately at all. She said LVN A was in the dining room and heard the interactions about Resident #1 not being able to eat dinner. RN C said after the Resident #1 had gone to the hospital and LVN A asked if she had feed the resident anything. She said LVN A said something was coming out of Resident #1'smouth. RN C said Resident #1 had a change in condition, she was sleeping and could not be awaken, her head was back, and she could not eat. She said she asked the DON today what she should have done? She said Resident #1 was not her resident, and she noted a change in condition. LVN C said the DON told her if the other nurse did not assess the resident, then she needed to assess, make all the necessary calls and documentation. Record review of the facilities change in a resident condition or status policy, last revised [DATE], indicated our facility shall promptly notify the resident attending physician changes in the resident medical condition. The nurse will notify the resident attending physician on call when there has been a significant change in the resident, physical, emotional, or mental condition. A significant change of condition is a major decline or improvement, in the resident status that will not normally resolve itself without intervention impacts more than one and impacts more than one area of the resident health. Prior to notifying the physician or healthcare provider the nurse will make detail observations and gather relevant pertinent information for the provider, including for example, information provided by the in-communication form, the nurse will record in the resident record information relative to changes in the resident medical mental condition or status. The Administrator was notified on [DATE] at 1:05 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The Administrator was provided the Immediate Jeopardy template on [DATE] at 1:05 p.m. and a Plan of Removal was requested. The facility's Plan of Removal was accepted on [DATE] at 11:12 a.m. and included: [Plan of Removal F-684 Action: The Director of Infection Prevention will provide education on company's policy related to assessment of a resident when they experience a change of condition to the DCO. [DATE] The employee that failed to follow the facility policies regarding parameters will receive not only the education outlined below, but will also receive disciplinary action. In-service on company's policy related to assessment of a resident when they experience a change of condition to all nurses conducted by the DCO/Designee. A copy of the inservice regarding change of condition will be provided for review. The policy and procedure outlines examples of occurrences that would necessitate notification of a change of condition. If an aide reports a change in condition, the nurse is expected to evaluate the resident and make a determination of necessary additional treatment. The facility assessment form will be completed when residents are sent to the hospital. All nursing staff expected to be in-serviced prior to the next shift worked. All nursing staff expected to be in-serviced by [DATE]. This education will also be included in all new nurse orientation for any newly hired nurses. Nurse aides were re-educated on utilization of the Stop and Watch notification in Point Click Care for changes in condition on [DATE]. Nurses were educated on reviewing the PCC dashboard for the automatically triggered alerts with visual demonstration on [DATE]. DCO/Designee to complete chart reviews daily during the clinical meeting to ensure thorough and accurate assessments are completed when a resident experiences a change of condition per policy. [DATE]. In reviewing resident charts, the DCO or designee will monitor for occurrences such as medication changes, falls and resident discharges to the ER. A chart audit was conducted by the DCO/Designee on [DATE] to see if any residents experienced a change in condition that required assessment. No additional concerns were identified. The Medical Director has been notified of the immediate jeopardy and reviewed current policy and procedures assessment of a resident when experiencing a change of condition. 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 assessments of residents who experience a change of condition per policy and procedures. [DATE] ] On [DATE] the investigator confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Review of the staff disciplinary actions indicated they were completed. Review of the Chart audits on medications indicated they were completed and all residents on blood pressure medications had parameters in place. Review of the medication competencies on medication pass were completed for the staff that were present. Review of disciplinary action for LVN A dated [DATE] indicated the employee had failed to notify the physician and provide an assessment for a resident prior to hospitalization . The employee will follow facility policy regarding physician notification and assessing a resident when they have a changing condition. The first employee will timely and accurately document all the Above in the computer system. Any future violations of this policy will result in termination. The form indicated spoke to the employee on the phone and she will be signed up upon return to work. Interviews were conducted with facility staff on [DATE] between 12:59 p.m. and 4:59 p.m. At 12:29 p.m. CNA I worked 6a to 2p At 1:07 p.m. CNA J worked 6a to 2p At 1:21p.m. CNA K worked 6a to 2p and 10 p to 6a At 1:45 p.m. RN D worked 6a to 2p At 2:16 p.m. LVN L worked 6a to 2p and 2p to 10 p At 2:28 p.m. CNA M worked 2p to 10 p At 2:41 p.m. CNA N worked 2p to 10 p At 3:05 p.m. CNA O worked from 2p to 10 p At 3:58 p.m. LVN P At 4:12 p.m. LVN Q worked form 10 p to 6 a At 4:20 p.m. LVN R worked form 10 p to 6a At 4:26 p.m. RN C worked 2p to 10 p At 4:37 p.m. worked 6a to 2 p Interviews with nurses indicated they were knowledgeable about the in-services provided regarding residents being assessed in a timely manner. Contacting the physician and documenting the residents change in the facility computer system. Interviews with nurse aides indicated they were knowledgeable regarding reporting a change in condition and if the nurse did not act, they would notify the immediate supervisor. They were also knowledgeable about documenting the change in the facility computer system. During an interview on [DATE] at 2:47 p.m. the Administrator said she worked at the facility for about two years. She said the incident with Resident #1 was not reported to her. She said they were all surprised the resident had gone to the hospital and passed away but did not think there were any issues at the facility regarding the Resident. She said if a resident admits, discharges, or passed away it was communicated in the morning meetings. She said they were going to train and educate and complete more monitoring of staff actions. She said they will conduct a more in depth review in the clinical meeting, we will tackle problems that they find or that are brought to their attention. During an interview on [DATE] at 4:59 p.m. the DON said she completed chart audit, regarding blood pressure medications and went through to see who had parameters. She said they audited new orders on medications. The DON said residents that did not have blood pressure have parameters they put those in place. Had one resident had ,d+[DATE] as a blood pressure parameter and clarified with the doctor. She said she completed medication administration competency with nurses that have been in the building. The DON said nurses should use common nursing judgement in some situations. She said they will make sure these things did not happen going forward. They had implemented standing orders, for blood pressure medications. The DON said nurses were in serviced and reminded of things they should already be doing. She said daily she would print out order list to monitor and print out vitals daily just to look over. The DON said the aides were also in serviced and reminded of things they should have already been doing. She said the stop and watch alert is not new. She said all staff are aware if there was a change in condition with a resident to report it and if no action is taken go to the next level. The Administrator and DON were informed the IJ was removed on [DATE] at 5:23 p.m.; however, the facility remained out of compliance with a scope of pattern and a severity level of 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 that were put into place.

Based on interview and record review the facility failed to immediately consult the physician when a resident had a significant change in physical and mental condition for 1 of 7 residents reviewed for physician notification (Resident #1.) LVN A noted Resident #1 had a change in condition on [DATE] around 2:00 p.m. but LVN A did not consult the physician until 8:00 p.m. Facility staff failed to consult the physician when Resident #1's oxygen level was 87 percent and had vomited a black substance. The resident was also lethargic/unresponsive at dinner and unable to eat with assistance. EMS was called and placed a face mask on Resident #1 at 15L of oxygen and transported the resident to the ER where she was diagnosed with sepsis secondary to pneumonia. The resident was intubated and placed in ICU. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 1:05 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These deficient practices could place residents at risk of not having their physician consulted when changes occur that may require treatment alterations and could lead to additional pain and suffering. Findings included: Record of Resident #1's face sheet dated [DATE] indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Some of her diagnoses were congestive heart failure, bipolar disorder, schizoaffective disorder (mental health disorder including symptoms such as hallucinations, delusions, disorganized thinking, mania, and depression) , dementia, and lack of coordination. Record review of Resident #1's admission MDS dated [DATE] indicated moderate cognitive impairment. The resident required supervision or touching assistance with eating. The resident required partial to moderate assistance with hygiene showers, upper body dressing, lower body dressing. The resident required partial to moderate assistance with transferring from chair to bed and toilet. Record review of Resident #1's care plan dated [DATE] indicated a focused area of the resident was at risk for adverse consequences related to receiving antipsychotic medications with a diagnosis of schizoaffective disorder. Some of the interventions were: Monitor resident for side effects of anti-anxiety medication, including but not limited to hypotension, sedation, and increase anxiety. Monitor the resident for side effects of anti-depressant medication's, including but not limited to increased confusion, changes in appetite, and changes in sleep pattern. Monitor the resident for side effects of antipsychotic medication's, such as muscle, rigidity, changes in appetite, sleep, disturbances, tardive, dyskinesia (side effect of antipsychotic medications that cause involutary movements of the head and body including lip smacking, grimacing, eye blinking, and repetitive movements), seizures, and cardiac changes. Record review of Resident #1's nursing note indicated: On [DATE] at 1:41 p.m. resident continued to be very sleepy, did not wake up to take meds and ate 30 percent of lunch. She was in the wheelchair in the hallway sleeping. Her vital signs were stable. On [DATE] at 5:09 a.m. the resident was in bed with eyes closed easily arouse with respirations even and unlabored. No shortness of breath noted discontinued Venlafaxine HCL day three no adverse reactions. No signs and symptoms of sedations. The residence behavior within normal limits. No pain or discomfort observed. At 8:50 a.m. the resident blood pressure medications metoprolol and lisinopril were held due to blood pressure of ,d+[DATE]. At 8:34 p.m. medications were held due to residence status. At 8:50 p.m. the resident was sent to the hospital due to change in condition. (There were no other notes or assessments.) Signed by LVN A Record review of Resident #1's EMS report dated [DATE] indicated arrived at the scene at 8:33 p.m. Upon arrival at the scene the patient was lying in bed, mumbling, and reaching aimlessly into the air. The patient could tell us her name and the staff ( LVN A) stated she was a [AGE] year-old female, and she started acting strangely at approximately 2:00 p.m. The patient was placed on monitor and vitals were obtained her temperature was 100.6 Fahrenheit. blood pressure was ,d+[DATE], respirations were 18 and labored and her oxygen stat was 93 percent. The sounds in her lungs revealed bubbling and gurgling. She was given a nebulizer treatment which improved her lung sounds and was placed on 15 mL of oxygen via facemask. The patient was transported to the ER and arrived at the destination at 9:15 p.m. The chief complaint was, altered consciousness, and lethargy (unusual decreased consciousness) for at least six hours and fever. Record review of Resident #1's emergency hospital records dated [DATE] with the arrival time of 9:20 p.m. indicated the patient was found in respiratory distress, low blood pressure and rapid heartbeat. On arrival the patient was in respiratory distress on a non-breather mask at 15 L oxygen. The nurses at the nursing home stated there was a possible aspiration (when food, liquid, vomit, or foreign object enters the lungs) episode today. Her blood pressure was ,d+[DATE], her pulse was 142, her temp was 103, her oxygen stat was 94%. The diagnosis was sepsis (the body's response to an infection or widespread inflammation) secondary to pneumonia. The patient will be transferred to an ICU for further management due to the complexity of the case and being a full code. Patient received from a nursing home with respiratory distress with a stat of 87 per nursing home. Staff said the condition noted at 2:00 p.m. The patient vomited around that time. She was transferred to the hospital on [DATE] at 2:00 a.m. Record review of Resident #1's hospital records indicated the resident was admitted to their facility on [DATE] on arrival she was on 12 L nasal cannula and unresponsive with blood pressures in the 80 systolic and O2 stats in the 80s. She was emergently intubated (to establish an airway and prevent secondary brain injury). During an interview on [DATE] at 3:36 p.m. the DON said she received a message from LVN A on the night of [DATE]. She said LVN A sent Resident #1 to the ER because she was not acting herself. The DON said LVN A said she contacted NP F and she said to send Resident #1 out. The DON said LVN A said Resident #1 did not eat supper and looked like she vomited something black. The LVN said Resident# 1's O2 stat was at 87 percent. The DON said the facility Interact transfer form was not in the clinical record and there was nothing in the nursing notes about Resident #1's condition prior to hospitalization . The DON said from what she saw in Resident #1's clinical record LVN A did not make the clinical document, she had likely assessed Resident #1 because she told her the blood pressure and oxygen status, but she did not document anything. During an interview on [DATE] at 5:05 p.m. RN C said Resident #1 had a steady decline. She said Resident #1 would repeat things over and over and over and sit in the hallway and yell out. She said the doctor put Resident #1 on Venlafaxine to aide with her behaviors. RN C said Resident#1 had been a lethargic for several days, the medications were reduced and discontinued. She said on [DATE] Resident #1 was sitting at the assisted dining table and refused to eat. The RN said Resident #1 appeared to be lethargic. She said Resident #1 would not wake up, and just blink, that was all. The RN said she was the one who tried to assist Resident #1 to eat and when she tried to put something in her mouth, she would not respond. She said the Resident #1 did not appear to be with it enough to chew. The RN said she was afraid Resident #1 would choke so she refused to feed her. She said she was not her nurse but had observed the resident was not her usual self for several days, and she was just assisting in the dining room. RN C said she thought Resident #1 was just having symptoms from the medications. During an interview on [DATE] at 5:07 p.m. LVN G said Resident #1 had been sleepy for the last couple of days. She said she worked with the Resident #1 the day before she was hospitalized on [DATE] and the Resident seemed fine. She said Resident #1's vitals were within normal limits for Resident #1 . She said Resident #1 was not coughing or wheezing and had no rattle. The LVN G said Resident #1's voice was raspy as always but not wet. She said the Resident #1 was put on some new medications because she would sit in the hallway and yell and scream. The LVN said when most residents that are put on the medications, they are usually sleepy the first few days. She said there were some changes with the Venlafaxine and it was discontinued. She said she administered the medication as prescribed. She said Resident#1 would wake up and respond when spoken to. During an interview on [DATE] at 5:11 p.m. CNA B said she worked at the facility for about 1 year. She said when Resident #1 first arrived at the facility she would repeat things over and over. She said Resident #1 had a moderate decline. She said she was at the facility on [DATE] when Resident #1 was sent to the hospital. She said when she arrived that day at 2:00 p.m. Resident #1 could hardly do anything. She said Resident #1 was just sitting in the wheelchair with her head back and appeared to be asleep but was hard to awaken. She said it was like Resident #1 could not hold her head down at all. CNA B said Resident #1 had been kind of out of it ( real sleepy and not herself, but she would respond) for the last couple of days, however on that day she would barley respond. She said all the nurses were aware the resident had a decline; Resident #1 would usually be placed right in front of the nurses' station. CNA B said the nurses said Resident #1 was like that because some medication they had put her on made her sleepy. CNA B said Resident #1 would not eat supper on [DATE], she would not open her mouth or hold her head down to take a bite. She had informed LVN A Resident #1 could not eat. She said that night around 8:00 p.m. when she was putting Resident #1 to bed, she had some black stuff coming out of her mouth and she told the nurse. CNA B said it was at that time the LVN A came and looked at Resident #1 and sent her out to the hospital. During an interview on [DATE] at 11:20 a.m. the DON said she saw LVN A but did not talk to her about Resident #1. She said she thought the LVN could not complete a note or an assessment after the Resident #1 was deceased . The DON said it appeared LVN A came in at 2p on [DATE] and failed to assess the resident when a change in condition was noted or to document what was going on with Resident#1. During a telephone interview on [DATE] at 11:25 a.m. LVN A said when she came to work on [DATE] at 2:00 p.m. Resident # 1 was in her wheelchair asleep and had her neck/head back. She said Resident #1 was usually up talking but she was not her normal self. She said when they went to supper the resident did not eat anything. She said around 8:00 p.m. she texted NP F and she told her Resident #1 need to be sent out. She said she texted the physician at the same time around 8:00 p.m. The LVN said she checked her vital signs and everything. She said she did not remember if she had written anything down or not. She said she worked PRN and did not know what was going on with Resident #1. She said she assessed her but did not complete the assessment because she did not have time. She said after they laid Resident#1 down that night her breathing was shallow, her 02 stat was under 90. She said Resident #1 was laying in the bed reaching in the air. The LVN said Resident #1 did not have a fever and EMS did not say anything about her breathing. During an interview on [DATE] at 11:44 a.m. NP F said she felt the nurses were good about reporting things, and she received mixed messages about Resident #1. She said one nurse would report one thing and one nurse would see something different. She said she had reports that Resident #1 would eat good one day and one day not. She said the reports that she received about Resident #1 were not consistent. She said she was shocked when they reported the resident had died , it was totally unexpected. On [DATE] at 8:04 p.m. she received a text from LVN A. She said the text stated Resident #1 was not acting herself, 02 stat was 87 at the time, bp was ,d+[DATE], and heart rate 67. NP F said Resident #1 was started on a high dose of Venlafaxine because she appeared to be able to tolerate high doses of medications. She said everyone was different, they held it ,decreased it, watched it, and discontinued the medication. She said she was not aware if anyone called her to restart the medications or when she told the staff to start Resident #1 back on the Venlafaxine. However, from the calls she had received the resident did not tolerate the medications well and she had discontinued it on [DATE] due to reports of continued lethargic behaviors. She said she did want Resident #1 to be monitored for low blood pressure and fever for drug interactions with the Venlafaxine and Resident #1's current medication for possible serotonin overdose. She said the Serotonin Syndrome had several different symptoms and could cause a resident medical distress. She said that was why she wanted the resident checked for fever and low blood pressure. She did not know that those checks did not appear to be done. She said she had gotten some calls from LVN G and RN D about Resident #1 but no acute calls. During an interview on [DATE] at 12:00 p.m. RN D said she had worked with Resident #1 the day before she had gone to the hospital. She said Resident #1 was sleepy but would respond. She said other than being sleepy she was her normal self. She said the resident did not have a cough and had taken her medications without incident. She had eaten only part of her lunch that day, but she did not note any distress. During an interview on [DATE] at 12:05 p.m. CNA H said when she arrived at the facility on [DATE] at 6:00 a.m. She said Resident #1 was extremely hard to get up that morning. She said Resident #1 seemed overly tired. She said Resident #1 was less coherent. CNA H said normally Resident #1 wanted to go out to smoke or go to the dining room to wait on breakfast but said did not want to do any of those things. She said for the last few days Resident #1 would sleep quite a bit. She said most days she would sleep some because she may have been up the night before. She said on that day she was sleeping and not eating. CNA H said RN D was the nurse on [DATE] and she knew Resident #1 was more tired than usual because she had told her. She had also placed the resident close to the nurse's station. During an interview and record review on [DATE] at 3:40 p.m. the DON said review of the EMS and hospital records indicated LVN A had told the hospital Resident #1 had a change in condition around 2:00 p.m. The DON said she was not made aware of the change until around 8:00 p.m. She could not say why the nurse had waited 6 hours before assessing Resident #1 and sending her out to the hospital. During a telephone interview on [DATE] at 3:50 p.m. LVN A said she told the hospital the Resident #1 had thrown up at about 2:00 p.m. and it was black. They had chocolate cake, she did not know if it was the cake or not. She also told the hospital Resident #1 had a change in condition around 2p. During an interview on [DATE] at 9:41 a.m. the NP F said there were no reports of any changes with Resident #1 until around 8:00 p.m. on [DATE]. During an interview on [DATE] at 10:01 the BOM said that the a family member texted her the day Resident #1 went to the hospital to say she seemed over medicated they could not get her to wake up. She said she had told the nurse. The family member had texted her again, but she did not recall exactly what the text said. During a telephone interview on [DATE] at 10:30 a.m. a family member said on the day Resident #1 went to the hospital her family member called her crying and upset because Resident #1 could not seem to get her breath to talk. That Family member said they were there on [DATE] about 2 or 3 in the afternoon. The family member said whoever she talked to told her Resident #1 had been like that for two or three days. The family member said Resident #1 was sitting in the wheelchair with her head back and she could not get her to really wake up. The family member said Resident#1 had a bruise on her face that looked like it was a few days old. The aide told her the resident had fallen in her room a few days earlier. The family member said they wheeled Resident #1 out by the nurse's station because they were concerned, she was not doing well. The family member said they talked to the nurse behind the nurse's station and asked what was going on with Resident#1? The family member said she did not really get an answer and was upset and confused when she left the facility. She thought something was wrong, but the staff acted like Resident #1 was fine, but she was not. The family member said the Resident had black stuff coming out of her mouth. She said they could not get her head down so she could clean her mouth, it looked like she had food in her mouth. They said Resident #1's neck was in almost an awkward position held back and she did not appear to be able to lift her head. The family member said when Resident #1 arrived at the hospital food was stuck to the top of her mouth, and it was so bad they had to throw the dentures away. The food looked like it had been there for a long time. The family member said the Resident #1's neck was held in a back position when she was in the hospital even while lying in the bed. It was like her neck was paralyzed in that position. During an interview on [DATE] at 1:21 p.m. CNA K said Resident #1 was not herself at all. She said some nurses they reported to would act and others would not. She said Resident #1 had a tremendous change. She was loud and very vocal. They changed her medications, and she was zonked out, sleeping like she was not in the world. She said they reported their concerns to the nurses, and they would say it was just the medication. CNA K said the last 3- or 4-days Resident #1 was in the facility, it did not matter if Resident #1 was up in the chair or in bed her head was back, her mouth was open, and she was asleep. During an interview on [DATE] at 1:45 p.m. RN D said she was thinking Resident #1's problem was the change in medications. She had seen her in the hallway picking things out of the air and she was still asleep. She said she had not really assessed her but if someone told her black stuff was coming out of her mouth, she would have assessed her for sure. During an interview on [DATE] at 4:26 p.m. RN C said she was not Resident #1's nurse on [DATE]. She said at dinner she tried to feed Resident #1, and she could not eat. The RN said she refused to feed Resident #1 and told the aide not to even try. She said it appeared Resident #1 was unable to hold her head down to eat. She sat with her head back like she was asleep and was not responding appropriately at all. She said LVN A was in the dining room and heard the interactions about Resident #1 not being able to eat dinner. RN C said after the Resident #1 had gone to the hospital and LVN A asked if she had feed the resident anything. She said LVN A said something was coming out of Resident #1'smouth. RN C said Resident #1 had a change in condition, she was sleeping and could not be awaken, her head was back, and she could not eat. She said she asked the DON today what she should have done? She said Resident #1 was not her resident, and she noted a change in condition. LVN C said the DON told her if the other nurse did not assess the resident, then she needed to assess, make all the necessary calls and documentation. Record review of the facilities change in a resident condition or status policy, last revised [DATE], indicated our facility shall promptly notify the resident attending physician changes in the resident medical condition. The nurse will notify the resident attending physician on call when there has been a significant change in the resident, physical, emotional, or mental condition. A significant change of condition is a major decline or improvement, in the resident status that will not normally resolve itself without intervention impacts more than one and impacts more than one area of the resident health. Prior to notifying the physician or healthcare provider the nurse will make detail observations and gather relevant pertinent information for the provider, including for example, information provided by the in-communication form, the nurse will record in the resident record information relative to changes in the resident medical mental condition or status. The Administrator was notified on [DATE] at 1:05 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The Administrator was provided the Immediate Jeopardy template on [DATE] at 1:05 p.m. and a Plan of Removal was requested. The facility's Plan of Removal was accepted on [DATE] at 11:12 a.m. and included: [Plan of Removal F-580 Action: The Director of Infection Prevention will provide education on company's policy related to physician and/or family notification of resident changes to the DCO. [DATE]. In-service on company's policy related to assessment of a resident when they experience a change of condition to all nurses conducted by the DCO/Designee. A copy of the inservice regarding change of condition will be provided for review. The policy and procedure outlines examples of occurrences that would necessitate notification of a change of condition. If an aide reports a change in condition, the nurse is expected to evaluate the resident and make a determination of necessary additional treatment. Nurse aides were re-educated on utilization of the Stop and Watch notification in Point Click Care for changes in condition on [DATE]. Nurses were educated on reviewing the PCC dashboard for the automatically triggered alerts with visual demonstration on [DATE]. The facility assessment form will be completed when residents are sent to the hospital. All nursing staff expected to be in-serviced prior to the next shift worked. All nursing staff expected to be in-serviced by [DATE]. This education will also be included in all new nurse orientation for any newly hired nurses. DCO/Designee to complete chart reviews daily during the clinical meeting to ensure physician and/or family notification for new orders and/or change in conditions are happening per policy. [DATE] - A random audit was conducted on [DATE] and no additional residents were identified as affected. The Medical Director has been notified of the immediate jeopardy and reviewed current policy and procedures for notification of new orders and/or change in condition. 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 notification of physician and family policy and procedures. [DATE] ] On [DATE] the investigator confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Review of the staff disciplinary actions indicated they were completed. Review of the Chart audits on medications indicated they were completed and all residents on blood pressure medications had parameters in place. Review of the medication competencies on medication pass were completed for the staff that were present. Review of disciplinary action for LVN A dated [DATE] indicated the employee had failed to notify the physician and provide an assessment for a resident prior to hospitalization . The employee will follow facility policy regarding physician notification and assessing a resident when they have a changing condition. The first employee will timely and accurately document all the Above in the computer system. Any future violations of this policy will result in termination. The form indicated spoke to the employee on the phone and she will be signed up upon return to work. Interviews were conducted with facility staff on [DATE] between 12:59 p.m. and 4:59 p.m. At 12:29 p.m. CNA I worked 6a to 2p At 1:07 p.m. CNA J worked 6a to 2p At 1:21p.m. CNA K worked 6a to 2p and 10 p to 6a At 1:45 p.m. RN D worked 6a to 2p At 2:16 p.m. LVN L worked 6a to 2p and 2p to 10 p At 2:28 p.m. CNA M worked 2p to 10 p At 2:41 p.m. CNA N worked 2p to 10 p At 3:05 p.m. CNA O worked from 2p to 10 p At 3:58 p.m. LVN P At 4:12 p.m. LVN Q worked form 10 p to 6 a At 4:20 p.m. LVN R worked form 10 p to 6a At 4:26 p.m. RN C worked 2p to 10 p At 4:37 p.m. worked 6a to 2 p Interviews with nurses indicated they were knowledgeable about the in-services provided regarding residents being assessed in a timely manner. Contacting the physician and documenting the residents change in the facility computer system. Interviews with nurse aides indicated they were knowledgeable regarding reporting a change in condition and if the nurse did not act, they would notify the immediate supervisor. They were also knowledgeable about documenting the change in the facility computer system. During an interview on [DATE] at 2:47 p.m. the Administrator said she worked at the facility for about two years. She said the incident with Resident #1 was not reported to her. She said they were all surprised the resident had gone to the hospital and passed away but did not think there were any issues at the facility regarding the Resident. She said if a resident admits, discharges, or passed away it was communicated in the morning meetings. She said they were going to train and educate and complete more monitoring of staff actions. She said they will conduct a more in depth review in the clinical meeting, we will tackle problems that they find or that are brought to their attention. During an interview on [DATE] at 4:59 p.m. the DON said nurses should use common nursing judgement in some situations. She said they will make sure these things did not happen going forward. The DON said nurses were in serviced and reminded of things they should already be doing. She said daily she would print out order list to monitor and print out vitals daily just to look over. The DON said the aides were also in serviced and reminded of things they should have already been doing. She said the stop and watch alert is not new. She said all staff are aware if there was a change in condition with a resident to report it and if no action is taken go to the next level. She said they are to contact the NP or physician when they have questions about order clarification and change of resident condition in a timely manner. She said nurses were in serviced on the importance of physician notification. The Administrator, and DON were informed the IJ was removed on [DATE] at 5:23 p.m.; however, the facility remained out of compliance with a scope of pattern and a severity level of 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 that were put into place.

Based on observation, interview and record review, the facility failed to ensure 1 of 9 residents sampled for pain was assessed and treated for [REDACTED]. Resident #1 told the RD on 10/11/10 she was having dental pain when eating. On 10/20/10, Resident #1 told nursing staff she did not want food because her teeth hurt. No pain assessments or pain medication were provided for Resident #1. This failure contributed to Resident #1's unresolved dental pain. This failure could place the facility census of 42 residents at risk for unresolved pain. Findings included: Resident #1 was an [AGE] year-old female with [DIAGNOSES REDACTED]. Resident #1's care plan dated 8/20/10 indicated the facility was to monitor for non-verbal pain related to recent decline in level of consciousness. Resident #1's MDS with an assessment reference date of 8/27/10 indicated she had short and long term memory problems. Her cognitive skills for daily decision making were moderately impaired. She usually made herself understood and usually understood verbal information. In an observation and interview with the ADON on 11/9/10 at 8:25 a.m., Resident #1 said her teeth hurt when she tried to eat and that was why she had lost weight. The resident's bottom teeth protruded outward toward her lip. The ADON said she was not aware the resident's teeth hurt when she ate. During an interview on 11/9/10 at 9:00 a.m., LVN A said she was not aware Resident #1 had dental pain while eating. She said staff were to assess residents for pain every shift and document assessment results on the pain flow sheet on the MAR. Resident #1's October and November 2010 MARs reflected no pain assessments. An RD note dated 10/11/10 indicated the following: "Spoke with resident in her room at lunch time today 10/11/10. She reports some chewing problems R/T mouth pain, which has resulted in decreased PO intake. The resident reports she recently had two teeth pulled. She reports mouth pain only when she chews. The resident feeds herself and reports a good appetite. Review of weight records shows weight loss of 8 pounds in one month which is related to her decreased PO intake secondary to poor dentition and mouth pain. The resident does not want any changes made to meal. Per staff the resident refuses supplements." A nursing note dated 10/20/10 at 10:00 a.m. indicated Resident #1 continued to have a decrease in appetite. The resident said she did not want food because her teeth hurt when she ate. "My teeth won't let me eat most of it." The nurse note indicated the resident's daughter had scheduled a dentist appointment for the resident. In an interview on 11/15/10 at 8:15 a.m., the resident said all her teeth had been pulled and she could now eat without pain. The CMS 672 dated 11/9/10 noted a census of 42 residents. During the exit conference, the facility was given opportunity to provide additional information. None was provided.

Based on observation, interview and record review, the facility failed to ensure 1 of 9 residents sampled for dental services was provided assistance in obtaining prompt dental care (Resident #1). Resident #1 complained of dental pain when she tried to eat. The resident reported to the RD on 10/11/10 she had dental pain when eating and to the nurse on 10/20/10. This failure contributed to Resident #1's unresolved dental pain and a delay in Resident #1 receiving dental treatment. This failure could place the facility census of 42 at risk for mouth pain and delay in dental treatment. Findings Included: Resident #1 was an [AGE] year old female with [DIAGNOSES REDACTED]. Resident #1's care plan dated 8/20/10 indicated the facility was to monitor for non-verbal pain related to recent decline in level of consciousness. Resident #1's MDS with an assessment reference date of 8/27/10 indicated she was [AGE] years old and had short and long term memory problems. Her cognitive skills for daily decision making were moderately impaired. She usually made herself understood and usually understood verbal information. She required set-up supervision to eat and drink. In an observation and interview with the ADON on 11/9/10 at 8:25 a.m., Resident #1 said her teeth hurt when she tried to eat and that was why she had lost weight. The resident's bottom teeth protruded outward toward her lip. The ADON said she was not aware the resident's teeth hurt when she ate. During an interview on 11/9/10 at 9:00 a.m., LVN A said she was not aware Resident #1 had dental pain while eating. She said staff were to assess residents for pain every shift and document assessment results on the pain flow sheet on the MAR. Resident #1's October and November 2010 MARs reflected no pain assessments. An RD note dated 10/11/10 indicated the following: "Spoke with resident in her room at lunch time today 10/11/10. She reports some chewing problems R/T mouth pain, which has resulted in decreased PO intake. The resident reports she recently had two teeth pulled. She reports mouth pain only when she chews. The resident feeds herself and reports a good appetite. Review of weight records shows weight loss of 8 pounds in one month which is related to her decreased PO intake secondary to poor dentition and mouth pain. The resident does not want any changes made to meal. Per staff the resident refuses supplements." A nursing note dated 10/20/10 at 10:00 a.m. indicated Resident #1 continued to have a decrease in appetite. The resident said she did not want food because her teeth hurt when she ate. "My teeth won't let me eat most of it." The nurse note indicated the resident's daughter had scheduled a dentist appointment for the resident. A nursing notes dated 10:25 at 9:00 a.m. noted Resident #1's dental appointment scheduled for 10/25/10 had to be rescheduled. During an interview on 11/9/10 at 9:45 a.m. with the social worker and the administrator, the social worker said Resident #1's daughter made a 10/25/10 dental appointment for Resident #1 but did not request a check until the day of the appointment. The administrator said the facility needed a 24 hour written notice to obtain money from the resident's trust fund; therefore, the daughter rescheduled the dental appointment for 10/27/10. The administrator said both vans were in the shop on 10/27/10 so the appointment was rescheduled for 11/9/10. The social worker said she was not aware the resident was having dental pain. In an interview on 11/15/10 at 8:15 a.m., the resident said all her teeth had been pulled and she could now eat without pain. The CMS 672 dated 11/9/10 noted a census of 42 residents. During the exit conference, the facility was given opportunity to provide additional information. None was provided.