Every finding on record at Focused Care at Pasadena

Based on interview and record review, the facility failed to ensure the assessment accurately reflected the resident status for 1 (Resident #1) of 8 residents reviewed for accuracy of assessments. The facility failed to ensure Resident #1 was coded on his Quarterly MDS assessment dated [DATE] for having verbal behavioral symptoms directed toward others.This failure could place residents at risk of inadequate care and services necessary for their physical, mental, and psychosocial well-being. The findings included:Record review of Resident #1 revealed an [AGE] year-old male originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 diagnoses included Hemiplegia and Hemiparesis following cerebral infarction affecting left non-dominant side (a medical condition where a patient experiences complete paralysis or weakness on one side of the body because of a cerebral infarction, commonly known as a stroke, affecting the non-dominant hemisphere of the brain), cognitive communication deficit (a condition where a person's ability to communicate effectively is compromised by an underlying impairment in mental processes, rather than a primary problem with language or speech), and Vascular Dementia (a type of brain problem caused by reduced blood flow, which damages brain cells and affects memory, thinking, and daily life). Record review of Resident #1's Quarterly MDS assessment revealed the following:* Section C-Cognitive Patterns dated 6/18/2026 revealed a BIMS score of 10 which indicated moderate cognitive impairment. * Section E- Behavior dated 6/18/2026 revealed Resident #1 was coded as 0 for Verbal behavior symptoms directed towards others (threatening others, screaming at others, cursing at others which indicated those behaviors were not exhibited.Record review of Resident #1's Comprehensive Care Plan did not reflect a focus of verbal aggression. Record review of Resident #1's progress notes revealed a nurses note dated 6/16/2026 by LVN A which stated Resident #1 called her a b***h while she rendered care.During an interview on 7/8/2026 at 12:30 p.m., LVN A stated she worked for the facility for four years. LVN A stated she was familiar with Resident #1 and had cared for him multiple times. LVN A stated that Resident #1 was very vocal about his likes and dislikes and had used profanity before when she cared for him. LVN A states she had documented Resident #1's verbal aggression. LVN A stated she was not involved with completing MDS assessments. During an interview on 7/8/2026 at 1:50 p.m., the ADON stated she worked at the facility 9 months. The ADON stated that Resident #1 can be verbally aggressive and cuss a lot. The ADON stated she was not involved with completing Section E - Behavior for Resident #1. The ADON stated the MDS nurse was responsible for that area. The ADON states she signed off the MDS assessment showing completion. The ADON stated that the risk of incorrect MDS coding assessment was possible inadequate care and care plans.During an interview on 7/9/2026 at 10:13 a.m., the MDS Nurse stated she worked at the facility intermittently for 3 years. The MDS Nurse stated the progress note written by LVN A on 6/16/2026 would be consistent with behavioral symptoms. The MDS nurse stated that behavioral symptoms were an area she was responsible for completing. The MDS nurse stated Resident #1 had never shown behavioral symptoms in her presence. The MDS nurse stated that she missed the progress note written by LVN A. The MDS nurse stated that Resident #1 should have been coded correctly due to verbal aggressiveness which was documented. The MDS nurse stated that the failure occurred due to oversight on her part. The MDS nurse stated incorrectly coded MDS assessments put residents at risk for inadequate care plans. During an interview on 7/9/2026 at 11:00 a.m., the DON stated she worked at the facility for 9 months. The DON stated she was not responsible for completing MDS assessments. The DON stated she was responsible for the MDS assessments to be completed and submitted on time. The DON stated that incorrectly coded MDS assessments would not put residents in harm directly because staff would still care for the residents appropriately.Record review of facility policy titled MDS Completion Accuracy and Timeliness, effective 11/2023 and last revised on 11/15/2023 reads in part. each facility must follow most updated MDS RAI rules and regulations for completing accurately and timely.each facility must also utilize most updated Texas TAC rules for MDS accuracy. Record review of CMS's RAI Version 3.0 Manual Section E: Behavior Symptoms, dated October 2025, - Steps for Assessment reads in part.1. Review the resident's medical record for the 7 day look back period.

Based on observations, interviews, and record review the facility failed to review and revise the comprehensive care plan for 1 (Resident #2) of 8 residents whose care plans were reviewed for care plan revision. The facility failed to develop a comprehensive care plan with objectives and interventions to address Resident 2's refusal to reposition and failed to provide education to the family regarding positioning, resulting in a care plan that did not reflect the resident's current status or needs. This failure could place residents at risk for decreased quality of care and preventable injury. Record review of Resident #2's face sheet revealed a [AGE] year-old female originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #2's diagnoses included Cerebral Infarction (the most common type of stroke and occurs when a blood vessel in the brain becomes blocked cutting off oxygen supply to brain tissue), Cerebellar Stroke Syndrome (refers to a group of neurological symptoms resulting from a stroke in the cerebellum, the part of the brain responsible for coordination and balance), Type 2 Diabetes Mellitus (a chronic disease that is characterized by high levels of sugar in the blood), and Muscle Wasting and Atrophy (the loss or thinning of muscle mass and strength often caused by disuse, disease, or aging). Record review of Resident #2's MDS Quarterly assessment in Section C-Cognitive Patterns dated assessment dated [DATE] revealed a BIMS score of 7 which indicated severe cognitive impairment. Section GG -Functional abilities revealed Resident #2 was completely dependent on staff to move from sitting to a lying position, from lying to sitting on the side of the bed, and for transfers to and from a bed to a chair or a wheelchair. Section GG-Functional abilities also revealed that Resident #2 needed substantial/maximal assistance (a staff member would do more than half the effort) to be able to roll back and forth from left to right. Record review of Resident #2's current Comprehensive Care Plan revealed the following: Focus: Resident #2 is at risk for frequent infections, pressure/venous/stasis ulcers, vision, impairment, hyper/hypoglycemia, renal failure, cognitive/physical impairment/skin desensitized to pain or pressure related to diabetes mellitus/Peripheral neuropathy. Date initiated 10/12/2020, revision on 11/18/2024. Goal: Resident #2 risk for complications related to DM will be minimized daily and ongoing thru the next review date. Date initiated 2/19/2025, revision on 6/10/2026, target date 9/8/2026.Interventions: Check all body for breaks in skin and treat promptly as ordered by doctor. Resident #2 has current skin concerns: edema. 9/17/2025 Right food edema. Date initiated 7/16/2024, revision 10/7/2025. Goal: Resident #2 areas will resolve without complications within the review date. Date initiated 2/19/2025, revision on 6/10/2026, target date 9/8/2026. Interventions: Assess skin weekly and record findings in clinical record.During an observation on 7/7/2026 at 9:26 a.m., Resident #2 was lying down in her bed on her back with the head of her bed raised at a 45-degree angle. Resident #2 stated she had not gotten out of bed yet and had stayed in her bed all night. Resident #2 stated she ate breakfast in bed. During an observation on 7/7/2026 at 11:52 a.m., Resident #2 was lying down in bed on her back with the head of her bed raised at a 45-degree angle. Resident #2 stated she had not gotten out of bed since the surveyor saw her earlier that morning. Resident #2 stated she stayed in bed because if she got out of bed the staff left her out of bed for too long. Resident #2 stated that was why she chose to stay in bed consistently. Resident #2 stated she was unsure what could happen to her if she stayed in bed and in the same position for too long. Resident #2 stated to call FM G because she might know what could happen. Resident #2 stated staff did not offer to help her get out of bed today. During an observation on 7/7/2026 at 3:48 p.m., Resident #2 was lying down in her bed in the same position she was in at 9:26 a.m. and at 11:52 a.m. Resident #2 stated she had eaten lunch in her bed and was now watching TV. Resident #2 stated she had not been out of bed so far that day. During an observation on 7/8/2026 at 8:10 a.m., Resident #2 was being assisted to eat while seated in her bed with the head of bed at 90-degrees. Resident #2 stated that she had not gotten out of bed today and had stayed in her bed all night. During an observation on 7/8/2026 at 10:45 a.m., Resident #2 was lying down on her back in her bed at a 45-dgree angle while she watched TV. During an observation on 7/9/2026 at 9:56 a.m., Resident #2 was lying on her back in her bed at a 45-degree angle and had her eyes closed. During an interview on 7/7/2026 at 12:00 p.m., LVN C stated she had worked for the facility for one year. LVN C stated she was Resident#2's assigned nurse. LVN C stated that Resident #2 did not like to get out of bed. LVN C stated that Resident #2 preferred to lay on her back. LVN C stated that was Resident#2's right to stay in the position that Resident #2 wanted to. LVN C stated that Resident #2 and family had been educated about staying in bed and risks associated with. LVN C could not provide documentation education had been performed. LVN C stated that CNA's usually do not tell her if Resident #2 would not get out of bed because that is consistent behavior for Resident #2. LVN C stated the risk to residents who prefer to stay in one position and do not know the risks associated with it could lead to skin breakdown. During an interview on 7/7/2026 at 11:34 a.m., CNA B stated she had worked at the facility for 2 months. CNA B stated she had cared for Resident #2. CNA B stated Resident #2 did not like to get out of her bed or turned. CNA B stated she notified the nurse on duty when Resident #2 would refuse. CNA B stated she had been trained CNA B stated the risk to residents of not getting out of bed nor changing positions was skin breakdown. During an interview on 7/8/2026 at 11:43 a.m., CNA E stated she had worked at the facility for almost one year. CNA E stated she cared for Resident #2 on 7/7/2026 and 7/8/2026. CNA E stated Resident 2 did not get out of bed during her shift yesterday on 7/7/2026. CNA E stated she worked 6:00 am to 2:00 pm on 7/7/2026. CNA E stated that Resident #2 did not like to shift her weight when she would try to place pillows under Resident #2's buttocks. CNA E stated she did not notify the nurse because the assigned nurse was working in another hallway. CNA E stated she could not force Resident #2 to get out of bed or reposition because that was when Resident rights came into the picture. CNA E stated she was sure the Resident #2's family was aware of Resident #2's refusal to move. CNA E stated the risk to residents of not being educated on the dangers of not repositioning were pressure ulcers. During an interview on 7/8/2026 at 12:30 p.m., LVN A stated she worked at the facility for 4 years. LVN A stated she was familiar with Resident #2. LVN A stated that Resident #2 was not very sociable and liked to stay in bed in the same position. LVN A stated a care conference was done about Resident #2 not getting out of bed and not wanting to be repositioned, but it was care planned. LVN A stated that the risk to residents who stay in the same position and are not aware of the dangers associated with such are skin breakdown. During an interview on 7/8/2026 at 1:50 pm, the ADON stated she had worked at facility since October 2025. The ADON stated that Resident #2 liked to stay in bed and did not like to move. The ADON stated that the family had been notified and education had been given. The ADON stated Resident #2's preference and education had been care planned. The ADON was unable to locate the documentation. The ADON stated Resident #2's preference to stay in bed and refusal of getting out of bed or reposition should be care planned. The ADON stated the risk to residents of not repositioning and not being educated on the dangers of such were pulmonary embolisms, deep vein thrombosis, and death. During an interview on 7/8/2026 at 3:02 p.m., the DON stated she had worked at the facility since October 2025. The DON stated Resident #2 liked to stay in bed. The DON stated the staff could not force her to get up. The DON stated the staff do not stop encouraging Resident #2 to get out of bed. The DON stated after a few days of a resident not wanting to get out of bed, the family should be notified. The DON stated Resident #2 showed a consistent pattern of not getting out of bed. The DON questioned if the facility was expected to care plan resident preferences and did not state Resident #2's consistent pattern of not getting out of bed should had been care planned. During an interview on 7/8/2026 at 6:24 p.m., FM G stated that Resident#2 told her she did not like to get out of bed because the staff took too long in returning into bed. FM G stated that she did not think that Resident #2 would never get out of bed for days but understood Resident #2 preferred to stay in bed. FM G stated that the facility had not educated her on all the risks associated with staying in bed and not repositioning. During an interview on 7/9/2026 at 11:29 a.m., the Administrator stated Resident #2 had shown a pattern of care and resident preference of staying in bed and not repositioning. The Administrator was not in Resident #2's care plan. The Administrator stated the risk to the resident of not repositioning and not being educated on the dangers associated with it included skin breakdown and ADL decline. Record review of facility policy titled Comprehensive Care Plan, effective 1/20/2021 and revised 4/25/2021, reads in part.The Care Plan is revised every quarter, significant change of condition, Annual or as the resident condition changes on an individualized basis.

Based on interview and record review the facility failed to ensure residents received medications that were free of significant medication errors for 2 of 5 residents (Resident #1 and #2) reviewed for medications. -The facility failed to ensure that Resident #1's blood pressure medication Metoprolol was held when the blood pressure was low.-The facility failed to ensure Resident #2 blood pressure medication Midodrine was held when the blood pressure was out of the parameter it should be held. These failures could place residents with high or low blood pressure at risk of fainting or stroke due to not getting their blood pressure medication as ordered by their physician. Record review of Resident #1's admission face sheet dated 3/17/2026 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included cerebral infarction (a condition were the blood flow to part of the brain is blocked), peripheral vascular disease(a condition which narrowed arteries reduce blood flow to the arms and legs), hypertension (high blood pressure), heart failure (a condition where the heart muscle doesn't pump blood as well as it should), chronic kidney disease (progressive loss of kidney function to remove waste from the blood), atrial fibrillation (irregular heart rhythm), chronic embolism/thrombosis (blood clot in a deep vein) and chronic obstructive pulmonary disease((lungs and airway disease that restrict breathing). Record review of Resident #1 quarterly MDS dated [DATE] Section C:500 revealed a BIMS score of 15 indicating the resident was cognitively aware. Record review of Resident #1's physician's order dated 9/8/2025 revealed Metoprolol Tartrate oral tablet 25 mg. Give 1 tablet by mouth to times a day for hypertension. Hold if SBP<110 or DBP<60 or heart rate <60. Record review of Resident #1's MAR for March 2026 revealed Metoprolol 25mg was not documented as held on 3/9/2026 when Resident #1 blood pressure was 106/70. There was no number coded on 3/9/2026 indicating whether the resident had refused or the, or Resident #1 was not in the facility. Resident #2 Record review of Resident #2's admission face sheet revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included depression (a mood disorder that that causes persistence loss of interest), anemia (a condition where there is not enough healthy red blood cells), hyperlipidemia (high levels of fat in the blood), cerebral infarction (a condition were the blood flow to part of the brain is blocked), hypotension (low blood pressure), acute respiratory failure (a condition where there is insufficient oxygen in the body), and type 2 diabetes (high blood sugar). Record review of Resident #2's quarterly MDS dated [DATE] Section C:500 revealed a BIMS score of 09 indicating the resident was moderately cognitively impaired for decision making. Record review of Resident #2's physician's order dated 2/27/2026 revealed Midodrine HCL oral tablet 10 mg. Give 1 tablet by mouth three times a day. Hold if SBP is greater than 120 or heart rate is greater than 60. Record review of Resident #2's MAR for March 2026 revealed Midodrine 10 mg was not documented as held on 3/2/2026 when the blood pressure was 137/73 and heart rate was 75 and on 3/3/2026 when the blood pressure was 133/63 and heart rate was 78 at 9:00 pm and on 3/5/2026 at 3:00pm when the blood pressure was 124/76 and the heart rate was 85.In an interview on 3/18/2026 at 4:05 pm with LVN B she said if residents refused their medications, it should be reported to the nurse, and the nurse should notify the physician. She said there should be no blanks on the MARs. She said blanks on the MARs was an indication the medications were not given. She said if residents refused their medications, it should be documented on their MARs. She said if the blood pressure was high and midodrine was given it would get higher and that could cause a stroke. She said if it's too low and Midodrine was not given it could cause the residents to faint and fall. She said if Metoprolol was given when the blood pressure was low it would cause the blood pressure to get lower and could cause the resident to get dizzy and fall. In an interview with Med Aide C on 3/18/2026 at 6:09 pm she said all medications should be signed when they were given. She said if the resident refused the medication, it should also be documented as refused, or resident not in the building. If it's blood pressure medication and it's out of parameter, the doctor ordered the medication should also be documented as not with the parameter. She said blanks on the MARs would be a medication error. She said there should be no blanks on the MARs. She said in the case of Midodrine if it's too high and the medication was given it could cause the resident to have headache or get a stroke, if the blood pressure was low and the medication was not given it could cause the resident to faint and fall. She said it Metoprolol was not held when the blood pressure was low it could cause the blood pressure to drop lower and could cause the resident to get dizzy and fall. In an interview on 3/18/2026 at 6:52 pm with LVN C she said if medications were given or not given, they should be documented. She said if it was not documented it was not done. She said there should be no blanks on the MARs. She said blanks on the MARs could be an indication that the medications were not given. She said if the blood pressure was low and Midodrine was not given the resident could pass out and it's too high and Midodrine was given the blood pressure would get higher, and it could result in a stroke. She said if Metoprolol was not held when the blood pressure was low, the blood pressure would get lower and could cause the resident to get dizzy and faint. In an interview on 3/18/2026 at 7:00 pm with LVN D he said if medications were given or not given, they should be documented. He said if it was not documented it was not done. He said there should be no blanks on the MARs. Blanks on the MARs was an indication that the medication was not given. He said if the blood pressure was low and Midodrine was not given the resident could pass out and if it was too high and Midodrine was given the blood pressure would get higher, and it could result in a stroke. He said in if Metoprolol was too low and the medication was not given it would cause the blood pressure to get lower and the resident passed out. In an interview on 3/18/2026 at 7:05 pm with the DON she said there should be no blanks on the MAR. She said the Nurses should follow the physician's order. She said if blood pressure medications were not given as ordered, the blood pressure could get too high or too low. She said when medications were given it should be documented. She said if it's not documented it was not done. She said she was going to in-service the staff on documentation and following physician's orders.Record review of the facility's policies and procedure title Charting and Documentation dated July 2017 read in part. Policy Statement All services provided to the resident progress towards care plan goal or any changes in the resident's medical, physical, functional or psychosocial condition and shall be documented in the residents' medical records. 7. Documentation of procedures and treatment specific details includinge. Whether the residents refused the procedure/treatment.g. The signature and title of the individual documenting.

Based on interview and record review the facility failed to maintain medical records on each resident that are complete and accurately documented for 1 (Resident #2) of 5 residents reviewed for medical records. The facility failed to maintain a complete and accurate MAR for Resident #2. This failure could place residents at risk of an incomplete medical record and possibly not being given medication and treatment as ordered by their physician. Record review of Resident #2's admission face sheet dated 3/18/2026 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included anemia (a condition where the blood does not have adequate healthy blood cells), depression (mood disorder that causes a persistent feelings of sadness and loss), hyperlipidemia (high levels of fat in the blood), cerebral infarction (a condition were the blood flow to part of the brain is blocked), hypotension (low blood pressure), acute respiratory failure (a condition where there is insufficient oxygen in the body) and type 2 diabetes (high blood sugar). Record review of Resident #2's quarterly MDS dated [DATE] Section C:500 revealed a BIMS score of 09 indicating the resident was moderately cognitively impaired for decision making. Record review of Resident #2's physician's order dated 2/27/2026 revealed Midodrine HCL oral tablet 10 mg. Give 1 tablet by mouth three times a day. Hold if SBP is greater than 120 or heart rate is greater than 60. Record review of Resident #2's MAR dated March 2026 revealed Midodrine HCL oral tablet 10 mg. Give 1 tablet by mouth three times a day. Hold if SBP is greater than 120 or heart rate is greater than 60. The blood pressure, and pulse were not documented as given on 3/12/2026 at 9:00pm. That section of the MAR was blank. In an interview on 3/18/2026 at 4:05 pm with LVN B she said if a resident refused their medication, it should be reported to the nurse, and the nurse should notify the physician. She said there should be no blanks on the MARS. She said blanks on the MAR indicate that the medication was not given. She said if the resident refused his/her medications it should be documented on the MAR. In an interview with Med Aide C on 3/18/2026 at 6:09 pm she said all medications should be signed when they were given. She said if the resident refused the medication, it should also be documented as refused, or resident not in the building. She said blanks on the MAR could be a medication error. She said there should be no blanks on the MAR. In an interview on 3/18/2026 at 6:62 pm with LVN C she said if medications were given or not given, they should be documented. She said if it was not documented it was not done. She said there should be no blanks on the MAR, blanks on the MAR were an indication that the medications were not given. In an interview on 3/18/2026 at 7:00 pm with LVN D he said if medications were given or not given, they should be documented. He said if it was not documented it was not done. He said there should be no blanks on the MAR, because it could be an indication that the medication was not given. In an interview on 3/18/2026 at 7:05 pm with the DON she said there should be no blanks on the MAR. She said the Nurses should follow the physician's order. She said when medications were given it should be documented if it's not documented it was not done. She said she was going to in-service the staff on documentation and following physician's orders. Record review of the facility's policies and procedure title Charting and Documentation , dated July 2017 red in part. Policy Statement All services provided to the resident progress towards care plan goal or any changes in the resident's medical, physical, functional or psychosocial condition and shall be documented in the residents' medical records. al records. al records. al records. al records. al records. al records. 3. Documentation in the medical record will be objective (cannot be opinionated or speculative) complete and accurate.7. Documentation of procedures and treatment specific details includinge. Whether the resident refused the procedure/treatment.g. The signature and title of the individual documenting.

Based on observation, records review and interview, the facility failed to conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity for 5 (Resident # 2 #10, #11, 21, and #52) of 18 residents reviewed for accuracy of assessments. The facility failed to ensure Resident # 2's MDS assessment accurately reflected discontinuation of G-tube and falls. The facility failed to ensure Resident #10's quarterly MDS assessments accurately reflected her impairment to her upper extremity on one side. Resident #11's annual comprehensive MDS assessment did not reflect his lack of natural teeth in his oral cavity. Resident #21's comprehensive significant change MDS assessment did not reflect his use of upper denture. Resident #52's significant change comprehensive MDS assessment did not reflect his lack of natural teeth in his oral cavity. These failures could place residents at risk of receiving inadequate care and services due to inaccurate assessments. The findings included: Resident #10 Record review of Resident #10's admission record dated 02/12/2026 revealed the resident was a [AGE] year old female who admitted to the facility on [DATE] and readmitted to the facility on [DATE] with the diagnoses including hemiplegia (paralysis) and hemiparesis (weakness) of the left side, seizures (sudden uncontrolled surge of abnormal electrical activity in the brain that causes temporary changes in behavior, movement, sensation or consciousness), left shoulder pain, and fracture of shaft of left fibula (a break in the midsection of the calf bone). Record review of Resident #10's Quarterly MDS dated [DATE] that was modified on 02/13/2026 revealed she had a BIMS score of 6 out of 15 indicating severe cognitive impairment and she was coded in section GG for Functional Abilities as having an impairment of her upper extremities on one side. Record review of Resident #10's Quarterly MDS dated [DATE] modified 02/13//2026 revealed she had a BIMS score of 7 out of 15 indicating severe cognitive impairment and she was coded in section GG for Functional Abilities as having an impairment of her upper extremities on one side. Observation and interview on 02/10/2026 at 09:57 am of Resident #10 lying in bed appropriately dressed and groomed, in her room with her left arm at the elbow bent upward toward her chest and her left ankle positioned inward. The resident was awake, alert, and oriented to person, and place and said she sometimes participated in therapy or exercises and did not seem to understand what a splint was. Resident #10 said she broke her left leg before, and her ankle had been positioned that way since. Resident #10 said and showed surveyor that she could move her arm but could not bend her left arm straight. Resident #10 said she had no pain at that time in her body and had no care concerns. Resident #11Review of Resident #11's face sheet, printed on 02\11\26, reflected an [AGE] year-old male who was originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included Essential hypertension (primary diagnoses), overactive bladder, type 2 diabetes mellitus (high blood sugar, insulin resistance, and relative lack of insulin), benign prostatic hyperplasia (also known as enlarged prostate), congestive heart diseases, shortness of breath, difficulty in walking, major depressive disorder, and vascular dementia. Record review of Resident # 11's comprehensive annual MDS dated [DATE] revealed his BIMS score was 12 out of 15 which indicated moderate impairment on cognition. Record review of section on oral dental L indicated he was assessed as having obvious or likely cavities or broken natural teeth in his oral cavity. Record review of Resident #11's care plan with a revision date of 11/24/25 revealed Resident #11 was care planned as at risk for altered oral/dental health problems r/t obvious or likely cavity or broken natural teeth. Observation and interview on 02/10/26 at 12:40 PM, revealed Resident # 11 was in bed during an interview, he said was doing fine. His lunch was on his bedside table untouched. He said he had his dentures and they were in his nightstand. He said he does not wear them because they don't fit right.Observation revealed his meal was a mechanically altered diet. He said he did not like what was served and was not hungry. He requested pudding which was provided. Resident #21Review of Resident #21's face sheet, dated 02\11\26, reflected a [AGE] year-old male who was originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included Dementia, schizoaffective disorder, psychotic disturbance, mood disturbance, essential hypertension, type 2 diabetes mellitus, congestive heart diseases, shortness of breath, difficulty in walking, muscle weakness, major depressive disorder, convulsion, and anemia Record review of Resident # 21's comprehensive Significant Change MDS dated [DATE] revealed his BIMS score was 8 out of 15 which indicated moderate impairment in cognition. Record review of Resident #21's care plan with a revision date of 12/31/25 revealed Resident #21 was care planned for falls as Resident #21 had an actual fall on 08/31/25 - Witnessed fall no injuries, 11/07/25 - Unwitnessed fall, no injuries, 12/16/25 - Unwitnessed fall, no injuries,12/25/25 - Witnessed Fall, no injuries. Date Initiated: 01/10/2025. Revision on: 12/29/2025. Goal: Resident #21 will be free from preventable falls through review date. Date initiated: 01/13/2025. Revision on: 12/31/2025. Target Date: 04/04/2026 Record review of Resident # 21's quarterly MDS assessment dated [DATE] revealed his BIMS score was 03 out of 15 which indicated severely impaired cognition.Record review of section on Fall History (section L) indicated section on fall history was left blank. Record review of Resident # 21's quarterly MDS assessment dated [DATE] revealed his BIMS score was 10 out of 15 which indicated moderate impaired cognition.Record review of section on Fall History (section L) indicated section on fall history was left blank. Resident #52 Review of Resident #52's face sheet, printed on 02/12/26, reflected a [AGE] year-old male who was originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included dementia, psychotic disturbance, mood disturbance, anxiety, depression, schizoaffective disorder, bipolar disorder, benign prostatic hyperplasia, chronic pain, hypothyroidism, malignant neoplasm ( also known as enlarged prostate) muscle weakness, lack of coordination, unsteadiness on feet, difficulty in walking, type 2 diabetes mellitus ((high blood sugar, insulin resistance, and relative lack of insulin), and seizures. Record review of Resident # 52's comprehensive Significant Change MDS assessment dated [DATE] revealed his BIMS score was 15 out of 15 which indicated intact cognition.Record review of section on Fall History (section L) indicated section on fall history was left blank. Record review of Resident # 52's annual comprehensive MDS assessment dated [DATE] revealed his BIMS score was 15 out of 15 which indicated intact cognition.Record review of section on Fall History (section L) indicated section on fall history was left blank. Record review of Resident #52's care plan with revision date of 01/21/26 revealed Resident #52 was care planned for resident had an actual fall on 08/25/25 - witnessed fall, no injury, 09/13/25 - witnessed fall, no injury.09/15/25 - witnessed fall, no injury, 10/11/25 - witnessed fall, no injury, 01/19/25 - unwitnessed fall, minor injury, 01/15/26 - unwitnessed fall, no injury. Date Initiated:06/23/25 Revision on: 01/15/26Goal: Resident #52 will resume usual activities without further incident through the review date. Date initiated: 06/23/25 Revision on:01/21/26. Target Date: 04/13/26. Observation and interview on 01/10/26 at 11:10AM revealed Resident # 52 was in bed alert and oriented. Observation indicated he was on G-Tube feeding. He said he gets his feeding every 2-3 hours, and he was doing well. He said he used to have frequent falls resulted from being dizzy. He said he bumped his head on one occasion and had to be transported to the hospital and had a few stitches at the back of his head. He said he was getting better. In an interview with MDS nurse on 02/11/26 at 2:00PM, she looked at Resident #21 and #52's MDS and said it was an overlook on her side. She would do a modification on Resident #21 and 52's MDS. Interview with DOR on 02/12/2026 at 12:33 pm regarding Resident #10 who said Resident #10 was discharged from therapy services after receiving therapy services related to her left sided upper and lower body hemiplegia and hemiparesis from 09/17/2025 through 09/26/2025. The DOR said she conducted monthly contracture management screens and quarterly reviews of ADL significant change reports and Resident #10 was part of those reviews because she had limited ROM in her upper and lower extremities on her left side after a stroke. Record review on 02/12/2026 at 1:32pm of Resident #10's therapy discharge notes dated 09/26/2025 revealed she received therapy for left sided hemiplegia and limitations to her left upper and lower extremities. Interview on 02/12/2026 at 2:44PM, with MDS Nurse who when shown Resident #10's 09/03/2025 Q MDS section GG which reflected B. Lower extremity (hip, knee, ankle, foot) -no impairment, stated, that was my error, the resident has left sided impairments, and I just coded that wrong. When shown Resident #10's, Q MDS dated [DATE] section GG was also coded as B. Lower extremity (hip, knee, ankle, foot) -No impairments, the MDS Nurse said it was her error, and she must have mis-clicked the MDS option. The MDS Nurse said that Resident #10 had both one-sided upper and lower extremity impairments and that she would modify and update both MDS assessments. The MDS Nurse was not sure if the facility had a specific policy and procedure on MDS accuracy and said accuracy of the MDS assessments were important because that was how residents' needs were met. The MDS Nurse said she had been trained upon hire and in 2023 and was trained at a sister facility location during that time, by a regional person, who conducted a 2-week training for her specific to the MDS Nurse role. The MDS Nurse said she received updated training for her role as MDS based on updates to MDS processes. During a telephone interview with Regional MDS on 02/13/2026 at 1:21 pm he said he had been in his role for almost 1 year and was regional oversight for multiple buildings and completed MDS training with on-site MDS staff. Regional MDS said the training covered anything MDS related including MDS accuracy and care plans. Regional MDS said most meetings were virtual unless there was an identified issue then an on-site 1:1 in-service or training would be conducted. Regional MDS said they kept no copies of any in-services with staff, and the training was mostly conversations. Regional MDS said they were unaware of and had not identified through any audits any significant issues with accuracy of MDS assessments or care plans. The Regional MDS said the expectation would be that the MDS assessments and care plans would be accurate to ensure continuity of resident care. The Regional MDS said that although he had conducted audits, he had not conducted any specific audits on accuracy of assessments or care plans. The Regional MDS said that he had done training with the facility MDS Nurse, but the training had been virtual, and group related. Record review on 02/12/2026 at 4:12 pm of Resident #10's Quarterly MDS dated [DATE] and Quarterly MDS dated [DATE] revealed they had both been modified by the MDS Nurse and reflected in section GG Functional Limitation in Range of Motion.1. Impairment on one side. and was coded for impairment on one side for both upper and lower extremities. Resident # 2Record review of the face sheet for Resident # 2 revealed admission date 5/8/25, with diagnoses including cerebral infarction (lack of blood flow to the brain), dysphagia (trouble swallowing after stroke), tracheostomy (surgical opening in the neck to provide an alternate airway), Diabetes (high blood sugar from inadequate insulin secretion), seizures (sudden disruption of brain activity), hypertension (high blood pressure), and anxiety disorder (excessive worry or fear). Record review of the Quarterly MDS dated [DATE] revealed Resident # 2 was usually understood and usually understands, BIMS score of 12, indicating moderately impaired cognition, maximum staff assistance required for toileting, bathing and personal hygiene, and frequently incontinent of bowel and bladder, and presence of feeding tube while a resident. Observation and interview with Resident # 2 on 2/10/26 revealed she was in bed, resting, watching TV, and had a tracheostomy with clean dressing and tubing present. There was a suction machine and ambu bag on the dresser in the corner of the room. There was no feeding tube present. When asked how she was, she motioned to her trach and whispered she couldn't talk. She nodded her head as if to say ok. Interview with LVN C at 10:00am revealed Resident # 2 eats ate her own meals, and they monitor her eating. She said Resident # 2 used to have a feeding tube, but it was discontinued in December, and they were trying to wean her off the trach. She said she eats ate her meals on her own. Observation on 2/11/26 at 12:15pm revealed Resident # 2 was sitting on the side of her bed with her lunch tray on the bedside table. She was eating her meal with no assistance. Record review of Resident # 2's physician orders dated February 2026 revealed regular diet with regular liquids. Further record review of the care plan dated 6/5/25 revealed monitor and document intake and offer substitute if less than 50% was eaten. Record review of progress note dated 12/16/25 revealed Resident # 2's feeding tube was discontinued by physician order on 12/16/25. The feeding tube removal was not reflected in the 12/25/25 MDS. Record review of Resident # 2's quarterly MDS dated [DATE] revealed no falls since admission or prior assessment. Resident # 2 had a fall on 8/23/25, since the prior assessment on 8/15/25. The fall on 8/23/25 was not captured in the 9/24/25 MDS assessment. In an interview with MDS nurse on 2/13/25 at 10:18am, she said she wasn't sure if Resident #2's feeding tube fell out or if it was discontinued, but it should have been taken off the MDS. She also said Resident # 2's fall on 8/23/25 should have been coded on the 9/24/25 MDS. She said the risk of not having an accurate MDS assessment would be not having an accurate picture of the resident. In an interview with the DON on 2/13/25 at 10:20am, she said the MDS reflects the resident's condition, and the feeding tube removal and fall for Resident # 2 should be coded on the appropriate MDS. She said the risk of having an inaccurate assessment would affect the plan of care for the residents. Record review of facility's policy titled MDS Completion Accuracy and Timeliness, dated effective 11/2023 and revised 11/15/2023, revealed in part: 1. Each facility must follow most updated MDS RAI rules and regulations for completing each MDS accurately and timely. 2. Each Facility must also utilize most updated Texas TAC rules for MDS accuracy.

Based on interviews and record reviews, the facility failed to ensure all Pre-admission Screening and Resident Review (PASRR) Level II residents with mental illness were provided with an accurate PASRR Level I for II (Resident #21 and Resident #52) of 5 Residents reviewed for PASRR screening. -Resident #21 did not have an accurate and updated PASRR Level II assessment reflecting a diagnosis of mental illness. -Resident #52 did not have an accurate and updated PASRR Level II assessment reflecting a diagnosis of mental illness. These failures could place residents with mental illness at risk of not receiving a PASRR Evaluation for individualized care, or special services to meet their needs Findings included: Review of Resident #21's face sheet, dated 02/11/26, reflected a [AGE] year-old male who was originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses include schizoaffective disorder, psychotic disturbance, mood disturbance, major depressive disorder, essential hypertension, type 2 diabetes mellitus, congestive heart diseases, shortness of breath, difficulty in walking, muscle weakness, convulsions, and anemia. Record review of Resident #21's face sheet revealed the following diagnoses, schizoaffective disorder, psychotic disturbance, mood disturbance, major depressive disorder, were all present on admission. Record review of Resident #21's PASRR evaluation dated 11/19/24 revealed section 009 diagnoses of Dementia as primary diagnoses was checked no on all section of mental illness and IDD were checked no. Record review of Resident #21's significant change MDS assessment dated [DATE] revealed his BIMS score was 8 out of 15 indicated he was moderately impaired cognition. Section on Level II PASRR screening was left blank.Record review of section on psychiatric \/mood disorder, he was checked for schizophrenia Record review of Resident #21's care plan with a revision date of 12/31/25 revealed he was care planned for the use antidepressant medication r/t Depression. Record review of Resident #21's clinical records revealed no evidence of PASRR Level II evaluation. Resident #52 Review of Resident #52's face sheet, printed on 02/12/26, reflected a [AGE] year-old male who was originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included dementia, psychotic disturbance, mood disturbance, anxiety, depression, schizoaffective disorder, bipolar disorder, benign prostatic hyperplasia, chronic pain, hypothyroidism, malignant neoplasm ( also known as enlarged prostate) muscle weakness, lack of coordination, unsteadiness on feet, difficulty in walking, type 2 diabetes mellitus (high blood sugar, insulin resistance, and relative lack of insulin), and seizures., Record review of Resident # 52's comprehensive Significant Change MDS assessment dated [DATE] revealed his BIMS score was 15 out of 15 which indicated intact cognition. Record review of section 1 active diagnoses revealed he was checked for anxiety disorder, depression, bipolar disorder and schizophrenia. Record review of Resident #52's care plan with a revision date of 01/21/26 revealed he was care planned for impaired decision-making abilities, is not always understood or able to understand verbal and non-verbal expression Dementia, Schizoaffective disorder and bipolar disorder. Goal: Resident #52 will be able to communicate basic needs on a daily basis through the review date. Date initiated 01/07/26 revision date04/13/26. Record review of Resident #52's Clinical record revealed no evidence of PASRR I and level II evaluation. Observation and interview on 02/10/26 at 11:10AM revealed Resident # 52 were in bed alert and oriented. Observation indicated he was on G-Tube feeding. He said he gets his feeding every 2-3 hours, and he was doing well. During an interview with MDS coordinator on 02/12/26 at 2:00PM, she said she was responsible for ensuring that residents with MI, IDD and related diagnoses had PASRR Leve I assessments on admission and were referred to local authority for Level II evaluation. She said she would complete a 1012 form for Residents #21 and #52. During an interview with Facility DON on 02\13\26 at 8:45AM, she said all MDS assessment should accurately reflect resident's condition if not the care plan would be missed and may result in delayed services. She said reviewed the MDS assessments for completion and occasionally reviewed a few as time permitted. Telephone interview with Regional MDS on 02/13/2026 at 1:21 PM he said he had been in his role for almost 1 year and was regional oversight for multiple buildings and completed MDS training with on-site MDS staff. Regional MDS said the training covered anything MDS related including MDS accuracy and care plans. Regional MDS said most meetings were virtual unless there was an identified issue then an on-site 1:1 in-service or training would be conducted. Regional MDS said they kept no copies of any in-services with staff, and the training was mostly conversations. Regional MDS said they were unaware of and had not identified through any audits any significant issues with accuracy of MDS assessments or care plans. The Regional MDS said the expectation would be that the MDS assessments and care plans would be accurate to ensure continuity of resident care. The Regional MDS said that although he had conducted audits, he had not conducted any specific audits on accuracy of assessments or care plans. The Regional MDS said that he had done training with the facility MDS Nurse, but the training had been virtual, and group related. Policy on PASRR was requested from MDS Coordinator on 02/13/26 at 11:00AM but was not provided.

Based on observation, interview, and record review, the facility failed to ensure that it was free of a medication error rate below 5 percent (%) or greater. The facility had a medication error rate of 19.35% based on 6 out of 31 opportunities which involved 1 of 5 residents (Resident #19) and 1 of 3 staff (MA B) observed for medication administration errors.MA B administered Acetaminophen (a drug that is used to treat moderate pain and is a fever reducer), Amlodipine Besylate (a drug used to treated elevated blood pressure), Keppra (a drug used to treat seizures), Clobazam (a drug used to treat seizures), Pregabalin (a drug used for pain), and Cyclobenzaprine (a drug used for muscle pain) 2 hours and 52 minutes after the scheduled time to Resident #19 on 2/11/2026 at 10:53 am.These failures could place residents at risk of not receiving therapeutic effects of the medications and possible adverse reactions. The findings included: Record review of Resident #19's face sheet dated 2/12/2026 revealed an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included transient cerebral ischemic attack (a temporary blockage of blood flow to the brain that can cause symptoms similar to those of a stroke), epilepsy (a chronic neurological disorder that is characterized by recurrent seizures), essential hypertension (a type of high blood pressure that has no identifiable cause), rheumatoid arthritis (an autoimmune disease where the body's immune system mistakenly attacks its own tissues leading to inflammation in the joints potentially affecting other organs), and vascular dementia (a type of dementia caused by problems with blood flow to the brain). Record review of Resident #19's quarterly MDS, dated [DATE], revealed Resident #19 had a BIMS score of 13 indicating intact cognitive function. Record review of Resident #19's physician orders as of 2/11/2026 revealed the following: Tylenol oral tablet 325 mg (Acetaminophen) Give 650 mg by mouth two times a day for right leg pain. Amlodipine Besylate tablet 10 mg Give 1 tablet by mouth one time a day for elevated blood pressure; Hold if SBP <110 or DBP<60 HR 60. Keppra tablet 750 mg (levetiracetam) Give 2 tablets by mouth two times a day for seizures. Clobazam tablet 10 mg. Give 1 tablet by mouth one time a day for seizure. Lyrica oral capsule (Pregabalin) Give 1 capsule by mouth three times a day for pain. Cyclobenzaprine HCL tablet 5 mg Give 1 tablet by mouth three times a day for muscle pain. Record review of Resident #19's MAR on 2/11/2026 revealed the following: Acetaminophen (Tylenol) oral tablet 325 mg. Give 650 mg by mouth two times a day for right leg pain. Start date 8/18/2024. (Scheduled times listed on MAR were 7:00 am and 4:00 pm). Amlodipine Besylate tablet 10 mg. Give 1 tablet by mouth one-time a day for elevated blood pressure (hypertension). Start date 2/24/2025. Hold if SBP<110 or DBP <60 HR 60. (Scheduled time listed on MAR was 7:00 am). Keppra tablet 750 mg (levetiracetam). Give 2 tablets by mouth two times a day for seizures. Start date 8/18/2024. (Scheduled times listed on MAR were 7:00 am and 4:00 pm). Clobazam tablet 10 mg. Give 1 tablet by mouth once a day for seizure. Start date 8/7/2023. (Scheduled time listed on MAR was 7:00 am) Pregabalin 100 mg (Lyrica). Give 1 capsule by mouth three times a day for pain. Start date 2/23/2025. (Scheduled times listed on MAR were 7:00 am, 1:00 pm, and 7:00 pm). Cyclobenzaprine HCL tablet 5 mg. Give 1 tablet by mouth three times a day for muscle pain. Start date 4/15/2025. (Scheduled times listed on MAR were 7:00 am, 1:00 pm, and 7:00 pm) Observation of MA B on 2/11/2026 at 10:35 am revealed her standing in front of a medication cart in hall 100 near room [ROOM NUMBER]. MA B stated she was passing medications and agreed to be observed by surveyor. MA B then entered Resident #19's room and obtained the blood pressure and heart rate of Resident #19. Afterwards, MA B performed hand hygiene and began to gather Resident #19's medication and placed them in a clear medication cup. MA B administered doses of Acetaminophen, Amlodipine, Keppra, Clobazam, Pregabalin, and Cyclobenzaprine as listed on MAR at 10:53 am. Interview with MA B on 2/11/2026 at 3:05 pm regarding the reason she was 2 hours and 52 minutes late giving Resident #19 her 7:00 am medications, MA B stated it is because she is unable to be in two places at one time. MA B stated she was supposed to give medication to residents in hall 300 first, also known as the hospital hall. MA B stated that she has received training within the year on medication administration and the 5 rights. When asked if she had mentioned her inability to administer medication on time according to facility policy, MA B stated she had mentioned it to ADON as recently as that day. MA B stated she had not yet notified the nurse caring for the resident about the delayed administration but stated she normally would. MA B stated the risk of not administering medication at the correct time and within correct intervals could make residents become very sleepy and cause unsafe conditions for the residents. Interview with ADON on 2/11/2026 at 3:21 pm revealed that she was not told by MA B that she was unable to administer medications on time as ordered by physician. The ADON stated that she spot-checked in PCC to ensure residents have received their medications on time every morning. The ADON stated that residents residing in the 300 hall are considered more acute and receive their medication before residents that live in the 100 hall. The ADON stated that nurses and medication aides have one hour before and after scheduled administration time to administer medications. The ADON stated that medication administration times have been adjusted previously to ensure residents would receive their medication on time and to alleviate staff burden and distress. The ADON stated the risk of not receiving medication on time could lead to adverse side effects, delayed therapeutic responses. Interview with the DON on 2/11/2026 at approximately 3:45 pm revealed that she was not aware that MA B had administered Resident #19's medication 2 hours and 52 minutes late. The DON was interviewed while she was at MA B's medication cart and spoke directly to MA B and requested to view administration details screen on PCC. A copy of these specific administration details were requested from the DON, but the DON stated she was unable to do so. The DON stated the risk of not giving medication as ordered could lead to adverse health effects for residents. Interview with RN B on 2/12/2026 at 1:45 pm, she stated she was the nurse that oversaw the care for Resident #19 yesterday. RN B revealed that MA B did not tell her about the late administration of medication. RN B stated the expectation from medication aides was that they notify her if a resident refused medication, if a medication was held, or was going to be late. RN B stated she normally has no issues with medication aides administering medication late. Record review of facility policy titled Administration Procedures for All Medications with an effective date of 09-2018 and revised in 8-2-2020, states in part .at a minimum, review the 5 rights at each of the following steps of the medication administration.check the MAR/TAR for the order. Review of the TAC Title 26 Chapter 557 Rule 557.105, titled Allowable and Prohibited Practices of a Medication Aide, reads in part. A medication aide permitted under this chapter may not.#14. Neglect to administer appropriate medications, as prescribed, in a responsible manner.

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and time frames to meet a resident's medical, nursing, mental and psychosocial needs with the services that are to be furnished to attain or maintain the resident's highest practicable physical well-being for 1 of 18 residents (Resident #3) reviewed for care plans. The facility failed to ensure Resident #3's comprehensive care plan included information about her Spanish speaking status. This failure could place residents at risk of not receiving appropriate care and interventions to meet their needs. Findings included: Resident #3 Record review of Resident #3's admission Record dated 02/10/2026, revealed the resident was an [AGE] year-old female admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including chronic (persisting or recurring illness) peripheral venous insufficiency (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), dysphagia oropharyngeal phase (a swallowing disorder caused by difficulty transferring food from the mouth to the esophagus (the muscular tube that transports food and liquids from the pharynx (the throat) to the stomach and functions as a critical part of the upper digestive system), dementia (decline in mental abilities including memory, thinking, language and reasoning), gastrostomy status (clinical condition of having an artificial opening (stoma) in the stomach, usually with a feeding tube (G-tube) inserted directly through the abdominal wall), and mood disorder (mental health condition characterized by significant, long-term disruptions in emotional state, such as intense sadness (depression) or extreme highs (mania), Record review of Resident #3's Annual MDS dated [DATE] revealed in section A under Language, that her preferred language was coded as Spanish and was also coded as 1. Yes for the question Do you need or want an interpreter to communicate with a doctor or health care staff? Resident #3 was also coded as having a BIMS score of 7 out of 15 that indicated severe cognitive impairment. MDS also revealed in Section V CAA's and Care Planning Resident #3 was identified and coded for communication as a triggered care area and had a care planning decision dated 12/12/2025. Observation with Resident #3 on 02/10/2026 at 10:47 am who was Spanish speaking only. Observation of Spanish speaking signs posted above Resident #3's bed and observed direct care staff including ADON, DON and RN B using mobile device translator applications as needed to communicate with Resident #3. Record review on 02/13/2026 at 10:54 am of Resident #3's undated care plan revealed no care plan for language/communication and no information on her Spanish speaking status. Interview with MDS Nurse on 02/13/2026 at 10:56 am surveyor asked MDS Nurse if Resident #3 had been care planned for her Spanish speaking status and MDS Nurse replied, she should be. Surveyor requested copy of Resident #3's care plan. Record review on 02/13/2026 at 10:58 am of printed copy of Resident #3's undated care plan revealed the following: Focus date initiated 02/13/2026. Resident #3 has an interpretation need.Resident #3 will communicate via an interpreter.Her preferred language is Spanish.She has translation needs. (Interpreter: Spanish). Interview on 02/13/2026 at 11:14 am with MDS Nurse, Administrator and DON (Staff began coming for surveyor interviews in pairs). The MDS Nurse said that Resident #3 did not have a care plan for Spanish speaking or translator needs until surveyor requested a copy of the care plan on 02/13/2026. The MDS Nurse said that Resident #3 had always been Spanish speaking since her admission and readmission and usually required a translator. The MDS Nurse said Resident #3 should have had a communication/Spanish speaking care plan and it must have been an oversight on her part because she was responsible for annual and quarterly updates to resident care plans. The MDS Nurse said that if Resident #3 did not have a care plan for communication and language preferences or needs, it could affect her plan of care and lead to miscommunication. The DON and Administrator both said inaccurate care plans could lead to Resident #3 being unable to communicate her needs. The DON, Administrator and MDS Nurse all said that care planning was an IDT effort, and that the SW completed section B of the MDS Hearing, Speech and Vision. Interview on 02/13/2026 at 11:17 am with SW (with Administrator present), she said she completed sections B, C, D, E and Q of the MDS. When asked how the SW completed the assessments for Resident #3, the SW said she used a language line translator application on her mobile device to communicate with Resident #3 because she was Spanish speaking. The SW said she was not aware that Resident #3 did not have a Spanish speaking or communication need care plan. The SW said that she completed care plans for some of the residents as part of the IDT. The SW said that if Resident #3 did not have a Spanish speaking care plan, it could lead to staff not being able to communicate with Resident #3 about her needs. The Administrator then said, it could have the potential of miscommunication with Resident #3. Telephone interview with Regional MDS on 02/13/2026 at 1:21 pm he said he had been in his role for almost 1 year and was regional oversight for multiple buildings and completed MDS training with on-site MDS staff. Regional MDS said the training covered anything MDS related including MDS accuracy and care plans. Regional MDS said most meetings were virtual unless there was an identified issue then an on-site 1:1 in-service or training would be conducted. Regional MDS said they kept no copies of any in-services with staff, and the training was mostly conversations. Regional MDS said they were unaware of and had not identified through any audits any significant issues with accuracy of MDS assessments or care plans. The Regional MDS said the expectation would be that the MDS assessments and care plans would be accurate to ensure continuity of resident care. The Regional MDS said that although he had conducted audits, he had not conducted any specific audits on accuracy of assessments or care plans. The Regional MDS said that he had done training with the facility MDS Nurse, but the training had been virtual, and group related. Record review of facility's policy Comprehensive Care Plan dated as effective 01/20/2021 and revised 04/25/2021 revealed in part: Every resident will have an individualized interdisciplinary plan of care in place.The Interdisciplinary Team will continue to develop the plan in conjunction with the RAI (MDS 3.0) and CAA's.The care plan is revised every quarter, significant change of condition, Annual or as the resident condition changes on an individualized basis.The care plan process is an on-going review process.

Based on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 out of 2 staff (RN B) and 1 of 4 residents (Resident#4) reviewed for infection control. The facility failed to ensure RN B used PPE (Personal Protective Equipment) appropriately while providing care to Resident #4 who was on EBP (Enhanced Barrier Precautions). These failures could place residents at risk for cross contamination, infection and decline in health. Findings include: Resident #4 Record Review of Resident #4's admission record dated 02/10/2026, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including epilepsy (chronic noncommunicable neurological disorder characterized by recurrent, unprovoked seizures caused by sudden excessive electrical discharges in brain cells), dysphagia oropharyngeal phase (a swallowing disorder caused by difficulty transferring food from the mouth to the esophagus (the muscular tube that transports food and liquids from the pharynx (the throat) to the stomach and functions as a critical part of the upper digestive system), dysphagia pharyngoesophageal phase (a swallowing disorder of difficulty transferring food/liquid from the throat to the esophagus, characterized by symptoms like coughing, choking, nasal regurgitation and a sticking sensation in the throat), and cerebral infarction (a medical emergency condition caused by blocked blood flow to the brain, leading to tissue death). Record review of Resident's #4's Annual MDS dated [DATE] revealed a BIMS score of 7 out of 15 that indicated severe cognitive impairment. Record review of Resident #4's Order Summary Report dated 02/13/2026 revealed the following order for Jevity 1.5 at 58 ML/HR X 10 HRS.every evening shift for appetite/nutrition enteral feeding to start at 08:00 pm and stop at 06:00 am. The order dated 02/03/2026 was Active and had a start date of 02/03/2026 with no end or discontinued date. Record review of Resident #4's Order Summary Report dated 02/13/2026 revealed the following order for Jevity 1.5 bolus (a single dose of a drug or other medicinal preparation given all at once) 237 ML three times a day for supplement. The order dated 02/03/2026 was Active and had a start date of 02/03/2026 with no end or discontinued date. Record review of Resident #4's MAR printed 02/13/2026 revealed, Jevity 1.5 bolus 237 ML three times a day for supplement was documented as administered by RN B on 02/10/2026 at 8 am. Record review of facility staffing sheet dated 02/10/2026 on 02/13/2026 at 3:23pm revealed RN B worked on 02/10/2026 on the 6:00 am to 6:00 pm shift. Record review of PPE and General Orientation Checklist, which included Infection Control/Isolation Procedures in-services dated 01/29/2026, revealed RN B signed acknowledgement of both in-services. Observation on 02/10/2026 at 08:58 am of Resident #4's door of her room that was closed and had an EBP sign taped to the front of the door, which read: Stop.Enhanced Barrier Precautions.Providers and Staff Must Also: Wear gloves and a gown for the following High-Contact Resident Care Activities.Device care or use: feeding tube. Knocked on the door to maintain Resident #4's privacy and dignity to enter and was told to come in but informed by RN B there was patient care being performed. Observed RN B at bedside with enteral feeding plunger syringe connected to Resident #4's enteral feeding tube with milk-like substance inside the syringe. RN B was holding a carton labeled Jevity 1.5 and was 237 ML. RN B was not wearing a gown. When asked if Resident #4 was on EBP, RN B did not reply. Observation of Resident #4's gastrostomy tube site revealed a clean dry white split gauze dressing to site dated 2/10/26. Resident #4 was awake, alert, and oriented X 2-3. Resident #4 said the gastrostomy tube dressings were changed every overnight shift, and she did not know if staff always wore a gown or gloves when giving her feeding or handling her gastrostomy tube. RN B continued the bolus feeding to gravity until the carton was completed. While at the door RN B was asked again if Resident #4 was on EBP and RN B said she was not aware that Resident #4 was on EBP before surveyor asked about it. When surveyor pointed to EBP sign taped on Resident #4's door, RN B said she should have been aware that Resident #4 was on EBP and that she should have been wearing the appropriate PPE while giving Resident #4 her bolus feeding as ordered. RN B said she should have put on a gown. She said that she was new and had only been working at the facility since last week. She said there were a lot of new nurses and new CNAs. Interview and observation with RN B on 02/10/2026 at 10:12 am, RN B returned to Resident #4's bedside and donned and doffed PPE appropriately to administer Resident #4's pain medication. RN B said she should have been wearing PPE the first time she provided care to Resident #4 because Resident #4 had a gastrostomy tube and said she originally did not see the sign posted on Resident #4's room door. Interview on 02/10/2026 at 11:29 am with the Infection Preventionist who was also the ADON said she was the IP since October of 2025. The IP said that all staff were trained on infection control, which included TBP, EBP and contact isolation. The IP said RN B should have seen the EBP signs posted on Resident #4's room door and the supply of PPE at the bedside. The IP said she conducted the last infection control training earlier in the month of February and was responsible for helping to stock and restock PPE daily and posting signs for any transmission-based precautions. The IP said she did not know why RN B did not adhere to Resident #4's EBP status and said that anyone with a gastrostomy tube or indwelling catheter or tube, should have EBP's in place. The IP said RN B could spread or give Resident #4 an infection by providing care without using proper PPE. Interview on 02/10/2026 at 11:35 am with DON who said that all staff should and were expected to adhere to any EBP or TBP order for a resident and that the IP was responsible for ensuring the appropriate PPE and any precautions were set in place for the residents as ordered. The DON said she was not aware that RN B had been observed not using the appropriate PPE while providing care to Resident #4's gastrostomy tube site and said that RN B should have been wearing appropriate PPE as indicated for any resident on EBP's. She said that RN B's failure to donn appropriate PPE and adhere to Resident #4's EBP status could be the spread of infection. Follow up interview with RN B on 02/11/2026 at 1:27 pm said the risk to Resident #4 for her not using EBP could be the spread of infection, or it could cause Resident #4 to get an infection. RN B said she had been trained on ANE and infection control including EBP and TBP during orientation because there was a video about it. RN B said she had subsequently used EBP and appropriate PPE. Record review of facility policy Infection Control Enhanced Barrier Precautions dated Effective 04/01/2024 revealed in part: Enhanced Barrier Precautions (EBP) are a CDC guidance to reduce the transmission of multi-drug-resistant organisms (MDRO), in health care settings, including nursing homes. EBP require team members to wear a gown and gloves while performing high contact care activities with residents. who have indwelling medical device. 2. Determine if any of the following indwelling medical devices are in use: .g-tube.EBP will be implemented if. any of the invasive medical devices are present.

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 1 of 1 kitchen reviewed for dietary services, in that: 1. The facility failed to ensure that the grill above the oven was free of grease. 2. The facility failed to keep one of one commercial can opener in the kitchen clean. 3. The facility failed to label, and date left over food items stored in the walk-in cooler. 4. The facility failed to ensure that expired food items were not stored in the walk-in cooler. These failures could place residents at risk for food contamination and foodborne illness due to cross contamination. The findings included: Initial kitchen observation on [DATE] at 9:20AM revealed the following - one of one vent hood in the kitchen had grease dropping along the grill track. One of one commercial can opener in the kitchen had dark brown substances between the cutting blade and around the can opener's holder attached to the food preparation table. Observation of one of one walk in cooler revealed the following food items unlabeled and undated. All food items were identified by the Dietary Manager (DM) -Mixed fruits in a plastic container unlabeled and undated- -Mashed potatoes in a medium size bake pan dated used by [DATE]. -,d+[DATE] lbs. bags of shredded cabbage (coleslaw) in original container dated used by [DATE]. -Left over chicken Tuna dated used by [DATE]. -Shredded carrots dated used by [DATE]. During an interview with the Dietary Manager on [DATE] at 9:40AM, he said he expected all food items in the walk-in cooler, to be labeled and dated. He said he had just started working in the kitchen about 3 days ago. He said he would take out all the expired food products and have the oven grill cleaned. During an interview with the acting Administrator on [DATE] at 12:40 PM, she said the dietary department had all new staff and the Dietary Manager was new trying and he was cleaning the entire kitchen. Record review of the facility's policy dated 2001 revised 2017 entitled Food Receiving and storage. Policy statement read in part- Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation 1. Food Services, or other designated staff, will always maintain clean food storage areas. 2. When food is delivered to the facility it will be inspected for safe transport and quality before being accepted. 3. Foods that are prepared off site will only be accepted from institutions that are subject to federal, state, or local inspection. The food and nutrition services manager shall verify the latest approved inspection and monitor the food quality of the supplier. 8. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date) . 10. Refrigerated foods will be stored in such a way that promotes adequate air circulation around food storage containers. Refrigerators/walk-ins will not be overcrowded. 13. Uncooked and raw animal products and fish will be stored separately in drip-proof containers and below fruits, vegetables, and other ready-to-eat foods. and labeled with a use by date .

Based on interview, and record review, the facility failed to immediately consult with the physician and notify the resident representative when the resident experienced significant change in the resident's physical status (a deterioration in health status either life-threatening conditions or clinical complications) for 1 of 6 residents (Resident #5) reviewed for a change of condition, in that: -The facility failed to notify the doctor when there was a change of condition with Resident #5's urine which had turned purple. -On 9/30/2024, Resident #5 was diagnosed with a urinary tract infection. Resident #5's change of condition was recognized by the nurses at the facility, on 10/5/2024. Resident #5 was not given antibiotics to treat her UTI until 10/8/2024. She was not sent to the hospital until 10/9/2024. The doctor was never notified of her change of condition until 10/8/2024 and on 10/8/2024 she was diagnosed with purple urine syndrome (a rare condition that causes the urine collection bag to turn purple or blue due to a urinary tract infection (UTI) and long-term catheter use). This failure could affect residents with urinary catheters and other medical conditions and could place them at untimely interventions, exacerbated symptoms, and hospitalization . Findings included: Record review of Resident #5's face sheet revealed she was an [AGE] year-old female who was admitted into the facility on [DATE]. She was diagnosed on [DATE] with, chronic kidney disease (long standing disease of the kidneys leading to renal failure. The kidneys filter waste and excess fluid from the blood. As kidneys fail, waste builds up), cognitive communication deficit (difficulty with communication caused by a disruption in cognitive process), neuromuscular dysfunction of bladder (a condition that occurs when the nerves and muscles of the bladder don't work together properly), and type 2 diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). On 9/30/24 she was diagnosed with urinary tract infection. For about a month, the resident had been having blue and purple urine. Her change of condition had not been reported to the doctor until 10/8/24. On 10/8/2024 she was diagnosed with purple urine syndrome (a rare condition that causes the urine collection bag to turn purple or blue due to a urinary tract infection (UTI) and long-term catheter use). Record review of Resident #5's Comprehensive MDS dated [DATE] revealed she had a BIMs score of 0 out of 15 which indicated she was severely cognitively impaired. She required substantial/maximal assistance with eating and oral hygiene. Resident #5 was dependent for toileting hygiene, shower/bath self, upper body dressing, lower body dressing, and personal hygiene. She was dependent when needed to roll left and right and sit to lying. Resident #5 had an indwelling catheter. Record review of Resident #5's undated comprehensive care plan revealed the following, Toilet use: She is not toileted. Toilet use: She is totally dependent on (1-2) staff for incontinent care. Record review of Resident #5's base line care plan completed until 4/9/24 revealed the following, [Resident #5] Indwelling Foley Catheter and is at Risk for Increased Urinary Tract Infections: Pressure Ulcer sacral Urinary Catheter 20FR,10 CC. Diagnosis: Urinary Retention. Record review of Resident #5's Progress Notes dated 9/16/24 at 6:43 p.m., entered by the ADON, reflected in part, . Foley catheter noted not to be in place and urine was coming out, using aseptic technique, foley catheter replaced with 18fr, 10ml balloon. Resident tolerated procedure and shows no s/s of pain or discomfort at this time Record review of Resident #5's Progress Notes dated 9/29/24 at 11:48 p.m., entered by the LVN C, reflected in part, .16 French, 10cc balloon foley catheter inserted into the urethra without resistance, sterile technique maintained throughout the process, perineal area cleaned with antiseptic solution, new sterile gloves donned (to put on PPE properly to achieve the intended protection and minimize the risk of exposure), clear yellow urine noted in drainage bag, balloon inflated with 10cc of sterile water, catheter secured to thigh with securing tape, resident tolerated the procedure well, no signs of pain after the procedure noted, will continue to monitor urine output . Record review of Resident #5's Progress Notes dated 9/30/24 at 10:45 p.m., entered by the LVN D, reflected in part, .16 French, 10cc balloon foley catheter inserted into the urethra without resistance, sterile technique maintained throughout the process, perinea! area cleaned with antiseptic solution, new sterile gloves donned, clear yellow urine noted in drainage bag, balloon inflated with 10cc of sterile water, catheter secured to thigh with securing tape, resident tolerated the procedure well, no signs of pain after the procedure noted, will continue to monitor urine output . Record review of Resident #5's Order Summary dated 9/30/24 revealed she had a diagnosis of urinary tract infection. Record review of Resident #5's Progress Notes dated 10/05/24 at 12:40a.m., entered by RN A, reflected in part, .Per family request, resident will be sent out to the hospital. The U/A lab results were reviewed and concluded client is positive with Gram negative and positive bacterium. HCP was contacted by documenting nurse with most recent lab results. Requesting how to move forward. No response considering its late hours of the night. After reviewing family concerns of client having blood tinge fluid in her catheter and reviewing medical docs. This nurse is honoring the request of the client's family and sending Resident #5 out . Record review of Resident #5's Progress Notes dated 10/05/24 at 7:56 a.m., entered by the DON, reflected in part, .This writer was made aware that resident RP is requesting her to be send to the hospital and stated [Resident #5] has UTI, [Physician A] made aware and have orders for 0.9%ns @60ml/hr x 2L, Encourage po fluids. Rp called x 2 no response . Record review of Resident #5's Progress Notes dated 10/05/24 at 5:29 p.m., entered by RN C, reflected in part, . cancelled transportation to hospital per DON. resident alert foley bag exhibits about 10cc of urine. new order for normal saline for hydration 2000 ml per iv. 22g to left wrist patent and no s/s infection. continue to monitor. once started, urine began to flow from catheter dark red urine again. family wanted patient to go to hospital but now they are allowing [resident] to stay at the facility at this time . Record review of Resident #5's Progress Notes dated 10/8/24 at 7:15p.m., entered by RN D, reflected in part, .Doxycycline Monohydrate, Oral Capsule 100MG, give 1 capsule by mouth two times a day for Prophylaxis for 10 days . Record review of Resident #5's Order summary Report dated 10/8/24, reflected in part, .Doxycycline Monohydrate (used to treat a wide variety of bacterial infections, including those that cause acne), Oral Capsule 100MG, give 1 capsule by mouth two times a day for Prophylaxis for 10 days . Start date: 10/9/24. Record review of Resident #5's hospital records dated 10/10/24 on page 5/16, revealed, altered mental status, unspecified altered mental status type: 2/2 UTI, UTI (urinary tract infection due to urinary indwelling foley catheter (CMS/HCC) (HCC). Observation on 10/8/24 at 1:35p.m. with Resident #5, revealed her lying asleep in bed. She had a fluid IV bag that was almost empty. She was covered up with a blanket. RN B removed the cover from Resident #5's catheter bag and it revealed that her urine was purple. RN B said Resident #5's urine had been a purple color for the past three days. She said she was not sure if it was blood or not. Interview on 10/8/2024 at 2:21p.m. RN A said Resident #5 had a medical diagnosis of a urinary tract infection on 9/30/2024. On 4/9/2024 Resident #5 was initiated for the catheter. RN A said Resident #5 was care planned for dehydration on, 4/11/2024 7/17/2024, 10/5/2024 and 10/8/2024. She said Resident #5 was not drinking or eating very well. She said Resident #5's family provided a bottle of water for them to give to her. She said sometimes she would take it and sometimes she would not. She said Resident #5 had a change of condition with her urine on 10/5/2024 and it was GI related. Physician A was contacted and put in an order for an IV. Interview on 10/8/24 at 2:36p.m., the NP said he assumed Resident #5 had a catheter to help her wounds heal faster. He said he first saw Resident #5 when she arrived at the facility from the hospital, upon admission, she had a foley catheter. He most of the time, nurses were to change the catheter in 30 days or if there was a malfunction. He said if Resident #5's urine changed color, he would not be able to explain why it happened. He said he would monitor Resident #5. He said he did not see a purple color in the catheter. He said staff should have notified him if there was a change of condition with the resident. Interview on 10/8/2024 at 3:38p.m., the DON said she cancelled the transportation for the Resident #5 going to the hospital on 10/5/2024 because she was able to get Physician A to order IV fluids after he reviewed Resident #5's lab results. She said Physician A gave an order for 2 liters of IV fluid and that if Resident #5 was not drinking any fluids, then her urine was going to be dark. She said she first notified Physician A of the discoloration of dark, yellow urine on 10/5/2024. The DON said when Physician A sent the order for IV fluids, she contacted Resident #5's family and the family agreed to not send Resident #5 to the hospital as they had requested. The DON then said she was first notified about Resident #5 change of condition when a nurse told her about Physician A wanting to prescribe antibiotics for a UTI. She said it happened a week ago. Interview on 10/8/2024 at 3:35p.m., RN B said the first time she saw discoloration in Resident #5's urine was on 10/7/24. She said she had been working on Resident #5's hall for 3 months. She said she changed her catheter every month. She said she last changed her catheter a month ago and her urine was clear. She said Resident #5's UA came back negative. She said she communicated with the RP that her urine came back negative on 10/1/24. She showed documentation that the lab results revealed, UTI Panel: Enterococcus Faecalis- Gram-positive, Escherichia Coli- Gram-negative, and Proteus Mirabilis- Gram-negative. [Physician A] ordered Doxycycline Monohydrate Oral Capsule 100MG, give 1 capsule by mouth two times a day for prophylaxis UTI for 10 days. Interview on 10/8/24 at 3:48p.m., Physician A said he was first notified on 10/5/2024 about Resident #5's dark urine because she was not drinking enough water. He said if the lab was negative, they would normally start with a fluid and for Resident #5 started on Saturday, 10/5/2024. He said Resident #5 came into the facility with a Foley catheter. He said he had not seen Resident #5 in 3 weeks. He said he had been going off what the facility was telling him about Resident #5. He said he was scheduled to go to the facility on ce a week. He said he was on a monthly schedule to see the residents. He said a nurse at the facility should have informed him that Resident #5 needed to be seen. He said the nurse should have told NP A to see Resident #5 while he was at the facility. He said he had an order for fluids. He said he can give an order over the phone. Observation and interview on 10/8/2024 at 5:06p.m. with Resident #5, the DON, RN B and CNA A revealed Resident #5 lying awake in bed and could hardly speak. The DON grabbed the catheter bag and observed the purple urine. She said the color of the urine was a problem because Resident #5 could have an infection. She said the urine looked purple . CNA A said Resident #5's urine looked like a brownish purple color. She said the color of Resident #5's urine was not a normal color. She said yellow urine would be a normal color. RN B said Resident #5's urine looked like a brownish color, and it was not a normal color. She said it could be due to an infection or the intake of her juice. She said Resident #5 did not drink cranberry juice. The DON said it was her first time seeing Resident #5's catheter filled with purple urine. She said yesterday it was a dark colored urine but not purple. Interview on 10/8/24 at 5:15p.m., Physician A said he was told on 10/5/2024 by a staff member that Resident #5's urine was dark, and they requested fluids. He said staff changed their minds about sending Resident #5 out to the hospital after the order of the fluids and he said he was told the family was okay with the that. He said he did not know the family had requested for Resident #5 to be sent to the hospital and was adamant about her going. He said someone at the facility was supposed to inform him first. Physician A said he did not give orders to send the Resident #5 out to the hospital. Interview on 10/8/2024 at 5:22p.m., the DON, said the nurses changed Resident #5's Foley catheter a few times in the past weeks because of the family's request. She said Resident #5's family wanted it done. Interview on 10/8/2024 at 5:30p.m., CNA A said Resident #5's urine was a brownish, a purple color due to dehydration. Interview on 10/8/2024 at 6:02p.m., the NP said he had not assessed Resident #5 since 4/7/2024. He said he was at the facility on 10/8/2024, but the nurse said everything was okay with Resident #5. He said he saw her lying in bed, but he did not go into her room to physically see her. He said one of the nurses told him about another resident but never mentioned Resident #5 to him. Interview on 10/9/2024 at 12:27p.m., Family member A said they did not change their minds about sending Resident #5 to the hospital. She said they were waiting at home on 10/5/2024, when they received a call from a staff member at the facility, and they told her they were going to leave Resident #5 at the facility. She said the family did not approve it. She said a staff member called yesterday on 10/8/2024 and asked if they wanted to send Resident #5 to the hospital. She said she told them that she wanted to wait and see how Resident #5 was going to do with the new orders. Family member B said she gave permission to staff to send Resident#5 to the hospital on 10/5/2024. She said as of 10/9/2024 she wanted staff to start the antibiotics for the infection. She said she told them to wait to see what her reaction would be to the medication, and they would decide if they wanted to send Resident #5 to the hospital. She said the nurses took the catheter out of Resident #5. She said Physician A told staff to take out the catheter. She said one nurse came in the room looking for the Foley catheter and did not know that it was gone. She said a nurse on 10/4/2024 told her that Resident #5 had an infection. Interview on 10/9/24 at 12:42p.m., Physician A said Resident #5 was diagnosed with a stage 4 ulcer when she was transferred from the hospital, and she received a Foley catheter. He said Resident #5 failed a trail removal of the Foley catheter and had urinary tract retention. He said it failed once and she had a diagnosis of urinary tract infection. He said the facility did not talk about changing Resident #5's Foley catheter on 9/16/2024 or 9/29/2024. He said he never given staff permission to use a different order or talked to staff about using a different Foley catheter against the initial order. Physician A said on 10/8/20024, he gave an order to remove Resident #5's Foley catheter to see if she could pass urine without it. He said it was a trial removal and her Foley catheter was leaking. Physician A said Resident #5's wound reopened, and he was just informed about it. He said it could be due to nutrition. He said Resident #5 had a bad wound when she first entered the facility. Follow-up interview on 10/9/24 at 2:55p.m., with CNA A, said she told nurses and RN B about Resident #5's purple urine a month ago. She said Resident #5's family was concerned about her urine. She said the nurse said it could be from dehydration. CNA A said she was concerned because the color of the urine was yellow in her catheter a month ago. She said she tries to accommodate residents as best she can. Interview on 10/10/24 at 9:27a.m., the Administrator said she had been working at the facility since 3/11/24. She said she would report change of conditions by following protocol. She said when Resident #5 had a change of condition she should have been a part of the conversation with the DON, but she was not notified about it. She said she was notified about Resident #5's purple urine during an end of day meeting, on 10/8/24. The Administrator said she was not aware that the size of Resident #5's Foley catheter that had been inserted by the nurses on 9/16/24 and 9/29/24 and was different from the physician orders. She said the IV was discussed during the morning meeting on 10/7/24. She said there was a problem with honoring the family's request to send Resident #5 to the hospital, providing education to staff and documentation. She said there was not a lot of documentation on what was going on with Resident #5. She said moving forward she would work on implementing staffing changes, removing people from their roles, providing training, and taking accountability. She said she would start contacting her for everything. She said she would set up a new template for clinical meetings and take advantage of quality monitoring resources that was made available to them. Interview on 10/10/24 at 11:27a.m., with the ADON said she had been working at the facility for over a year. She said she believed the communication between her, and staff had been going well. She said the family requested that Resident #5 be sent out to the hospital. She said the doctor was called and he gave an order for an IV due to possible dehydration and not eating well. She said she did not know there was an issue with Resident #5. She said she was not aware that Resident #5's urine was purple. She said no one mentioned anything to her about Resident #5's purple urine. Interview on 10/14/2024 at 12:31p.m., with a staff member who requested to remain anonymous, said communication with the staff at the facility was not good. She said staff did not respond quickly when a resident needed assistance with care. She said she told the DON about another resident's urine being a dark blue color about a month and a half ago and was told it was that color due to him being on a lot of medications. She said staff did not follow the stop and watch protocol. Interview on 10/14/2024 at 4:32p.m., with the Administrator and Facility Abuse Coordinator revealed when asked how she thought the IJ happened, said ultimately it was communication failure with Resident #5. She said that nursing should have been responsible for the catheter competencies and that they were in the process or reviewing. She said the DON was responsible for infection control tracking, trending and ABT stewardship. She said that they held a monthly QAPI, and that this month had to be rescheduled due to current state investigations and subsequent IJs. She said an Ad Hoc rescheduled QAPI had not been set with a date yet. She said that regarding Resident #5, she had not spoken to the family yet regarding their concerns but that there was a care plan meeting scheduled for 10/15/2024 that she would attend. She said there had been one scheduled last week, but family could not attend at that time and the date they had rescheduled for, the resident was out at the hospital. She said that upon initial hire, nursing was responsible for ensuring all nursing competencies and that nursing was responsible for documentation, but that moving forward she would also have to be oversight and was in the process of hiring a new ADON as well to help. Record Review of the facility's policy titled Change in a Resident's Condition or Status dated 5/2017, reflected in part, . Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): accident or incident involving the resident; discovery of injuries of an unknown source; adverse reaction to medication; significant change in the resident's physical/emotional/mental condition; need to alter the resident's medical treatment significantly; refusal of treatment or medications two (2) or more consecutive times); need to transfer the resident to a hospital/treatment center; discharge without proper medical authority; and/or specific instruction to notify the Physician of changes in the resident's condition. A significant change of condition is a major decline or improvement in the resident's status that: Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting); Impacts more than one area of the residents health status; Requires interdisciplinary review and/or revision to the care plan; and Ultimately is based on the judgment of the clinical staff and the guidelines outlined in the Resident Assessment Instrument .

Based on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for one of 6 residents (Resident #5) reviewed for urinary catheters. 1. The facility failed to ensure Resident #5 received treatment without delays for change in condition related to black, purple, and bloody urine in her Foley catheter . 2. The facility failed to follow the doctor's order regarding the size of the catheter that was supposed to be used and the indication for changing the Foley catheter . 3. The facility failed to provide care to Resident #5 in a timely manner after the family repeatedly requested Resident #5 be sent to the emergency room for evaluation of her purple urine and decline which caused a delay in care . These failures could affect residents with urinary catheters and other medical conditions and could place them at risk for physical harm, pain, mental anguish, or emotional distress. Findings included: Record review of Resident #5's face sheet revealed she was an [AGE] year-old female who was admitted into the facility on [DATE]. She was diagnosed on [DATE] with, chronic kidney disease (long standing disease of the kidneys leading to renal failure. The kidneys filter waste and excess fluid from the blood. As kidneys fail, waste builds up), cognitive communication deficit (difficulty with communication caused by a disruption in cognitive process), neuromuscular dysfunction of bladder (a condition that occurs when the nerves and muscles of the bladder don't work together properly), and type 2 diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). On 9/30/24 she was diagnosed with urinary tract infection. For about a month, the resident had been having blue and purple urine. Her change of condition had not been reported to the doctor until 10/8/24. On 10/8/2024 she was diagnosed with purple urine syndrome (a rare condition that causes the urine collection bag to turn purple or blue due to a urinary tract infection (UTI) and long-term catheter use). Record review of Resident #5's Comprehensive MDS dated [DATE] revealed she had a BIMs score of 0 out of 15 which indicated she was severely cognitively impaired. She required substantial/maximal assistance with eating and oral hygiene. Resident #5 was dependent for toileting hygiene, shower/bath self, upper body dressing, lower body dressing, and personal hygiene. She was dependent when needed to roll left and right and sit to lying. Resident #5 had an indwelling catheter. Record review of Resident #5's undated comprehensive care plan revealed the following, Toilet use: She is not toileted. Toilet use: She is totally dependent on (1-2) staff for incontinent care. Record review of Resident #5's base line care plan completed until 4/9/24 revealed the following, [Resident #5] Indwelling Foley Catheter and is at Risk for Increased Urinary Tract Infections: Pressure Ulcer sacral Urinary Catheter 20FR,10 CC. Diagnosis: Urinary Retention. Record review of Resident #5's Progress Notes dated 9/16/24 at 6:43 p.m., entered by the ADON, reflected in part, . Foley catheter noted not to be in place and urine was coming out, using aseptic technique, foley catheter replaced with 18fr, 10ml balloon. Resident tolerated procedure and shows no s/s of pain or discomfort at this time Record review of Resident #5's Progress Notes dated 9/29/24 at 11:48 p.m., entered by the LVN C, reflected in part, .16 French, 10cc balloon foley catheter inserted into the urethra without resistance, sterile technique maintained throughout the process, perineal area cleaned with antiseptic solution, new sterile gloves donned (to put on PPE properly to achieve the intended protection and minimize the risk of exposure), clear yellow urine noted in drainage bag, balloon inflated with 10cc of sterile water, catheter secured to thigh with securing tape, resident tolerated the procedure well, no signs of pain after the procedure noted, will continue to monitor urine output . Record review of Resident #5's Progress Notes dated 9/30/24 at 10:45 p.m., entered by the LVN D, reflected in part, .16 French, 10cc balloon foley catheter inserted into the urethra without resistance, sterile technique maintained throughout the process, perinea! area cleaned with antiseptic solution, new sterile gloves donned, clear yellow urine noted in drainage bag, balloon inflated with 10cc of sterile water, catheter secured to thigh with securing tape, resident tolerated the procedure well, no signs of pain after the procedure noted, will continue to monitor urine output . Record review of Resident #5's Order Summary dated 9/30/24 revealed she had a diagnosis of urinary tract infection. Record review of Resident #5's Progress Notes dated 10/05/24 at 12:40a.m., entered by RN A, reflected in part, .Per family request, resident will be sent out to the hospital. The U/A lab results were reviewed and concluded client is positive with Gram negative and positive bacterium. HCP was contacted by documenting nurse with most recent lab results. Requesting how to move forward. No response considering its late hours of the night. After reviewing family concerns of client having blood tinge fluid in her catheter and reviewing medical docs. This nurse is honoring the request of the client's family and sending Resident #5 out . Record review of Resident #5's Progress Notes dated 10/05/24 at 7:56 a.m., entered by the DON, reflected in part, .This writer was made aware that resident RP is requesting her to be send to the hospital and stated [Resident #5] has UTI, [Physician A] made aware and have orders for 0.9%ns @60ml/hr x 2L, Encourage po fluids. Rp called x 2 no response . Record review of Resident #5's Progress Notes dated 10/05/24 at 5:29 p.m., entered by RN C, reflected in part, . cancelled transportation to hospital per DON. resident alert foley bag exhibits about 10cc of urine. new order for normal saline for hydration 2000 ml per iv. 22g to left wrist patent and no s/s infection. continue to monitor. once started, urine began to flow from catheter dark red urine again. family wanted patient to go to hospital but now they are allowing [resident] to stay at the facility at this time . Record review of Resident #5's Progress Notes dated 10/8/24 at 7:15p.m., entered by RN D, reflected in part, .Doxycycline Monohydrate, Oral Capsule 100MG, give 1 capsule by mouth two times a day for Prophylaxis for 10 days . Record review of Resident #5's Order summary Report dated 10/8/24, reflected in part, .Doxycycline Monohydrate (used to treat a wide variety of bacterial infections, including those that cause acne), Oral Capsule 100MG, give 1 capsule by mouth two times a day for Prophylaxis for 10 days . Start date: 10/9/24. Record review of Resident #5's hospital records dated 10/10/24 on page 5/16, revealed, altered mental status, unspecified altered mental status type: 2/2 UTI, UTI (urinary tract infection due to urinary indwelling foley catheter (CMS/HCC) (HCC). Observation on 10/8/24 at 1:35p.m. with Resident #5, revealed her lying asleep in bed. She had a fluid IV bag that was almost empty. She was covered up with a blanket. RN B removed the cover from Resident #5's catheter bag and it revealed that her urine was purple. RN B said Resident #5's urine had been a purple color for the past three days. She said she was not sure if it was blood or not. Interview on 10/8/2024 at 2:21p.m. RN A said Resident #5 had a medical diagnosis of a urinary tract infection on 9/30/2024. On 4/9/2024 Resident #5 was initiated for the catheter. RN A said Resident #5 was care planned for dehydration on, 4/11/2024 7/17/2024, 10/5/2024 and 10/8/2024. She said Resident #5 was not drinking or eating very well. She said Resident #5's family provided a bottle of water for them to give to her. She said sometimes she would take it and sometimes she would not. She said Resident #5 had a change of condition with her urine on 10/5/2024 and it was GI related. Physician A was contacted and put in an order for an IV. Interview on 10/8/24 at 2:36p.m., the NP said he assumed Resident #5 had a catheter to help her wounds heal faster. He said he first saw Resident #5 when she arrived at the facility from the hospital, upon admission, she had a foley catheter. He most of the time, nurses were to change the catheter in 30 days or if there was a malfunction. He said if Resident #5's urine changed color, he would not be able to explain why it happened. He said he would monitor Resident #5. He said he did not see a purple color in the catheter. He said staff should have notified him if there was a change of condition with the resident. Interview on 10/8/2024 at 3:38p.m., the DON said she cancelled the transportation for the Resident #5 going to the hospital on 10/5/2024 because she was able to get Physician A to order IV fluids after he reviewed Resident #5's lab results. She said Physician A gave an order for 2 liters of IV fluid and that if Resident #5 was not drinking any fluids, then her urine was going to be dark. She said she first notified Physician A of the discoloration of dark, yellow urine on 10/5/2024. The DON said when Physician A sent the order for IV fluids, she contacted Resident #5's family and the family agreed to not send Resident #5 to the hospital as they had requested. The DON then said she was first notified about Resident #5 change of condition when a nurse told her about Physician A wanting to prescribe antibiotics for a UTI. She said it happened a week ago. Interview on 10/8/2024 at 3:35p.m., RN B said the first time she saw discoloration in Resident #5's urine was on 10/7/24. She said she had been working on Resident #5's hall for 3 months. She said she changed her catheter every month. She said she last changed her catheter a month ago and her urine was clear. She said Resident #5's UA came back negative. She said she communicated with the RP that her urine came back negative on 10/1/24. She showed documentation that the lab results revealed, UTI Panel: Enterococcus Faecalis- Gram-positive, Escherichia Coli- Gram-negative, and Proteus Mirabilis- Gram-negative. [Physician A] ordered Doxycycline Monohydrate Oral Capsule 100MG, give 1 capsule by mouth two times a day for prophylaxis UTI for 10 days. Interview on 10/8/24 at 3:48p.m., Physician A said he was first notified on 10/5/2024 about Resident #5's dark urine because she was not drinking enough water. He said if the lab was negative, they would normally start with a fluid and for Resident #5 started on Saturday, 10/5/2024. He said Resident #5 came into the facility with a Foley catheter. He said he had not seen Resident #5 in 3 weeks. He said he had been going off what the facility was telling him about Resident #5. He said he was scheduled to go to the facility on ce a week. He said he was on a monthly schedule to see the residents. He said a nurse at the facility should have informed him that Resident #5 needed to be seen. He said the nurse should have told NP A to see Resident #5 while he was at the facility. He said he had an order for fluids. He said he can give an order over the phone. Observation and interview on 10/8/2024 at 5:06p.m. with Resident #5, the DON, RN B and CNA A revealed Resident #5 lying awake in bed and could hardly speak. The DON grabbed the catheter bag and observed the purple urine. She said the color of the urine was a problem because Resident #5 could have an infection. She said the urine looked purple . CNA A said Resident #5's urine looked like a brownish purple color. She said the color of Resident #5's urine was not a normal color. She said yellow urine would be a normal color. RN B said Resident #5's urine looked like a brownish color, and it was not a normal color. She said it could be due to an infection or the intake of her juice. She said Resident #5 did not drink cranberry juice. The DON said it was her first time seeing Resident #5's catheter filled with purple urine. She said yesterday it was a dark colored urine but not purple. Interview on 10/8/24 at 5:15p.m., Physician A said he was told on 10/5/2024 by a staff member that Resident #5's urine was dark, and they requested fluids. He said staff changed their minds about sending Resident #5 out to the hospital after the order of the fluids and he said he was told the family was okay with the that. He said he did not know the family had requested for Resident #5 to be sent to the hospital and was adamant about her going. He said someone at the facility was supposed to inform him first. Physician A said he did not give orders to send the Resident #5 out to the hospital. Interview on 10/8/2024 at 5:22p.m., the DON, said the nurses changed Resident #5's Foley catheter a few times in the past weeks because of the family's request. She said Resident #5's family wanted it done. Interview on 10/8/2024 at 5:30p.m., CNA A said Resident #5's urine was a brownish, a purple color due to dehydration. Interview on 10/8/2024 at 6:02p.m., the NP said he had not assessed Resident #5 since 4/7/2024. He said he was at the facility on 10/8/2024, but the nurse said everything was okay with Resident #5. He said he saw her lying in bed, but he did not go into her room to physically see her. He said one of the nurses told him about another resident but never mentioned Resident #5 to him. Interview on 10/9/2024 at 12:27p.m., Family member A said they did not change their minds about sending Resident #5 to the hospital. She said they were waiting at home on 10/5/2024, when they received a call from a staff member at the facility, and they told her they were going to leave Resident #5 at the facility. She said the family did not approve it. She said a staff member called yesterday on 10/8/2024 and asked if they wanted to send Resident #5 to the hospital. She said she told them that she wanted to wait and see how Resident #5 was going to do with the new orders. Family member B said she gave permission to staff to send Resident#5 to the hospital on 10/5/2024. She said as of 10/9/2024 she wanted staff to start the antibiotics for the infection. She said she told them to wait to see what her reaction would be to the medication, and they would decide if they wanted to send Resident #5 to the hospital. She said the nurses took the catheter out of Resident #5. She said Physician A told staff to take out the catheter. She said one nurse came in the room looking for the Foley catheter and did not know that it was gone. She said a nurse on 10/4/2024 told her that Resident #5 had an infection. Interview on 10/9/24 at 12:42p.m., Physician A said Resident #5 was diagnosed with a stage 4 ulcer when she was transferred from the hospital, and she received a Foley catheter. He said Resident #5 failed a trail removal of the Foley catheter and had urinary tract retention. He said it failed once and she had a diagnosis of urinary tract infection. He said the facility did not talk about changing Resident #5's Foley catheter on 9/16/2024 or 9/29/2024. He said he never given staff permission to use a different order or talked to staff about using a different Foley catheter against the initial order. Physician A said on 10/8/20024, he gave an order to remove Resident #5's Foley catheter to see if she could pass urine without it. He said it was a trial removal and her Foley catheter was leaking. Physician A said Resident #5's wound reopened, and he was just informed about it. He said it could be due to nutrition. He said Resident #5 had a bad wound when she first entered the facility. Follow-up interview on 10/9/24 at 2:55p.m., with CNA A, said she told nurses and RN B about Resident #5's purple urine a month ago. She said Resident #5's family was concerned about her urine. She said the nurse said it could be from dehydration. CNA A said she was concerned because the color of the urine was yellow in her catheter a month ago. She said she tries to accommodate residents as best she can. Interview on 10/10/24 at 9:27 a.m., the Administrator, said she had been working at the facility since 3/11/24. She said she recently received an IJ for quality of care. She said she would report change of conditions by following protocol. She said when Resident #5 had a change of condition she should have been a part of the conversation with the DON, but she was not notified about it. She said she was notified about Resident #5's purple urine during an end of day on 10/8/24. The Administrator said she was not aware that the size of Resident #5's Foley Catheter was inserted by the nurses on 9/16/24 and 9/29/24 was different from the physician orders. She said the IV was discussed during the morning meeting on 10/7/24. She said there was a problem with the DON not honoring the family's request to send Resident #5 to the hospital, not providing education to staff and lack documentation. She said there was not a lot of documentation on what was going on with Resident #5. She said moving forward she would work on implementing staffing changes, removing people from their roles, providing training, and taking accountability. She said she would start contacting her for everything. She said she would set up a new template for clinical meetings and take advantage of quality monitoring resources that was made available to them. Interview on 10/10/24 at 11:27a.m., with the ADON said she had been working at the facility for over a year. She said she believed the communication between her, and staff had been going well. She said the family requested that Resident #5 be sent out to the hospital. She said the doctor was called and he gave an order for an IV due to possible dehydration and not eating well. She said she did not know there was an issue with Resident #5. She said she was not aware that Resident #5's urine was purple. She said no one mentioned anything to her about Resident #5's purple urine. During a phone interview on 10/13/2024 at 1:17p.m., with CNA B, said she had been working at the facility since 7/23/24. She said she had been working 200-hall, the same hall as Resident #5, since she started at the facility. She said she had noticed that Resident #5's urine in her catheter was purple about a month ago. She said she mentioned it several times to the nurses that were on duty during that time. She said she did not know if it was normal for Resident #5 to have purple urine, or if something was wrong. She said nurses reinserted Resident #5's catheter several times because of the purple urine. She said if there was a change of condition with a resident and nothing was done, the resident could die depending on how serious the situation was. She said she told a male and female nurse about Resident #5's purple urine, but she could not remember their names. Interview on 10/13/24 at 3:20p.m., with CNA C, said she had been working at the facility for 7 months. She said she would work 200-hall with Resident #5 depending on the schedule. She said at the beginning when she would measure the urine and the urine was yellow. She said in September 2024, she noticed the color change of Resident #5's urine. She said it would stain the bag and it was purple and brownish urine. She said when she drained the urine. It was a dark color but not as purple. She said she told RN B and another male nurse that works night shift about the color of the urine. She said RN B saw Resident #5's urine. She said the family would point it out to the nurses. She said she told staff about it two or three weeks ago. She said if a change of condition was not being treated, it could be bad for the resident or it could cause a problem that would require the resident to be sent to the hospital. She said it could also lead to death depending on how serious the condition of the resident. Interview on 10/14/2024 at 12:31p.m., with a staff member who requested to remain anonymous, said communication with the staff at the facility was not good. She said staff did not respond quickly when a resident needed assistance with care. She said she told the DON about another resident's urine being a dark blue color about a month and a half ago and was told it was that color due to him being on a lot of medications. She said staff did not follow the stop and watch protocol. Interview on 10/14/2024 at 4:32p.m., with the Administrator and Facility Abuse Coordinator revealed when asked how she thought the IJ happened, said ultimately it was communication failure with Resident #5. She said that nursing should have been responsible for the catheter competencies and that they were in the process or reviewing. She said the DON was responsible for infection control tracking, trending and ABT stewardship. She said that they held a monthly QAPI, and that this month had to be rescheduled due to current state investigations and subsequent IJs. She said an Ad Hoc rescheduled QAPI had not been set with a date yet. She said that regarding Resident #5, she had not spoken to the family yet regarding their concerns but that there was a care plan meeting scheduled for 10/15/2024 that she would attend. She said there had been one scheduled last week, but family could not attend at that time and the date they had rescheduled for, the resident was out at the hospital. She said that upon initial hire, nursing was responsible for ensuring all nursing competencies and that nursing was responsible for documentation, but that moving forward she would also have to be oversight and was in the process of hiring a new ADON as well to help. Record Review of the facility's policy titled Change in a Resident's Condition or Status dated 5/2017, reflected in part, . Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): accident or incident involving the resident; discovery of injuries of an unknown source; adverse reaction to medication; significant change in the resident's physical/emotional/mental condition; need to alter the resident's medical treatment significantly; refusal of treatment or medications two (2) or more consecutive times); need to transfer the resident to a hospital/treatment center; discharge without proper medical authority; and/or specific instruction to notify the Physician of changes in the resident's condition. A significant change of condition is a major decline or improvement in the resident's status that: Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting); Impacts more than one area of the residents health status; Requires interdisciplinary review and/or revision to the care plan; and Ultimately is based on the judgment of the clinical staff and the guidelines outlined in the Resident Assessment Instrument .

Based on observation, interview and record review, the facility failed to store, prepare, and serve food under sanitary conditions in 1 of 1 kitchen: -The facility failed to ensure that the kitchen floors were clean and free of food particles. -The facility failed to ensure gloves were worn by staff during food preparation. These failures placed all residents who ate food served by the kitchen at risk of a food-borne illness. Findings included: Observation on 10/16/24 from 2:25 p.m., revealed the following: The kitchen floor near the stove, deep fryer, and handwashing sink, was dirty with food particles and grease stains. Cook A was preparing food and placed turkey meet in a grinder without wearing gloves. Interview on 10/16/24 at 2:28p.m., the Dietary Manager said he needed to buy soap. He said he put in an order to purchase soap for the kitchen. He said housekeeping was supposed to refill it, but they did not do it. He said they used dishwashing liquid, but he could not find the dishwashing liquid. He said staff is supposed to wear gloves when preparing or touching the food. He said if a cook is not wearing gloves when preparing the food, it could cause cross contamination. Interview on 10/16/24 at 2:32p.m., [NAME] A said he had been working at the facility for about a year. He said he did not need to wear gloves to stir the food. He said he was only supposed to wear gloves when he was handling food. He said not wearing gloves can cause cross contamination. He said the turkey was cooked and not raw, so he did not have to wear gloves while placing it in the grinder. Interview on 10/16/24 at 2:38p.m., the FSA said staff was supposed to wear gloves when handling food. She said if gloves are not worn while handling food, it could cause cross contamination, and someone could get sick. She said if hands are not washed while handling food, it could cause bacteria and spread a virus. Record review of the facility's policy entitled Preventing Foodborne Illness - Food Handling dated 4/20/2022, reflected in part- .This facility recognizes that the critical factors implicated in foodborne illness are: Poor personal hygiene of food service employees; Inadequate cooking and improper holding temperatures; Contaminated equipment; and Unsafe food sources. With these factors as the primary focus of preventative measures, this facility strives to minimize the risk of foodborne illness to our residents. All employees who handle, prepare, or serve food will be trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food or serving food to residents. This facility only accepts prepared foods from suppliers subject to federal, state, or Local food service inspections and who remain in good standing with such agencies .

Based on observation, interview and record review, the facility failed to ensure waste were properly contained in dumpster and covered, in 2 of 2 kitchen and outside dumpster: -The facility failed close the lid to the dumpster. -The facility failed to provide lids to two trash cans that were placed inside of the kitchen. This failure placed residents at risk for infection and a decreased quality of life due to having an exterior environment which could attract flying pests, rodents, and other animals. Findings include: Observation on 10/16/24 at 2:45 p.m., revealed a commercial-sized dumpster in the lot behind the dietary department and the lid was open and trash inside. Observation on 10/16/24 at 2:32p.m., revealed two trash cans in the kitchen that was not being used, with no lids on them. One of the trash cans was near the stove and the other trash can was between the deep fryer and the back door. Both trash cans had food particles inside of them. Interview on 10/16/2024 at 2:50p.m., with the Dietary Manager, he said trash cans with no lids should not be inside of the kitchen. He said it was unsanitary. He said he had been working in the kitchen for a month and the trash near the door and the deep fryer never had a lid on it. He said he ordered one, but it hasn't come in yet. He said the lid to the dumpster was supposed to be closed. He observed that the lid was open and said it was supposed to be closed. He said if the lid was open, it could cause dogs, rodents, debris, flies, and maggots to take over the trash and come on the facility grounds. Interview on 10/16/2024 at 3:00p.m., with the Regional VP of Operations, said the lid to the dumpster should have been closed. She said the trash cans in the kitchen should have had lids on them as well. She said it was not sanitary to have the lids off the trash cans in the kitchen. Record review of the facility's policy entitled Food and Nutrition Services will ensure that waste containers are properly maintained dated 4/20/2022, reflected in part- . Waste containers and dumpsters have lids covering them when not in use and are not overflowing. Area around dumpsters are kept clean and odor and rodent free. Dumpster plug is to be in place if not a sealed unit

Based on interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (CR#1) of five residents reviewed for quality of care. The facility failed to immediately assess and treat CR #1 and contact the doctor from [DATE]- [DATE] after CR#1 experienced ongoing vomiting and distress. CR#1 was transported to the hospital on [DATE] at 11am. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 4:31 PM. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for delay in needed treatment and care. Findings included: Record review of CR#1's face sheet dated [DATE] reflected he was an [AGE] year-old male that was admitted to the facility on [DATE] with diagnoses of rhabdomyolysis (a breakdown of muscle tissue that releases a damaging protein into the blood), dysphagia (difficulty swallowing) Type II Diabetes, and hypertension (high blood pressure). He was coded to DNR. Record review of CR #1's care plan last updated [DATE] reflected he had an ADL self-care performance deficit accompanied with impaired balance and limited mobility. CR#1 also had the potential for complications related to the diagnosis of hypertension. Interventions initiated [DATE] stated to monitor/document/report any s/s of headaches, confusion, disorientation, difficulty breathing, and nauseas and vomiting. Record review of CR #1 doctors' orders from [DATE]- [DATE] reflected that there was no documentation (orders) that CR #1 received medication for acid reflux, vomiting, or pain. Record review of the shift-to-shift report on [DATE]- [DATE] documented by the night nurse LPN A reflected that each resident had either a handwritten update regarding their condition from that shift or the words ok next to their nane. CR #1 did not have any documentation next to his name. Record review of the progress notes for CR #1 reflected on [DATE] and [DATE], no progress notes were documented. Record review of the progress note for CR #1 dated [DATE] at 10:29 am reflected RN A documented that she noticed pain while changing him. Vitals were BP ,d+[DATE], Heart rate was 127. Per the aid (name undisclosed), resident was vomiting for 2 days, and roommate stated that CR #1 was up all-night moaning. He was given Tylenol and midodrine, but resident vomited up the medicine. Dr. was called and resident was instructed to send resident to hospital due to acidosis. Record review of the hospital record for CR #1 dated [DATE] at 12:03 pm reflected that CR #1 was admitted in a wheelchair due to shortness of breath, weakness, tachycardia (a heart rate that exceeded the normal resting rate), and he was not able to verbalize complaints. His pain intensity was measured as an 8 on a scale of 1- 10 and the chief complaint noted was respiratory. CR #1 also had a blood pressure reading of ,d+[DATE]. The final record of his expiration have not yet been received. In an interview on [DATE] at 12:41 pm with the Roommate of CR #1, he stated that if he was the aid, he would have sent CR#1 to the hospital that night. He expressed that during the night of [DATE], CR#1 was getting over heated and the aids kept checking on him. He couldn't say what was wrong with him, but he made a lot of noise throughout the night and the in-room ac unit was set to 69 degrees. CR#1 was sent to the hospital the next day ([DATE]) but Roommate stated that he would not have kept him at the facility under his conditions and sent him out sooner. He did not speak with he aids or the nurse regarding his roommate. In an interview on [DATE] at 3:11 pm, RN A stated that she was off on [DATE] and [DATE]. When she returned on [DATE] and was told by CNA A that CR#1 was throwing up and had been throwing up for the past 2 days. Upon rounds, CR #1 was nauseous and vomiting. RN A asked CR#1 what was wrong, and he stated, I don't know, but I know something isn't right. Resident was sweaty and after the assessment she contacted Dr. and informed him his heart rate was high, but BP was low. Dr. agreed to send him to the hospital and came by the facility before he left with the EMT to assess him. LPN A, who worked the night shift did not inform RN A of any changes in CR #1's condition. In an interview on [DATE] at 3:29 pm, CNA A stated that she worked on [DATE] from 6am-10pm. CR #1 started to vomit around 6:30 pm and his vomit was a dark brown that resembled hot chocolate. Around 7pm, she relayed his condition to LPN A, who stated that he would check on the CR#1 but she was unsure if he did. During her 2nd round around 9pm, CR #1 had vomited on the floor and all over his sheets. LPN A told CNA A that he would give him something for acid reflux. CNA A returned to work with CR#1 on [DATE] at 6am. When she changed him, she heard gurgling noises, he was not speaking, she and verbally reported it to RN A at 8am. RN A did not come to immediately check on the CR #! and she sent RN A a text at 9:14am saying CR #1was grunting and needed to be looked at. CNA A stated at 9:30am, RN A came to check on the CR#1 and gave him a covid test. CNA A stated CR#1 was taken by EMT around 11am. In an interview on [DATE] at 3:43 pm with CNA B, who stated she worked on [DATE] from 10pm-6am. When she saw CR #1 at 10pm, he complained of being hot and she adjusted his AC to 69 and turned the AC on in the hallway. CNA B informed LPN A and LPN A stated that would give CR #1 something. However, CR #1 continued to tell CNA B that something was not right, and he rang the call light so much that night that it made it hard for her to tend to other residents. She said she did not know if LPN A contacted the doctor, but she tried to hint that he should. She informed LPN A of CR #1's status at 10:30pm and at 2am. In an interview on [DATE] at 3:56 pm with Dr. Z, who explained that when he saw CR #1 on [DATE], he was fine. Resident was normally verbal, and he could express his likes, dislikes, and pain. Once RN A told him that CR #1 was not well, he immediately went to the facility, entering before the EMT, and assessed the resident. Upon assessment, CR #1 was not responsive, hypotensive, and septic. When he went to the hospital, Dr. Z was also CR#1's treatment doctor at the hospital. The CP scan reflected that he had bilateral aspiration (could have choked on saliva laying down) and cause of death was aspiration pneumonia on [DATE]. The first time he was contacted regarding CR#1's symptoms was [DATE]. Dr. Z expressed that if he had been informed that CR#1 was vomiting and had diarrhea on [DATE], he would not have sent him to the hospital, but ran labs and prescribed him something for his symptoms. He stated that he was prompted to send the resident out because of his abnormal vitals, altered mental status, and low blood pressure. In an interview on [DATE] at 4:28 pm, the DON who stated that if a resident had a change in condition, they were supposed to assess the patient and get with the doctor. A change in condition was described as anything that deviated from the patient's baseline. She stated that CR#1 was a very pleasant man, and he was able to verbalize when something was wrong with him. She was not informed that CR #1 was ill until [DATE]. RN A told her the morning of [DATE] and when she went to check on CR#1, he was weak, nausea, his eyes were closed, and kept trying to clear his throat. Dr. Z was contacted, and CR#1 was sent out that morning. Through investigation, DON learned that CNA A had noticed that CR#1 had vomited, and she cleaned him up each time. CNA A also stated that she informed LPN A. DON preformed an in-service with CNA A and followed up with LPN A, who denied any knowledge of CR#1 being sick. CNA A was told that in the future, she should wait until the nurse came to view the vomit before she cleaned it up and all aids were informed to reach out to the DON if they tell a nurse about a sick resident, and they do not follow up. DON also verbally reeducated RN A on the facilities change in condition policy and she disclosed that RN A shift started at 6am, but she arrived at the facility late that day and did not start her rounds until 9 am. LPN A was interviewed but he was not reeducated. DON expressed that she did not reeducate LPN A because she had worked with him at a different facility and felt that he was a very competent nurse, and she believed his statement because the other staff have been messy. DON stated that the harm in not communicating when a resident changed from baseline could be hospitalization . In an interview on [DATE] at 5:04 pm, LPN A stated that he started working at the facility during the month of August and worked on [DATE] and [DATE] from 6pm-6am. He explained that nurses were to round as much as possible and he remembered entering the room for CR#1 on [DATE], but he did not wake him because he was asleep. He denied that CNA A or CNA B informed him that CR #1 was vomiting and he did not administer any medication to him outside of what was prescribed. LPN A stated that if he knew there was a change in condition with CR#1, he would have checked what type of medications he was already prescribed and let the on-call doctor know. The type of assessment would have depended on the condition of the resident, but in the case of CR#1, he would have checked vitals, examined the vomit and its frequency, then followed up with the doctor. He could not remember if he did rounds with RN A on the morning of [DATE]. In an interview on [DATE] at 5:25 pm, Admin stated that her first-time hearing of the incident with CR#1 was during the morning of [DATE]. RN A told her that she was informed by the aid that CR#1 had been vomiting for several days and Dr. Z was called in before he went to the hospital. She stated that CNA A was educated in their stop and watch documentation system in the resident portal. Admin also stated that she felt that if RN A had arrived to work at 6am and did rounds immediately once she arrived, she might have been able to check on him sooner. Admin got the text later that day that CR#1 had expired. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 4:31 pm. The Admin and DON were notified. The Admin was provided with the IJ template on [DATE] at 4:31 pm. The following Plan of Removal submitted by the facility was accepted on [DATE] at 7:25 am: Immediate Jeopardy Facility X: On [DATE], an incident survey was initiated at Facility X. On [DATE] the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safety. The facility failed to immediately assess and treat CR#1 and contact the doctor from [DATE] - [DATE] after CR#1 experienced ongoing vomiting and distress. CR#1 was transported to the hospital on [DATE] at 11am. Immediate Action: o The Executive Director/Director of Clinical Operations will be educated by the Regional Directors on [DATE] to Rounding and Monitoring of residents on change of condition and timely Notification of physician and responsible party. o The DCO/Designee will conduct 1:1 in-service with LPN A to include Resident Change in condition, Shift-to-Shift reporting & Documenting changes in condition, Clinical documentation/Charting, timely notification of the physician and responsible party on change of condition to be completed on [DATE]. o The Director of Clinical Operations initiated education on [DATE] to charge nurses on: Resident Change in condition, Shift-to-Shift reporting & Documenting changes in condition, Clinical documentation/Charting, timely notification of the physician and responsible party on change of condition to be completed on [DATE]. Staff will not be allowed to provide direct resident care until training has been completed. o The DCO/Designee initiated education on [DATE] to Certified Nursing Assistants on notifying charge nurses on change of condition and documenting on Stop & Watch in PCC to be completed on [DATE]. Staff will not be allowed to provide direct resident care until training has been completed. o The clinical team (DCO, ADCO , and designated nursing staff) initiated chart audits on all residents with a change in condition on [DATE]. Resident assessments were completed on [DATE] and no new changes in condition identified. Facilities Plan to ensure compliance quickly: o The clinical team (DCO, ADCO, and designated nursing staff) initiated chart audits on all residents with a change in condition to ensure timely notification of physician and responsible party was completed. o The DCO/Designee with review 24-hour report daily to ensure that timely notification of the physician and responsible was completed, starting [DATE]. o The Medical Director was notified of the Immediate Jeopardy on [DATE]. o The current policies reviewed with the Medical Director on [DATE] on Resident Assessment, Shift-to-Shift reporting & Documenting changes on the 24-hour report, Clinical documentation/Charting, change in condition, notifying the physician, Stop & Watch, with no changes to the current policy. This practice will be reviewed monthly with the QA committee to ensure compliance in place. o Daily rounds will be conducted by Nurse management to communicate any changes of condition and timely notification of the physician and RP will occur starting [DATE]. Monitoring Day 1: Sunday [DATE]th, 2024 Review of the plan of correction included 1:1 education for CNA B and LPN A, an audit for all residents with changes in conditions, in services for all charge nurses on facility policy, and in-service to all CNA 's regarding how to report and document any changes. -POC was accepted. Nurses were interviewed on: -When should you notify the physician? Like what things are noticeable? -What is described as a significant change or a change in condition? -When should you notify the doctor when there is a change in condition? -How often do you monitor them? And what do you do if you cannot reach the doctor? -Where do you document any changes? How do you left the nurse on the next shift know what occurred on your shift? How do you exchange information? In an interview on [DATE] at 4:40 pm, LVN A stated today was her first day. She explained Nurses should notify the physician immediately after changes in the resident's condition. They would notify the ADON when there was a change in condition in their breathing, change in respiratory, altered mental status. Other examples would be if the patient had an adverse reaction to medication or antibiotics and she also said if they had poor intake or output different from baseline, nausea, and vomiting. Once the doctor was notified, she would check on them every ,d+[DATE] minutes. If there were any thing that could be linked to respiratory issues, she would stay with the resident. If there was an emergency, we could use her nursing judgment to notify the doctor. Once that resident was sent out, she would then notify the physician. She stated you could document the resident's change in condition on the SBAR in the resident's assessment section. She would inform the nurse coming after her with the 24-hour report, chart on progress notes, and verbally let the nurse know with a handoff report. In an interview on [DATE] at 4:46 pm, CNA C stated that she had worked at the facility for ,d+[DATE] years and was PRN. She stated aids should notify the nurse immediately if there was a change in condition and they would document it as well. She would document the change in condition in her tablet and tell the nurse verbally. She explained that there was a certain section in the Kardex (resident charting for CNA's) that she would find the stop and watch alert. Staff could add specifically what was wrong with the resident if it was not listed. They would also notify the ADON or another nurse but mainly someone in nursing. In an interview on [DATE] at 4:50 pm, CNA D stated she had been working at the facility for one month and she worked the 2pm- 10pm shift She stated aids should notify the nurse as soon as a change in condition was noticed or immediately. A change in condition could be any behavior that was abnormal for that individual. They would document it in the POC under the new alert stop and watch tab. She stated she was comfortable going in the POC using the stop and watch. Staff would also let the coworkers who are relieving her know and if the situation was not handled, we could also notify the DON. In an interview on [DATE] at 4:54 pm, LVN B stated that he had been working at the facility for ,d+[DATE] weeks and he worked the 6am-6pm shift. He described that a change of condition could be anything outside of the normal like injuries, shortness of breath, and anything outside of their baseline, which could be something as small as a scrape. Nurses have two ways to document which is using the daily 24-hour report. They also have documentation in PCC so it was passed agency wide. There was a change in condition assessment in PCC and he would also add a progress note for nursing. The doctor should be notified as soon as possible, and he would also notify the DON. If there was an emergency, he would call 911, even if the doctor could not be reached. If there was a change in condition, he would try to check on them every ,d+[DATE] minutes or try to have someone stay with them. If they could not reach the doctor, then staff could call the medical group the facility works with. In an interview on [DATE] at 5:03 pm, MA A stated he had worked at the facility since October of 2023 and worked the 7am-7pm shift. He stated that aids notified the nurse if there was change in condition whenever they notice it or immediately. A change in condition could be swelling in the feet, nausea, vomiting, not eating, restlessness, coughing, or congestion. Aids could also notify the nurse, DON, or Administrator. They documented the change in condition by clicking on the new alert in the POC and they could add a new alert in the stop and watch. He stated he was comfortable with using the stop and watch. In an interview on [DATE] at 4:46 pm, MA B stated that she had worked at the facility for 1 week and she worked the 7am- 7pm shift. She explained that a change in condition could be anything such as no stool, diarrhea, change in skin color, quiet but now talking louder, slurring speech, or someone who normally talks but was now quiet. The nurse should be notified as soon as a change in condition was noticed. Aids documented the change in condition in the POC. They would go into the new alert section and place what is going on there. She stated she was comfortable with documenting in the new alert section. Aids could also notify the ADON or DON if the change in condition was not addressed by a nurse. In an interview on [DATE] at 5:10 pm, CNA E stated she had worked at the facility for 1 year and worked the 2pm- 10pm shift. She stated a change in condition could be when a resident skin color changes, they were feeling sick, or face drooping. If they were nonverbal, she would try and figure out what was wrong and then she would let the nurse know. The nurse should be informed immediately of any changes. These changes in condition would be documented in the stop and watch in the POC. Aids could go into the new alert and put it in there and she was comfortable with documenting it there. If there was a change in condition and the nurse could not get to that resident, she would also notify the ADON. In an interview on [DATE] at 5:15 pm, RN B stated that he had worked at the facility for over a year, and he worked the 6am- 6pm shift. He stated a change in condition could be classified as anything abnormal, diarrhea that was ongoing, constipation for more than 3 days, change in appetite, or behaviors. Nurses would notify the doctor immediately after the assessment. If they contacted the doctor and they did not answer within 2 hours, nurse could utilize their online service doctors for assistance. If a resident was having an emergency like active bleeding, they would not wait for the doctor, but they would call 911. If there was a change in condition, they checked on the resident based off the policy like every ,d+[DATE] minutes. Nurse would document the change in the SBAR and also do a note in the PCC. The nurse that comes in after him would do a verbal communication with the next nurse on what happened, any new orders, and what procedures so that they could know what was happening. They also have a shift to shift 24-hour report. In an interview on [DATE] at 5:21 pm, CNA F stated she had worked at the facility for 6 months and worked the 2pm- 10pm shift. She stated that a change in condition could be anything you could see like bruising, swelling, blood, and changes in diet. Aids should notify the nurse immediately, if they could not come right away, they could let the other nurse know as well as the DON's. They could update changes in the POC in the new alerts and on the first page, they could click on specific ones. She explained that they could also add custom symptoms on the stop and watch, but they still have to make sure they informed the nurses. In an interview on [DATE] at 5:53 pm, LVN C stated that she had worked at the facility for 4 months and worked from 8am-5pm. She described a change in condition could be different from baseline, like changes in vitals, labored breathing, bowel changes such as not voiding, sweaty, and also change in the alert and orientation. The doctor should be notified immediately whenever the change was noticed. They always get vital signs and give them to the physician to see what interventions should be given. Nurses have to make sure all orders were placed in PCC. She would also document the change in condition assessment in PCC, which asked what were the symptoms and who was notified. They always notified the DON, ADON, PCP, and responsible party. She stated she didnt have anyone to relieve her because she was the treatment nurse, but she would always add a PRN order for nurses to follow up with. Nurses have access to the wound care cart and order in PCC. She said she would get together with floor nurses to discuss skin assessments so the nurse could add it to 24-hour report. If they were to catch something she didn't, she would go and assess as soon as notified. If there was a change in condition, depending on the situation, she would check on them as often as needed, especially for things like oxygen and blood sugar. LVN C stated they were also able to use their nursing judgement and call 911 if the doctor was not responsive and the level of care they needed was outside of what they could do at the facility. In an interview on [DATE] at 6:03 pm, LVN D stated she had been working at the facility for 2 years and worked the 6pm-6am shift. She stated a change in condition could be anything that was abnormal with the patient. Examples would be someone coughing, rashes, scratchy throat, anything that would not be the resident's normal demeanor. The doctor should be contacted after the assessment. If she checked the orders and they have a standing order, she would follow those. If the manner was persistent manner or they didn't have orders, she would call the doctor. If the doctor was contacted and it had been a while since we got a response, she would let the DON know so she could contact the doctor. If that does not work, then they could call the medical director. She stated she would check on a resident at least every hour with a change in condition. Change in conditions were documented in the form in the computer. They would also do a progress note. She would let the next nurse know about what happened on her last shift by doing rounds with the new nurse and giving them the 24-hours report. If they reported something to her that happened to their shift, she would still follow up every hour. In an interview on [DATE] at 6:17 pm, WCN stated that he had been working at the facility for 2 weeks and worked the 6pm- 6am shift. He explained that a change in condition could be anything that was out of their normal stasis. This could be skin tears, wounds, coughing, loss of appetite, anything that is outside of normal. These changes would be documented in the progress notes, and we would do an incident report and also a SBAR. The progress notes would be the main note that would stick out. The doctor would be notified after the vitals and pain scales so the doctor could make a precise assessment for proper patient care. He would notify the doctor, ADON, DON, and the family so they were not the last to know. If a resident had an emergency, we could send them out via 911 because we have to use critical thinking or be proactive, so we won't have a dead person. Nurses exchanged information by using the 24-hour report, and they also walked room to room with the previous nurse. Nurses will both have a 24-hour report and take notes based off the initial notes. He stated they have to know everything that was going on, even the little things. Monitoring Day 2: Monday [DATE]th, 2024 In an interview on [DATE] at 1:51 pm, CNA G stated she had worked at the facility for ,d+[DATE] years and worked the 6am- 2pm. She stated a change in behavior could be everything, if they were throwing up and having diarrhea, not eating, or declining. They reported by letting the nurses know, then going into the POC to the new alerts to add what was going on with the resident. She stated she was comfortable with using the POC to make repots. If the nurse was not available, she would tell the ADON to let them know what was going on. In an interview on [DATE] at 1:57 pm, CNA H stated she had worked at the facility for 1 year and a half and worked the 6am- 2pm shift. She stated a change could range from someone getting aggressive, wandering, crying, or stopping eating. Anything that came off of their daily routine. If they have a change, she verbally told the nurse and she also put it in the POC. If she came back the next day and something wasn't done, she would tell the ADON or DON. In the POC, she would go to patient charting and click on new alert and stop and watch. It allowed them to put in what was the different reason for their change. They could also create a custom alert. She stated she was comfortable with creating customs alerts and the stop and watch. In an interview on [DATE] at 2:01 pm, RN C stated she had worked at the facility for ,d+[DATE] months and worked the 6am- 6pm shift. She stated that a change of confirm is any behavior that was different from the patient's baseline. This could be disorientation and confusion, abdominal pain, and diarrhea. She would have to do my assessment and check vital signs. She would check the medication to see if they have medication prescribed for that ailment then notify the doctor and family. If the doctors gave her an order, she would follow up on their recommendations. The DON would also be notified. The change was documented in the SBAR in the POC, and she would also create a progress note. If they reached out to the doctor and they did not respond right away, she would call 911 to send the resident out and let the DON know. Then she would follow back up with the doctor to let them know what was done. When a resident had a change in condition, they should be checked on frequently. In an interview on [DATE] at 2:10 pm, RN D stated she had worked at the facility for 1 year and worked the 6am- 6pm shift. She stated that a change in condition is anything that was not from the baseline, like commuting, diarrhea, anything that was not normal for them. When they have a change, they did their assessment and did a change of condition assessment form. Nurses were to notify the MD, RP, and the DON. If the doctor took a while to respond, she would let the DON know and they would reach out through a different route. In the event of a medical emergency, she would use her nursing judgement and send the patient out and document. The change of condition was documented in the form under assessment, she would do a progress note, and an incident report. If there was a change, they would check on the resident every 15 minutes, then every hour. Then she would check every hour. In an interview on [DATE] at 2:16 pm, ADON stated she had worked at the facility for 1 year and a half and worked from 8am- 5pm. She stated RN A was supposed to come in on [DATE] today but she did not but she was scheduled to come tomorrow. The DON was on PTO, but she was on schedule to work ,d+[DATE] and ,d+[DATE]. She stated she was out the week of ,d+[DATE] to,d+[DATE] but she said she nor the DON were notified of any changes in condition. She said if the DON had known, she knew she would have taken care of it herself. In an interview on [DATE] at 8:49 pm, LPN A stated that a change in condition could be when the resident that was not their normal self. Their blood pressure could be high, abnormal vomiting, or skin teas. If there was a change, they check the vitals, and examine what could have caused the change. They could also call the doctor to see if there was an order and they would follow it. This could be a lab or a diagnosis. He would also call the family and notify the DON. The documentation was the change in condition assessment, and he would do a progress report. If there was a change in condition the resident, he would monitor them every 15- 30 minutes, and if a medical emergency, he would call 911 even if the doctor had not responded. He stated he would fully document the changes on the reports. They exchanged information with the next shift nurse by using the 24-hour report and doing rounds. ADON and the investigator reviewed the staff roster with the in-service sing in sheet and pointed out that there were 4 staff members left to in-service. She stated that 2 staff were on PTO and would not be back that week, 2 staff were on nurse who worked PRN. She said she had reached out to them, but they did not answer. She stated she would reach out to them again to attempt to relay the information by phone. She sent a text message to the investigator at 7:28 pm informing that she was able to reach but PRN nurses successfully. Monitoring Day 3: Tuesday [DATE]th, 2024 -Reviewed the in-service list for CNA's and Nurse and all staff had been successfully in serviced. QAPI Charts were reviewed and all documents were completed. All residents were reviewed for recent changes in condition and no changes were identified. 24-hour reports were monitored and updates were completed per shift and notification was noted to the Dr. as needed. An Immediate Jeopardy (IJ) was identified on [DATE]. An IJ Template was provided to the facility on [DATE] at 4:31 pm. While the Immediate Jeopardy was removed on [DATE] at 1:52 pm, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their plan of removal.

Based on interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (CR#1) of five residents reviewed for quality of care. The facility failed to immediately assess and treat CR #1 and contact the doctor from [DATE]- [DATE] after CR#1 experienced ongoing vomiting and distress. CR#1 was transported to the hospital on [DATE] at 11am. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 4:31 PM. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for delay in needed treatment and care. Findings included: Record review of CR#1's face sheet dated [DATE] reflected he was an [AGE] year-old male that was admitted to the facility on [DATE] with diagnoses of rhabdomyolysis (a breakdown of muscle tissue that releases a damaging protein into the blood), dysphagia (difficulty swallowing) Type II Diabetes, and hypertension (high blood pressure). He was coded to DNR. Record review of CR #1's care plan last updated [DATE] reflected he had an ADL self-care performance deficit accompanied with impaired balance and limited mobility. CR#1 also had the potential for complications related to the diagnosis of hypertension. Interventions initiated [DATE] stated to monitor/document/report any s/s of headaches, confusion, disorientation, difficulty breathing, and nauseas and vomiting. Record review of CR #1 doctors' orders from [DATE]- [DATE] reflected that there was no documentation (orders) that CR #1 received medication for acid reflux, vomiting, or pain. Record review of the shift-to-shift report on [DATE]- [DATE] documented by the night nurse LPN A reflected that each resident had either a handwritten update regarding their condition from that shift or the words ok next to their nane. CR #1 did not have any documentation next to his name. Record review of the progress notes for CR #1 reflected on [DATE] and [DATE], no progress notes were documented. Record review of the progress note for CR #1 dated [DATE] at 10:29 am reflected RN A documented that she noticed pain while changing him. Vitals were BP ,d+[DATE], Heart rate was 127. Per the aid (name undisclosed), resident was vomiting for 2 days, and roommate stated that CR #1 was up all-night moaning. He was given Tylenol and midodrine, but resident vomited up the medicine. Dr. was called and resident was instructed to send resident to hospital due to acidosis. Record review of the hospital record for CR #1 dated [DATE] at 12:03 pm reflected that CR #1 was admitted in a wheelchair due to shortness of breath, weakness, tachycardia (a heart rate that exceeded the normal resting rate), and he was not able to verbalize complaints. His pain intensity was measured as an 8 on a scale of 1- 10 and the chief complaint noted was respiratory. CR #1 also had a blood pressure reading of ,d+[DATE]. The final record of his expiration have not yet been received. In an interview on [DATE] at 12:41 pm with the Roommate of CR #1, he stated that if he was the aid, he would have sent CR#1 to the hospital that night. He expressed that during the night of [DATE], CR#1 was getting over heated and the aids kept checking on him. He couldn't say what was wrong with him, but he made a lot of noise throughout the night and the in-room ac unit was set to 69 degrees. CR#1 was sent to the hospital the next day ([DATE]) but Roommate stated that he would not have kept him at the facility under his conditions and sent him out sooner. He did not speak with he aids or the nurse regarding his roommate. In an interview on [DATE] at 3:11 pm, RN A stated that she was off on [DATE] and [DATE]. When she returned on [DATE] and was told by CNA A that CR#1 was throwing up and had been throwing up for the past 2 days. Upon rounds, CR #1 was nauseous and vomiting. RN A asked CR#1 what was wrong, and he stated, I don't know, but I know something isn't right. Resident was sweaty and after the assessment she contacted Dr. and informed him his heart rate was high, but BP was low. Dr. agreed to send him to the hospital and came by the facility before he left with the EMT to assess him. LPN A, who worked the night shift did not inform RN A of any changes in CR #1's condition. In an interview on [DATE] at 3:29 pm, CNA A stated that she worked on [DATE] from 6am-10pm. CR #1 started to vomit around 6:30 pm and his vomit was a dark brown that resembled hot chocolate. Around 7pm, she relayed his condition to LPN A, who stated that he would check on the CR#1 but she was unsure if he did. During her 2nd round around 9pm, CR #1 had vomited on the floor and all over his sheets. LPN A told CNA A that he would give him something for acid reflux. CNA A returned to work with CR#1 on [DATE] at 6am. When she changed him, she heard gurgling noises, he was not speaking, she and verbally reported it to RN A at 8am. RN A did not come to immediately check on the CR #! and she sent RN A a text at 9:14am saying CR #1was grunting and needed to be looked at. CNA A stated at 9:30am, RN A came to check on the CR#1 and gave him a covid test. CNA A stated CR#1 was taken by EMT around 11am. In an interview on [DATE] at 3:43 pm with CNA B, who stated she worked on [DATE] from 10pm-6am. When she saw CR #1 at 10pm, he complained of being hot and she adjusted his AC to 69 and turned the AC on in the hallway. CNA B informed LPN A and LPN A stated that would give CR #1 something. However, CR #1 continued to tell CNA B that something was not right, and he rang the call light so much that night that it made it hard for her to tend to other residents. She said she did not know if LPN A contacted the doctor, but she tried to hint that he should. She informed LPN A of CR #1's status at 10:30pm and at 2am. In an interview on [DATE] at 3:56 pm with Dr. Z, who explained that when he saw CR #1 on [DATE], he was fine. Resident was normally verbal, and he could express his likes, dislikes, and pain. Once RN A told him that CR #1 was not well, he immediately went to the facility, entering before the EMT, and assessed the resident. Upon assessment, CR #1 was not responsive, hypotensive, and septic. When he went to the hospital, Dr. Z was also CR#1's treatment doctor at the hospital. The CP scan reflected that he had bilateral aspiration (could have choked on saliva laying down) and cause of death was aspiration pneumonia on [DATE]. The first time he was contacted regarding CR#1's symptoms was [DATE]. Dr. Z expressed that if he had been informed that CR#1 was vomiting and had diarrhea on [DATE], he would not have sent him to the hospital, but ran labs and prescribed him something for his symptoms. He stated that he was prompted to send the resident out because of his abnormal vitals, altered mental status, and low blood pressure. In an interview on [DATE] at 4:28 pm, the DON who stated that if a resident had a change in condition, they were supposed to assess the patient and get with the doctor. A change in condition was described as anything that deviated from the patient's baseline. She stated that CR#1 was a very pleasant man, and he was able to verbalize when something was wrong with him. She was not informed that CR #1 was ill until [DATE]. RN A told her the morning of [DATE] and when she went to check on CR#1, he was weak, nausea, his eyes were closed, and kept trying to clear his throat. Dr. Z was contacted, and CR#1 was sent out that morning. Through investigation, DON learned that CNA A had noticed that CR#1 had vomited, and she cleaned him up each time. CNA A also stated that she informed LPN A. DON preformed an in-service with CNA A and followed up with LPN A, who denied any knowledge of CR#1 being sick. CNA A was told that in the future, she should wait until the nurse came to view the vomit before she cleaned it up and all aids were informed to reach out to the DON if they tell a nurse about a sick resident, and they do not follow up. DON also verbally reeducated RN A on the facilities change in condition policy and she disclosed that RN A shift started at 6am, but she arrived at the facility late that day and did not start her rounds until 9 am. LPN A was interviewed but he was not reeducated. DON expressed that she did not reeducate LPN A because she had worked with him at a different facility and felt that he was a very competent nurse, and she believed his statement because the other staff have been messy. DON stated that the harm in not communicating when a resident changed from baseline could be hospitalization . In an interview on [DATE] at 5:04 pm, LPN A stated that he started working at the facility during the month of August and worked on [DATE] and [DATE] from 6pm-6am. He explained that nurses were to round as much as possible and he remembered entering the room for CR#1 on [DATE], but he did not wake him because he was asleep. He denied that CNA A or CNA B informed him that CR #1 was vomiting and he did not administer any medication to him outside of what was prescribed. LPN A stated that if he knew there was a change in condition with CR#1, he would have checked what type of medications he was already prescribed and let the on-call doctor know. The type of assessment would have depended on the condition of the resident, but in the case of CR#1, he would have checked vitals, examined the vomit and its frequency, then followed up with the doctor. He could not remember if he did rounds with RN A on the morning of [DATE]. In an interview on [DATE] at 5:25 pm, Admin stated that her first-time hearing of the incident with CR#1 was during the morning of [DATE]. RN A told her that she was informed by the aid that CR#1 had been vomiting for several days and Dr. Z was called in before he went to the hospital. She stated that CNA A was educated in their stop and watch documentation system in the resident portal. Admin also stated that she felt that if RN A had arrived to work at 6am and did rounds immediately once she arrived, she might have been able to check on him sooner. Admin got the text later that day that CR#1 had expired. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 4:31 pm. The Admin and DON were notified. The Admin was provided with the IJ template on [DATE] at 4:31 pm. The following Plan of Removal submitted by the facility was accepted on [DATE] at 7:25 am: Immediate Jeopardy Facility X: On [DATE], an incident survey was initiated at Facility X. On [DATE] the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safety. The facility failed to immediately assess and treat CR#1 and contact the doctor from [DATE] - [DATE] after CR#1 experienced ongoing vomiting and distress. CR#1 was transported to the hospital on [DATE] at 11am. Immediate Action: o The Executive Director/Director of Clinical Operations will be educated by the Regional Directors on [DATE] to Rounding and Monitoring of residents on change of condition and timely Notification of physician and responsible party. o The DCO/Designee will conduct 1:1 in-service with LPN A to include Resident Change in condition, Shift-to-Shift reporting & Documenting changes in condition, Clinical documentation/Charting, timely notification of the physician and responsible party on change of condition to be completed on [DATE]. o The Director of Clinical Operations initiated education on [DATE] to charge nurses on: Resident Change in condition, Shift-to-Shift reporting & Documenting changes in condition, Clinical documentation/Charting, timely notification of the physician and responsible party on change of condition to be completed on [DATE]. Staff will not be allowed to provide direct resident care until training has been completed. o The DCO/Designee initiated education on [DATE] to Certified Nursing Assistants on notifying charge nurses on change of condition and documenting on Stop & Watch in PCC to be completed on [DATE]. Staff will not be allowed to provide direct resident care until training has been completed. o The clinical team (DCO, ADCO , and designated nursing staff) initiated chart audits on all residents with a change in condition on [DATE]. Resident assessments were completed on [DATE] and no new changes in condition identified. Facilities Plan to ensure compliance quickly: o The clinical team (DCO, ADCO, and designated nursing staff) initiated chart audits on all residents with a change in condition to ensure timely notification of physician and responsible party was completed. o The DCO/Designee with review 24-hour report daily to ensure that timely notification of the physician and responsible was completed, starting [DATE]. o The Medical Director was notified of the Immediate Jeopardy on [DATE]. o The current policies reviewed with the Medical Director on [DATE] on Resident Assessment, Shift-to-Shift reporting & Documenting changes on the 24-hour report, Clinical documentation/Charting, change in condition, notifying the physician, Stop & Watch, with no changes to the current policy. This practice will be reviewed monthly with the QA committee to ensure compliance in place. o Daily rounds will be conducted by Nurse management to communicate any changes of condition and timely notification of the physician and RP will occur starting [DATE]. Monitoring Day 1: Sunday [DATE]th, 2024 Review of the plan of correction included 1:1 education for CNA B and LPN A, an audit for all residents with changes in conditions, in services for all charge nurses on facility policy, and in-service to all CNA 's regarding how to report and document any changes. -POC was accepted. Nurses were interviewed on: -When should you notify the physician? Like what things are noticeable? -What is described as a significant change or a change in condition? -When should you notify the doctor when there is a change in condition? -How often do you monitor them? And what do you do if you cannot reach the doctor? -Where do you document any changes? How do you left the nurse on the next shift know what occurred on your shift? How do you exchange information? In an interview on [DATE] at 4:40 pm, LVN A stated today was her first day. She explained Nurses should notify the physician immediately after changes in the resident's condition. They would notify the ADON when there was a change in condition in their breathing, change in respiratory, altered mental status. Other examples would be if the patient had an adverse reaction to medication or antibiotics and she also said if they had poor intake or output different from baseline, nausea, and vomiting. Once the doctor was notified, she would check on them every ,d+[DATE] minutes. If there were any thing that could be linked to respiratory issues, she would stay with the resident. If there was an emergency, we could use her nursing judgment to notify the doctor. Once that resident was sent out, she would then notify the physician. She stated you could document the resident's change in condition on the SBAR in the resident's assessment section. She would inform the nurse coming after her with the 24-hour report, chart on progress notes, and verbally let the nurse know with a handoff report. In an interview on [DATE] at 4:46 pm, CNA C stated that she had worked at the facility for ,d+[DATE] years and was PRN. She stated aids should notify the nurse immediately if there was a change in condition and they would document it as well. She would document the change in condition in her tablet and tell the nurse verbally. She explained that there was a certain section in the Kardex (resident charting for CNA's) that she would find the stop and watch alert. Staff could add specifically what was wrong with the resident if it was not listed. They would also notify the ADON or another nurse but mainly someone in nursing. In an interview on [DATE] at 4:50 pm, CNA D stated she had been working at the facility for one month and she worked the 2pm- 10pm shift She stated aids should notify the nurse as soon as a change in condition was noticed or immediately. A change in condition could be any behavior that was abnormal for that individual. They would document it in the POC under the new alert stop and watch tab. She stated she was comfortable going in the POC using the stop and watch. Staff would also let the coworkers who are relieving her know and if the situation was not handled, we could also notify the DON. In an interview on [DATE] at 4:54 pm, LVN B stated that he had been working at the facility for ,d+[DATE] weeks and he worked the 6am-6pm shift. He described that a change of condition could be anything outside of the normal like injuries, shortness of breath, and anything outside of their baseline, which could be something as small as a scrape. Nurses have two ways to document which is using the daily 24-hour report. They also have documentation in PCC so it was passed agency wide. There was a change in condition assessment in PCC and he would also add a progress note for nursing. The doctor should be notified as soon as possible, and he would also notify the DON. If there was an emergency, he would call 911, even if the doctor could not be reached. If there was a change in condition, he would try to check on them every ,d+[DATE] minutes or try to have someone stay with them. If they could not reach the doctor, then staff could call the medical group the facility works with. In an interview on [DATE] at 5:03 pm, MA A stated he had worked at the facility since October of 2023 and worked the 7am-7pm shift. He stated that aids notified the nurse if there was change in condition whenever they notice it or immediately. A change in condition could be swelling in the feet, nausea, vomiting, not eating, restlessness, coughing, or congestion. Aids could also notify the nurse, DON, or Administrator. They documented the change in condition by clicking on the new alert in the POC and they could add a new alert in the stop and watch. He stated he was comfortable with using the stop and watch. In an interview on [DATE] at 4:46 pm, MA B stated that she had worked at the facility for 1 week and she worked the 7am- 7pm shift. She explained that a change in condition could be anything such as no stool, diarrhea, change in skin color, quiet but now talking louder, slurring speech, or someone who normally talks but was now quiet. The nurse should be notified as soon as a change in condition was noticed. Aids documented the change in condition in the POC. They would go into the new alert section and place what is going on there. She stated she was comfortable with documenting in the new alert section. Aids could also notify the ADON or DON if the change in condition was not addressed by a nurse. In an interview on [DATE] at 5:10 pm, CNA E stated she had worked at the facility for 1 year and worked the 2pm- 10pm shift. She stated a change in condition could be when a resident skin color changes, they were feeling sick, or face drooping. If they were nonverbal, she would try and figure out what was wrong and then she would let the nurse know. The nurse should be informed immediately of any changes. These changes in condition would be documented in the stop and watch in the POC. Aids could go into the new alert and put it in there and she was comfortable with documenting it there. If there was a change in condition and the nurse could not get to that resident, she would also notify the ADON. In an interview on [DATE] at 5:15 pm, RN B stated that he had worked at the facility for over a year, and he worked the 6am- 6pm shift. He stated a change in condition could be classified as anything abnormal, diarrhea that was ongoing, constipation for more than 3 days, change in appetite, or behaviors. Nurses would notify the doctor immediately after the assessment. If they contacted the doctor and they did not answer within 2 hours, nurse could utilize their online service doctors for assistance. If a resident was having an emergency like active bleeding, they would not wait for the doctor, but they would call 911. If there was a change in condition, they checked on the resident based off the policy like every ,d+[DATE] minutes. Nurse would document the change in the SBAR and also do a note in the PCC. The nurse that comes in after him would do a verbal communication with the next nurse on what happened, any new orders, and what procedures so that they could know what was happening. They also have a shift to shift 24-hour report. In an interview on [DATE] at 5:21 pm, CNA F stated she had worked at the facility for 6 months and worked the 2pm- 10pm shift. She stated that a change in condition could be anything you could see like bruising, swelling, blood, and changes in diet. Aids should notify the nurse immediately, if they could not come right away, they could let the other nurse know as well as the DON's. They could update changes in the POC in the new alerts and on the first page, they could click on specific ones. She explained that they could also add custom symptoms on the stop and watch, but they still have to make sure they informed the nurses. In an interview on [DATE] at 5:53 pm, LVN C stated that she had worked at the facility for 4 months and worked from 8am-5pm. She described a change in condition could be different from baseline, like changes in vitals, labored breathing, bowel changes such as not voiding, sweaty, and also change in the alert and orientation. The doctor should be notified immediately whenever the change was noticed. They always get vital signs and give them to the physician to see what interventions should be given. Nurses have to make sure all orders were placed in PCC. She would also document the change in condition assessment in PCC, which asked what were the symptoms and who was notified. They always notified the DON, ADON, PCP, and responsible party. She stated she didnt have anyone to relieve her because she was the treatment nurse, but she would always add a PRN order for nurses to follow up with. Nurses have access to the wound care cart and order in PCC. She said she would get together with floor nurses to discuss skin assessments so the nurse could add it to 24-hour report. If they were to catch something she didn't, she would go and assess as soon as notified. If there was a change in condition, depending on the situation, she would check on them as often as needed, especially for things like oxygen and blood sugar. LVN C stated they were also able to use their nursing judgement and call 911 if the doctor was not responsive and the level of care they needed was outside of what they could do at the facility. In an interview on [DATE] at 6:03 pm, LVN D stated she had been working at the facility for 2 years and worked the 6pm-6am shift. She stated a change in condition could be anything that was abnormal with the patient. Examples would be someone coughing, rashes, scratchy throat, anything that would not be the resident's normal demeanor. The doctor should be contacted after the assessment. If she checked the orders and they have a standing order, she would follow those. If the manner was persistent manner or they didn't have orders, she would call the doctor. If the doctor was contacted and it had been a while since we got a response, she would let the DON know so she could contact the doctor. If that does not work, then they could call the medical director. She stated she would check on a resident at least every hour with a change in condition. Change in conditions were documented in the form in the computer. They would also do a progress note. She would let the next nurse know about what happened on her last shift by doing rounds with the new nurse and giving them the 24-hours report. If they reported something to her that happened to their shift, she would still follow up every hour. In an interview on [DATE] at 6:17 pm, WCN stated that he had been working at the facility for 2 weeks and worked the 6pm- 6am shift. He explained that a change in condition could be anything that was out of their normal stasis. This could be skin tears, wounds, coughing, loss of appetite, anything that is outside of normal. These changes would be documented in the progress notes, and we would do an incident report and also a SBAR. The progress notes would be the main note that would stick out. The doctor would be notified after the vitals and pain scales so the doctor could make a precise assessment for proper patient care. He would notify the doctor, ADON, DON, and the family so they were not the last to know. If a resident had an emergency, we could send them out via 911 because we have to use critical thinking or be proactive, so we won't have a dead person. Nurses exchanged information by using the 24-hour report, and they also walked room to room with the previous nurse. Nurses will both have a 24-hour report and take notes based off the initial notes. He stated they have to know everything that was going on, even the little things. Monitoring Day 2: Monday [DATE]th, 2024 In an interview on [DATE] at 1:51 pm, CNA G stated she had worked at the facility for ,d+[DATE] years and worked the 6am- 2pm. She stated a change in behavior could be everything, if they were throwing up and having diarrhea, not eating, or declining. They reported by letting the nurses know, then going into the POC to the new alerts to add what was going on with the resident. She stated she was comfortable with using the POC to make repots. If the nurse was not available, she would tell the ADON to let them know what was going on. In an interview on [DATE] at 1:57 pm, CNA H stated she had worked at the facility for 1 year and a half and worked the 6am- 2pm shift. She stated a change could range from someone getting aggressive, wandering, crying, or stopping eating. Anything that came off of their daily routine. If they have a change, she verbally told the nurse and she also put it in the POC. If she came back the next day and something wasn't done, she would tell the ADON or DON. In the POC, she would go to patient charting and click on new alert and stop and watch. It allowed them to put in what was the different reason for their change. They could also create a custom alert. She stated she was comfortable with creating customs alerts and the stop and watch. In an interview on [DATE] at 2:01 pm, RN C stated she had worked at the facility for ,d+[DATE] months and worked the 6am- 6pm shift. She stated that a change of confirm is any behavior that was different from the patient's baseline. This could be disorientation and confusion, abdominal pain, and diarrhea. She would have to do my assessment and check vital signs. She would check the medication to see if they have medication prescribed for that ailment then notify the doctor and family. If the doctors gave her an order, she would follow up on their recommendations. The DON would also be notified. The change was documented in the SBAR in the POC, and she would also create a progress note. If they reached out to the doctor and they did not respond right away, she would call 911 to send the resident out and let the DON know. Then she would follow back up with the doctor to let them know what was done. When a resident had a change in condition, they should be checked on frequently. In an interview on [DATE] at 2:10 pm, RN D stated she had worked at the facility for 1 year and worked the 6am- 6pm shift. She stated that a change in condition is anything that was not from the baseline, like commuting, diarrhea, anything that was not normal for them. When they have a change, they did their assessment and did a change of condition assessment form. Nurses were to notify the MD, RP, and the DON. If the doctor took a while to respond, she would let the DON know and they would reach out through a different route. In the event of a medical emergency, she would use her nursing judgement and send the patient out and document. The change of condition was documented in the form under assessment, she would do a progress note, and an incident report. If there was a change, they would check on the resident every 15 minutes, then every hour. Then she would check every hour. In an interview on [DATE] at 2:16 pm, ADON stated she had worked at the facility for 1 year and a half and worked from 8am- 5pm. She stated RN A was supposed to come in on [DATE] today but she did not but she was scheduled to come tomorrow. The DON was on PTO, but she was on schedule to work ,d+[DATE] and ,d+[DATE]. She stated she was out the week of ,d+[DATE] to,d+[DATE] but she said she nor the DON were notified of any changes in condition. She said if the DON had known, she knew she would have taken care of it herself. In an interview on [DATE] at 8:49 pm, LPN A stated that a change in condition could be when the resident that was not their normal self. Their blood pressure could be high, abnormal vomiting, or skin teas. If there was a change, they check the vitals, and examine what could have caused the change. They could also call the doctor to see if there was an order and they would follow it. This could be a lab or a diagnosis. He would also call the family and notify the DON. The documentation was the change in condition assessment, and he would do a progress report. If there was a change in condition the resident, he would monitor them every 15- 30 minutes, and if a medical emergency, he would call 911 even if the doctor had not responded. He stated he would fully document the changes on the reports. They exchanged information with the next shift nurse by using the 24-hour report and doing rounds. ADON and the investigator reviewed the staff roster with the in-service sing in sheet and pointed out that there were 4 staff members left to in-service. She stated that 2 staff were on PTO and would not be back that week, 2 staff were on nurse who worked PRN. She said she had reached out to them, but they did not answer. She stated she would reach out to them again to attempt to relay the information by phone. She sent a text message to the investigator at 7:28 pm informing that she was able to reach but PRN nurses successfully. Monitoring Day 3: Tuesday [DATE]th, 2024 -Reviewed the in-service list for CNA's and Nurse and all staff had been successfully in serviced. QAPI Charts were reviewed and all documents were completed. All residents were reviewed for recent changes in condition and no changes were identified. 24-hour reports were monitored and updates were completed per shift and notification was noted to the Dr. as needed. An Immediate Jeopardy (IJ) was identified on [DATE]. An IJ Template was provided to the facility on [DATE] at 4:31 pm. While the Immediate Jeopardy was removed on [DATE] at 1:52 pm, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their plan of removal.

Based on observation, interview and record review the facility failed to ensure residents were treated respect and dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for one (Resident #2) of five residents reviewed for dignity. The facility failed to ensure Resident #2 was not referred to as a feeder. This failure could place residents at risk for diminished quality of life, loss of dignity, and self-worth . Findings include: A record review of Resident #2's face sheet, dated 8/8/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included contracted left hand, lack of coordination, muscle weakness, dysphagia (difficulty swallowing) and dementia (loss of memory/thinking). A record review of Resident #2's admission MDS assessment, dated 6/24/24, reflected a BIMS score of 00, which indicated severely impaired cognition. This assessment reflected Resident #2 required total dependance and a one-person physical assist with eating. During an observation and interview on 8/8/24 at 12:38 p.m., Resident #2 was observed lying in bed with a meal tray by her side. CNA A said, she's a feeder and stated she had three other feeders on the hall to feed. She said she was new to the job and did not remember if she was trained on rights and dignity towards residents. During an interview on 8/8/24 at 3:55 PM, the DON said CNA A should not have used the word feeder to refer to residents who needed help eating. The DON said the language was not appropriate and could affect a resident's dignity in a negative manner. The DON stated she thought staff were trained on resident rights and dignity via computer-based trainings. The DON stated staff were monitored for resident rights and dignity through interviews and rounding by management staff. During an interview on 8/8/24 at 4:00 PM, the Administrator said residents should be referred to as the Red Napkin Program assisted dining residents. The Administrator said staff were trained on resident rights and dignity via computer-based trainings. The Administrator said the DON and other nurses monitored staff for resident rights and dignity when they made rounds. She said residents referred to as feeders was not dignified and did not show respect. A record review of the facility's policy titled Resident Rights, dated December 2016, reflected the following: Policy Statement Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 6 residents (Resident #1) reviewed for care plans. The facility failed to ensure Resident #1 received supervision during her meals in accordance with her care plan. This failure could place residents at risk of not having their needs met and decreased nutritional intake. The findings include: Record review of Resident #1's face sheet, dated 8/8/24, reflected a [AGE] year-old female who was originally admitted to the facility on [DATE] and most recently on 3/3/23. Her diagnoses included hemiplegia and hemiparesis affecting right dominant side (weakness/paralysis), muscle weakness, lack of coordination, vascular dementia (brain damage from impaired blood floor), muscle wasting, heart failure, mild protein-calorie malnutrition, hypertension (high blood pressure), and gastro-esophageal reflux disease (condition in which stomach acid repeatedly flows back up into the esophagus, causing irritation and discomfort). Record review of Resident #1's quarterly MDS assessment, dated 6/13/24, reflected her had moderately impaired cognition as indicated by a BIMS score of 11. Resident #1 required - (GG section) Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs . Eating - (how resident eats and drinks .Self-Performance - Limited assistance - resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance. Support - One person physical assist. Resident #1's active diagnoses included stroke, Neurological: Cerebrovascular Accident/Transient Ischemic Attack, Stroke, Non-Alzheimer's dementia (Lewy body dementia [a common type of dementia that affects memory, movement, thinking, mood, and behavior.])Hemiplegia or Hemiparesis (weakness/paralysis). Record review of Resident #1's care plan, dated 8/8/2024, reflected the following in part: Focus: [Resident #1] have an ADL self-care performance deficit r/t disease processes/decline in health. Date initiated and revised 10/22/20. Goal: [Resident #1] risk for decline with ADL's will be minimized QD and ongoing thru the next review date. Date initiated 10/22/20, Revised on: 5/22/2024, Target Date: 8/20/24. Intervention: Eating: The resident requires supervision of 1 staff to eat initiated and revised 10/22/20. Record review of Resident #1's Nutritional Risk Assessment, dated 3/4/2024, (most recent) reflected the following in part: .Eating: self-performance - Supervision .Nutritional assessment 1. inadequate food intake r/t mechanical problem with hand AEB resident report of pain/ trouble opening and closing left hand with food intake. Goal: No weight loss >5% 30 days. Resident to be able to consume foods adequate using her left-hand 2 .Additional Information - She reports she has a lot of pain in her left hand and that she has noticed greater difficulty when opening and closing it to self-feed . She is able to use her left hand to self feed. Still struggles with hand/arm control. Right side doesn't move Record review of the facility POC report for Resident #1, dated 8/8/24, reflected the following in part: POC [Key] 1 - Eating: Self performance - 0-Independent - no help or staff oversight at any time. 1-Supervision - oversight, encouragement, or cueing. 2 - Limited Assistance - Resident highly involved in activity. Staff provided guided maneuvering of limbs or other non-weight-bearing assistance . 2- Eating: Support Provided - (How resident eats and drinks, regardless of skill . 1-Setup help only. 2- One-person physical assist . 8/1/24 - 8/8/24 - Resident #1 did not received the level of assistance required based on her Care Plan and MDS (The Resident requires Supervision of 1 staff to eat) 21 out of 23 meals documented. 8/1/24: Breakfast (Supervision/Setup help only) Lunch (Supervision/Setup help only) Dinner (Independent/No Set up or physical help from staff). 8/2//24: Breakfast (Supervision/Setup help only) Lunch (Supervision/Setup help only) Dinner (Independent/No Set up or physical help from staff). 8/3/24: Breakfast (Independent/Setup help only) Lunch (Independent/Setup help only) Dinner (Independent/No Set up or physical help from staff). 8/4/24: Breakfast (Supervision/Setup help only) Lunch (Supervision/Setup help only) Dinner (Independent/Setup help only). 8/5/24: Breakfast (Supervision/Setup help only) Lunch (Supervision/Setup help only) Dinner (Supervision/Setup help only). 8/6/24: Breakfast (Limited Assistance/One person physical assist) Lunch (Limited Assistance/One person physical assist) Dinner (Supervision/Setup help only). 8/7/24: Breakfast (Independent/Setup help only) Lunch (Independent/Setup help only) Dinner (Supervision/Setup help only). 8/8/24: Breakfast (Supervision/Setup help only), Lunch (Observed) - (Independent/Setup help only). Record review of Resident #1's weights reflected the following: 7/2/24 - 220.6 lbs. 7/3/24 - 218.4 lbs. 7/4/24 - 217.2 lbs. 7/5/24 - 218.4 lbs. 7/18/24 - 216.4 lbs. 7/22/24 - 212.8 lbs. 3.54% weight loss between 7/2/24 - 7/22/24 In an observation and interview on 8/8/24 at 12:36 PM - 12:56 PM, revealed Resident #1 was delivered her lunch tray (meat, vegetables, mashed potatoes and two beverages) at 12:36 PM and the staff left the room and continued delivering lunch trays. Staff did not enter the room to assist Resident #1 eat her food. She ate with her left hand. When Resident #1 brought each bite of food to her mouth it would fall off the fork because her hand was unsteady and shook while she ate. She said her hand was weak and it was difficult. Resident #1 attempted to drink her juice. She picked up the cup and attempted to drink the beverage as her hand began to shake. Resident #1 attempted to bring the cup to her lips but she wasted the beverage due to her hand shaking. She said she did not receive assistance or asked if she needed assistance while she ate. She continued to try and eat her food. This State Surveyor requested Resident #1 push her call light. CNA A responded to the call light. Resident #1 said she was tired of trying to eat because her hand was shaking and said to CNA A it was hard to eat because she kept wasting her food. Resident #1 said if she had help she would have finished her food. Resident #1 ate 25% of her food. Staff did not supervise Resident #1 when she ate her food. During an interview on 8/8/24 at 12:58 PM, CNA A said, Resident #1 did not require assistance or supervision while she ate. She said Resident #1 required set up with her meal tray. She said Resident #1 was able to eat independently. She said the nurses informed her about the amount of assistance Resident #1 needed. CNA A said Resident #1 may have eaten slow, but she was able to eat without assistance or supervision. She said she could check the POC. She said she was feeding another resident when Resident #1 pushed her call light. She said she was not aware of Resident #1's care plan interventions. In an interview on 8/8/24 at 1:03 PM, the DON said if Resident #1 needed help, she should have been assisted with her meal. She said Resident #1 was able to feed herself. She said the care plan intervention (the resident requires supervision of 1 staff to eat ate initiated and revised) meant the facility staff should have Resident #1 by going in and out of her room while she ate her food. She said it did not mean a staff did not need to physically assist Resident #1. The DON said she was not able to answer questions on the coding for the MDS Nurse and the Reg. The MDS RN would answer questions related to assistance level indicated in Resident #1's MDS. She said Resident #1's food intake could be diminished if she was not assisted to eat. In an interview on 8/8/24 at 1:15 PM with the Regional MDS RN said Resident #1 needed supervision for eating. She said Resident #1 should have been provided set up and periodically supervised through out the time she ate. She said if staff did not go in the room and supervise Resident #1 while she ate then Resident #1, did not receive the correct level of assistance. She said the facility should re-educate staff on what was expected related to care plans and how interventions should be carried out. In an interview on 8/8/24 at 4:00 PM with the ADMIN and the DON, the ADMIN said she expected staff to support and assist Resident #1 based on the care plan intervention ( The Resident requires Supervision of 1 staff to eat). The ADMIN said staff should have been available in the room to meet Resident #1's needs. The DON said the care plan may not have been updated because she thought the resident did not need physical assistance. The ADMIN said the care plan should be followed until it was updated if needed. The ADMIN said the resident was at risk for not being able to eat all of her food. Record review of the facility policy on Comprehensive Care Plan (effective date 1/20/21 and revised 4/25/21) reflected the following in part: .Policy - Every resident will have an individualized interdisciplinary plan of care in place .6. The resident .a. The initial goals of the resident include the GG section . c. Any services and treatment to be administered by the community and personnel acting on behalf of the community

Based on observations, interviews, and record review, the facility failed to provide the necessary services to maintain good nutrition for 1 of 6 residents reviewed for ADLs (Residents #1.) The facility failed to ensure Resident #1 received supervision and assistance during her meals. 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 nutrition. The findings include: Record review of Resident #1's face sheet, dated 8/8/24, reflected a [AGE] year-old female who was originally admitted to the facility on [DATE] and most recently on 3/3/23. Her diagnoses included hemiplegia and hemiparesis affecting right dominant side (weakness/paralysis), muscle weakness, lack of coordination, vascular dementia (brain damage from impaired blood floor), muscle wasting, heart failure, mild protein-calorie malnutrition, hypertension (high blood pressure), and gastro-esophageal reflux disease (condition in which stomach acid repeatedly flows back up into the esophagus, causing irritation and discomfort). Record review of Resident #1's quarterly MDS assessment, dated 6/13/24, reflected her had moderately impaired cognition as indicated by a BIMS score of 11. Resident #1 required - (GG section) Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs . Eating - (how resident eats and drinks .Self-Performance - Limited assistance - resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance. Support - One person physical assist. Resident #1's active diagnoses included stroke, Neurological: Cerebrovascular Accident/Transient Ischemic Attack, Stroke, Non-Alzheimer's dementia (Lewy body dementia [a common type of dementia that affects memory, movement, thinking, mood, and behavior.])Hemiplegia or Hemiparesis (weakness/paralysis). Record review of Resident #1's care plan, dated 8/8/2024, reflected the following in part: Focus: [Resident #1] have an ADL self-care performance deficit r/t disease processes/decline in health. Date initiated and revised 10/22/20. Goal: [Resident #1] risk for decline with ADL's will be minimized QD and ongoing thru the next review date. Date initiated 10/22/20, Revised on: 5/22/2024, Target Date: 8/20/24. Intervention: Eating: The resident requires supervision of 1 staff to eat initiated and revised 10/22/20. Record review of Resident #1's Nutritional Risk Assessment, dated 3/4/2024, (most recent) reflected the following in part: .Eating: self-performance - Supervision .Nutritional assessment 1. inadequate food intake r/t mechanical problem with hand AEB resident report of pain/ trouble opening and closing left hand with food intake. Goal: No weight loss >5% 30 days. Resident to be able to consume foods adequate using her left-hand 2 .Additional Information - She reports she has a lot of pain in her left hand and that she has noticed greater difficulty when opening and closing it to self-feed . She is able to use her left hand to self feed. Still struggles with hand/arm control. Right side doesn't move Record review of the facility POC report for Resident #1, dated 8/8/24, reflected the following in part: POC [Key] 1 - Eating: Self performance - 0-Independent - no help or staff oversight at any time. 1-Supervision - oversight, encouragement, or cueing. 2 - Limited Assistance - Resident highly involved in activity. Staff provided guided maneuvering of limbs or other non-weight-bearing assistance . 2- Eating: Support Provided - (How resident eats and drinks, regardless of skill . 1-Setup help only. 2- One-person physical assist . 8/1/24 - 8/8/24 - Resident #1 did not received the level of assistance required based on her Care Plan and MDS (The Resident requires Supervision of 1 staff to eat) 21 out of 23 meals documented. 8/1/24: Breakfast (Supervision/Setup help only) Lunch (Supervision/Setup help only) Dinner (Independent/No Set up or physical help from staff). 8/2//24: Breakfast (Supervision/Setup help only) Lunch (Supervision/Setup help only) Dinner (Independent/No Set up or physical help from staff). 8/3/24: Breakfast (Independent/Setup help only) Lunch (Independent/Setup help only) Dinner (Independent/No Set up or physical help from staff). 8/4/24: Breakfast (Supervision/Setup help only) Lunch (Supervision/Setup help only) Dinner (Independent/Setup help only). 8/5/24: Breakfast (Supervision/Setup help only) Lunch (Supervision/Setup help only) Dinner (Supervision/Setup help only). 8/6/24: Breakfast (Limited Assistance/One person physical assist) Lunch (Limited Assistance/One person physical assist) Dinner (Supervision/Setup help only). 8/7/24: Breakfast (Independent/Setup help only) Lunch (Independent/Setup help only) Dinner (Supervision/Setup help only). 8/8/24: Breakfast (Supervision/Setup help only), Lunch (Observed) - (Independent/Setup help only). Record review of Resident #1's weights reflected the following: 7/2/24 - 220.6 lbs. 7/3/24 - 218.4 lbs. 7/4/24 - 217.2 lbs. 7/5/24 - 218.4 lbs. 7/18/24 - 216.4 lbs. 7/22/24 - 212.8 lbs. 3.54% weight loss between 7/2/24 - 7/22/24 In an observation and interview on 8/8/24 at 12:36 PM - 12:56 PM, revealed Resident #1 was delivered her lunch tray (meat, vegetables, mashed potatoes and two beverages) at 12:36 PM and the staff left the room and continued delivering lunch trays. Staff did not enter the room to assist Resident #1 eat her food. She ate with her left hand. When Resident #1 brought each bite of food to her mouth it would fall off the fork because her hand was unsteady and shook while she ate. She said her hand was weak and it was difficult. Resident #1 attempted to drink her juice. She picked up the cup and attempted to drink the beverage as her hand began to shake. Resident #1 attempted to bring the cup to her lips but she wasted the beverage due to her hand shaking. She said she did not receive assistance or asked if she needed assistance while she ate. She continued to try and eat her food. This State Surveyor requested Resident #1 push her call light. CNA A responded to the call light. Resident #1 said she was tired of trying to eat because her hand was shaking and said to CNA A it was hard to eat because she kept wasting her food. Resident #1 said if she had help she would have finished her food. Resident #1 ate 25% of her food. Staff did not supervise Resident #1 when she ate her food. During an interview on 8/8/24 at 12:58 PM, CNA A said, Resident #1 did not require assistance or supervision while she ate. She said Resident #1 required set up with her meal tray. She said Resident #1 was able to eat independently. She said the nurses informed her about the amount of assistance Resident #1 needed. CNA A said Resident #1 may have eaten slow, but she was able to eat without assistance or supervision. She said she could check the POC. She said she was feeding another resident when Resident #1 pushed her call light. She said she was not aware of Resident #1's care plan interventions. In an interview on 8/8/24 at 1:03 PM, the DON said if Resident #1 needed help, she should have been assisted with her meal. She said Resident #1 was able to feed herself. She said the care plan intervention (the resident requires supervision of 1 staff to eat ate initiated and revised) meant the facility staff should have Resident #1 by going in and out of her room while she ate her food. She said it did not mean a staff did not need to physically assist Resident #1. The DON said she was not able to answer questions on the coding for the MDS Nurse and the Reg. The MDS RN would answer questions related to assistance level indicated in Resident #1's MDS. She said Resident #1's food intake could be diminished if she was not assisted to eat. In an interview on 8/8/24 at 1:15 PM with the Regional MDS RN said Resident #1 needed supervision for eating. She said Resident #1 should have been provided set up and periodically supervised throughout the time she ate. She said if staff did not go in the room and supervise Resident #1 while she ate then Resident #1, did not receive the correct level of assistance. She said the facility should re-educate staff on what was expected related to care plans and how interventions should be carried out. In an interview on 8/8/24 at 4:00 PM with the ADMIN and the DON, the ADMIN said she expected staff to support and assist Resident #1 based on the care plan intervention (The Resident requires Supervision of 1 staff to eat). The ADMIN said staff should have been available in the room to meet Resident #1's needs. The DON said the care plan may not have been updated because she thought the resident did not need physical assistance. The ADMIN said the care plan should be followed until it was updated if needed. The ADMIN said the resident was at risk for not being able to eat all of her food. Record review of the facility policy on Comprehensive Care Plan (effective date 1/20/21 and revised 4/25/21) reflected the following in part: .Policy - Every resident will have an individualized interdisciplinary plan of care in place .6. The resident .a. The initial goals of the resident include the GG section . c. Any services and treatment to be administered by the community and personnel acting on behalf of the community

Based on interview and record review, the facility failed to ensure the resident's right to be free from abuse for 1 resident (CR#1) of 10 reviewed for neglect. -The facility failed to ensure CR#1 was free from neglect when she had multiple falls with serious injuries. -The facility failed to complete assessments, assess her pain, and implement adequate interventions to address CR#1's repeated falls with injuries. CR#1 died on [DATE] at the hospital after a fall, sustaining a head injury on [DATE]. -The facility failed to adequately assess CR#1 when she cried out in pain saying her leg was broken on [DATE] when she readmitted to the facility at 2:14 p.m. and no order was given for Stat x-ray until [DATE] at 9:47 a.m. -The facility failed to adequately address and manage CR#1's pain although she screamed out in pain repeatedly telling the facility staff her leg was broken from [DATE] at 2:14 p.m. until [DATE] when CR#1's family member called 911 and found that CR#1 had a right hip fracture. -The facility failed to seek emergency medical treatment and evaluation when CR#1 arrived at the facility on [DATE] crying out in pain and saying that her leg was broken until seen by an MD on [DATE] who stated send CR#1 to acute care hospital at 12:19 p.m. and CR#1 was not sent until CR#1's family member called 911 after 2 p.m. An Immediate Jeopardy (IJ) was identified on [DATE] at 12:47 p.m. While the IJ was lowered on [DATE] at 11:46 a.m., to no actual harm with potential for more than minimal harm that is not Immediate Jeopardy at a scope of pattern while the facility continued to monitor the implementation of effectiveness of their plan of removal. These failures could place residents at risk of neglect and not having their care needs met, receiving treatments, which could cause a decline in physical and psychosocial health or even death. Findings include: CR #1 Record review of CR #1's face sheet dated [DATE] revealed a [AGE] year-old female who initially admitted to the Nursing Facility on [DATE] and readmitted on [DATE] with the diagnoses of dementia, displaced intertrochanteric fracture of right femur-initial encounter for a closed fracture dated [DATE] (broken right leg), traumatic subarachnoid hemorrhage without loss of consciousness dated [DATE] ( true emergencies that demand prompt treatment. Subarachnoid hemorrhages result from a medical aneurysmal rupture or traumatic head injury, resulting in bleeding in the subarachnoid space between the arachnoid membrane and the [NAME] mater surrounding the brain)., major depressive disorder dated [DATE], muscle wasting and atrophy, difficulty in walking, type 2 diabetes (high blood sugar), hyperlipidemia (high cholesterol), hypothyroidism, morbid (severe) obesity, atherosclerotic heart disease, bipolar disorder, and hypertension (high blood pressure). Record review of CR#1's Quarterly MDS dated [DATE] revealed a BIMS score of 13 indicating cognition is intact. Section on Behavior revealed none of the above. Section on Functional Abilities and goals revealed wheelchair, roll left and right, sit to lying were substantial/maximal assistance, Sit to stand and walk 10 feet were not applicable. Pain presence was occasional and pain intensity was a 7. Falls revealed injury (except major) skin tears, abrasions, lacerations, superficial bruises, hematomas and sprains, or any fall-related injury that causes the resident to complain of pain. Restraints and Alarms section revealed there was no bed rail, bed alarm, chair alarm, or floor mat alarm. Record review of CR#1's Quarterly MDS dated [DATE] did not reveal a fall mat. Record review of CR# 1's Comprehensive Care plan undated revealed: CR #1 was identified to be at risk for increased falls and fractures as evidence by: Actual fall with c/o pain to neck and head - [DATE], Actual fall no injury - [DATE], Actual fall no injury - [DATE], Actual fall with hematoma to middle of forehead/ bleeding from nostrils - [DATE] Date Initiated: [DATE] Revision on: [DATE]. Interventions: Personal items to be placed within reach. Date Initiated: [DATE], Transferred to [Hospital] for further evaluation Date Initiated: [DATE], Transferred to ER for further eval [DATE] Date Initiated: [DATE]. Revision on: [DATE], Anticipate needs, provide prompt assistance. Date Initiated: [DATE], Assure lighting is adequate and areas are free of clutter. Date Initiated: [DATE], Encourage resident to ask for assistance of staff. Date Initiated: [DATE], Encourage socialization and activity attendance as tolerated. Date Initiated: [DATE], Ensure call light is in reach and answer promptly. Date Initiated: [DATE] .Focus: [CR#1] is Moderate risk for increased falls and fractures as evidence by: Gait/balance problems Date Initiated: [DATE] Revision on: [DATE] .Interventions: Anticipate and meet The resident's needs. Date Initiated: [DATE], Be sure The resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Date Initiated: [DATE], Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Date Initiated: [DATE], Follow facility fall protocol. Date Initiated: [DATE], Pt evaluate and treat as ordered or PRN. Date Initiated: [DATE] .Focus: [CR#1] has a behavior problem r/t Low frustration tolerance .Resident stated she had a fall at [local behavior facility] with pain on her right leg - [DATE] .Interventions: Send to [Local Hospital] for further evaluation Date Initiated: [DATE], Stat Xray Date Initiated: [DATE]. Focus: ADL self-care performance deficit d/t complications r/t disease processes. Date Initiated: [DATE] Revision on: [DATE]. Interventions: BATHING/SHOWERING: The resident totally Dependent by ,d+[DATE] staff with bathing/showering as necessary. Date Initiated: [DATE] Revision on: [DATE], BED MOBILITY: The resident requires Extensive assistance by ,d+[DATE] staff to turn and reposition in bed as necessary. Date Initiated: [DATE] Revision on: [DATE], DRESSING: The resident requires Extensive assistance by ,d+[DATE] staff to dress. Date Initiated: [DATE] Revision on: [DATE], EATING: The resident requires Supervision by 1 staff to eat. Date Initiated: [DATE] Revision on: [DATE], PERSONAL HYGIENE: The resident requires Extensive assistance by 1 staff with personal hygiene and oral care. Date Initiated: [DATE] Revision on: [DATE], TOILET USE: The resident requires Extensive Assistance by ,d+[DATE] staff for toileting. Date Initiated: [DATE] Revision on: [DATE], TRANSFER: The resident requires Mechanical Lift Hoyer lift with 2 staff assistance for transfers. Date Initiated: [DATE] Revision on: [DATE], Encourage the resident to participate to the fullest extent possible with each interaction. Date Initiated: [DATE], Encourage the resident to use bell to call for assistance. Date Initiated: [DATE], Praise all efforts at self-care. Date Initiated: [DATE], PT/OT evaluation and treatment as per MD orders. Date Initiated: [DATE]. Focus: Right Femur fracture r/t fall Date Initiated: [DATE] Revision on: [DATE]. Interventions: Anticipate and meet needs. Be sure call light is within reach and respond promptly to all requests for assistance. Date Initiated: [DATE], Follow MD orders for weight bearing status. See MD orders and/or PT treatment plan. Date Initiated: [DATE], Monitor/document pain on a scale of 0 to 10 before and after implementing measures to reduce pain. Date Initiated: [DATE], PT, OT evaluation and treatment per orders. Date Initiated: [DATE], Reposition as necessary to prevent skin breakdown. Prevent 90-degree flexion to prevent circulation problems. Date Initiated: [DATE]. Record review of CR#1's Order Summary Report dated [DATE] revealed: STAT X-RAY TO RIGHT HIP/KNEE R/T PAIN. STAT Phone ordered [DATE]. Assess if resident has shortness of breath while lying flat. every shift ordered [DATE]. Assess if resident has shortness of breath while lying flat. every shift Verbal Discontinued [DATE]. May have side rails up at HS and while in bed to enhance positioning and mobility Phone ordered [DATE]. May have side rails up at HS and while in bed to enhance positioning and mobility Phone Discontinued [DATE]. May have side rails up at HS and while in bed to enhance positioning and mobility Phone Discontinued [DATE]. May have side rails up at HS and while in bed to enhance positioning and mobility Verbal Discontinued [DATE]. Monitor for signs and symptoms of adverse reaction: interocular hemorrhage, abdominal pain, flatulence, alopecia, rash, pruritus, taste disturbance, tissue necrosis, headache, lethargy, dizziness, hematuria, anemia, hepatitis, respiratory tract bleeding, hypersensitivity reaction, hemorrhage, bloody dyscrasias, fever, purple toe syndrome, increased fracture risk with long term use. every shift Phone ordered [DATE]. Monitor for signs and symptoms of adverse reaction: interocular hemorrhage, abdominal pain, flatulence, alopecia, rash, pruritus, taste disturbance, tissue necrosis, headache, lethargy, dizziness, hematuria, anemia, hepatitis, respiratory tract bleeding, hypersensitivity reaction, hemorrhage, bloody dyscrasias, fever, purple toe syndrome, increased fracture risk with long term use. every shift Phone Discontinued [DATE]. monitor for signs and symptoms of adverse reaction: interocular hemorrhage, abdominal pain, flatulence, alopecia, rash, pruritus, taste disturbance, tissue necrosis, headache, lethargy, dizziness, hematuria, anemia, hepatitis, respiratory tract bleeding, hypersensitivity reaction, hemorrhage, bloody dyscrasias, fever, purple toe syndrome, increased fracture risk with long term use. every shift Verbal Discontinued [DATE]. monitor for signs and symptoms of adverse reaction: interocular hemorrhage, abdominal pain, flatulence, alopecia, rash, pruritus, taste disturbance, tissue necrosis, headache, lethargy, dizziness, hematuria, anemia, hepatitis, respiratory tract bleeding, hypersensitivity reaction, hemorrhage, bloody dyscrasias, fever, purple toe syndrome, increased fracture risk with long term use. Y/N every shift for Assessment Phone Discontinued [DATE]. MONITORING OF PAIN -if pain is noted, chart in nurses notes the interventions/treatments used and the effectiveness - Intervention Codes: 0 - none, 1 -medication, 2 - re-position, 3 - heat, 4 - cold, 5 - gentle range of motion, 6 - other (see nurses note) every shift Phone ordered [DATE]. MONITORING OF PAIN -if pain is noted, chart in nurses notes the interventions/treatments used and the effectiveness - Intervention Codes: 0 - none, 1 -medication, 2 - re-position, 3 - heat, 4 - cold, 5 - gentle range of motion, 6 - other (see nurses note) every shift Phone Discontinued [DATE]. MONITORING OF PAIN -if pain is noted, chart in nurses notes the interventions/treatments used and the effectiveness - Intervention Codes: 0 - none, 1 -medication, 2 - re-position, 3 - heat, 4 - cold, 5 - gentle range of motion, 6 - other (see nurses note) every shift Verbal Discontinued [DATE]. MONITORING OF PAIN -if pain is noted, chart in nurses notes the interventions/treatments used and the effectiveness - Intervention Codes: 0 - none, 1 -medication, 2 - re-position, 3 - heat, 4 - cold, 5 - gentle range of motion, 6 - other (see nurses note) every shift for Pain Phone Discontinued [DATE]. OT to eval and Tx as indicated Phone Discontinued [DATE]. OT to eval and Tx AS INDICATED Verbal Discontinued [DATE]. Pain Management consult Prescriber Written Discontinued [DATE]. PT clarification: Pt to be seen 3x/wk x 5 wks for therapy ex, therapy act, gait training, neuro re-ed, modalities, group and pt/caregiver training to improve functional mobility and increase functional independence. Phone Discontinued [DATE]. PT clarification: Pt to be seen 3x/wk x 6 wks for therapy ex, therapy act, gait training, neuro re-ed, modalities and pt/caregiver training to improve functional mobility and independence. Phone Discontinued [DATE]. PT CLARIFICATION: Skilled Pt services for 3x/week for 30days to address m62.81, m62.59, R27.8, r26.2 with therapy ex, therapy act, neuro re-ed, group therapy. one time only for 30 Days Phone Discontinued [DATE] [DATE] [DATE]. PT recertification: Pt to be seen 3x/wk x 6 wks for therapy ex, therapy act, gait training, neuro re-ed, modalities and pt/caregiver training to improve functional mobility and independence. Phone Active [DATE] Pt to eval and treat. one time only for 1 Day Phone Completed [DATE] [DATE] [DATE]. PT TO EVAL AND TX AS INDICATED Phone Active [DATE]. PT TO EVAL AND TX AS INDICATED Phone Discontinued [DATE]. PT TO EVAL AND TX AS INDICATED Phone Discontinued [DATE]. PT TO EVAL AND TX AS INDICATED Verbal Discontinued [DATE]. PT/OT TO EVAL AND TREAT AS INDICATED Prescriber Written Discontinued [DATE]. PT/OT/ST TO EVAL AND TREAT AS INDICATED Prescriber Written Active [DATE]. Resident transferred to [local acute hospital] r/t fall for observation. Phone Active [DATE] Send resident to methodist hospital r/t right leg pain r/o fracture per MD. Phone Discontinued [DATE]. Acetaminophen Oral Tablet 325 MG (Acetaminophen) Give 2 tablet by mouth every 4 hours as needed for Pain Phone Active [DATE]. Acetaminophen Oral Tablet 500 MG (Acetaminophen) Give 1 tablet by mouth every 6 hours as needed for mild pain. Phone Discontinued [DATE]. Advil PM Oral Capsule ,d+[DATE] MG (Ibuprofen-Diphenhydramine HCl) Give 1 capsule by mouth at bedtime for Insomnia. Phone Discontinued [DATE]. Advil PM Oral Capsule ,d+[DATE] MG (Ibuprofen-Diphenhydramine HCl) Give 1 capsule by mouth at bedtime for insomnia. Prescriber Written Discontinued [DATE]. Aspirin EC Low Strength Oral Tablet Delayed Release 81 MG (Aspirin) Give 1 tablet by mouth one time a day for CAD. Phone Discontinued [DATE]. Aspirin EC Low Strength Oral Tablet Delayed Release 81 MG (Aspirin) Give 1 tablet by mouth one time a day for CAD. Phone Discontinued [DATE]. Aspirin EC Tablet Delayed Release 81 MG (Aspirin) Give 1 tablet by mouth one time a day for MI Do Not Crush Phone Discontinued [DATE]. Aspirin Low Dose Oral Tablet Delayed Release 81 MG (Aspirin) Give 1 tablet by mouth one time a day for blood thinner. Verbal Discontinued [DATE]. Aspirin Low Dose Oral Tablet Delayed Release 81 MG (Aspirin) Give 1 tablet by mouth one time a day for MI Phone Active [DATE]. Eliquis Oral Tablet 5 MG (Apixaban) Give 1 tablet by mouth two times a day for DVT prevention Phone Active [DATE]. Eliquis Oral Tablet 5 MG (Apixaban) Give 5 mg by mouth two times a day for Prophylaxis; dvt Prescriber Written Discontinued [DATE]. Hydrocodone-Acetaminophen Oral Tablet ,d+[DATE] MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth every 6 hours as needed for pain mgmt. Prescriber Written Discontinued [DATE]. Hydrocodone-Acetaminophen Oral Tablet ,d+[DATE] MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth every 8 hours as needed for Pain Phone Active [DATE]. Hydrocodone-Acetaminophen Oral Tablet ,d+[DATE] MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth every 8 hours as needed for Pain Phone Discontinued [DATE]. Hydrocodone-Acetaminophen Oral Tablet ,d+[DATE] MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth every 8 hours as needed for pain Verbal Discontinued [DATE]. Hydrocodone-Acetaminophen Tablet ,d+[DATE] MG Give 1 tablet by mouth every 6 hours as needed for pain Phone Discontinued [DATE]. Record review of CR#1's Pain Level Summary: [DATE] 3:23 a.m. level 6 [DATE] 8:45 p.m. level 6 [DATE] 12:21 a.m. level 0 [DATE] 10:00 p.m. level 3 [DATE] 8:22 p.m. level 3 [DATE] 4:50 a.m. level 5 [DATE] 7:47 a.m. level 5 [DATE] 7:59 a.m. level 5 [DATE] 10:17 p.m. level 0 [DATE] 1:51 a.m. level 7 [DATE] 10:54 p.m. level 0 [DATE] nothing noted [DATE] 5:17 a.m. level 0 [DATE] 5:18 a.m. level 1 [DATE] 8:32 a.m. level 3 [DATE] 9:18 a.m. level 0 [DATE] 1:47 p.m. level 5 Record review of CR#1's [DATE] Medication Administration Record revealed: MONITORING OF PAIN -if pain is noted, chart in nurses notes the interventions/treatments used and the effectiveness - Intervention Codes: 0 - none, 1 - medication, 2 - re-position, 3 - heat, 4 - cold, 5 - gentle range of motion, 6 - other (see nurses note) every shift. -D/C Date- [DATE] 12:03 p.m.- [DATE] at 6 p.m. to did not reveal any pain. [DATE] at 6 a.m. revealed level 5 pain Diclofenac Sodium External Gel 1 % (Diclofenac Sodium (Topical)) Apply to knee/back topically three times a day for osteoarthritis -D/C Date- [DATE] 12:03 p.m. [DATE] at 9 p.m. pain level 1 [DATE] at 9 a.m. pain level 3 [DATE] at 2 p.m. pain level 5 Hydrocodone-Acetaminophen Tablet ,d+[DATE] MG Give 1 tablet by mouth every 6 hours as needed for pain -D/C Date- [DATE] 12:03 p.m. [DATE] left blank [DATE] pain level 5 at 1:37 p.m. Tylenol Extra Strength Oral Tablet 500 MG (Acetaminophen) Give 1 tablet by mouth every 6 hours as needed for pain -D/C Date- [DATE] 3:57 p.m. nothing noted. STAT X-RAY TO RIGHT HIP/KNEE R/T PAIN. STAT -Start Date- [DATE] 9:53 a.m. [DATE] not completed. Record review of CR#1's Nurse notes dated [DATE] at 2:14 p.m. written by ADON A revealed, Resident arrived via wheelchair with EMS from Behavior Hospital, AA&Ox3, respiratory even and unlabored skin warm and dry to touch, denies pain at this time, notified MD and [CR#1's family member] call light in reach will continues to monitor. Record review of CR#1's Morse Fall Scale dated [DATE] at 2:39 p.m. revealed Moderate Risk for Falling. No History of falling, no ambulatory aides are used (bedrest/wheelchair/nurse assisted), gait impaired with difficulty rising from chair, uses chair arms to get up, bounces to rise-keeps head down when walking, watches the ground- grasps furniture, person or aide when ambulating. Cannot walk unassisted. Mental Status: Overestimates or forgets limits. Record review of CR#1's Skin/Wound Note dated [DATE] at 7:47 p.m. by Wound Care Nurse revealed, Resident readmitted to facility. Head to toe skin assessment performed. Sacrum intact. Bilateral heels noted dry & flaky. Left heel noted with peeling skin. Will continue to monitor. Record review of CR#1's Weekly Skin assessment dated [DATE] at 7:45 p.m. by Wound Care Nurse did not reveal anything about CR#1 being in pain. Record review of CR#1's Health Status Note dated [DATE] at 9:35 a.m. by ADON A revealed, While in room changing resident complained of pain to right leg stating she fell at the other place, notified MD for new orders, [CR#1's family member] is aware. Calling other facility to confirm resident had a fall. Record review of CR#1's Incident note dated [DATE] at 2:24 p.m. written by DON/DCO Note Text: ADCO stopped by resident rm to provide, resident told ADCO that her right leg hurt because I had a fall at the other place MD [CR #1's family member] notified, Pain ,eds administered pe[CR #1's family member] prn order, MD gave orders for stat x-ray, DCO called [local psychiatric center] to investigate incident of fall as stated by resident .Resident now to be transferred to [CR #1's family member] choice of hospital for further eval. National EMS called and scheduled transportation p/u, eta 1hr, [CR #1 family member] notify with p/u information. Record review of CR#1's Nurse Note dated [DATE] at 10:45 a.m. written by MDS Coordinator revealed, CR#1's family member approached writer at nurses station requesting to speak to someone regarding her mother. Writer inquired was there anything that I can assist with? [CR#1's family member] stated I need someone to arrange transportation for my mother to go to the hospital, she told me that she had a fall at [local psychiatric facility] and now her leg is hurting, she needs X-rays Informed [CR#1's family member] that we could do X-rays here at the facility, [CR #1'S FAMILY MEMBER] inquired When I can't wait all day for her X-rays? Writer informed Management staff and charge nurse of [CR#1's family member] request and was informed that a STAT X-ray of right hip/knee was ordered and requested already. Informed [CR #1'S FAMILY MEMBER] that we received an order from the DR for STAT X-rays, X-ray tech was on their way to facility to obtained X-ray's. [CR #1'S FAMILY MEMBER] stated Fine I will wait until 12pm, then she's going to the hospital. That's my mother and I have to take care of her. Writer comforted [CR #1'S FAMILY MEMBER] and voiced understanding. [CR #1'S FAMILY MEMBER] returned to resident room, to await X-ray tech. Record review of CR#1's Progress note date [DATE] at 12:19 p.m. written by Physician revealed, CR#1 readmitted from [local psychiatric facility]. [CR#1] seen/examined. Complained of right thigh area pain with rom. Stated that she fell at [local psychiatric facility] without workup. Will send to acute hospital for workup fracture versus dislocations .fall precautions, pain control .concerns/questions/plan of care addressed with CR#1's family member at bedside. Record review of CR#1's Local Hospital noes dated [DATE] at 12:30 p.m. revealed s/p fall Fractured right hip, right heel deep tissue injury. Arrival date [DATE] at 4:41 p.m. Arrived by ambulance. Record review of CR#1's Nurse notes dated [DATE] at 18:02 by LVN B revealed CR#1 was Received via bed. Color is good, skin is warm/dry to touch. Resp. are easy/unlabored. Able to make her needs known staff. Requires 1:1 assist with her ADLS. No hypo/hyperglycemic reactions noted. Slight bleeding noted from her buttock during ADL care. She is constantly c/o why we don't like her and why we are out to get her, unable to re-direct @ this time, made as comfortable as possible. Was medicated with PRN Hydrocodone & Hydroxyzine. Will cont.to monitor. Record review of CR#1's screenshot of video dated [DATE] at 11:55 p.m. revealed a CNA standing by CR#1's bedside wither hands in her pocket and looking at CR#1. The CNA was observed standing away from CR#1 and CR#1 was observed lying to one side of the bed all the way to at the edge of the bed and looking at the CNA. Observation revealed CR#1 was not laying on her pillow and was laying to in the corner of the bed by the window. Record review of CR#1's screenshot of video dated [DATE] at 12:45 a.m. revealed CR#1 on the floor by her window and lying leaning on the air conditioner. Observation revealed there was no fall mat on either side of the bed. Record review of CR#1's Nurse note dated [DATE] at 12:59 by LVN A revealed, At approximately 12:50 a.m. [CR31] was observed on the floor screaming in severe pain to her head and neck. During assessment a raised area was noted on her right forehead.res stated she was trying to adjust her bedsheet. Nurse initiated 911 for further medical evaluation .V/S at this time were Bp ,d+[DATE], P 73, T 97.8, RR 20,02 SAT 97% RA.RP notified via VM , Md ,DON,ADON notified. Record review of CR#1's SBAR, Change in Condition dated [DATE] at 1:54 a.m. revealed, The Change in Condition/s reported on this CIC Evaluation are/were Falls. Resident is on anticoagulant other than warfarin. Pain Status: Yes. Record review of CR#1's Nurse note dated [DATE] at 3:17 a.m. by LVN A revealed, 911 initiated,2 technicians p/u resident via stretcher to [Local Hospital] for further medical evaluation and treatment. Record review of CR#1's Local Hospital Progress note dated [DATE] at 11:18 a.m. revealed admitted [DATE], Chief complaint: Fall on blood thinners .Subarachnoid hemorrhage after fall on blood thinners, received Kcentra in ER, neurosurgery consulted, appreciate recs, received loading dose of Keppra, rapid response was called as patient was having a seizure .Chief complaint: slip and fall out of bed .CT of the head showed age indeterminate nondisplaced bilateral nasal bone fracture and a single focus of subarachnoid hemorrhage in the right inferior frontal region. She was diagnosed with subarachnoid hemorrhage. She's wheelchair bound and needed 2 persons to assist her Right periorbital soft tissue swelling. No retrobulbar hematoma, globe injury or orbital fracture. Record review of CR#1's Nurse note dated [DATE] at 5:54 p.m. by CMA A revealed, CR#1 returned from [Local Hospital] accompanied by E.M.S Personnel. Res is returning to [facility] with DX; fall, Cerebral Hemorrhage. Res is AAOX2, Denies pain and discomfort at this time. Res is total care of ADLs, Inconsonant of B/B. VS,d+[DATE], 70, 18, 97.4. R/P, M.D notified. call light within reach will continue to monitor. Record review of CR#1's Bed Mobility Device assessment dated [DATE] at 10:05 a.m. description Initial revealed; Bed Mobility Device Assessment: None of the above was selected. What other alternatives have been used to assist the resident prior to the application of bed rails, grab/assist bars? Meaningful/Engaging individualized activities, frequent prompting/reminders, comfortable bed, comfortable bed environment. How have alternative interventions failed to meet the residents assessed needs? n/a. Has the Interdisciplinary Team determined the use of a bed rail, grab /assist bars to be an enabler to promote independence? Yes. How will/do the bed rails or grab/assist bat assist the resident? Turning side to side, moving up or down in the bed, holding self t one side, assist with lying to sitting, improve balance during transfer, support self during transfer, exiting the bed and entering the bed. Does the resident have a diagnosis of seizures or involuntary movements? No. Type of bed rail to be used. ,d+[DATE] Rail on both sides. Record review of CR#1's Bed Mobility Device assessment dated [DATE] at 10:05 a.m. reveled that low bed, increased monitoring, soft mat on floor were not selected. Record review of CR#1's Nurse note dated [DATE] at 3:20 a.m. by LVN A revealed, At approx. 3:20 a.m., Resident was observed with an unwitnessed fall, laying faced down. Resident stated she was trying to get out of the bed to get the nurse. Nurse assessed the resident, no redness or swelling noted, resident denied head injury. V/s Bp,d+[DATE] ,P 59 ,T 97.3 ,02 sat 95% RA. Nurse and the CNA assisted the resident back to bed via Hoyer lift. Resident c/o lower backpain, Prn Hydrocodone ,d+[DATE]mg PO 1 tab administered to aid back pain, MD, ADON and RP notified via VM. Will continue to monitor. Call light within reach, bed at lowest position. Record review of CR#1's February Medication Administration record revealed: MONITORING OF PAIN -if pain is noted, chart in nurses notes the interventions/treatments used and the effectiveness - Intervention Codes: 0 - none, 1 - medication, 2 - re-position, 3 - heat, 4 - cold, 5 - gentle range of motion, 6 - other (see nurses note) every shift [DATE] at 6a.m. to pain level 5 [DATE] at 6 p.m. to pain level 0 [DATE] nothing noted. Acetaminophen Oral Tablet 325 MG (Acetaminophen) Give 2 tablet by mouth every 4 hours as needed for Pain: nothing administered. Hydrocodone-Acetaminophen Oral Tablet ,d+[DATE] MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth every 8 hours as needed for Pain. [DATE] Pain level 4 at 2:00 a.m. [DATE] Pain level 3 at 10 p.m. [DATE] Pain level 5 at 10:56 p.m. [DATE] Pain level 6 at 12:45 a.m. Hydroxyzine Pamoate Oral Capsule 50 MG (Hydroxyzine Pamoate) Give 1 capsule by mouth every 6 hours as needed for anxiety. [DATE] administered at 8:44 p.m. Record review of CR#1's SBAR Summary, Change in Condition Evaluation dated [DATE] at 1:30 a.m. by LVN C revealed, Nursing observations, evaluation, and recommendations are Resident had an unwitnessed fall in her room. No injuries noted. Denies pain or hitting her head. Neuros stared, bed in lowest position, call light within reach. Record review of CR#1's Incident Note dated [DATE] at 1:30 a.m. with LVN C revealed, CNA called me to the room. Resident was lying in a supine position on the floor next to her bed. Resident stated that she doesn't remember how she fell out of bed. She denies pain or hitting her head. Head to toe assessment done. Assisted CNAs with getting resident back in bed via Hoyer lift. No injury noted. Neuros started, bed in lowest position, call light within reach. Advised resident to call for assistance when she needs anything. Record review of CR#1's video dated [DATE] at 3:04 a.m. revealed CR#1 was observed in bed reaching with the paper towels in her hand towards the floor at 3:04 a.m. Bed rails were observed to be by residents head only, no bed rails observed by residents hands. Observation revealed bedside table was next to the bed. Record review of CR#1's video dated [DATE] at 3:14 a.m. revealed CNA A came into the room at 3:14 a.m. and CR#1 was observed face down on the floor next to the bed, and CNA A was observed turning off the call light, turning on the light and she stated she would get the nurse to help her with this and she said how did you do this and she asked are you okay and CR#1 said no ma'am. CR#1 was observed on the bottom bars of the bedside table face down. CNA A was observed leaving the room. Record review of CR#1's screen shot of video dated [DATE] at 3:19 a.m. revealed LVN B turned CR#1 to her side, observation revealed lots of blood on the floor. Observation revealed the bedside table had been moved away. Record review of CR#1's video dated [DATE] at 3:28 a.m. revealed LVN A in the room and CR#1 was observed being turned over onto her back, blood was observed. Resident was observed lying on her back and the nurses were attempting to get vital signs. The nurse was observed putting gloves on. Observation revealed the blood was cleaned up; they had removed CR#1's gown. CR #1 was observed laying with her head and body lying flat on the floor. Observation revealed the staff move the bed because CR#1 appeared to be very close to the bed. Observation revealed the nurses pulling CR#1 by her arm and her hip and turning her on her side and placing a Hoyer pad under her. At 3:30 a.m. the staff are observed using the Hoyer lift to attach to the Hoyer pad. They begin lifting CR#1 at 3:31 a.m. and she screamed out ouch. At 3:32 a.m. the nurses were observed to continue the process of lifting CR#1 until she was placed into the bed. There was no observation of Nurses checking to see if anything was broken. Record review of CR#1's SBAR Summary: Change in Condition reported: Falls dated [DATE] at 3:40 a.m. by LVN A and LVN B revealed, Resident is on anticoagulant other than warfarin, Nursing observations, evaluation, and recommendations are Resident had an unwitnessed fall in her room. hematoma noted on middle forehead, bleeding from the nostrils noted. Res continue to nod at every question asked. Record review of CR#1's Nurse Note dated [DATE] at 4:00 a.m. with LVN A revealed, At approximately 3:20 a.m. Resident had an unwitnessed fall, Nurse was notified that [CR#1] was observed on the floor faced down. A large, noticeable hematoma observed on the middle of the forehead ,bleeding noted from the nostrils following the fall .Assisted resident to a seated position and assessed for injuries, Applied gentle pressure to the nose to control bleeding. Elevated the resident's head to minimize swelling and facilitate breathing, vital signs V/s Bp ,d+[DATE],P 68,RR 19,Temp 98.5,02 97%RA. 911 initiated,2 EMTs picked resident up to [local ] Hospital for further treatment. Notified MD,DON,ADON. Record review of CR#1's nurses Note dated [DATE] at 4:28 p.m. by ADON B revealed, CR#1's family member reached out to facility stating mom [CR#1] expired in the ICU after having 5 seizures. DCO/administrator reached out to facility to extend condolences. < [TRUNCATED]

Based on interview and record review, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent falls and major injuries causing her to be hospitalized several times with major injuries for 1 (CR#1) of ten residents reviewed for accidents, hazards, and supervision. -The facility failed to provide adequate assistive devices for CR#1 who was on anticoagulants had a history of major falls with injury on [DATE] (unwitnessed fall-fractured nose and femur), [DATE] (unwitnessed fall), [DATE] (unwitnessed fall found face down), [DATE] (unwitnessed fall cerebral hemorrhage and neck pain). -The facility failed to conduct a thorough assessment and manage pain after CR#1's fall on [DATE] and left CR#1 unattended. -The facility failed to properly support CR#1's head after her fall as her head laid flat on the floor and staff observed CR#1 gulping and swallowing blood. An Immediate Jeopardy (IJ) was identified on [DATE] at 2:52 p.m. While the IJ was lowered on [DATE] at 11:46 a.m., to no actual harm with potential for more than minimal harm that is not Immediate Jeopardy at a scope of pattern while the facility continued to monitor the implementation of effectiveness of their plan of removal. These failures could place residents at risk of harm, severe injuries, hospitalization , and death who are totally dependent on staff for Activities of daily living, supervision, bed mobility, and safety at risk for falls, not being adequately care planned to receive devices to prevent falls, not being thoroughly assessed after a fall, not being properly assessed for pain that resulted in actual harm to CR #1 causing her pain, lower quality of life, falls with fractures, hematomas and CR #1 passed away on [DATE]. Findings include: Record review of CR #1's face sheet dated [DATE] revealed a [AGE] year-old female who initially admitted to the Nursing Facility on [DATE] and readmitted on [DATE] with the diagnoses of displaced intertrochanteric fracture of right femur-initial encounter for a closed fracture dated [DATE] (broken right leg), traumatic subarachnoid hemorrhage without loss of consciousness dated [DATE] ( true emergencies that demand prompt treatment. Subarachnoid hemorrhages result from a medical aneurysmal rupture or traumatic head injury, resulting in bleeding in the subarachnoid space between the arachnoid membrane and the [NAME] mater surrounding the brain)., muscle wasting and atrophy, difficulty in walking, and morbid (severe) obesity (over weight). Record review of CR#1's Quarterly MDS dated [DATE] revealed a BIMS score of 13 indicating the residents cognition was intact. The resident did not have behavior problems noted. The resident used a wheelchair for mobility. She required substantial/maximal assistance with rolling left and right and moving from a sit to lying down position. The resident had occasional pain with an intensity level of 7. RCR #1 had falls that resulted in injury (except major) such as: skin tears, abrasions, lacerations, superficial bruises, hematomas and sprains, or any fall-related injury that causes the resident to complain of pain. CR #1did not have bed rail, bed alarm, chair alarm, or floor mat alarm. The MDS did not address a fall mat being used. Record review of CR# 1's Comprehensive Care plan undated revealed the following care areas: *Falls, the resident was at risk for increased falls and fractures as evidence by: Actual fall with c/o pain to neck and head -[DATE], Actual fall no injury - [DATE], Actual fall no injury - [DATE], Actual fall with hematoma to middle of forehead/ bleeding from nostrils - [DATE] Date Initiated: [DATE] Revision on: [DATE]. The interventions included for Personal items to be placed within reach. Date Initiated: [DATE], Transferred to [Hospital] for further evaluation Date Initiated: [DATE], Transferred to ER for further eval [DATE] Date Initiated: [DATE] Revision on: [DATE], Anticipate needs, provide prompt assistance. Date Initiated: [DATE], Assure lighting is adequate and areas are free of clutter. Date Initiated: [DATE], Encourage resident to ask for assistance of staff. Date Initiated: [DATE], Encourage socialization and activity attendance as tolerated. Date Initiated: [DATE], Ensure call light is in reach and answer promptly. * CR#1 was Moderate risk for increased falls and fractures as evidence by: Gait/balance problems Date Initiated: [DATE] Revision on: [DATE] . The Interventions included to Anticipate and meet The resident's needs, Be sure The resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance, Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs, Follow facility fall protocol, Pt evaluate and treat as ordered or PRN. * CR#1 had a behavior problem r/t Low frustration tolerance .Resident stated she had a fall at [local behavior facility] with pain on her right leg Date Initiated: [DATE] . The interventions were to send to [Local Hospital] for further evaluation and Stat Xray. * ADL self-care performance deficit d/t complications r/t disease processes. Date Initiated: [DATE] Revision on: [DATE]. The interventions indicated the resident was totally Dependent by ,d+[DATE] staff with bathing and showering. Required extensive assistance by ,d+[DATE] staff to turn and reposition in bed, personal hygiene and oral care, toileting, and dressing. The resident required Supervision by 1 staff to eat. The resident required Mechanical Lift Hoyer lift with 2 staff assistance for transfers. Additional interventions were to Encourage the resident to participate to the fullest extent possible with each interaction. use bell to call for assistance. Praise all efforts at self-care., PT/OT evaluation and treatment as per MD orders. * Right Femur fracture r/t fall Date Initiated: [DATE] Revision on: [DATE]. The interventions included to anticipate and meet needs, be sure call light was within reach and respond promptly to all requests for assistance, follow MD orders for weight bearing status, see MD orders and/or PT treatment plan, Monitor/document pain on a scale of 0 to 10 before and after implementing measures to reduce pain, PT/ OT evaluation and treatment per orders, Reposition as necessary to prevent skin breakdown, and to prevent 90-degree flexion to prevent circulation problems. Record review of CR#1's Order Summary Report dated [DATE] revealed: *STAT X-RAY TO RIGHT HIP/KNEE R/T PAIN. STAT Phone ordered [DATE] *Assess if resident has shortness of breath while lying flat. every shift ordered [DATE] *Assess if resident has shortness of breath while lying flat. every shift Verbal Discontinued [DATE] 0*May have side rails up at HS and while in bed to enhance positioning and mobility Phone ordered [DATE] *May have side rails up at HS and while in bed to enhance positioning and mobility Phone Discontinued [DATE] *May have side rails up at HS and while in bed to enhance positioning and mobility Phone Discontinued [DATE] *May have side rails up at HS and while in bed to enhance positioning and mobility Verbal Discontinued [DATE] *Monitor for signs and symptoms of adverse reaction: interocular hemorrhage, abdominal pain, flatulence, alopecia, rash, pruritus, taste disturbance, tissue necrosis, headache, lethargy, dizziness, hematuria, anemia, hepatitis, respiratory tract bleeding, hypersensitivity reaction, hemorrhage, bloody dyscrasias, fever, purple toe syndrome, increased fracture risk with long term use. every shift Phone ordered [DATE] *Monitor for signs and symptoms of adverse reaction: interocular hemorrhage, abdominal pain, flatulence, alopecia, rash, pruritus, taste disturbance, tissue necrosis, headache, lethargy, dizziness, hematuria, anemia, hepatitis, respiratory tract bleeding, hypersensitivity reaction, hemorrhage, bloody dyscrasias, fever, purple toe syndrome, increased fracture risk with long term use. every shift Phone Discontinued [DATE] *monitor for signs and symptoms of adverse reaction: interocular hemorrhage, abdominal pain, flatulence, alopecia, rash, pruritus, taste disturbance, tissue necrosis, headache, lethargy, dizziness, hematuria, anemia, hepatitis, respiratory tract bleeding, hypersensitivity reaction, hemorrhage, bloody dyscrasias, fever, purple toe syndrome, increased fracture risk with long term use. every shift Verbal Discontinued [DATE] *monitor for signs and symptoms of adverse reaction: interocular hemorrhage, abdominal pain, flatulence, alopecia, rash, pruritus, taste disturbance, tissue necrosis, headache, lethargy, dizziness, hematuria, anemia, hepatitis, respiratory tract bleeding, hypersensitivity reaction, hemorrhage, bloody dyscrasias, fever, purple toe syndrome, increased fracture risk with long term use. Y/N every shift for Assessment Phone Discontinued [DATE] *MONITORING OF PAIN -if pain is noted, chart in nurses notes the interventions/treatments used and the effectiveness - Intervention Codes: 0 - none, 1 -medication, 2 - re-position, 3 - heat, 4 - cold, 5 - gentle range of motion, 6 - other (see nurses note) every shift Phone ordered [DATE] *MONITORING OF PAIN -if pain is noted, chart in nurses notes the interventions/treatments used and the effectiveness - Intervention Codes: 0 - none, 1 -medication, 2 - re-position, 3 - heat, 4 - cold, 5 - gentle range of motion, 6 - other (see nurses note) every shift Phone Discontinued [DATE] *MONITORING OF PAIN -if pain is noted, chart in nurses notes the interventions/treatments used and the effectiveness - Intervention Codes: 0 - none, 1 -medication, 2 - re-position, 3 - heat, 4 - cold, 5 - gentle range of motion, 6 - other (see nurses note) every shift Verbal Discontinued [DATE] *PT TO EVAL AND TX AS INDICATED Phone Discontinued [DATE] *PT TO EVAL AND TX AS INDICATED Verbal Discontinued [DATE] *Resident transferred to [local hospital] r/t fall for observation. Phone Active [DATE] *Send resident to [local] hospital r/t right leg pain r/o fracture per MD. Phone Discontinued [DATE] *Acetaminophen Oral Tablet 325 MG (Acetaminophen) Give 2 tablet by mouth every 4 hours as needed for Pain Phone Active [DATE] *Acetaminophen Oral Tablet 500 MG (Acetaminophen) Give 1 tablet by mouth every 6 hours as needed for mild pain Phone Discontinued [DATE] *Advil PM Oral Capsule ,d+[DATE] MG (Ibuprofen-Diphenhydramine HCl) Give 1 capsule by mouth at bedtime for Insomnia Phone Discontinued [DATE] *Advil PM Oral Capsule ,d+[DATE] MG (Ibuprofen-Diphenhydramine HCl) Give 1 capsule by mouth at bedtime for insomnia Prescriber Written Discontinued [DATE] *Aspirin EC Low Strength Oral Tablet Delayed Release 81 MG (Aspirin) Give 1 tablet by mouth one time a day for CAD Phone Discontinued [DATE] *Aspirin EC Low Strength Oral Tablet Delayed Release 81 MG (Aspirin) Give 1 tablet by mouth one time a day for CAD Phone Discontinued [DATE] *Aspirin EC Tablet Delayed Release 81 MG (Aspirin) Give 1 tablet by mouth one time a day for MI Do Not Crush Phone Discontinued [DATE] *Aspirin Low Dose Oral Tablet Delayed Release 81 MG (Aspirin) Give 1 tablet by mouth one time a day for blood thinner Verbal Discontinued [DATE] *Aspirin Low Dose Oral Tablet Delayed Release 81 MG (Aspirin) Give 1 tablet by mouth one time a day for MI Phone Active [DATE] *Eliquis Oral Tablet 5 MG (Apixaban) Give 1 tablet by mouth two times a day for DVT prevention Phone Active [DATE] *Eliquis Oral Tablet 5 MG (Apixaban) Give 5 mg by mouth two times a day for Prophylaxis; dvt Prescriber Written Discontinued [DATE] *Hydrocodone-Acetaminophen Oral Tablet ,d+[DATE] MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth every 6 hours as needed for pain mgmt. Prescriber Written Discontinued [DATE] *Hydrocodone-Acetaminophen Oral Tablet ,d+[DATE] MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth every 8 hours as needed for Pain Phone Active [DATE] *Hydrocodone-Acetaminophen Oral Tablet ,d+[DATE] MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth every 8 hours as needed for Pain Phone Discontinued [DATE] *Hydrocodone-Acetaminophen Oral Tablet ,d+[DATE] MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth every 8 hours as needed for pain Verbal Discontinued [DATE] *Hydrocodone-Acetaminophen Tablet ,d+[DATE] MG Give 1 tablet by mouth every 6 hours as needed for pain Phone Discontinued [DATE] Record review of CR#1's Pain Level Summary dated [DATE]: [DATE] 3:23 a.m. level 6 [DATE] 8:45 p.m. level 6 [DATE] 12:21 a.m. level 0 [DATE] 10:00 p.m. level 3 [DATE] 8:22 p.m. level 3 [DATE] 4:50 a.m. level 5 [DATE] 7:47 a.m. level 5 [DATE] 7:59 a.m. level 5 [DATE] 10:17 p.m. level 0 [DATE] 1:51 a.m. level 7 [DATE] 10:54 p.m. level 0 [DATE] nothing noted [DATE] 5:17 a.m. level 0 [DATE] 5:18 a.m. level 1 [DATE] 8:32 a.m. level 3 [DATE] 9:18 a.m. level 0 [DATE] 1:47 p.m. level 5 Record review of CR#1's Nurse notes dated [DATE] at 2:14 p.m. written by ADON A revealed, Resident arrived via wheelchair with EMS from Behavior Hospital, Alert and orientedx3, respiratory even and unlabored skin warm and dry to touch, denies pain at this time, notified MD and [CR#1's family member] call light in reach will continues to monitor. Record review of CR#1's Health Status Note dated [DATE] at 9:35 a.m. by ADON A revealed, While in room changing resident complained of pain to right leg stating she fell at the other place, notified MD for new orders, [CR#1's family member] was aware. Calling other facility to confirm resident had a fall. Record review of CR#1's Incident note dated [DATE] at 2:24 p.m. written by DON/DCO revealed, the ADCO stopped by resident rm to provide, resident told ADCO that her right leg hurt because I had a fall at the other place MD [CR #1's family member] notified, Pain, meds administered per [CR #1's family member] prn order, MD gave orders for stat x-ray, DCO called [Behavior Hospital] to investigate incident of fall as stated by resident .Resident now to be transferred to [CR #1's family member] choice of hospital for further eval. EMS called and scheduled transportation p/u, eta 1hr, [CR #1 family member] notify with p/u information. Record review of CR#1's Progress note date [DATE] at 12:19 p.m. written by Physician revealed, CR#1 readmitted from [Behavior Hospital]. [CR#1] seen/examined. Complained of right thigh area pain with rom. Stated that she fell at [Behavior Hospital] without workup. Will send to acute hospital for workup fracture versus dislocations .fall precautions, pain control . concerns/questions/plan of care addressed with CR#1's family member at bedside. Record review of CR#1's Local Hospital noes dated [DATE] at 12:30 p.m. revealed s/p fall Fractured right hip, right heel deep tissue injury. Arrival date [DATE] at 4:41 p.m. Arrived by ambulance. Record review of CR#1's screenshot of video dated [DATE] at 11:55 p.m. revealed a CNA standing by CR#1's bedside with her hands in her pocket and looking at CR#1. The CNA was observed standing away from CR#1 and CR#1 was observed laying to one side of the bed all the way to at the edge of the bed and looking at the CNA. Observation revealed CR#1 was not laying on her pillow and was laying to in the corner of the bed by the window. Observation of video did not reveal a fall mat in the room. Record review of CR#1's screenshot of video dated [DATE] at 12:45 a.m. revealed CR#1 on the floor by her window and lying leaning on the air conditioner. Observation revealed there was no fall mat on either side of the bed. Record review of CR#1's Nurse note dated [DATE] at 12:59 by LVN A revealed, At approximately 12:50 a.m. [CR#1] was observed on the floor screaming in severe pain to her head and neck. During assessment a raised area was noted on her right forehead. [CR#1] stated she was trying to adjust her bedsheet. Nurse initiated 911 for further medical evaluation .V/S at this time were Bp ,d+[DATE], P 73, T 97.8, RR 20,02 SAT 97% RA.RP notified via VM, Md, DON, ADON notified. Record review of CR#1's SBAR, Change in Condition dated [DATE] at 1:54 a.m. revealed, The Change in Condition/s reported on this CIC Evaluation are/were: Falls. Resident is on anticoagulant other than warfarin. Pain Status: Yes. Record review of CR#1's Nurse note dated [DATE] at 3:17 a.m. by LVN A revealed, 911 initiated,2 technicians p/u resident via stretcher to [Local Hospital] for further medical evaluation and treatment. Record review of CR#1's Local Hospital Progress note dated [DATE] at 11:18 a.m. revealed admitted [DATE], Chief complaint: Fall on blood thinners .Subarachnoid hemorrhage after fall on blood thinners, received Kcentra in ER, neurosurgery consulted, appreciate recs, received loading dose of Keppra, rapid response was called as patient was having a seizure .Chief complaint: slip and fall out of bed .CT of the head showed age indeterminate nondisplaced bilateral nasal bone fracture and a single focus of subarachnoid hemorrhage in the right inferior frontal region. She was diagnosed with subarachnoid hemorrhage. She's wheelchair bound and needed 2 person to assist her Right periorbital soft tissue swelling. No retrobulbar hematoma, globe injury or orbital fracture. Record review of CR#1's Nurse note dated [DATE] at 5:54 p.m. by CMA A revealed, CR#1 returned from [Local Hospital] accompanied by E.M.S Personnel. Res is returning to [facility] with DX; fall, Cerebral Hemorrhage. Res is AAOX2, Denies pain and discomfort at this time. Res is total care of ADLs, Inconsonant of B/B. VS,d+[DATE], 70, 18, 97.4. R/P, M.D notified. call light within reach will continue to monitor. Record review of CR#1's Bed Mobility Device assessment dated [DATE] at 10:05 a.m. description Initial revealed; Bed Mobility Device Assessment: None of the above was selected. What other alternatives have been used to assist the resident prior to the application of bed rails, grab/assist bars? Meaningful/Engaging individualized activities, frequent prompting/reminders, comfortable bed, comfortable bed environment. How have alternative interventions failed to meet the residents assessed needs? n/a. Has the Interdisciplinary Team determined the use of a bed rail, grab /assist bars to be an enabler to promote independence? Yes. How will/do the bed rails or grab/assist bat assist the resident? Turning side to side, moving up or down in the bed, holding self to one side, assist with laying to sitting, improve balance during transfer, support self during transfer, exiting the bed and entering the bed. Does the resident have a diagnosis of seizures or involuntary movements? No. Type of bed rail to be used. ,d+[DATE] Rail on both sides. Record review of CR#1's Bed Mobility Device assessment dated [DATE] at 10:05 a.m. reveled that low bed, increased monitoring, soft mat on floor were not selected. Record review of CR#1's Nurse note dated [DATE] at 3:20 a.m. by LVN A revealed, At approximately 3:20 a.m., Resident was observed with an unwitnessed fall, laying faced down. Resident stated she was trying to get out of the bed to get the nurse. Nurse assessed the resident, no redness or swelling noted, resident denied head injury. V/s Bp,d+[DATE] ,P 59 ,T 97.3 ,02 sat 95% RA. Nurse and the CNA assisted the resident back to bed via Hoyer lift. Resident c/o lower backpain, Prn Hydrocodone ,d+[DATE]mg PO 1 tab administered to aid back pain, MD, ADON and RP notified via VM. Will continue to monitor. Call light within reach, bed at lowest position. Record review of CR#1's February Medication Administration record revealed: MONITORING OF PAIN -if pain is noted, chart in nurses notes the interventions/treatments used and the effectiveness - Intervention Codes:0 - none, 1 - medication, 2 - re-position, 3 - heat, 4 - cold, 5 - gentle range of motion, 6 - other (see nurses note) every shift. *[DATE] at 6a.m. to pain level 5 *[DATE] at 6 p.m. to pain level 0 *[DATE] nothing noted Acetaminophen Oral Tablet 325 MG (Acetaminophen) Give 2 tablet by mouth every 4 hours as needed for Pain: nothing administered Hydrocodone-Acetaminophen Oral Tablet ,d+[DATE] MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth every 8 hours as needed for Pain *[DATE] Pain level 4 at 2:00 a.m. *[DATE] Pain level 3 at 10 p.m. *[DATE] Pain level 5 at 10:56 p.m. *[DATE] Pain level 6 at 12:45 a.m. Hydroxyzine Pamoate Oral Capsule 50 MG (Hydroxyzine Pamoate) Give 1 capsule by mouth every 6 hours as needed for anxiety *[DATE] administered at 8:44 p.m. Record review of CR#1's SBAR Summary, Change in Condition Evaluation dated [DATE] at 1:30 a.m. by LVN C revealed, Nursing observations, evaluation, and recommendations are: Resident had an unwitnessed fall in her room. No injuries noted. Denies pain or hitting her head. Neuros stared, bed in lowest position, call light within reach. Record review of CR#1's Incident Note dated [DATE] at 1:30 a.m. with LVN C revealed, CNA called me to the room. Resident was lying in a supine position on the floor next to her bed. Resident stated that she doesn't remember how she fell out of bed. She denies pain or hitting her head. Head to toe assessment done. Assisted CNAs with getting resident back in bed via Hoyer lift. No injury noted. Neuros started, bed in lowest position, call light within reach. Advised resident to call for assistance when she needs anything. Record review of CR#1's video dated [DATE] at 3:04 a.m. revealed CR#1 was observed in bed reaching with the paper towels in her hand towards the floor at 3:04 a.m. Bed rails were observed to be by residents head only, no bed rails observed by residents hands. Observation revealed bedside table was next to the bed. Observation revealed there was no fall mat in CR#1's room. Record review of CR#1's video dated [DATE] at 3:14 a.m. revealed CNA A came into the room at 3:14 a.m. and CR#1 was observed face down on the floor next to the bed, and CNA A was observed turning off the call light, turning on the light and she stated she would get the nurse to help her with this and she said how did you do this and she asked are you okay and CR#1 said no ma'am. CR#1 was observed on the bottom bars of the bedside table face down. CNA A was observed leaving the room. Record review of CR#1's screen shot of video dated [DATE] at 3:19 a.m. revealed LVN B turned CR#1 to her side, observation revealed lots of blood on the floor. Observation revealed the bedside table had been moved away. Record review of CR#1's video dated [DATE] at 3:28 a.m. revealed LVN A in the room and CR#1 was observed being turned over onto her back, blood was observed. Resident was observed lying on her back and the nurses were attempting to get vital signs. The nurse was observed putting gloves on. Observation revealed the blood was cleaned up, they had removed CR#1's gown. CR #1 was observed laying with her head and body laying flat on the floor. Observation revealed the staff move the bed because CR#1 appeared to be very close to the bed. Observation revealed the nurses pulling CR#1 by her arm and her hip and turning her on her side and placing a Hoyer pad under her. At 3:30 a.m. the staff are observed using the Hoyer lift to attach to the Hoyer pad. They begin lifting CR#1 at 3:31 a.m. and she screamed out ouch. At 3:32 a.m. the nurses were observed to continue the process of lifting CR#1 until she was placed into the bed. There was no observation of Nurses checking to see if anything was broken. Record review of CR#1's SBAR Summary: Change in Condition reported: Falls dated [DATE] at 3:40 a.m. by LVN A and LVN B revealed, Resident is on anticoagulant other than warfarin, Nursing observations, evaluation, and recommendations are: Resident had an unwitnessed fall in her room. Hematoma noted on middle forehead, bleeding from the nostrils noted. Resident continue to nod at every question asked. Record review of CR#1's Nurse Note dated [DATE] at 4:00 a.m. with LVN A revealed, At approximately 3:20 a.m. Resident had an unwitnessed fall, Nurse was notified that [CR#1] was observed on the floor faced down. A large, noticeable hematoma observed on the middle of the forehead ,bleeding noted from the nostrils following the fall. Assisted resident to a seated position and assessed for injuries, Applied gentle pressure to the nose to control bleeding. Elevated the resident's head to minimize swelling and facilitate breathing, vital signs V/s Bp ,d+[DATE],P 68,RR 19,Temp 98.5,02 97%RA. 911 initiated,2 EMTs picked resident up to [local ] Hospital for further treatment. Notified MD, DON, ADON. Record review of CR#1's nurses Note dated [DATE] at 4:28 p.m. by ADON B revealed, CR#1's family member reached out to facility stating [CR#1] expired in the ICU after having 5 seizures. DCO/administrator reached out to facility to extend condolences. In an interview on [DATE] at 11:46 a.m. with CR#1's family member she stated CR#1 fell from her bed on Wednesday, [DATE] at 3 a.m. and CR#1 passed away the following day at about 4 a.m. She stated right now she was not being given CR#1's body because her death was under investigation. She stated when CR#1 was in the hospital they noticed CR#1's fall was really bad. CR#1's family member stated she pleaded with the facility to put alarms on CR#1's bed or full bed rails. She stated CR#1 fell in [DATE] and they sent her to the hospital and CR#1 had a small bleeding of the brain, so it healed on its own. She stated on [DATE], CR#1 fell at 3 a.m. and she has video footage for when they found CR#1. She stated CR#1 had an emergency seizure and she had not had a seizure in 4 years. She stated the hospital rushed CR#1 in the room and they were getting the medication for seizures and CR#1 had another seizure. CR#1's family member stated CR#1 lost a lot of blood through the nose bleed and there was a lot of blood behind her head. She stated CR#1 passed away and the hospital did CPR and brought CR#1 back, but she went for 40 minutes without getting oxygen and they would do a cat scan. CR#1's family member sated they brought CR#1 to ICU and CR#1's heart stopped beating. CR#1's family member stated CR#1 would call out to the facility staff and sometimes they came and sometimes they did not. She stated CR#1 did not have a fall mat in the room and she told the facility about it, putting the bed all the way down and not having the bed so high. She stated CR#1's fall could have been avoided and the facility should have taken other measures. She stated she was sure the facility had fall mats in the building, but she just lost CR#1. CR#1's family member stated she went to see CR#1 every morning to spend time with and CR#1 will be missed. CR#1's family member stated she thought that the facility neglected CR#1 because they have never given her a fall mat and they knew CR#1 had falls. She stated on [DATE] CR#1 had a fall and she was very messed up from her face and this fall was worse and they did not save CR#1. She stated CR#1 had a fall at [local behavioral hospital] and they brushed it under the rug. She stated it had been 10 days and CR#1 screamed when she returned to the facility and said Meha my leg is broken. She stated she asked the DON why was CR#1 screaming her leg was broken and she said she did not know. She stated the DON said she did not know and they started calling [local behavioral hospital] and they did not answer the phone. CR#1's family member stated nobody ever came to do x-rays for CR#1 and there was no concern. She stated 4 p.m. came back to the facility from the local behavioral health and the facility had not done anything. She stated at 4 p.m. CR#1 was so sedated that she did not complain from 4 p.m. that day until the next day at 8:30 a.m., she was not making noise, not asking for assistance, and no one checked on her. CR#1's family member stated when she came from the local behavioral hospital no one changed her pamper, she was so sedated, they did not know what was going on. CR#1's family member stated the local behavioral hospital had put CR#1 so much sedation and no one was concerned. She said she was not sure if CR#1 told the facility that her leg was broken until the following day when she went to see CR#1 and she told her that her leg was broken. She stated the facility did not pay attention to CR#1 when she came back from [local behavioral hospital]. In an interview and Record review of CR#1's Care Plan and Clinical records on [DATE] at 1:33 p.m. with the DON she stated CR#1 had a fall on [DATE] and she was called by LVN A the night nurse saying CR#1 had a fall and bleeding form her nose and the middle of her head. She stated LVN A just called 911 and she said she wanted to let her know. She stated LVN A went to finish paperwork and she called the DON back. The DON stated LVN A said she went into the room and CR#1 was face down, they called CR#1's family member and the family member said she saw CR#1 on the camera attempting to pick up a paper towel. She stated LVN A said she checked CR#1's neuro's to make sure she was still breathing before they took her to the hospital. The DON stated CR#1 had a fall mat and that maybe the staff took it out to clean. The DON reviewed the care plan for a fall mat stated there was no fall mat found on the care plan. The DON stated CR#1's fall on [DATE] CR#1 was trying to get her lipstick bag and that's how she ended up on the floor. The DON stated it was in the night time and even when CR#1 was on the floor she was still applying lipstick. The DON stated CR#1 did not hit her head, but she complained that she was in pain. She stated there was no injury, but they did send her out to the local hospital. The DON stated on the day CR#1 came back from [local behavioral hospital] they were trying to put CR#1 in the chair and CR#1 screamed saying that she broke her hip. The DON stated the staff were trying to change her and put her in the wheelchair. She stated the nurse at [the local behavioral hospital] never reported it to their facility so they did not know until they called them. She stated the local behavioral hospital nurse finally admitted CR#1 had a fall. The DON stated the facility staff did not touch her all night when she returned back from the [local behavioral hospital]. She stated CR#1 told the staff that she had a fall at [local behavioral hospital] so no one touched her all night. The DON stated in the morning was when they called [the local behavioral hospital] and they called CR#1's family member. She stated they sent CR#1 out to the hospital and found CR#1's right femur fractured, and it was the same leg that fractured again for this fall on [DATE]. In an interview on [DATE] at 1:58 p.m. the ED stated he did not make a report to the State regarding CR#1's fall at [The Local Behavioral hospital]. He stated he did not know where the fall happened, who the nurse was or the time it happened. In an interview on [DATE] at 9:20 p.m. with LVN B she stated on [DATE] the CNA came up to the nurse's desk and said CR#1 was on the floor, so all 3 nurses went to the room and they found CR#1 on the floor. LVN B stated she turned CR#1 over because she was trying to figure out where she was bleeding from and it was nose and she had a hematoma on the forehead. She stated LVN A figured out where CR#1 was bleeding from, did her vital signs while she was on the floor and they picked CR#1 up and put her back in the bed and by that time 911 was here. LVN B stated she exited the room. LVN B stated CR#1 did not have a floor mat, but she was alert. LVN B stated she asked CR#1 was she in any pain and CR#1 said no. LVN B stated CR#1 was responding, but she did not work that hall that night. LVN B stated they took CR#1's gown off while she was on the floor

Based on interviews and record review, the facility failed to immediately consult with the resident's physician of a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 of 12 residents (Resident #1) reviewed for resident rights. -The facility failed to notify Resident #1's physician on [DATE] when resident verbally expressed to staff that he wanted to die and go and be with his deceased parents. Resident #1 asked for a knife so he could kill himself. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 11:38AM. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of actual harm because all staff had not been trained on suicide ideations and one on one supervision. This failure placed other residents in the NF with psych behaviors at risk for harm or death. Findings: Record review of Resident #1's face sheet revealed a 70year old male admitted to the facility originally on [DATE] and readmitted [DATE] with diagnoses that included the following; dementia (memory loss and judgement) with mood disturbance, bipolar disorder (episodes of mood swings ranging from depression lows to excitement and energy), major depression, insomnia (difficulty sleeping), heart disease, hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of body) following cerebral infarction (disrupted blood flow to the brain) affecting the right dominant side, acquired absence of right leg above knee, and diabetes mellitus. Record review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS score of 14 indicating that resident cognition was intact. Record review of Resident #1's Physician Orders revealed the following: -Sertraline oral tablet 75mg by mouth one time a day for depression date ordered [DATE]. -Trazodone oral tablet 100mg give 1 tablet by mouth at bedtime for depression date ordered [DATE]. Record review of Resident #1's care plan dated [DATE] revealed that resident was being care planned for antidepressant medication r/t depression with intervention that included monitoring and documenting change in behavior/mood/cognition that included suicidal thoughts. Record review of Resident #1's Psychiatric Subsequent assessment dated [DATE] revealed in part: .psychiatric hx: Per chart MDD. Prior h/o suicidal attempts x 2. Per pt. long hx of depression and mood swings .Includes: Bipolar; depression; harm to self . Record review of Resident #1's Nursing Progress Notes dated [DATE] documented by RN B revealed in part: .Resident was found by CNA A trying to kill himself with call light cord wrapped around his neck at 5:30pm. CNA A and RN B struggled and pulled the cord out of his neck . Resident made verbal attempts to CNA A about 5:20pm that no one care about him and he just want to kill himself and join his mom and dad before attempting to take his own life. 911 was called at 5:35pm and they arrived to the unit about 5:43pm. Resident #1 was transported by EMS and Cops at 6:00pm to Psych/behavioral Unit. Record review of the NF list of residents on psych services dated [DATE] was 43 residents. Interview on [DATE] at 9:17 AM, the Administrator said Resident #1 was still at the hospital. The Administrator said Resident #1 was transferred to the hospital on [DATE] for refusing his medications and returned to the facility a few days later. Interview on [DATE] at 9:32 AM, the Social Worker said Resident #1 tried to kill himself over the weekend, which she was not present at the time of the incident. The Social Worker said when she returned to the facility, she reached out to Resident #1's Physician who said resident needed to be a direct admit to the hospital. The facility Social Worker said the facility had other residents on psych services but had not spoken to the other residents on psych services at this time. Further interview with the Administrator on [DATE] at 10:00am said he was still working on the investigation regarding Resident #1 and that he was in the morning meeting discussing with staff about Resident #1. The Administrator said he would be speaking to CNA A later when she reported to work for the 2pm-10pm shift. The Administrator said he would also call RN B for his statement. Interview on [DATE] at 12:30pm via phone CNA A said she worked the 2pm-10pm shift full time. CNA A said when she arrived to work on [DATE] at 2:00pm, Resident #1 was sitting outside at the front entrance in his w/c. CNA A said around 5:00pm Resident #1 had come inside the NF heading toward his room. CNA A said shortly after, she heard Resident #1 sobbing real loud in his room. CNA A said when she arrived at resident room, resident was sobbing and said he needed help getting into his bed and saying that no one loved him. CNA A said Resident #1 proceeded to say he wanted to die and go be with his deceased parents. CNA A said resident was requesting that the nurse give him something so he could die or that she gives him a knife so he could kill himself. CNA A said she kept trying to comfort Resident #1. CNA A said she left Resident #1 room to inform RN B what was going on. CNA A said RN B said Resident #1 was probably having a meltdown. CNA A said she went to the Dining Room to help serve the residents because it was dinner time. CNA A said when she arrived in the Dining Room, she saw there were enough staff to serve the residents and therefore, started to assist with passing trays on the hallway. CNA A said the time was closer to 5:20pm. CNA A said the first tray she got from the food cart was Resident #1. CNA A said when she arrived at Resident #1's room, she saw resident leaning to the left side of his bed with the cord from his motorized wheelchair tied around his neck in knot. CNA A said Resident #1 was red and purple in color. CNA A said Resident #1 was trying to kill himself. CNA said she was screaming for help and trying to release the cord from around resident neck. CNA A said RN B arrived at resident room to assist with releasing the cord from around resident's neck. CNA A said RN B told her and another CNA that came to Resident #1's room to stay with resident while he went to call 911 services. CNA A said after Resident #1 tried to kill himself, the NF never provided her in-service regarding suicide precautions. Interview on [DATE] at 12:40pm RN B said on [DATE] around 5:00PM or so Resident #1 had been sitting outside in his w/c. RN B said he saw resident going down the hallway towards his room. RN B said not too long after, CNA A came and told him that Resident #1 was saying that he wanted to kill himself. RN B said he was in the middle of doing blood sugars and told CNA A to start monitoring Resident #1 every 15 minutes. RN B said around 5:27pm the CNA called him to room. RN B said when he arrived at resident room, the Resident #1 had a cord tied around his neck in knot and he had to help the CNA remove the cord from around resident neck. RN B said after Resident #1 tried to kill himself, he placed resident on 1 on 1 monitoring by asking the CNA A to stay with resident while he went to call 911. Further interview with RN B said the reason he did not place Resident #1 on 1 on1 supervision when the CNA A informed him of the resident wanting to kill himself was because he was not aware of the facility policy and therefore told CNA B to monitor Resident #1 every 15 minutes. Interview om [DATE] at 1:54PM RP of Resident #1 said resident was doing much better. The RP said resident had a long history of threaten to do harm to himself. The RP said Resident #1 was very depressed and had suffered throughout his life with mental illness. Interview on [DATE] at 2:26pm the Corporate Nurse said she did not know how many residents in the NF was on psych services and that she had not done an audit of how many residents in the facility on psych services and if they had a history of suicidal ideation. Record review of the facility policy on Suicide Threats revised [DATE] revealed in part: .Resident suicide threats shall be taken seriously and addressed appropriately .Staff shall report any resident threats of suicide immediately to the Nurse Supervisor/Charge Nurse .The Nurse Supervisor/Charge Nurse shall immediately assess the situation and shall notify the Charge Nurse/Supervisor and/or Director of Nursing Services of such threats .A staff member shall remain with resident until Nurse Supervisor/Charge Nurse arrives to evaluate the resident .After assessing the resident in more detail, the Nurse Supervisor/Charge Nurse shall notify the resident's attending Physician and responsible party, and seek further direction from the physician . The Administrator was notified on [DATE] at 11:38AM an Immediate Jeopardy situation (IJ) was identified due to the above failure. The Administrator was provided the IJ template on [DATE] at 11:38AM and a Plan or Removal (POR) was requested. The facility POR was accepted on [DATE] at 11:33AM and indicated: PLAN OF REMOVAL F689 Name of facility: [DATE] Immediate Action The facility failed to place Resident #1 immediately on 1 on 1 supervision when resident verbally expressed to staff that he wanted to die and go and be with his deceased parents and asking for a knife so that he could kill himself. The Facility will implement a system that ensures all staff know the appropriate steps to take when a resident expresses or verbalizes behavior of self-harm and supervised adequately. Plan of Action The Regional RDCO in-serviced all Assistant Directors of Nursing, (Director of Nursing is out of the country), on [DATE] on Suicidal Ideation/attempt Policy. The Regional RDO in-serviced the Executive Director on [DATE] on Suicidal Ideation/attempt Policy. The Regional RDO in-serviced all Department Coordinators on [DATE] on Suicidal Ideation/attempt Policy. The Assistant Directors of Nursing initiated in-services completed in-services on [DATE] all facility staff on Suicidal Ideations/attempt Policy. Any employees not present will be in-serviced on Suicidal Ideations/threats attempt Policy before start of shift. On [DATE], Social Services completed an audit of all residents on Psych Services for any identifiable or suicidal ideations, no residents were identified to have any suicidal ideations. An audit was completed, [DATE], for all residents with suicidal ideations/depression to ensure accuracy on care plans by MDS Coordinators and will be updated as needed for accuracy. Resident #1's care plan was updated to reflect the incident on [DATE]. All interventions on Suicidal Ideation/attempt policy were reviewed and clarified to ensure staff implementation, [DATE]. The Regional RDCO and Assistant of Nursing completed a one-to-one in-service on [DATE] to RN B on Suicidal Ideation/ attempt. The policy states: Staff shall report any resident threats of suicide immediately to the Nurse Supervisor/Charge Nurse. 2. The Nurse Supervisor/Charge Nurse shall immediately assess the situation and shall notify the Charge Nurse/Supervisor and/or Director of Nursing Services of such threats. 3. A staff member shall remain with the resident until the Nurse Supervisor/Charge Nurse arrives to evaluate the resident. 4. After assessing the resident in more detail, the Nurse Supervisor/Charge Nurse shall notify the resident's Attending Physician and responsible party and shall seek further direction from the physician. 5. All nursing personnel and other staff involved in caring for the resident shall be informed of the suicide threat and instructed to report changes in the resident's behavior immediately. 6. As indicated, a psychiatric consultation or transfer for emergency psychiatric evaluation may be initiated. 7. If the resident remains in the facility, staff will monitor the resident's mood and behavior and update care plans accordingly, until a physician has determined that a risk of suicide does not appear to be present. 8. Staff shall document details of the situation objectively in the resident's medical record. Validations/Monitoring Tools IDT team to review and discuss any change in behavior in clinical daily meetings and ensure follow up is completed. QAPI The IDT Team and Executive Director held and Ad hoc QAPI meeting to include Medical Director on [DATE] and develop a plan of action to ensure all staff follow policy on Suicidal Ideation/threat and immediate action to ensure residents are safe from self-harm and supervised adequately. Plan was completed [DATE]. The surveyor confirmed the plan of removal had been implemented sufficiently to remove the IJ by the following: Interview on [DATE] at 2:34PM RN C said she worked at the facility on the 6am-6pm shift and was in serviced on suicidal threats to take the following steps: place the resident on 1 on 1 supervision never leaving the resident, remove any objects in the resident room that the resident could use to try and harm themselves, call the RP, doctor, and Administration. Interview on [DATE] at 2:40 PM LVN G said she worked the 6am-6pm shift full time. LVN G said she was in-serviced on suicide precautions that if a resident expressed suicide ideation to not leave the resident alone, place the resident on to one supervision, remove any objects that resident could use to harm himself, notify the family, doctor, and Administrator. LVN G said resident had to remain on one-to-one supervision until further notice. Interview on [DATE] at 2:46 PM the Social Worker said she had been in serviced on suicidal threats that if a resident expressed harm to themselves, stay with the resident do not leave them alone, inform the charged nurse, and continue to monitor the residents as well as do a psych assessment. The Social Worker said she had also been in serviced to interview other residents to ensure that they were ok and not having thoughts of wanting of self-harm. Interview on [DATE] at 2:48PM the Physical Therapist said that he worked at the facility full time. The Physical Therapist said he had had been in-serviced on suicidal precautions to stay with the resident do not leave them alone, inform the nurse immediately so that he or her or she could notify the doctor and responsible party right away. Interview on [DATE] at 2:50 PM CNA H who worked 6am-2pm said she had been in-serviced on suicidal attempts. CNA H said that if a resident expressed that they wanted to harm themselves she was not to leave the resident alone, have someone to go and inform the nurse, make sure that she removed any objects from the resident room to prevent the resident from harming themselves. Interview on [DATE] At 2:55 PM the OTA said she was in-serviced on suicidal threats that if a resident expressed self-harm to notifying the nurse immediately so that the nurse could inform the doctor and RP and remove any objects from around the resident to prevent harm. Interview on [DATE] at 3:00 PM CNA I said he worked the 2:00 PM-10:00 PM shift full time. CNA I said he received in-serve on suicidal precautions to never to leave the resident alone and to remove any objects that the resident might use to harm themselves, and to send for the nurse. Interview on [DATE] at 3:11 PM with Housekeeping said they had been in-serviced on suicide precautions. Housekeeping said if she overheard a resident say that they wanted to harm or threatened to kill themselves, she had to stay with the resident turn on the call light so the nurse could come and assessed a resident. Interview by phone on [DATE] 11:12 PM RN J who worked the 6pm-6am shift full time said she had been in-serviced on residents that expressed suicide to place resident on one-to-one supervision, remove any sharp objects that the resident could use to harm themselves, notify the Administrator, RP, and physician. Interview on [DATE] at 11:20 PM LVN K said she worked at the facility for a year and four months for the 6:00 PM to 6:00 AM shift. LVN K said that she had been in service on suicidal precautions that if a resident expressed harm to themselves, she had to place the resident on one-on-one supervision, remove any objects to prevent the resident from harming himself, call the administrator, call the responsible party and the doctor, and document the incident and actions taken. Interview on [DATE] at 11:33PM CNA L said he worked the 2:00 PM to 10:00 PM shift as well as the 10:00 PM to 6:00 AM shift. CNA L said that he had been in serviced on suicidal precautions to never leave the resident alone and immediately alert the nurse. Interview on [DATE] At 11:40 PM with CNA M said she worked the 10:00 PM to 6:00 AM shift full time. CNA M said that she had been in-serviced on suicidal precautions that if a resident expressed that they wanted to harm themselves to remove all objects from the room that could harm the resident, not to leave the resident alone, and call for the nurse immediately. Interview on [DATE] at 12:00am LVN N said she worked the 6p-6a shift full time. LVN N said she was in-serviced on suicide, 1 to 1 supervision, not to leave the resident alone, removing any objects in room that resident could use to harm themselves, notify the doctor and RP, and document all actions taken. Interview on [DATE] at 12:59 AM RN B said he worked at the nursing facility PRN on the 6:00 AM to 6:00 PM shift. RN B said he had been in-serviced on suicidal precautions that if a CNA informed him of a resident wanting to commit suicide to assess the resident immediately and placed the resident on one-on-one supervision immediately. RN B said he was instructed to inform the physician and all parties involved. Interview on [DATE] at 1:13 PM CNA F said she worked the 2:00 PM to 10:00 PM shift and had been in serviced on suicidal threat to place the residential on ,d+[DATE] supervision, never leaving the resident, notifying the nurse immediately, and removing any objects to prevent the resident from harming themselves. Interview on [DATE] at 11:25AM CNA Q said she worked the 2:00PM-10PM shift but was doing a double shift. CNA Q said she was in-serviced on suicide precautions to never leave the resident alone, send for the nurse, and remove any objects from resident room to keep them from harming themselves. Interview on [DATE] at 11:37AM CNA R who worked the on the 6AM-2PM shift said she received in-service on suicidal threats to never leave resident alone and send for the nurse immediately. Interview on [DATE] at 11:44 AM interview with CNA U said that she worked the morning shift and had been in service on suicide precautions not to leave the resident alone and to notify the nurse right away. Interview on [DATE] at 11:53 AM interview with CNA V said he worked 6:00 AM to 2:00 PM shift. CNA V said he had been in serviced on suicidal precautions to place the residential on one-on-one supervision, never to leave the resident, and to alert the nurse immediately. Interview on [DATE] at 11:55 AM interview with CNA T said she was in-serviced on suicidal ideation. CNA T said if a resident expressed harm to themself, she was instructed to never to leave the resident alone, remove objects from the room that could harm the resident, and alert the nurse immediately. Interview on [DATE] 11:58 AM CNA S said she worked the 6:00 AM to 2:00 PM shift. CNA S said she just started working at the nursing facility. CNS said she had been in serviced on suicidal threats to not leave the resident, and immediately called the nurse. Interview on [DATE] at 1:03 PM CNA A said that she had received in services on suicidal precautions. CNA A said if a resident expressed wanting to harm or kill themselves, she was instructed to not leave the resident alone, remove any items in resident room that they may use to harm themselves, and send for the nurse. Interview on [DATE] at 11:20 AM LVN O said she worked the 6AM-2PM shift and had been in-serviced on suicide precautions and documentation. Interview on [DATE] at 11:27 AM interview with CNA P said she worked 6AM-2PM. CNA P said she received in service on suicide precautions that if a resident expressed self-harm to never leave the resident and call for the nurse. On [DATE] at 11:33 AM the Administrator was informed that the IJ was removed, however, the facility remained out of compliance at a scope of an isolated and severity of actual harm that is not IJ as the facility was continuing to monitor the implementation and effectiveness of their plan of removal.

Based on interview and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accident for 1 of 12 residents (Resident #1) reviewed for accidents. -The facility failed to place Resident #1 immediately on 1 on 1 supervision on [DATE] when resident verbally expressed to staff that he wanted to die and go and be with his deceased parents. Resident #1 asked for a knife so he could kill himself. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 11:38AM. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of actual harm because all staff had not been trained on suicide ideations and one on one supervision. This failure placed other residents in the NF with psych behaviors at risk for harm or death. Findings: Record review of Resident #1's face sheet revealed a 70year old male admitted to the facility originally on [DATE] and readmitted [DATE] with diagnoses that included the following; dementia (memory loss and judgement) with mood disturbance, bipolar disorder (episodes of mood swings ranging from depression lows to excitement and energy), major depression, insomnia (difficulty sleeping), heart disease, hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of body) following cerebral infarction (disrupted blood flow to the brain) affecting the right dominant side, acquired absence of right leg above knee, and diabetes mellitus. Record review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS score of 14 indicating that resident cognition was intact. Record review of Resident #1's Physician Orders revealed the following: -Sertraline oral tablet 75mg by mouth one time a day for depression date ordered [DATE]. -Trazodone oral tablet 100mg give 1 tablet by mouth at bedtime for depression date ordered [DATE]. Record review of Resident #1's care plan dated [DATE] revealed that resident was being care planned for antidepressant medication r/t depression with intervention that included monitoring and documenting change in behavior/mood/cognition that included suicidal thoughts. Record review of Resident #1's Psychiatric Subsequent assessment dated [DATE] revealed in part: .psychiatric hx: Per chart MDD. Prior h/o suicidal attempts x 2. Per pt. long hx of depression and mood swings .Includes: Bipolar; depression; harm to self . Record review of Resident #1's Nursing Progress Notes dated [DATE] documented by RN B revealed in part: .Resident was found by CNA A trying to kill himself with call light cord wrapped around his neck at 5:30pm. CNA A and RN B struggled and pulled the cord out of his neck . Resident made verbal attempts to CNA A about 5:20pm that no one care about him and he just want to kill himself and join his mom and dad before attempting to take his own life. 911 was called at 5:35pm and they arrived to the unit about 5:43pm. Resident #1 was transported by EMS and Cops at 6:00pm to Psych/behavioral Unit. Record review of the NF list of residents on psych services dated [DATE] was 43 residents. Interview on [DATE] at 9:17 AM, the Administrator said Resident #1 was still at the hospital. The Administrator said Resident #1 was transferred to the hospital on [DATE] for refusing his medications and returned to the facility a few days later. Interview on [DATE] at 9:32 AM, the Social Worker said Resident #1 tried to kill himself over the weekend, which she was not present at the time of the incident. The Social Worker said when she returned to the facility, she reached out to Resident #1's Physician who said resident needed to be a direct admit to the hospital. The facility Social Worker said the facility had other residents on psych services but had not spoken to the other residents on psych services at this time. Further interview with the Administrator on [DATE] at 10:00am said he was still working on the investigation regarding Resident #1 and that he was in the morning meeting discussing with staff about Resident #1. The Administrator said he would be speaking to CNA A later when she reported to work for the 2pm-10pm shift. The Administrator said he would also call RN B for his statement. Interview on [DATE] at 12:30pm via phone CNA A said she worked the 2pm-10pm shift full time. CNA A said when she arrived to work on [DATE] at 2:00pm, Resident #1 was sitting outside at the front entrance in his w/c. CNA A said around 5:00pm Resident #1 had come inside the NF heading toward his room. CNA A said shortly after, she heard Resident #1 sobbing real loud in his room. CNA A said when she arrived at resident room, resident was sobbing and said he needed help getting into his bed and saying that no one loved him. CNA A said Resident #1 proceeded to say he wanted to die and go be with his deceased parents. CNA A said resident was requesting that the nurse give him something so he could die or that she gives him a knife so he could kill himself. CNA A said she kept trying to comfort Resident #1. CNA A said she left Resident #1 room to inform RN B what was going on. CNA A said RN B said Resident #1 was probably having a meltdown. CNA A said she went to the Dining Room to help serve the residents because it was dinner time. CNA A said when she arrived in the Dining Room, she saw there were enough staff to serve the residents and therefore, started to assist with passing trays on the hallway. CNA A said the time was closer to 5:20pm. CNA A said the first tray she got from the food cart was Resident #1. CNA A said when she arrived at Resident #1's room, she saw resident leaning to the left side of his bed with the cord from his motorized wheelchair tied around his neck in knot. CNA A said Resident #1 was red and purple in color. CNA A said Resident #1 was trying to kill himself. CNA said she was screaming for help and trying to release the cord from around resident neck. CNA A said RN B arrived at resident room to assist with releasing the cord from around resident's neck. CNA A said RN B told her and another CNA that came to Resident #1's room to stay with resident while he went to call 911 services. CNA A said after Resident #1 tried to kill himself, the NF never provided her in-service regarding suicide precautions. Interview on [DATE] at 12:40pm RN B said on [DATE] around 5:00PM or so Resident #1 had been sitting outside in his w/c. RN B said he saw resident going down the hallway towards his room. RN B said not too long after, CNA A came and told him that Resident #1 was saying that he wanted to kill himself. RN B said he was in the middle of doing blood sugars and told CNA A to start monitoring Resident #1 every 15 minutes. RN B said around 5:27pm the CNA called him to room. RN B said when he arrived at resident room, the Resident #1 had a cord tied around his neck in knot and he had to help the CNA remove the cord from around resident neck. RN B said after Resident #1 tried to kill himself, he placed resident on 1 on 1 monitoring by asking the CNA A to stay with resident while he went to call 911. Further interview with RN B said the reason he did not place Resident #1 on 1 on1 supervision when the CNA A informed him of the resident wanting to kill himself was because he was not aware of the facility policy and therefore told CNA B to monitor Resident #1 every 15 minutes. Interview om [DATE] at 1:54PM RP of Resident #1 said resident was doing much better. The RP said resident had a long history of threaten to do harm to himself. The RP said Resident #1 was very depressed and had suffered throughout his life with mental illness. Interview on [DATE] at 2:26pm the Corporate Nurse said she did not know how many residents in the NF was on psych services and that she had not done an audit of how many residents in the facility on psych services and if they had a history of suicidal ideation. Record review of the facility policy on Suicide Threats revised [DATE] revealed in part: .Resident suicide threats shall be taken seriously and addressed appropriately .Staff shall report any resident threats of suicide immediately to the Nurse Supervisor/Charge Nurse .The Nurse Supervisor/Charge Nurse shall immediately assess the situation and shall notify the Charge Nurse/Supervisor and/or Director of Nursing Services of such threats .A staff member shall remain with resident until Nurse Supervisor/Charge Nurse arrives to evaluate the resident .After assessing the resident in more detail, the Nurse Supervisor/Charge Nurse shall notify the resident's attending Physician and responsible party, and seek further direction from the physician . The Administrator was notified on [DATE] at 11:38AM an Immediate Jeopardy situation (IJ) was identified due to the above failure. The Administrator was provided the IJ template on [DATE] at 11:38AM and a Plan or Removal (POR) was requested. The facility POR was accepted on [DATE] at 11:33AM and indicated: PLAN OF REMOVAL F689 Name of facility: [DATE] Immediate Action The facility failed to place Resident #1 immediately on 1 on 1 supervision when resident verbally expressed to staff that he wanted to die and go and be with his deceased parents and asking for a knife so that he could kill himself. The Facility will implement a system that ensures all staff know the appropriate steps to take when a resident expresses or verbalizes behavior of self-harm and supervised adequately. Plan of Action The Regional RDCO in-serviced all Assistant Directors of Nursing, (Director of Nursing is out of the country), on [DATE] on Suicidal Ideation/attempt Policy. The Regional RDO in-serviced the Executive Director on [DATE] on Suicidal Ideation/attempt Policy. The Regional RDO in-serviced all Department Coordinators on [DATE] on Suicidal Ideation/attempt Policy. The Assistant Directors of Nursing initiated in-services completed in-services on [DATE] all facility staff on Suicidal Ideations/attempt Policy. Any employees not present will be in-serviced on Suicidal Ideations/threats attempt Policy before start of shift. On [DATE], Social Services completed an audit of all residents on Psych Services for any identifiable or suicidal ideations, no residents were identified to have any suicidal ideations. An audit was completed, [DATE], for all residents with suicidal ideations/depression to ensure accuracy on care plans by MDS Coordinators and will be updated as needed for accuracy. Resident #1's care plan was updated to reflect the incident on [DATE]. All interventions on Suicidal Ideation/attempt policy were reviewed and clarified to ensure staff implementation, [DATE]. The Regional RDCO and Assistant of Nursing completed a one-to-one in-service on [DATE] to RN B on Suicidal Ideation/ attempt. The policy states: Staff shall report any resident threats of suicide immediately to the Nurse Supervisor/Charge Nurse. 2. The Nurse Supervisor/Charge Nurse shall immediately assess the situation and shall notify the Charge Nurse/Supervisor and/or Director of Nursing Services of such threats. 3. A staff member shall remain with the resident until the Nurse Supervisor/Charge Nurse arrives to evaluate the resident. 4. After assessing the resident in more detail, the Nurse Supervisor/Charge Nurse shall notify the resident's Attending Physician and responsible party and shall seek further direction from the physician. 5. All nursing personnel and other staff involved in caring for the resident shall be informed of the suicide threat and instructed to report changes in the resident's behavior immediately. 6. As indicated, a psychiatric consultation or transfer for emergency psychiatric evaluation may be initiated. 7. If the resident remains in the facility, staff will monitor the resident's mood and behavior and update care plans accordingly, until a physician has determined that a risk of suicide does not appear to be present. 8. Staff shall document details of the situation objectively in the resident's medical record. Validations/Monitoring Tools IDT team to review and discuss any change in behavior in clinical daily meetings and ensure follow up is completed. QAPI The IDT Team and Executive Director held and Ad hoc QAPI meeting to include Medical Director on [DATE] and develop a plan of action to ensure all staff follow policy on Suicidal Ideation/threat and immediate action to ensure residents are safe from self-harm and supervised adequately. Plan was completed [DATE]. The surveyor confirmed the plan of removal had been implemented sufficiently to remove the IJ by the following: Interview on [DATE] at 2:34PM RN C said she worked at the facility on the 6am-6pm shift and was in serviced on suicidal threats to take the following steps: place the resident on 1 on 1 supervision never leaving the resident, remove any objects in the resident room that the resident could use to try and harm themselves, call the RP, doctor, and Administration. Interview on [DATE] at 2:40 PM LVN G said she worked the 6am-6pm shift full time. LVN G said she was in-serviced on suicide precautions that if a resident expressed suicide ideation to not leave the resident alone, place the resident on to one supervision, remove any objects that resident could use to harm himself, notify the family, doctor, and Administrator. LVN G said resident had to remain on one-to-one supervision until further notice. Interview on [DATE] at 2:46 PM the Social Worker said she had been in serviced on suicidal threats that if a resident expressed harm to themselves, stay with the resident do not leave them alone, inform the charged nurse, and continue to monitor the residents as well as do a psych assessment. The Social Worker said she had also been in serviced to interview other residents to ensure that they were ok and not having thoughts of wanting of self-harm. Interview on [DATE] at 2:48PM the Physical Therapist said that he worked at the facility full time. The Physical Therapist said he had had been in-serviced on suicidal precautions to stay with the resident do not leave them alone, inform the nurse immediately so that he or her or she could notify the doctor and responsible party right away. Interview on [DATE] at 2:50 PM CNA H who worked 6am-2pm said she had been in-serviced on suicidal attempts. CNA H said that if a resident expressed that they wanted to harm themselves she was not to leave the resident alone, have someone to go and inform the nurse, make sure that she removed any objects from the resident room to prevent the resident from harming themselves. Interview on [DATE] At 2:55 PM the OTA said she was in-serviced on suicidal threats that if a resident expressed self-harm to notifying the nurse immediately so that the nurse could inform the doctor and RP and remove any objects from around the resident to prevent harm. Interview on [DATE] at 3:00 PM CNA I said he worked the 2:00 PM-10:00 PM shift full time. CNA I said he received in-serve on suicidal precautions to never to leave the resident alone and to remove any objects that the resident might use to harm themselves, and to send for the nurse. Interview on [DATE] at 3:11 PM with Housekeeping said they had been in-serviced on suicide precautions. Housekeeping said if she overheard a resident say that they wanted to harm or threatened to kill themselves, she had to stay with the resident turn on the call light so the nurse could come and assessed a resident. Interview by phone on [DATE] 11:12 PM RN J who worked the 6pm-6am shift full time said she had been in-serviced on residents that expressed suicide to place resident on one-to-one supervision, remove any sharp objects that the resident could use to harm themselves, notify the Administrator, RP, and physician. Interview on [DATE] at 11:20 PM LVN K said she worked at the facility for a year and four months for the 6:00 PM to 6:00 AM shift. LVN K said that she had been in service on suicidal precautions that if a resident expressed harm to themselves, she had to place the resident on one-on-one supervision, remove any objects to prevent the resident from harming himself, call the administrator, call the responsible party and the doctor, and document the incident and actions taken. Interview on [DATE] at 11:33PM CNA L said he worked the 2:00 PM to 10:00 PM shift as well as the 10:00 PM to 6:00 AM shift. CNA L said that he had been in serviced on suicidal precautions to never leave the resident alone and immediately alert the nurse. Interview on [DATE] At 11:40 PM with CNA M said she worked the 10:00 PM to 6:00 AM shift full time. CNA M said that she had been in-serviced on suicidal precautions that if a resident expressed that they wanted to harm themselves to remove all objects from the room that could harm the resident, not to leave the resident alone, and call for the nurse immediately. Interview on [DATE] at 12:00am LVN N said she worked the 6p-6a shift full time. LVN N said she was in-serviced on suicide, 1 to 1 supervision, not to leave the resident alone, removing any objects in room that resident could use to harm themselves, notify the doctor and RP, and document all actions taken. Interview on [DATE] at 12:59 AM RN B said he worked at the nursing facility PRN on the 6:00 AM to 6:00 PM shift. RN B said he had been in-serviced on suicidal precautions that if a CNA informed him of a resident wanting to commit suicide to assess the resident immediately and placed the resident on one-on-one supervision immediately. RN B said he was instructed to inform the physician and all parties involved. Interview on [DATE] at 1:13 PM CNA F said she worked the 2:00 PM to 10:00 PM shift and had been in serviced on suicidal threat to place the residential on ,d+[DATE] supervision, never leaving the resident, notifying the nurse immediately, and removing any objects to prevent the resident from harming themselves. Interview on [DATE] at 11:25AM CNA Q said she worked the 2:00PM-10PM shift but was doing a double shift. CNA Q said she was in-serviced on suicide precautions to never leave the resident alone, send for the nurse, and remove any objects from resident room to keep them from harming themselves. Interview on [DATE] at 11:37AM CNA R who worked the on the 6AM-2PM shift said she received in-service on suicidal threats to never leave resident alone and send for the nurse immediately. Interview on [DATE] at 11:44 AM interview with CNA U said that she worked the morning shift and had been in service on suicide precautions not to leave the resident alone and to notify the nurse right away. Interview on [DATE] at 11:53 AM interview with CNA V said he worked 6:00 AM to 2:00 PM shift. CNA V said he had been in serviced on suicidal precautions to place the residential on one-on-one supervision, never to leave the resident, and to alert the nurse immediately. Interview on [DATE] at 11:55 AM interview with CNA T said she was in-serviced on suicidal ideation. CNA T said if a resident expressed harm to themself, she was instructed to never to leave the resident alone, remove objects from the room that could harm the resident, and alert the nurse immediately. Interview on [DATE] 11:58 AM CNA S said she worked the 6:00 AM to 2:00 PM shift. CNA S said she just started working at the nursing facility. CNS said she had been in serviced on suicidal threats to not leave the resident, and immediately called the nurse. Interview on [DATE] at 1:03 PM CNA A said that she had received in services on suicidal precautions. CNA A said if a resident expressed wanting to harm or kill themselves, she was instructed to not leave the resident alone, remove any items in resident room that they may use to harm themselves, and send for the nurse. Interview on [DATE] at 11:20 AM LVN O said she worked the 6AM-2PM shift and had been in-serviced on suicide precautions and documentation. Interview on [DATE] at 11:27 AM interview with CNA P said she worked 6AM-2PM. CNA P said she received in service on suicide precautions that if a resident expressed self-harm to never leave the resident and call for the nurse. On [DATE] at 11:33 AM the Administrator was informed that the IJ was removed, however, the facility remained out of compliance at a scope of an isolated and severity of actual harm that is not IJ as the facility was continuing to monitor the implementation and effectiveness of their plan of removal.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program as evidenced by: - CR#1 was found on [DATE] covered in fire ants and sustained hundreds of ant bites. CR#1 died at the facility within 4 hours after sustaining the fire ant bites. -Observation of the facility's grounds on [DATE] at 11:30 a.m. with Maintenance revealed this Surveyor found 1 untreated ant mound outside, near CR #1's room. Maintenance said Pest Control just left the facility that morning and also walked around the facility and grounds and did not see the ant mound. - Observation on [DATE] at 12:00 p.m. of room 214 revealed one dead black ant by the window and a/c unit. -The facility had an ant infestation that caused them to have to move Resident #1 (CR#1's roommate), Resident #2, and Resident #3 to a different rooms. -The following rooms had ants: [DATE] room 211, had ants, and on [DATE] he they made rounds around the building and inspected rooms 103, 203, 207 and 213 and found unknown species of ants. An Immediate Jeopardy (IJ) was identified on [DATE] at 3:19 p.m. While the IJ was lowered on [DATE], the facility remained out of compliance at a severity level of actual harm that is not an Immediate Jeopardy and a scope of widespread as the facility continued to monitor the implementation and effectiveness of their plan of removal. These failures placed residents all residents at risk of experiencing pain, physical and emotional distress, and possible death. Findings include: Record review of a Face Sheet for CR #1 revealed an [AGE] year-old male admitted on [DATE] and readmitted [DATE]. CR#1 was diagnosed with senile degeneration of brain (mental decline), cognitive communication, [CONDITION(S)] (hardening of the arteries in the heart), [CONDITION(S)] and [CONDITION(S)] (complete loss of strength and weakness on one side of the body) and , hypertension (high blood pressure), ataxia (loss of full control of body movements) and [CONDITION(S)] (high cholesterol). Record review of CR#1's Minimum Data Set, dated dated dated [DATE] revealed his BIMS Summary score was 8 indicating his cognition was mildly impaired; walking in room and corridor did not occur; he was totally dependent with two staff for transfers, and dressing; totally dependent with one staff for locomotion on and off unit, eating, toilet use, and personal hygiene and he needed extensive assistance with two staff for bed mobility. CR #2 was totally dependent on staff for bathing with one staff assisting; urinary continence was not rated, and he was frequently incontinent of bowel. Record review of CR#1's Care Plan dated [DATE] revealed CR#1 was incontinent of bowel and bladder with intervention was to check as required for incontinence, wash, rinse and dry perineum, change clothing PRN after each incontinent episode; Activities of Daily Living (ADL) self-care performance deficit with intervention was bathing required physical help of ,d+[DATE] staff participation with bathing, bed mobility required ,d+[DATE] staff participation to reposition and turn in bed, dressing required limited-extensive assistance of ,d+[DATE] staff participation to dress, eating required limited extensive assist of 1 staff participation to eat, Geri chair for positioning, comfort and proper body alignment, hygiene/oral care required limited-extensive assist of ,d+[DATE] staff participation with personal hygiene and oral care , and toilet use required limited-extensive assist of ,d+[DATE] staff participation to use toilet; transfer required extensive assist of 2 staff participation with Hoyer lift transfers; impaired cognitive function or impaired thought processes r/t dementia with intervention as BIMS 10, administer medications as ordered, ask yes/no questions in order to determine the resident's needs; cognitive deficit as evidenced by trouble concentrating with interventions was administer anti-anxiety medication, Evaluate for side effects of medications, monitor for non-verbal signs of anxiety: restlessness, trembling, rocking and pacing, indwelling suprapubic Catheter and is at risk for increased Urinary tract infections; pressure ulcers with interventions was the resident has a 16 FR catheter. Position catheter bag and tubing below the level of the bladder and away from entrance room door and check tube for kinks. Record review of video #1 revealed CR#1 was covered with black ants. Observation revealed hundreds of ants all over CR#1. The nurses were saying they were all over him, his mouth, and that he was still breathing. Record review of Video #2 revealed a trail of hundreds of black ants leading from the wall by the outside by the nightstand leading to CR#1. Record review of Hospice notes dated [DATE] revealed 2 pictures of CR#1 revealing the ants had eaten CR#1's flesh all around his mouth, eyes, the inside of his cheek, ear and possibly bites on his tongue. Hospice notes further revealed, This RN received call from DON that CR#1 had passed. After assessment including auscultation of chest for 1 minute, no signs of life noted. Confirmed time of death of on [DATE] at 9:19 a.m. CR#1 was found covered in ant bites from an ant infestation in his room at the facility .Medical examiner's office taking over case .DON stated CR#1 was found in ants around 4:30 a.m. and aides were instructed to give CR#1 a shower to rinse off ants. Record review of facility's Daily Maintenance Log revealed: [DATE] Ants coming through A/C; [DATE] ants infestation; and [DATE] ants on the floor by refrigerator. Record review of facility's local pest control service dated [DATE] revealed: I drenched and treated 3 large mounds. Record review of facility's local Pest Control Service dated [DATE] revealed: I treated the exterior for occasional invaders and drenched and treated 2 fire ant mounds . Record review of Facility's local Pest Control Service dated [DATE] revealed: no treatment noted for ants. Record review of Facility's local Pest Control Service dated [DATE] revealed: Upon arrival I checked in at front desk and met with [maintenance director]. I began with inspecting resident rooms 103, 203, 207, and 213 for ants. I found a couple of unknown species of ants in 103 and baited all rooms because residents were present. Record review of Facility's local Pest Control Service dated [DATE] revealed: Facility requested additional service. Upon arrival I checked in at front desk and met with maintenance director. I inspected and/or treated all resident rooms throughout the facility. Resident rooms 103 and 214 had minor fire ant activity near ac units. All occupied rooms were baited around windows and ac units . The outside of both rooms had large ant mounds which I drenched and treated. I also applied local treatment around the building. In an interview on [DATE] at 3:55 p.m. with Family member of Resident #2 in room 101 he said he saw some ants in the room, and he told Maintenance. He said he killed several of them, but none of them made it into Resident #2's bed or to Resident #3's bed. The family member said the ants were in this room last week unknown date and there were like 3 to 4 ants. The family member said Resident #3 is not able to speak, totally dependent on staff, but he was not on hospice. Resident #2 was observed to have a feeding tube and a foley. The family member said when he saw the ants, they were in the middle of the floor crawling in between the residents (Resident #2 and Resident #3 and he killed all that he saw. Observation and interview on [DATE] at 11:58 a.m. with Resident #4 she said she had seen some ants in her room (room 212), but she denied the ants biting her. Resident #4 said they sprayed in her room today and she pointed towards the window and the a/c unit and observation revealed several dead black ants. Interview on [DATE] at 11:15 a.m. with Maintenance he said he came in the morning, and he did not see anything. He checked outside on the grounds of the facility and inside the facility. Maintenance said there was 1 room (room 211) this morning with 3 ants. He sprayed for ants and walked the entire perimeter. Maintenance said room 211 had ants that morning and that pest control came to the facility today, [DATE]. On [DATE], he said he and Pest Control made rounds around the building and inspected rooms 103, 203, 207 and 213 and found unknown species of ants. Observation of the facility's grounds on [DATE] at 11:30 a.m. with Maintenance revealed this Surveyor found 1 untreated ant mound outside, near CR #1's room. Maintenance said Pest Control just left the facility that morning and also walked around the facility and grounds and did not see the ant mound. Interview on [DATE] at 11:50 a.m. with Housekeeping A revealed she had only seen a a few ants around the faciity, but she saw a lot of ants in room 211. Observation on [DATE] at 11:53 a.m. of room 211 did not reveal any ants. Observation on [DATE] at 12:00 p.m. of room 214 revealed one dead black ant by the window and a/c unit. In a telephone interview on [DATE] at 12:57 p.m. with local Pest Control revealed on [DATE], he said he found 3 or 4 ant mounds in the exterior of the facility which he treated and 2 resident rooms (103 and 214) that had 3 to 4 unknown species of ants, maybe fire ants. Pest Control said there were 3 or 4 fire ant mounds close to the building. He said when it rained, the ants make their way onto the lawn or grass. He has never seen the mounds against the concrete or brick. He has never seen it happen where ants would form a mound inside the ac unit. He denied finding anything on the 400 Hall area. The Administrator asked him to come back to treat the mound outside of 400 near CR#1's room. He said he would come back the following day, [DATE]. Interview on [DATE] at 10:24 a.m. LVN A said she was making her rounds and around 4 a.m. she was putting on CR #1's oxygen, foley and she left the room, but she came back because she forgot to get the dirty oxygen canula. LVN A said she went back to the room and CR#1 had some red on his face and she thought he threw up, so she went to get a towel to wash his face and she looked, and it was ants. LVN A said she started brushing the ants off his face and she saw there were more on the other side of his face. She said she went to get help and the other aides came in and started brushing his face. She said there were ants around CR#1's mouth, eyes, all over the bed, and there were a lot of ants. LVN A said she had just been in CR#1's room in under 45 minutes previously when she drained CR#1's foley drainage bag and changed the O2 canula. LVN A said she left the room and returned to CR#1's room to get the dirty canula and she said she went to CR#1's face to put the nasal cannula on and the lights were on, and she saw some ants in the residents bed. LVN A said she went to get help from LVN B and CNA A, and they got CR#1 out of the bed, showered him, and moved him to a different room. LVN A said there were a lot of ants, and it scared the hell out of her. LVN A said when they pulled CR#1's blanket back on his bed there were ants all in his bed. She said while they were brushing the ants off, LVN B was taking a video of the ants. She said LVN B sent the video to the DON to show her what was going on in the room. LVN A said she had to get the ants off of herself and after she made sure the ants were off of her, she called the DON to see how she would handle it. LVN A said the ants bit her too and she was standing in them, and she did not know she was standing in the ants. She said she was brushing the ants off of CR#1's face and they were crawling up her leg. LVN A said the ants came from under the air conditioner on the right side of the bed and the trail was long, and they were black ants. LVN A said LVN B, and all the resident CNA's came to assist them. She said the CNA's got the Hoyer lift to get CR#1 out of bed to get him into the shower. She said the CNA that worked the hall was CNA A, and she was PRN. LVN A said she has worked at the facility for about 2 weeks now. LVN A said the incident happened on [DATE] at around 5 a.m. LVN A said she started rounds at 2 a.m. and was in CR#1's room at 4:14 a.m. LVN A said CR#1 did not grimace like he was in pain, and she had just given CR#1 his [MEDICATION(S)]. LVN A said there were more ants around his mouth and eyes area. She said she did not get CR#1's face on the video and that was where the majority of the ants were. LVN A said CR#1 died on the next shift. LVN A said she called the DON, but she did not call the Doctor or CR#1's responsible party. LVN A said she called the DON and she said she would handle it when she came to work. Interview on [DATE] at 3:41 p.m. with Hospice RN she said when the hospice aide went to the facility at 5 a.m. he was actively transitioning after the ant bites. Hospice policy says if the resident is having an emergency its according to the facility's policy. Hospice policy is to notify them before transport and to notify them before calling 911. The nurse did not arrive until the facility called to say he passed. Interview on [DATE] at 3:50 p.m. with LVN A said she called her DON she said she would handle it when she came to the facility. LVN A said she did not call the doctor because the DON said she would take care of it when she got to the facility. She said LVN B is the one who called the DON originally and she did not call 911 because of the DON. LVN A said after the ant bites the resident changed in his breathing. She said she took CR#1's vitals, the oncoming nurse took over and the Hospice CNA came before she left. LVN A said she did not call 911 because he was hospice and a DNR and because her DON said she would handle it. After the bites, when they moved CR#1 from room 410 to room 306, CR#1 started breathing different. She did not call 911 or the Doctor because she followed her chain of command who told her what to do. Interview on [DATE] at 4:05 p.m. the facility Doctor said she heard CR#1 passed away. She said the DON did not call her about CR#1 until this morning, [DATE] after 9 a.m. The Facility Doctor said she was coming into this incident after the fact. She said hospice stopped the daily visits with CR#1, but they were doing daily visits until Friday, [DATE]. The Facility Doctor said she had not seen the resident, normally she would expect that the resident would stop breathing because of the ant bites venom. The Doctor said she did not want to give an opinion about whether the fire ants caused CR#1's death. She said when she talked with the DON, the DON said he had some trailing around his face and a few covering his legs. The Facility Doctor said she did not get the impression that he was covered in ants. The Facility Doctor said since the coroner was involved, he would give the Surveyor a better assessment. The Facility Doctor said what the DON described was not that he was completely covered with ants. The Facility Doctor said she did not want to answer this Surveyor if CR#1 could have died from the fire ant bites or if CR#1 should have been sent to the hospital. She said if she had someone with a broken bone, she would send them to the hospital. She said if a resident were covered from head to toe with ants, she would probably have sent the resident to the hospital. The Facility Doctor said she did not recall a message on her answering service, and she checked her messages and found that no one had called to report the incident. The Facility Doctor said she spoke with the hospice nurse who saw CR#1 and she was horrified at what she saw. The Facility Doctor said as best as she could tell she was not notified. The Facility Doctor said CR #1 was on scheduled [MEDICATION(S)] and was on hospice. She said she asked this morning and was told hospice was doing frequent visits and then they took him off of frequent visits because he was no longer actively dying. In an interview on [DATE] at 8:47 p.m. with CR#1's family member she said Hospice called her after the incident with CR#1 saying that CR#1 had passed away. The family member said the facility did not call her until after hospice called her. She said if the facility would have called her, she would have wanted CR#1 to go to the hospital or to even call the doctor. The family member said the facility should have called the Doctor right away for the Doctor to see CR#1. The family member said what happened to CR#1 was horrible. She said the DON called her about 10 or 15 minutes after Hospice called. The Family member said Hospice told her about the ant bites on CR#1's face. The DON said the resident passed away and that she was sorry and that they called and checked on him at about 5 or 5:30 a.m. and they discovered ants, the cleaned him up and took him a shower. She said CR#1's other family member 1 wanted to know why the facility did not call the doctor. She says she does not think it's right and CR#1's family cannot understand how this happened. The family member said she wondered if CR#1 ate by himself or did they clean him up after eating for the ants to be around his mouth. In an interview on [DATE] at 8:56 p.m. with CR#1's family member 1 (main RP) and family member 2 family member #2 said he was very sad and disappointed about how the facility took care of CR#1. Family member 2 said they felt the facility bated (made him [NAME] for the ants) CR#1 and put him back in the bed and he thought they would have called the doctor because CR#1 might have gone into shock with all the fire ant bites. Family member 2 said someone needed to be responsible for that. Family member 1 said the hospice nurse told them they were evacuating 2 other rooms because they found ants in those other rooms, too. Both family members said that was not acceptable for them and the hospice nurse said it was so much worse than what they told her on the phone. Family member 1 said the hospice nurse said it was pretty bad and that CR#1's face was all swollen with ant bites all over his face. Family member 2 said when they found CR#1 with those ants it was 4:30 a.m. and he died at 9:15 a.m., and he felt the facility should call the doctor or take him to the emergency room . Family member 2 said CR#1 could not use his hands so he could not swipe the ants from his face. In an interview on [DATE] at 11:37 a.m. with LVN B she said she took a short video of the ants on CR#1 because she wanted her supervisor, DON, and maintenance to see. She said CR#1's roommate (Resident #1) had some ants on him too, so they took his clothes off, put him in the chair and moved him to another room. LVN B said they took CR#1's clothes off and brought CR#1 out of the room. LVN B said she called DON and sent her the video. LVN B said the DON said make sure the residents get a shower and don't take any of the clothes into the new room. LVN B said she got CR#1 and Resident #1 out the room and out of the situation. LVN B said there were hundreds of ants on the floor and on CR#1. LVN B said she had not seen the resident until after he was bitten, and he was breathing like he was actively dying. In an Interview on [DATE] at 12:53 p.m. with the Administrator she said she woke up to a text message sent on [DATE] at 4:30 a.m., but she did not see it until 6 a.m. or 6:30 a.m. She said she called the nurses at the facility and asked who the resident was, and they said they already spoke to DON and she gave them orders to get CR#1 and Resident #1 up, showered and change their rooms. The Administrator said LVN A said she had already talked to the DON and gotten all of LVN A and LVN B's orders and instructions from the DON. The Administrator said when the staff told her that they already talked to the DON, she did not question it. She said on a hospice patient they usually don't send anyone out on a 911 emergency and when she talked to everybody, they said everything was done. She said she was not aware of the severity of the situation. The Administrator said she would have sent the resident to the hospital if she had known the severity of the ant bites, but that was not communicated to her. She said she could not answer what the outcome would be if someone was bitten by hundreds of ants. The Administrator said it was so unbelievable and she thought about it a thousand times of how to even prepare for something like that. She said the facility had exterminators coming in, they got the treatments, and they did not miss any. She said, How do you prevent something like that?. The Administrator said the facility in-serviced the staff on what they were doing for their room rounds, to look more closely by the window seals, make sure they notified the Maintenance Director, the DON and the Administrator. They had the exterminator to come out twice already to spray inside and outside the building twice now. The Administrator said she also included notifying the doctor as a part of the in-service. In an interview on [DATE] at 1:15 p.m. with the DON she said she was notified of the incident at on [DATE] at 4:21 a.m. by text and phone call by LVN B that there were ants on CR#1. She said she told the staff to get CR#1 up, showered and to another room. The DON said she asked if there were bites and they said there were not a lot of bites and that there was a little red around CR#1's mouth and eyes. DON said she asked the color of the ants and they said they were black. She said the nurses would do as she instructed and she would notify the doctor and family in the morning. She said LVN B sent her the video she took of the ants on CR#1, but not any pictures, so she could not see CR#1's face on the video. The DON said LVN A and LVN B did not explain that it was an emergency, so she followed normal protocol and she bathed the resident, but in hindsight she would not have said to go to the hospital because they don't send hospice residents out to the hospital. The DON said if they fall and break their arm and they are actively dying they would notify the doctor. The DON said the facility had the exterminators coming and spraying since the incident. She said if any residents had bites on them, they should let the doctors know immediately. She said she did not see it, but she should have let the nurse call the doctor. The DON said she did not call the family because she was not told about the severity of the ant bites. The DON said LVN C called hospice at 6:30 a.m. and that was why they came, and CR#1 passed away at 9:19 a.m. The DON said, she does not feel she did anything wrong. She said she felt that the movement from the ambulance would have killed CR#1 and when she saw CR#1's face she still would not have sent the resident to the hospital because he did not look like the picture that hospice took when she saw him. She said she did not know if the ant bites turned that way after CR#1 passed. She said she had this to happen to her before, not to this degree, they had sugar ants in the bed, so they got the resident up and showered the resident and moved them to a different room. The DON said, she probably would have asked the doctor for a Benadryl, but that is not what she saw. The DON said she did not get to the facility until after he died at about 9:30 a.m. The DON said she spoke with LVN A and asked her why she would call her when they should call the doctor and follow what their procedures were. In an interview on [DATE] at 4:02 p.m., the local pest control said the ant mound this Surveyor found on [DATE] by CR#1's room was imported fire ants and they are a biting species. He said he never found mounds inside the building, but the facility called him for unscheduled visits for a couple of rooms they found ants in on [DATE]. He said he could not really answer as to why the ants come in. Pest Control said the window seals in the facility are not sealed perfectly and ants do not need a lot of space to be able to come into the facility. He said they found 1 or 2 mounds on the building or really close to the building. Pest Control said he thought the ant mounds were on the 300 Hall, and he did find a mound on the outside of the 400 hall and there was one about 15 feet from the building. He said the a/c units can be entry points, but the facility had him go into all the rooms, but he did not see where the ants come in. Pest Control said some of the rooms had residents so he could not spray, so he put clear gel in the room to treat the ants. In an interview on [DATE] at 2:10 p.m., the Housekeeping Supervisor said she received a text at 4:23 a.m. to come to spray for ants, so she went to get the spray. She said there were a bunch of ants behind the nightstand next to the a/c unit, but nothing under the ac. The Housekeeping Supervisor said she did not see any food in the room, but they had already taken all CR#1's things. She had not seen so many ants, so she sprayed everything from privacy curtains to everything. Housekeeping said she did not know how the ants got into the facility and that may be because they had little cracks outside between the brick. She said now they walk the building twice a day checking for ants. The housekeepers are also looking for ants and as soon as they see something they call her. The housekeepers are going to be checking more and doing deep cleaning. They are using a little bit stronger treatment to keep the ants out. They will check the privacy curtains up and down and in the closets for any pests. Interview on [DATE] at 2:30 p.m. with CNA A she said she worked 10 p.m. to 6 a.m. shift and she heard some commotion in CR#1's room. LVN A found the resident with all the fire ants at that point, and they panicked, and they got scared to see what to do. CNA A said it was very ugly and she cannot get what happened out of her head. She said she saw the fire ants in his mouth, and everywhere, and CNA B started helping her. She said they stripped the bed, stripped CR#1, bathed him, put a fresh diaper on him and moved CR#1 to a different hall. CNA A said CNA B checked CR#1's penis and found 4 or 5 fire ants inside the skin of CR#1's penis. CNA A said CR#1 had a foley catheter. She said CR#1's eye lids were swollen, and his eyes were so red. CNA A said CR#1 had to be bleeding because when they touched his eyes with a wipe, she was afraid the skin would come off and the wipe was red, and CR#1 did not make any sounds. She said his breathing remained the same. CNA A said the way CR#1 was breathing they thought he was about to expire right then. She said when they got off at 6 am CR#1 was still alive. She said before the incident CR#1 was not breathing bad and she believed that CR#1's breathing changed after the incident. CNA A said maybe CR#1 was in pain and could not tell them. CNA A said she had to clean his buttocks because he had a large bowel movement, and she could see some ant bites and it looked scary. CNA A said at one point she kept scrubbing and then she realized that it was ant bites. She said she thought it was bowel movement, but it was ant bites so she started just dabbing him because common sense says he was in pain and could not tell them. CNA A said she thought CR#1's skin was going to fall off and it looked like he was in pain. CNA A said CR#1's skin was red, bumpy too from the ant bites, she saw blood, but not dripping. CNA A said CR#1's bottom was swollen with little bumps. She said the ants bit everywhere inside CR#1's mouth even his tongue. She said she and the Nurse were cleaning the outside of his mouth and they did not know where to start because the ants were everywhere. CNA A said the ants were all around CR#1's mouth and they realized they could not wipe because it was blood smeared on his face, she started shaking she was so scared. CNA A said she went to get the Hoyer lift to get the sling under CR#1 to get the Hoyer and transferred him out of the room ASAP. She said the trail of ants was by the window, so she started stepping on them and then she saw the bed. CNA A said they had previously moved CR#1 and Resident #1 from 200 Hall because there were fire ants on the 200 Hall and 100 hall had a problem with ants in room 101 and they moved those 2 residents (Resident #2 and Resident #3). CNA A said she does not believe Resident #2 and Resident #3 were bitten and the only one that was bitten was CR#1. In an interview on [DATE] at 10:55 a.m. with Pest Control he said he writes everything he does in his reports. The areas he normally hits are the kitchen, breakroom, entry points, and the exterior and the rest are based on Management and if they say rooms; then he goes to the rooms they say. Pest Control said he does not go into the rooms unless the facility tells him to go to a room. In an interview on [DATE] at 11:20 a.m. with LVN A she said CR#1 had his oxygen on the whole shift and the last time she went into the room was 4 a.m. LVN A said she forgot to take the dirty nasal cannula out of the room and that is why she went back into CR#1's room. She said CR#1 was sleeping the majority of the night, she checked on him, changed his foley catheter bag, and CR#1 slept the entire time. LVN A Sais she is sure when CR#1's family found out what happened it probably traumatized the family because it would traumatize her. LVN A said if she had an opportunity to go back and do things different, she made her rounds like she was supposed to, but if she would have walked around to the other side of the bed maybe she would have found the ants earlier. She said she got the ants off the resident, she moved him and Resident #1 to a separate then she would call 911. LVN A said LVN B called the DON and sent her the video LVN B came back and told LVN A that the DON said she would handle it when they got to the facility. LVN A said she thought to herself, wow so she called the DON herself and she told LVN A the same thing. LVN A said she would have done something different. She said she would have called hospice and she would have sent CR#1 to the hospital. LVN A said she was ready to send CR#1 out when she saw the blood was on his face. Once she got in the room and saw it was ants she was standing in the ants and getting them off CR#1, she would have called hospice and sent CR#1 out to 911. LVN A said the facility has since changed the way they want them to do things. She said to her she was going to do what she needed to do, but when the nurse told her that DON said not to do anything until she got there in the morning, she thought it did not sound right so when she came out the room, she called the DON again and got the same instructions. LVN A said she asked the DON if she saw the video's and the DON said yes. Since the incident, they have had in-service after in-service and quiz after quiz and if one person misses the question, they do it all over again. LVN A said if LVN B would have just let her do what she needed to do, if she would have called DON, she would have explained it different. LVN said she called the DON and said, this is LVN A, did you receive the videos, how do you want me to handle this? LVN A said she wished she would have listened to her first mind; she was going to send him out. DON called her when she got home and told her to go ahead to get some sleep. LVN A said they said follow your chain of command, even though she gave her the wrong advice she followed her chain of command, but she knew better and now she is the villain. The new protocol is if they see a situation that warrants calling 911 just call 911, then call the MD, and RP. Since this incident a whole new system has been put in place. It is a learning situation. She said things are going to happen, but you learn from your mistakes. In an interview on [DATE] at 11:39 a.m. with CNA B she said she was in the facility that night, but she did not see all the ants on him. CNA B said she came in when there may have been maybe 5 or 6 ants left on him. They had already cleaned him up. When she walked in CR#1 was in a brief, no gown she and LVN B, CNA A and LVN A was with CR#1. CNA B said she helped Resident #1 get transferred into the wheelchair and there was only 1 ant in his bed. She said she went to C [TRUNCATED]

Based on observation, interview and record review, the facility failed to immediately consult with the resident's physician and notify the resident representative regarding a significant change in the resident's medical status, for one former resident (CR#1) of eight residents reviewed for changes in condition, in that: -The facility failed to contact CR#1's physician, hospice nurse or Responsible Party for guidance or direction after he sustained numerous ant bites which left open wounds around and inside CR#1's mouth, eyes, and ears. CR#1 died at the facility within 4 hours after sustaining the ant bites. An Immediate Jeopardy (IJ) was identified on [DATE] at 3:19 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that is not an Immediate Jeopardy and a scope of isolated as the facility continued to monitor the implementation and effectiveness of their plan of removal. These failures placed residents who were totally dependent on staff for ADL's and with communication deficits at risk of experiencing pain, physical and emotional distress, and death. Findings include: Record review of a Face Sheet for CR #1 on [DATE] revealed an [AGE] year-old male admitted to the facility on [DATE] and readmitted [DATE]. CR#1 was diagnosed with senile degeneration of brain (mental decline), cognitive communication, [CONDITION(S)] (hardening of the arteries in the heart), [CONDITION(S)] and [CONDITION(S)] (complete loss of strength and weakness on one side of the body), hypertension (high blood pressure), ataxia (loss of full control of body movements) and [CONDITION(S)] (high cholesterol). Record review of CR#1's Minimum Data Set, dated dated dated [DATE] revealed his BIMS Summary score was an 8 indicating his cognition was moderately impaired; walking in room and corridor did not occur; he was totally dependent with two staff for transfers, and dressing; totally dependent with one staff for locomotion on and off unit, eating, toilet use, and personal hygiene and he needed extensive assistance with two staff for bed mobility. CR#1 was totally dependent on staff for bathing with one staff assisting; urinary continence was not rated, and he was frequently incontinent of bowel. Record review of CR#1's Care Plan dated [DATE] revealed CR#1 had a terminal diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] determine the resident's needs; cognitive deficit as evidenced by trouble concentrating with interventions was administer anti-anxiety medication, Evaluate for side effects of medications, monitor for non-verbal signs of anxiety: restlessness, trembling, rocking and pacing, indwelling suprapubic Catheter and is at risk for increased Urinary tract infections; pressure ulcers with interventions was the resident has a 16 FR catheter. Position catheter bag and tubing below the level of the bladder and away from entrance room door and check tube for kinks. Record review of video #1 taken by LVN B on [DATE] revealed CR#1 was covered with black ants. The video revealed hundreds of ants were all over CR#1. LVN A and LVN B were saying the ants were all over him, his mouth, and that he was still breathing. Record review of video #2 taken on [DATE] by LVN B revealed a trail of hundreds of black ants leading from the window and the wall by the nightstand leading to CR#1's bed. Record review of CR#1's local hospice nurses notes dated [DATE] revealed, Integumentary (skin) Assessment was pale and poor turgor (sign of dehydration), no abnormal respiratory findings identified, his appetite was poor eating bite sizes, and no imminent signs of death noted. Record review of CR#1's hospice notes dated [DATE] revealed 2 pictures of CR#1. The pictures revealed the ants had eaten CR#1's flesh all around his mouth, eyes, the inside of his left cheek, ears and possibly bites on his tongue. The hospice notes further revealed, This RN received call from [DON] that [CR#1] had passed. After assessment including auscultation (listening to the sounds) of chest for 1 minute, no signs of life noted. Confirmed time of death of on [DATE] at 9:19 a.m. [CR#1] was found covered in ant bites from an ant infestation in his room at the facility .Medical examiners office taking over case .DON stated [CR#1] was found in ants around 4:30 a.m. and aides were instructed to give [CR#1] a shower to rinse off ants. Interview on [DATE] at 10:24 a.m. LVN A said she was making her rounds and around 4 a.m. she was putting on CR #1's oxygen, foley and she left the room, but she came back because she forgot to get the dirty oxygen canula. LVN A said she went back to the room and CR#1 had some red on his face and she thought he threw up, so she went to get a towel to wash his face and she looked, and it was ants. LVN A said she started brushing the ants off his face and she saw there were more on the other side of his face. She said she went to get help and the other aides came in and started brushing his face. She said there were ants around CR#1's mouth, eyes, all over the bed, and there were a lot of ants. LVN A said she had just been in CR#1's room in under 45 minutes previously when she drained CR#1's foley drainage bag and changed the O2 canula. LVN A said she left the room and returned to CR#1's room to get the dirty canula and she said she went to CR#1's face to put the nasal cannula on and the lights were on, and she saw some ants in the residents bed. LVN A said she went to get help from LVN B and CNA A, and they got CR#1 out of the bed, showered him, and moved him to a different room. LVN A said there were a lot of ants, and it scared the hell out of her. LVN A said when they pulled CR#1's blanket back on his bed there were ants all in his bed. She said while they were brushing the ants off, LVN B was taking a video of the ants. She said LVN B sent the video to the DON to show her what was going on in the room. LVN A said she had to get the ants off of herself and after she made sure the ants were off of her, she called the DON to see how she would handle it. LVN A said the ants bit her too and she was standing in them, and she did not know she was standing in the ants. She said she was brushing the ants off of CR#1's face and they were crawling up her leg. LVN A said the ants came from under the air conditioner on the right side of the bed and the trail was long, and they were black ants. LVN A said LVN B, and all the resident CNA's came to assist them. She said the CNA's got the Hoyer lift to get CR#1 out of bed to get him into the shower. She said the CNA that worked the hall was CNA A, and she was PRN. LVN A said she has worked at the facility for about 2 weeks now. LVN A said the incident happened on [DATE] at around 5 a.m. LVN A said she started rounds at 2 a.m. and was in CR#1's room at 4:14 a.m. LVN A said CR#1 did not grimace like he was in pain, and she had just given CR#1 his [MEDICATION(S)]. LVN A said there were more ants around his mouth and eyes area. She said she did not get CR#1's face on the video and that was where the majority of the ants were. LVN A said CR#1 died on the next shift. LVN A said she called the DON, but she did not call the Doctor or CR#1's responsible party. LVN A said she called the DON and she said she would handle it when she came to work. Interview on [DATE] at 3:41 p.m. the Hospice RN said when the hospice aide went to the facility on [DATE] at 5 a.m. he was actively transitioning after the ant bites, and she went for her normal routine. The Hospice RN said the hospice policy reflected if the resident was having an emergency, then the operate according to the facility's policy. The Hospice RN said the hospice policy was to notify the hospice provider before transport and to notify them before calling 911. The Hospice RN said the nurse did not arrive until the facility called to say CR#1 passed. Hospice RN said the nurse would have ordinarily come before CR#1 passed. Interview on [DATE] at 3:50 p.m. LVN A said she could not say CR#1 was actively dying but he was getting [MEDICATION(S)] every 4 hours. LVN A said the only change she saw in CR#1 that day was when she tried to feed him lunch, and he was not swallowing. LVN A said he was just lying in the bed, no problems breathing, and his eyes were open. She said he never talked to her. She said she made sure there was no food in his mouth. She said since she had been taking care of the resident, he had been same way, and there was no real change in the resident. She said she had never seen anyone visit the resident on her shift. LVN A said CR#1 was taking [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)] and that was what put CR#1 into a deep sleep, and she gave CR#1's med's at 2 a.m. LVN A said she called her DON and she told her she would handle everything with CR#1 when she came to the facility. LVN A said she did not call the doctor because the DON said she would take care of it when she got to the facility. She said LVN B was the one who called the DON originally and she did not call 911 because of the DON. LVN A said after the ant bites the resident changed in his breathing. She said she took CR#1's vitals, the oncoming nurse took over and the Hospice CNA came before she left. LVN A said she did not call 911 because he was on hospice, had a DNR and because her DON said she would handle it. She said CR#1's vitals were the same as they had always been before the ant bites when she came to work between 6 p.m. and 8 p.m. CR#1's temperature was 97.2 degrees Fahrenheit, pulse 96, respirations were 20 (breaths per minute), and blood pressure was ,d+[DATE]. She said after the ant bites CR#1's vitals were temperature was 97.4 degrees Fahrenheit, pulse was 84, respiration were 18, blood pressure was ,d+[DATE] and his pulse was 95. LVN A said the original vitals were in the computer, but she did not record the 2nd set of vitals. LVA said after the bites, when they moved CR#1 from room [ROOM NUMBER] and placed him in room [ROOM NUMBER], CR#1 started breathing different like he was going to die. She said she did not call 911 or the doctor because she followed her chain of command who told her what to do. Interview on [DATE] at 4:05 p.m. the facility Doctor said she heard CR#1 passed away. She said the DON did not call her about CR#1 until this morning, [DATE] after 9 a.m. The Facility Doctor said she was coming into this incident after the fact. She said hospice stopped the daily visits with CR#1, but they were doing daily visits until Friday, [DATE]. The Facility Doctor said she had not seen the resident, normally she would expect that the resident would stop breathing because of the ant bites venom. The Doctor said she did not want to give an opinion about whether the fire ants caused CR#1's death. She said when she talked with the DON, the DON said he had some trailing around his face and a few covering his legs. The Facility Doctor said she did not get the impression that he was covered in ants. The Facility Doctor said since the coroner was involved, he would give the Surveyor a better assessment. The Facility Doctor said what the DON described was not that he was completely covered with ants. The Facility Doctor said she did not want to answer this Surveyor if CR#1 could have died from the fire ant bites or if CR#1 should have been sent to the hospital. She said if she had someone with a broken bone, she would send them to the hospital. She said if a resident were covered from head to toe with ants, she would probably have sent the resident to the hospital. The Facility Doctor said she did not recall a message on her answering service, and she checked her messages and found that no one had called to report the incident. The Facility Doctor said she spoke with the hospice nurse who saw CR#1 and she was horrified at what she saw. The Facility Doctor said as best as she could tell she was not notified. The Facility Doctor said CR #1 was on scheduled [MEDICATION(S)] and was on hospice. She said she asked this morning and was told hospice was doing frequent visits and then they took him off of frequent visits because he was no longer actively dying. In an interview on [DATE] at 8:47 p.m. with CR#1's family member she said hospice called her after the incident with CR#1 saying that CR#1 had passed away. CR#1's family member said hospice called her right after he passed at about 9:20 a.m. The family member said the facility did not call her until after hospice called her. She said if the facility would have called her, she would have wanted CR#1 to go to the hospital or to even call the doctor. The family member said the facility should have called the doctor right away for the doctor to see CR#1. The family member said what happened to CR#1 was horrible. She said the DON called her about 10 or 15 minutes after hospice called. The family member said hospice told her about the ant bites on CR#1's face. The DON said the resident passed away and that she was sorry and that they called and checked on him at about 5 a.m. or 5:30 a.m. and they discovered ants, they cleaned him up and got him showered. She said CR#1's other family member, family member 1, wanted to know why the facility did not call the doctor. She said she did not think it was right and CR#1's family could not understand how this happened. The family member said CR#1 had not been eating and he started eating again. The family member said she wondered if CR#1 ate by himself or did they clean him up after eating for the ants to be around his mouth. In an interview on [DATE] at 8:56 p.m. with CR#1's family member 1 (main RP) and family member 2 family member #2 said he was very sad and disappointed about how the facility took care of CR#1. Family member 2 said they felt the facility bated (made him [NAME] for the ants) CR#1 and put him back in the bed and he thought they would have called the doctor because CR#1 might have gone into shock with all the fire ant bites. Family member 2 said someone needed to be responsible for that. Family member 1 said the hospice nurse told them they were evacuating 2 other rooms because they found ants in those other rooms, too. Both family members said that was not acceptable for them and the hospice nurse said it was so much worse than what they told her on the phone. Family member 1 said the hospice nurse said it was pretty bad and that CR#1's face was all swollen with ant bites all over his face. Family member 2 said when they found CR#1 with those ants it was 4:30 a.m. and he died at 9:15 a.m., and he felt the facility should call the doctor or take him to the emergency room . Family member 2 said CR#1 could not use his hands so he could not swipe the ants from his face. In an interview on [DATE] at 11:37 a.m. with LVN B she said she was on her hallway on 300 hall doing rounds on the date of the incident. LVN B said LVN A from the 400 hall came looking for help, asking LVN B to come, and she pulled CNA B with her, too. LVN B said she took a short video of the ants that were on CR#1 because she wanted her supervisor, the DON, and maintenance to see. LVN B said they took CR#1's clothes off and brought CR#1 out of the room. LVN B said she called the DON and sent her the video. LVN B said the DON said to make sure the residents (CR#1 and his roommate, Resident #1) get a shower and don't take any of the clothes into the new room. LVN B said Resident #1 was not bitten, but they did find ants in his bed and on the sheets. LVN B said the ants were headed to Resident #1's bed. LVN B said she got CR#1 and Resident #1 out the room and out of the situation. LVN B said there were hundreds of ants on the floor and on [CR#1]. LVN B said CR#1 was actively dying already from the night before. LVN B said she did not call hospice because LVN A said she could handle it. This Surveyor asked why the doctor or 911 was not called LVN B said she let LVN A handle her resident. LVN B said if it was on her hall, she would have called the doctor, hospice and CR#1's family to let them know. LVN B said she did not see the reason to call 911 because she did not know what they would have done because he was already actively dying. LVN B said she had not seen the resident until after he was bitten, and he was breathing like he was actively dying. She said the CNA's were CNA A and CNA B on her hall. In an Interview on [DATE] at 12:53 p.m. with the Administrator she said she woke up to a text message sent on [DATE] at 4:30 a.m., but she did not see it until 6 a.m. or 6:30 a.m. She said she called the nurses at the facility and asked who the resident was, and they said they already spoke to DON and she gave them orders to get CR#1 and Resident #1 up, showered and change their rooms. The Administrator said LVN A said she had already talked to the DON and gotten all of LVN A and LVN B's orders and instructions from the DON. The Administrator said when the staff told her that they already talked to the DON, she did not question it. She said on a hospice patient they usually don't send anyone out on a 911 emergency and when she talked to everybody, they said everything was done. She said she was not aware of the severity of the situation. The Administrator said she would have sent the resident to the hospital if she had known the severity of the ant bites, but that was not communicated to her. She said she could not answer what the outcome would be if someone was bitten by hundreds of ants. The Administrator said it was so unbelievable and she thought about it a thousand times of how to even prepare for something like that. She said the facility had exterminators coming in, they got the treatments, and they did not miss any. She said, How do you prevent something like that?. The Administrator said the facility in-serviced the staff on what they were doing for their room rounds, to look more closely by the window seals, make sure they notified the Maintenance Director, the DON and the Administrator. They had the exterminator to come out twice already to spray inside and outside the building twice now. The Administrator said she also included notifying the doctor as a part of the in-service. In an interview on [DATE] at 1:15 p.m. with the DON she said she was notified of the incident at on [DATE] at 4:21 a.m. by text and phone call by LVN B that there were ants on CR#1. She said she told the staff to get CR#1 up, showered and to another room. The DON said she asked if there were bites and they said there were not a lot of bites and that there was a little red around CR#1's mouth and eyes. DON said she asked the color of the ants and they said they were black. She said the nurses would do as she instructed and she would notify the doctor and family in the morning. She said LVN B sent her the video she took of the ants on CR#1, but not any pictures, so she could not see CR#1's face on the video. The DON said LVN A and LVN B did not explain that it was an emergency, so she followed normal protocol and she bathed the resident, but in hindsight she would not have said to go to the hospital because they don't send hospice residents out to the hospital. The DON said if they fall and break their arm and they are actively dying they would notify the doctor. The DON said the facility had the exterminators coming and spraying since the incident. She said if any residents had bites on them, they should let the doctors know immediately. She said she did not see it, but she should have let the nurse call the doctor. The DON said she did not call the family because she was not told about the severity of the ant bites. The DON said LVN C called hospice at 6:30 a.m. and that was why they came, and CR#1 passed away at 9:19 a.m. The DON said, she does not feel she did anything wrong. She said she felt that the movement from the ambulance would have killed CR#1 and when she saw CR#1's face she still would not have sent the resident to the hospital because he did not look like the picture that hospice took when she saw him. She said she did not know if the ant bites turned that way after CR#1 passed. She said she had this to happen to her before, not to this degree, they had sugar ants in the bed, so they got the resident up and showered the resident and moved them to a different room. The DON said, she probably would have asked the doctor for a Benadryl, but that is not what she saw. The DON said she did not get to the facility until after he died at about 9:30 a.m. The DON said she spoke with LVN A and asked her why she would call her when they should call the doctor and follow what their procedures were. Record review of Change in a Resident's Condition or Status Policy revised [DATE] revealed, Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): accident or incident involving the resident; discovery of injuries of an unknown source; .A significant change of condition is a major decline or improvement in the resident's status that: Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is-not self-limiting); .Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: The resident is involved in any accident or incident that results in an injury including injuries of an unknown source; There is a significant change in the residents physical, mental, or psychological status; There is a significant change in the resident's room assignment Record review of Facility's policy on Hospice Program dated [DATE] revealed, In general, it is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative and ensure that the level of care provided is appropriately based on the individual resident's needs. These include .Notifying the hospice about the following: A significant change in the resident's physical, mental, social, or emotional status. Clinical complications that suggest a need to alter the plan of care. A need to transfer the resident from the facility for any condition. The resident's death. Communicating with the hospice provider (and documenting such communication) to ensure that the needs of the resident are addressed and met 24 hours per day; and Reporting any alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of resident property by hospice personnel, to the hospice administrator immediately upon awareness of the alleged violation. On [DATE] at 3:19 p.m., an Immediate Jeopardy (IJ) was identified. The Administrator was notified. The Administrator was provided with the IJ template, and a Plan of Removal (POR) was requested at that time. Interview on [DATE] at 10:40 a.m. the DON said if she had been the nurse, she would have gotten the patient to safety and called the doctor. The DON said the nurses should have called the doctor and hospice before calling her and notified her what they were doing. The DON said LVN A said she went back into the resident's room to change the canula because the resident was on oxygen and that is when she saw the ants on CR#1. The DON stated in an emergency, they are supposed to call the doctor first, she did not know why LVN A called her first. The POR submitted by the Administrator was accepted on [DATE] at 9:27 a.m The POR revealed: Systematic Approach: 1. Medical Director reviewed policies of Change of condition, notifying MD, RP and any third-party companies and emergent situations, Abuse & Neglect, Resident Right and Pest Control on [DATE] 2. Regional Director of Clinical Operations in-serviced/educated DON on following policy with consulting with physicians, RP and any third-party services as appropriate with Change of Condition, In emergent situations call 911 and then notify MD, RP, and any third-party services per policy. DON given a copy of change of condition policy by Regional Director of Clinical Operations. Training included effective communication of full situation/findings/observations/vital signs and DON to complete post-test competency by [DATE] 3. DON in-serviced/educated ADONs on following policy with consulting with physicians with Change of Condition, notifying MD, RP and third-party, In emergent situations call 911 and then notify MD, RP and any third-party services per policy. ADONs given a copy of the change of condition policy. Policy given to ADONs by DON. Training included effective communication of full situation/findings/observations/vital signs and Clinical staff to complete post-test competency by [DATE] 4. ADONs/Clinical Designee in-serviced/educated charge nurses on consulting with physicians with Change of Conditions, notifying RP and any third-party services per policy. All charge nurses given a copy of the change of condition policy by the ADON. Education will be on-going, prior to the start of each shift until all nurses have been provided the education. Effective [DATE] - [DATE]. All Licensed Nurses including PRN nurses who are unavailable for in-services will not be allowed to work until such in-services and competency test completed. 5. All staff including new hires will be educated on change in condition and notifying charge nurse as part of the orientation process and will routinely complete a competency test prior to working at Facility. 6. Administrator in-serviced on [DATE] by VP of Operations on the following policies - Change of Condition, In emergent situations call 911, Abuse and Neglect, Resident Rights and Hospice services. Administrator to complete competency test by [DATE] 7. Change of Condition policy addresses and details what is considered a change of condition and an emergent situation. Staff in-serviced /educated by ADON's/MDS nurses on Change of conditions. Staff also given a copy of policy to read and sign plus required to complete a competency test to be completed by [DATE]. 8. DON will confer with Executive Director of Operations on what she has directed to all nursing staff during a change of condition including emergent situations to ensure policy is being followed. Effective [DATE]. 9. Clinical Staff in-serviced/educated by DON and ADON's on properly completing Einteract change and condition evaluation assessment timely with all change in conditions on [DATE] Monitoring 1. All residents who have experienced a change of condition will be reviewed by DON or designee in the daily clinical meeting to verify MD, RP, and any third-party services are notified. Monday through Friday will be reviewed by DON/ADON's and Saturday/Sunday will be reviewed by RN Weekend Supervisor for the next 30 days. Starting [DATE]. 2. All residents who experience a change of condition will be reviewed by DON/designee again in the weekly SOC meeting to ensure MD, RP and third-party services are notified of any change of conditions starting [DATE]. Quality Service DON & EDO will submit audit findings to the QA Committee for review for analysis and recommendations The review of the Change of Condition notifications of MD, RP and any third party services findings will be submitted to the QA Committee for review, analysis and recommendations. Monitoring of the plan of removal included: Following acceptance of the facility's Plan of Removal, the facility was monitored from [DATE] to [DATE]. The surveyor confirmed the facility implemented their plan of removal sufficiently from [DATE]-[DATE] to remove the IJ by: Record Review of, In-Service Training Report, dated [DATE] revealed the Director of Clinical Services was educated by the RN on the topics of: Abuse/Neglect prohibition, change in condition/Resident assessment, notification of MD/RP, Pest Control evaluation and notifying. Record review revealed the staff were tested and retested when staff missed a question. Record Review of, In-Service Training Report, dated [DATE] revealed the ADON staff were educated by the DON on the topics of Abuse, Neglect, Change of Condition, Notifications, and Pest Control. Record review revealed the ADON staff were tested and retested when staff missed a question. The ADONs were educated and will educate staff on Change of Condition, notifying MD, family, third party immediately and DON was notified last. Record Review of, In-Service Training Report, dated [DATE] revealed Charge Nurses were educated by the RN on the topics of Change in Condition, pest control, assessments, notification of MD/RP and abuse/neglect prohibition. Record review revealed the Charge Nurse was tested on the topics. Charge Nurse was able to explain processes to take when there is a change in condition on resident. Record Review of, In-Service Training Report, dated [DATE] revealed All Staff Departments were educated by the RN on the topic of Resident's Rights. Record review revealed staff were tested and retested when staff missed a question. The staff were educated on Resident's rights and able to verbalize understanding of the topic which include right to a dignified existence, right to be treated with respect, kindness and dignity right to be free from neglect, abuse, misappropriation of property and exploitation. Record Review of, In-Service Emergent Situations, dated [DATE] revealed Clinical or Nonclinical staff who come across any type of emergency with resident. 1. Call charge nurse immediately. 2. Do not move resident unless in immediate danger. 3. Charge nurse will take over, assist nurse as requested. If asked to call 911, get crash cart, supplies or additional staff. Interview on [DATE] at 12:30 p.m. with the DON revealed the facility completed the following in-services: a respiratory assessment and in-service with testing for the Nurses (LVN and RN's), they did a head to toe assessment competency, abuse/neglect in-service and pest control, hospice, emergent services with a test for all staff, hospice for all staff, change in condition in-service and test, in-service on notification so there was no doubt in their mind what came first for everyone and that included housekeeping. The DON said staff such as the CNA would tell the nurse about an incident and if they couldn't find the nurse then they call 911. The DON said the first step the CNA takes was to call the nurse and if they couldn't get one immed [TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure the resident's right to be free from neglect for 1 of 8 residents (CR #1) reviewed for neglect. - The facility failed to seek medical care for CR#1 who was totally dependent on staff for ADL's and unable to communicate when he was found covered in ants and sustained hundreds of ant bites on his eyes, left cheek, inside his mouth and all over CR#1's body. CR#1 died at the facility within 4 hours after sustaining the ant bites. -The Administrator and DON failed to give adequate guidance when they received notification and video from staff of CR#1 covered in ants with open wounds from ant bites. -The facility failed to contact CR#1's physician, hospice Nurse and Responsible Party for guidance or direction after he sustained numerous ant bites which left open wounds around and inside CR#1's mouth, eyes, and ear. An Immediate Jeopardy (IJ) was identified on [DATE] at 3:19 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that is not an Immediate Threat and a scope of isolated as the facility continued to monitor the implementation and effectiveness of their plan of removal. These failures placed residents who are totally dependent on Staff for ADL's with communication deficits at risk of experiencing pain, physical and emotional distress, and death. Findings include: CR#1 Record review of a Face Sheet for CR #1 revealed an [AGE] year-old male admitted on [DATE] and readmitted [DATE]. CR#1 was diagnosed with senile degeneration of brain (mental decline), cognitive communication, [CONDITION(S)] (hardening of the arteries in the heart), [CONDITION(S)] and [CONDITION(S)] (complete loss of strength and weakness on one side of the body) and , hypertension (high blood pressure), ataxia (loss of full control of body movements) and [CONDITION(S)] (high cholesterol). Record review of CR#1's Minimum Data Set, dated dated dated [DATE] revealed his BIMS Summary score was 8 indicating his cognition was mildly impaired; walking in room and corridor did not occur; he was totally dependent with two staff for transfers, and dressing; totally dependent with one staff for locomotion on and off unit, eating, toilet use, and personal hygiene and he needed extensive assistance with two staff for bed mobility. CR #2 was totally dependent on staff for bathing with one staff assisting; urinary continence was not rated, and he was frequently incontinent of bowel. Record review of CR#1's Care Plan dated [DATE] revealed CR#1 was incontinent of bowel and bladder and the intervention to check him as required for incontinence, wash, rinse and dry perineum (the area between the anus and scrotum), change clothing PRN after each incontinent episode; Activities of Daily Living (ADL) self-care performance deficit and the intervention was bathing required physical help of ,d+[DATE] staff participation with bathing, bed mobility required ,d+[DATE] staff participation to reposition and turn in bed, dressing required limited-extensive assistance of ,d+[DATE] staff participation to dress, eating required limited extensive assist of 1 staff participation to eat, Geri chair for positioning, comfort and proper body alignment, hygiene/oral care required limited-extensive assist of ,d+[DATE] staff participation with personal hygiene and oral care, and toilet use required limited-extensive assist of ,d+[DATE] staff participation to use toilet; transfer required extensive assist of 2 staff participation with Hoyer lift transfers; impaired cognitive function or impaired thought processes r/t dementia with intervention as BIMS 10 revealing moderate cognitive impairment, administer medications as ordered, ask yes/no questions in order to determine the resident's needs; cognitive deficit as evidenced by trouble concentrating and the interventions were to administer anti-anxiety medication, evaluate for side effects of medications, monitor for non-verbal signs of anxiety: restlessness, trembling, rocking and pacing, indwelling suprapubic catheter and was at risk for increased urinary tract infections; pressure ulcers and the interventions were the resident had a 16 French catheter and to position the catheter bag and tubing below the level of the bladder and away from entrance room door and to check the tube for kinks. Record review of CR#1's Narcotic sheet, labeled [MEDICATION(S)] Sul 501 revealed the last time it was given was 2 a.m. Record review of Medication Administration Record dated [DATE] revealed the last medication [MEDICATION(S)] Sul 501 and [MEDICATION(S)] was given at 2 a.m. Record review of video #1 dated [DATE] recorded by LVN B revealed CR#1 was covered with black ants. Observation revealed hundreds of ants all over CR#1. The nurses LVN A and LVN B were saying they were all over him, his mouth, and that he was still breathing. Record review of video #2 taken on [DATE] by LVN B revealed a trail of hundreds of black ants leading from the window and the wall by the nightstand leading to CR#1's bed. Record review of Local Hospice Nurses notes dated [DATE] revealed, Integumentary (skin) Assessment was pale and poor turgor, no abnormal respiratory findings identified, his appetite was poor eating bite sizes, and no imminent signs of death noted. Record review of Hospice notes dated [DATE] revealed 2 pictures of CR#1 revealing the ants had eaten CR#1's flesh all around his mouth, eyes, the inside of his left cheek, ears and possibly bites on his tongue. Hospice notes further revealed, This RN received call from DON that CR#1 had passed. After assessment including auscultation of chest for 1 minute, no signs of life noted. Confirmed time of death of on [DATE] at 9:19 a.m. CR#1 was found covered in ant bites from an ant infestation in his room at the facility .Medical examiner's office taking over case .DON stated CR#1 was found in ants around 4:30 a.m. and aides were instructed to give CR#1 a shower to rinse off ants. Record review of Facility's Daily Maintenance Log revealed: [DATE] Ants coming through a/c; [DATE] ants infestation; and [DATE] ants on the floor by refrigerator. Record review of LVN A's General Orientation Checklist for Training dated [DATE] revealed training in Abuse, Incidents/Accidents Reporting, Emergency 911, Resident Rights, HIPAA, and Reporting Safety Concerns. Interview on [DATE] at 10:24 a.m. LVN A said she was making her rounds and around 4 a.m. she was putting on CR #1's oxygen, foley and she left the room, but she came back because she forgot to get the dirty oxygen canula. LVN A said she went back to the room and CR#1 had some red on his face and she thought he threw up, so she went to get a towel to wash his face and she looked, and it was ants. LVN A said she started brushing the ants off his face and she saw there were more on the other side of his face. She said she went to get help and the other aides came in and started brushing his face. She said there were ants around CR#1's mouth, eyes, all over the bed, and there were a lot of ants. LVN A said she had just been in CR#1's room in under 45 minutes previously when she drained CR#1's foley drainage bag and changed the O2 canula. LVN A said she left the room and returned to CR#1's room to get the dirty canula and she said she went to CR#1's face to put the nasal cannula on and the lights were on, and she saw some ants in the residents bed. LVN A said she went to get help from LVN B and CNA A, and they got CR#1 out of the bed, showered him, and moved him to a different room. LVN A said there were a lot of ants, and it scared the hell out of her. LVN A said when they pulled CR#1's blanket back on his bed there were ants all in his bed. She said while they were brushing the ants off, LVN B was taking a video of the ants. She said LVN B sent the video to the DON to show her what was going on in the room. LVN A said she had to get the ants off of herself and after she made sure the ants were off of her, she called the DON to see how she would handle it. LVN A said the ants bit her too and she was standing in them, and she did not know she was standing in the ants. She said she was brushing the ants off of CR#1's face and they were crawling up her leg. LVN A said the ants came from under the air conditioner on the right side of the bed and the trail was long, and they were black ants. LVN A said LVN B, and all the resident CNA's came to assist them. She said the CNA's got the Hoyer lift to get CR#1 out of bed to get him into the shower. She said the CNA that worked the hall was CNA A, and she was PRN. LVN A said she has worked at the facility for about 2 weeks now. LVN A said the incident happened on [DATE] at around 5 a.m. LVN A said she started rounds at 2 a.m. and was in CR#1's room at 4:14 a.m. LVN A said CR#1 did not grimace like he was in pain, and she had just given CR#1 his [MEDICATION(S)]. LVN A said there were more ants around his mouth and eyes area. She said she did not get CR#1's face on the video and that was where the majority of the ants were. LVN A said CR#1 died on the next shift. LVN A said she called the DON, but she did not call the Doctor or CR#1's responsible party. LVN A said she called the DON and she said she would handle it when she came to work. Interview on [DATE] at 11:15 a.m. Maintenance said he came in the morning on [DATE], and he did not see any ants outside or inside the facility. Maintenance said there was 1 room this morning with 3 ants in one of the rooms. He said he sprayed and walked the entire perimeter. Maintenance said pest control came to the facility today, [DATE] and on [DATE]. He said they made rounds around the building. Observation and interview, around the physical environment of the facility, on [DATE] at 11:30 a.m. with Maintenance revealed this Surveyor found 1 untreated ant bed outside, near CR #1's room . Maintenance said Pest Control just left the facility this morning and he had also walked around the facility and did not see the ant mound. In a telephone interview on [DATE] at 12:57 p.m. with the local Pest Control, he said he found 3 or 4 ant mounds on the exterior of the facility which he treated, and 2 resident rooms that had 3 to 4 unknown species of ants, maybe fire ants. Pest Control said there were 3 or 4 fire ant mounds close to the building. He said when it rained, the ants made their way on the lawn or grass. He said he had never seen the mounds against the concrete or brick. He said he had never seen it happen where an ant would form a mound inside the a/c unit. He denied finding anything on the 400 Hall area. Pest Control said the Administrator asked him to come back to shoot the mound outside of the 400 hall, near CR#1's room. He said he would come back tomorrow, [DATE]. Interview on [DATE] at 3:41 p.m. the Hospice RN said when the hospice aide went to the facility on [DATE] at 5 a.m. he was actively transitioning after the ant bites, and she went for her normal routine. The Hospice RN said the hospice policy reflected if the resident was having an emergency, then the operate according to the facility's policy. The Hospice RN said the hospice policy was to notify the hospice provider before transport and to notify them before calling 911. The Hospice RN said the nurse did not arrive until the facility called to say CR#1 passed. Hospice RN said the nurse would have ordinarily come before CR#1 passed. Interview on [DATE] at 3:50 p.m. LVN A said she could not say CR#1 was actively dying but he was getting [MEDICATION(S)] every 4 hours. LVN A said the only change she saw in CR#1 that day was when she tried to feed him lunch, and he was not swallowing. LVN A said he was just lying in the bed, no problems breathing, and his eyes were open. She said he never talked to her. She said she made sure there was no food in his mouth. She said since she had been taking care of the resident, he had been same way, and there was no real change in the resident. She said she had never seen anyone visit the resident on her shift. LVN A said CR#1 was taking [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)] and that was what put CR#1 into a deep sleep, and she gave CR#1's med's at 2 a.m. LVN A said she called her DON and she told her she would handle everything with CR#1 when she came to the facility. LVN A said she did not call the doctor because the DON said she would take care of it when she got to the facility. She said LVN B was the one who called the DON originally and she did not call 911 because of the DON. LVN A said after the ant bites the resident changed in his breathing. She said she took CR#1's vitals, the oncoming nurse took over and the Hospice CNA came before she left. LVN A said she did not call 911 because he was on hospice, had a DNR and because her DON said she would handle it. She said CR#1's vitals were the same as they had always been before the ant bites when she came to work between 6 p.m. and 8 p.m. CR#1's temperature was 97.2 degrees Fahrenheit, pulse 96, respirations were 20 (breaths per minute), and blood pressure was ,d+[DATE]. She said after the ant bites CR#1's vitals were temperature was 97.4 degrees Fahrenheit, pulse was 84, respiration were 18, blood pressure was ,d+[DATE] and his pulse was 95. LVN A said the original vitals were in the computer, but she did not record the 2nd set of vitals. LVA said after the bites, when they moved CR#1 from room [ROOM NUMBER] and placed him in room [ROOM NUMBER], CR#1 started breathing different like he was going to die. She said she did not call 911 or the doctor because she followed her chain of command who told her what to do. Interview on [DATE] at 4:05 p.m. the facility Doctor said she heard CR#1 passed away. She said the DON did not call her about CR#1 until this morning, [DATE] after 9 a.m. The Facility Doctor said she was coming into this incident after the fact. She said hospice stopped the daily visits with CR#1, but they were doing daily visits until Friday, [DATE]. The Facility Doctor said she had not seen the resident, normally she would expect that the resident would stop breathing because of the ant bites venom. The Doctor said she did not want to give an opinion about whether the fire ants caused CR#1's death. She said when she talked with the DON, the DON said he had some trailing around his face and a few covering his legs. The Facility Doctor said she did not get the impression that he was covered in ants. The Facility Doctor said since the coroner was involved, he would give the Surveyor a better assessment. The Facility Doctor said what the DON described was not that he was completely covered with ants. The Facility Doctor said she did not want to answer this Surveyor if CR#1 could have died from the fire ant bites or if CR#1 should have been sent to the hospital. She said if she had someone with a broken bone, she would send them to the hospital. She said if a resident were covered from head to toe with ants, she would probably have sent the resident to the hospital. The Facility Doctor said she did not recall a message on her answering service, and she checked her messages and found that no one had called to report the incident. The Facility Doctor said she spoke with the hospice nurse who saw CR#1 and she was horrified at what she saw. The Facility Doctor said as best as she could tell she was not notified. The Facility Doctor said CR #1 was on scheduled [MEDICATION(S)] and was on hospice. She said she asked this morning and was told hospice was doing frequent visits and then they took him off of frequent visits because he was no longer actively dying. In an interview on [DATE] at 8:47 p.m. with CR#1's family member 1 (RP), she said Hospice called her after the incident with CR#1 saying that CR#1 had passed away. Hospice called her right after he passed at about 9:20 a.m. The family member said the facility did not call her until after hospice called her. She said if the facility would have called her, she would have wanted CR#1 to go to the hospital or to even call the doctor. The family member said the facility should have called the Doctor right away for the Doctor to see CR#1. The family member said what happened to CR#1 was horrible. She said the DON called her about 10 or 15 minutes after Hospice called. Family member 1 said Hospice told her about the ant bites on CR#1's face. The DON called and said the resident passed away and that she was sorry and that they checked on him at about 5 or 5:30 a.m. and they discovered ants, the cleaned him up and took him a shower. She said CR#1's other family member 1 wanted to know why the facility did not call the doctor. She says she does not think it's right and CR#1's family cannot understand how this happened. The family member said CR#1 had not been eating and he started eating again. The family member said she wondered if CR#1 ate by himself or did they clean him up after eating for the ants to be around his mouth. In an interview on [DATE] at 8:56 p.m. with CR#1's family member 1 (main RP) and family member 2 family member #2 said he was very sad and disappointed about how the facility took care of CR#1. Family member 2 said they felt the facility bated (made him [NAME] for the ants) CR#1 and put him back in the bed and he thought they would have called the doctor because CR#1 might have gone into shock with all the fire ant bites. Family member 2 said someone needed to be responsible for that. Family member 1 said the hospice nurse told them they were evacuating 2 other rooms because they found ants in those other rooms, too. Both family members said that was not acceptable for them and the hospice nurse said it was so much worse than what they told her on the phone. Family member 1 said the hospice nurse said it was pretty bad and that CR#1's face was all swollen with ant bites all over his face. Family member 2 said when they found CR#1 with those ants it was 4:30 a.m. and he died at 9:15 a.m., and he felt the facility should call the doctor or take him to the emergency room . Family member 2 said CR#1 could not use his hands so he could not swipe the ants from his face. In an interview on [DATE] at 11:37 a.m. with LVN B she said she was on her hallway on 300 hall doing rounds on the date of the incident. LVN B said LVN A from the 400 hall came looking for help, asking LVN B to come, and she pulled CNA B with her, too. LVN B said she took a short video of the ants that were on CR#1 because she wanted her supervisor, the DON, and maintenance to see. LVN B said they took CR#1's clothes off and brought CR#1 out of the room. LVN B said she called the DON and sent her the video. LVN B said the DON said to make sure the residents (CR#1 and his roommate, Resident #1) get a shower and don't take any of the clothes into the new room. LVN B said Resident #1 was not bitten, but they did find ants in his bed and on the sheets. LVN B said the ants were headed to Resident #1's bed. LVN B said she got CR#1 and Resident #1 out the room and out of the situation. LVN B said there were hundreds of ants on the floor and on [CR#1]. LVN B said CR#1 was actively dying already from the night before. LVN B said she did not call hospice because LVN A said she could handle it. This Surveyor asked why the doctor or 911 was not called LVN B said she let LVN A handle her resident. LVN B said if it was on her hall, she would have called the doctor, hospice and CR#1's family to let them know. LVN B said she did not see the reason to call 911 because she did not know what they would have done because he was already actively dying. LVN B said she had not seen the resident until after he was bitten, and he was breathing like he was actively dying. She said the CNA's were CNA A and CNA B on her hall. In an Interview on [DATE] at 12:53 p.m. with the Administrator she said she woke up to a text message sent on [DATE] at 4:30 a.m., but she did not see it until 6 a.m. or 6:30 a.m. She said she called the nurses at the facility and asked who the resident was, and they said they already spoke to DON and she gave them orders to get CR#1 and Resident #1 up, showered and change their rooms. The Administrator said LVN A said she had already talked to the DON and gotten all of LVN A and LVN B's orders and instructions from the DON. The Administrator said when the staff told her that they already talked to the DON, she did not question it. She said on a hospice patient they usually don't send anyone out on a 911 emergency and when she talked to everybody, they said everything was done. She said she was not aware of the severity of the situation. The Administrator said she would have sent the resident to the hospital if she had known the severity of the ant bites, but that was not communicated to her. She said she could not answer what the outcome would be if someone was bitten by hundreds of ants. The Administrator said it was so unbelievable and she thought about it a thousand times of how to even prepare for something like that. She said the facility had exterminators coming in, they got the treatments, and they did not miss any. She said, How do you prevent something like that?. The Administrator said the facility in-serviced the staff on what they were doing for their room rounds, to look more closely by the window seals, make sure they notified the Maintenance Director, the DON and the Administrator. They had the exterminator to come out twice already to spray inside and outside the building twice now. The Administrator said she also included notifying the doctor as a part of the in-service. In an interview on [DATE] at 1:15 p.m. with the DON she said she was notified of the incident at on [DATE] at 4:21 a.m. by text and phone call by LVN B that there were ants on CR#1. She said she told the staff to get CR#1 up, showered and to another room. The DON said she asked if there were bites and they said there were not a lot of bites and that there was a little red around CR#1's mouth and eyes. DON said she asked the color of the ants and they said they were black. She said the nurses would do as she instructed and she would notify the doctor and family in the morning. She said LVN B sent her the video she took of the ants on CR#1, but not any pictures, so she could not see CR#1's face on the video. The DON said LVN A and LVN B did not explain that it was an emergency, so she followed normal protocol and she bathed the resident, but in hindsight she would not have said to go to the hospital because they don't send hospice residents out to the hospital. The DON said if they fall and break their arm and they are actively dying they would notify the doctor. The DON said the facility had the exterminators coming and spraying since the incident. She said if any residents had bites on them, they should let the doctors know immediately. She said she did not see it, but she should have let the nurse call the doctor. The DON said she did not call the family because she was not told about the severity of the ant bites. The DON said LVN C called hospice at 6:30 a.m. and that was why they came, and CR#1 passed away at 9:19 a.m. The DON said, she does not feel she did anything wrong. She said she felt that the movement from the ambulance would have killed CR#1 and when she saw CR#1's face she still would not have sent the resident to the hospital because he did not look like the picture that hospice took when she saw him. She said she did not know if the ant bites turned that way after CR#1 passed. She said she had this to happen to her before, not to this degree, they had sugar ants in the bed, so they got the resident up and showered the resident and moved them to a different room. The DON said, she probably would have asked the doctor for a Benadryl, but that is not what she saw. The DON said she did not get to the facility until after he died at about 9:30 a.m. The DON said she spoke with LVN A and asked her why she would call her when they should call the doctor and follow what their procedures were. In an interview on [DATE] at 4:02 p.m. with Local Pest Control he said the ant mound this Surveyor found by CR#1's room was imported fire ants and they were a biting species. He said he never found mounds inside the building, but the facility called him for unscheduled visits for a couple of rooms they found ants in on [DATE]. He said he could not really answer as to why the ants came in. Pest Control said the window seals in the facility were not sealed perfectly and ants did not need a lot of space to be able to come into the facility. He said they found 1 or 2 mounds touching on the building or really close to the building. Pest Control said he thought the ant mounds were outside of the 300 Hall, and he did find a mound on the outside of the 400 hall and there was one about 15 feet from the building. He said the a/c units could be entry points, but the facility had him go into all the rooms, but he did not see where the ants came in. Pest Control said some of the rooms had residents so he could not spray, so he put clear gel in the rooms to treat the ants. In an interview on [DATE] at 4:32 p.m. with Hospice Nurse she said her aide arrived at the facility on [DATE] at 5:25 a.m. after CR#1 had been bitten by ants, completed care, exited the facility at 6:23 a.m. and CR#1 was still alive. She said her nurse attended CR#1's death at 9:15 a.m. and left the facility at 9:50 a.m. She said on Friday, [DATE] CR#1 was alert and talking and at that time the facility reported to the hospice nurse that CR#1 was actively dying, but according to their triage no one from the facility reported CR#1 was actively dying. Hospice said, hospice clearly communicated that she was taking the resident off of actively dying status. She said CR#1 was taking 2 ml of [MEDICATION(S)] concentrate every 4 hours scheduled, and had an order of .25 ml up to 1 ml every hour as needed, and that was based off of symptom management. She said the [MEDICATION(S)] was started on [DATE]. Hospice said the facility should have immediately notified the attending physician, hospice, and the family regarding the incident. Hospice said the facility should have completed an incident report. She said hospice would have agreed to send the resident to the hospital because the family had every right. In an interview on [DATE] at 2:10 p.m. with the Housekeeping Supervisor she said she received a text at 4:23 a.m. to come to spray for ants, and she was already at the facility so she went to get the spray. She said there were a bunch of ants in CR#1 's room behind the nightstand, but nothing under the a/c. The Housekeeping Supervisor said she did not see any food in the room, but they had already taken all of CR#1's things out of the room. She said the ants were still in the room and she had not seen so many ants, so she sprayed everything from privacy curtains to everything. The Housekeeping Supervisor said she did not know how the ants got into the facility and that maybe they had little cracks outside from between the brick. She said now she and Maintenance were walking the building twice a day checking for ants. The Housekeeping Supervisor said the housekeepers were also looking for ants and as soon as they saw something they called her. The Housekeeping Supervisor said the housekeepers were going to be checking more and doing deep cleaning. The Housekeeping Supervisor said they were using a little bit stronger stuff to keep the ants out. The Housekeeping Supervisor said they would check the privacy curtains up and down and in the closets. Interview on [DATE] at 2:30 p.m. with CNA A she said she worked 10 p.m. to 6 a.m. shift and she started her first round checking the residents close to midnight. She said she goes back at 2 a.m. to start here 2nd round. She said usually, the residents were not wet at that time, but she did check their beds. CNA A said at 4 a.m. the nurse would go in before she did. She said she started from the back of 400 to the front. She said on the date of the incident she heard some commotion in CR#1's room. CNA A said LVN A found the resident with all the fire ants at that point, they panicked, and they got scared and could not to see what to do. CNA A said it was very ugly and she could not get what happened out of her head. She said she saw the fire ants in his mouth, and everywhere, and CNA B started helping her. She said they stripped the bed, stripped CR#1, bathed him, put a fresh brief on him and moved CR#1 to a different hall. CNA A said CNA B checked CR#1's penis and found 4 or 5 fire ants inside the skin of CR#1's penis. CNA A said CR#1 had a foley catheter. She said CR#1's eye lids were swollen, and his eyes were so red. CNA A said CR#1 had to be bleeding because when they touched his eyes with a wipe, she was afraid the skin would come off and the wipe was red, and CR#1 did not make any sounds. She said his breathing remained the same. CNA A said the way CR#1 was breathing they thought he was about to expire right then. She said when they got off their shift at 6 a.m. CR#1 was still alive. She said before the incident CR#1 was not breathing bad and she believed that CR#1's breathing changed after the incident. CNA A said maybe CR#1 was in pain and could not tell them. CNA A said she had to clean his buttocks because he had a large bowel movement, and she could see some ant bites and it looked scary. CNA A said at one point she kept scrubbing his behind and then she realized that it was ant bites. She said she thought it was bowel movement, but it was ant bites so she started just dabbing him because common sense says he was in pain and could not tell them. CNA A said she thought CR#1's skin was going to fall off and it looked like he was in pain. CNA A said CR#1's skin was red and bumpy from the ant bites, and she saw blood, but not dripping. CNA A said CR#1's bottom was swollen with little bumps. She said the ants bit everywhere inside CR#1's mouth even his tongue. She said she and LVN A was cleaning the outside of his mouth and they did not know where to start because the ants were everywhere. CNA A said the ants were all around CR#1's mouth and they realized they could not wipe because blood was smeared on his face, she started shaking she was so scared. CNA A said LVN B called the DON, but she did not know what was mentioned there. She was there with another CNA, and they did the best they could. CNA A said she went to get the Hoyer lift to transfer him out of the room ASAP. She said the trail of ants was by the window, so she started stepping on them and then she saw the bed. CNA A said they had previously moved CR#1 and Resident #1 from 200 Hall because there were fire ants on the 200 Hall and the 100 hall had a problem with ants in room [ROOM NUMBER] and they moved those 2 residents (Resident #2 and Resident #3). CNA A said she did not believe Resident #2 and Resident #3 were bitten and the only one that was bitten was CR#1. Record Review and interview on [DATE] at 10:40 a.m. with the DON of CR#1's MAR and Treatment Notes dated [DATE] revealed LVN A did not document oxygen as administered. DON said they were supposed to hit the button on the computer as soon as they administered medication or treatments, and oxygen was not documented. She said Sundays were the days they changed the canula, but she did not know if she did change the canula. The DON said the last time LVN A documented that she was in the room was 2 a.m. when [MEDICATION(S)] and [MEDICATION(S)] were administered. She said the administrations were: 12 a.m.- [MEDICATION(S)], 1 a.m. - [MEDICATION(S)], 2 a.m.- [MEDICATION(S)] and 2 a.m.- [MEDICATION(S)]. The DON said LVN C called the Hospice Nurse at 6:30 a.m. to inform them that CR#1 was dying. The DON said if she had been the nurse on duty at the time of the incident, she would have gotten the patient to safety and called the doctor. She said they should have called the doctor and hospice before calling her and notified her what they were doing. The DON said LVN A said she went back into the resident's room to change the canula because the resident was on oxygen and that is when LVN A saw the ants. The DON said they were supposed to call the doctor first, she did not know why LVN A and LVN B called her first. She said LVN A had been doing [TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (CR #1) of eight residents reviewed quality of care. - The facility failed to seek medical care for CR#1 who was totally dependent on staff for ADL's and unable to communicate when he was found covered in ants and sustained hundreds of ant bites on his eyes, left cheek, inside his mouth and all over CR#1's body. CR#1 died at the facility within 4 hours after sustaining the ant bites. -The Administrator and DON failed to give adequate guidance when they received notification and video from staff of CR#1 covered in ants with open wounds from ant bites. -The facility failed to contact CR#1's physician, hospice Nurse and Responsible Party for guidance or direction after he sustained numerous ant bites which left open wounds around and inside CR#1's mouth, eyes, and ear. An Immediate Jeopardy (IJ) was identified on [DATE] at 3:19 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that is not an Immediate Threat and a scope of isolated as the facility continued to monitor the implementation and effectiveness of their plan of removal. These failures placed residents who are totally dependent on Staff for ADL's with communication deficits at risk of experiencing pain, physical and emotional distress, and death. Findings include: CR#1 Record review of a Face Sheet for CR #1 revealed an [AGE] year-old male admitted on [DATE] and readmitted [DATE]. CR#1 was diagnosed with senile degeneration of brain (mental decline), cognitive communication, [CONDITION(S)] (hardening of the arteries in the heart), [CONDITION(S)] and [CONDITION(S)] (complete loss of strength and weakness on one side of the body) and , hypertension (high blood pressure), ataxia (loss of full control of body movements) and [CONDITION(S)] (high cholesterol). Record review of CR#1's Minimum Data Set, dated dated dated [DATE] revealed his BIMS Summary score was 8 indicating his cognition was mildly impaired; walking in room and corridor did not occur; he was totally dependent with two staff for transfers, and dressing; totally dependent with one staff for locomotion on and off unit, eating, toilet use, and personal hygiene and he needed extensive assistance with two staff for bed mobility. CR #2 was totally dependent on staff for bathing with one staff assisting; urinary continence was not rated, and he was frequently incontinent of bowel. Record review of CR#1's Care Plan dated [DATE] revealed CR#1 was incontinent of bowel and bladder and the intervention to check him as required for incontinence, wash, rinse and dry perineum (the area between the anus and scrotum), change clothing PRN after each incontinent episode; Activities of Daily Living (ADL) self-care performance deficit and the intervention was bathing required physical help of ,d+[DATE] staff participation with bathing, bed mobility required ,d+[DATE] staff participation to reposition and turn in bed, dressing required limited-extensive assistance of ,d+[DATE] staff participation to dress, eating required limited extensive assist of 1 staff participation to eat, Geri chair for positioning, comfort and proper body alignment, hygiene/oral care required limited-extensive assist of ,d+[DATE] staff participation with personal hygiene and oral care, and toilet use required limited-extensive assist of ,d+[DATE] staff participation to use toilet; transfer required extensive assist of 2 staff participation with Hoyer lift transfers; impaired cognitive function or impaired thought processes r/t dementia with intervention as BIMS 10 revealing moderate cognitive impairment, administer medications as ordered, ask yes/no questions in order to determine the resident's needs; cognitive deficit as evidenced by trouble concentrating and the interventions were to administer anti-anxiety medication, evaluate for side effects of medications, monitor for non-verbal signs of anxiety: restlessness, trembling, rocking and pacing, indwelling suprapubic catheter and was at risk for increased urinary tract infections; pressure ulcers and the interventions were the resident had a 16 French catheter and to position the catheter bag and tubing below the level of the bladder and away from entrance room door and to check the tube for kinks. Record review of CR#1's Narcotic sheet, labeled [MEDICATION(S)] Sul 501 revealed the last time it was given was 2 a.m. Record review of Medication Administration Record dated [DATE] revealed the last medication [MEDICATION(S)] Sul 501 and [MEDICATION(S)] was given at 2 a.m. Record review of video #1 dated [DATE] recorded by LVN B revealed CR#1 was covered with black ants. Observation revealed hundreds of ants all over CR#1. The nurses LVN A and LVN B were saying they were all over him, his mouth, and that he was still breathing. Record review of video #2 taken on [DATE] by LVN B revealed a trail of hundreds of black ants leading from the window and the wall by the nightstand leading to CR#1's bed. Record review of Local Hospice Nurses notes dated [DATE] revealed, Integumentary (skin) Assessment was pale and poor turgor, no abnormal respiratory findings identified, his appetite was poor eating bite sizes, and no imminent signs of death noted. Record review of Hospice notes dated [DATE] revealed 2 pictures of CR#1 revealing the ants had eaten CR#1's flesh all around his mouth, eyes, the inside of his left cheek, ears and possibly bites on his tongue. Hospice notes further revealed, This RN received call from DON that CR#1 had passed. After assessment including auscultation of chest for 1 minute, no signs of life noted. Confirmed time of death of on [DATE] at 9:19 a.m. CR#1 was found covered in ant bites from an ant infestation in his room at the facility .Medical examiner's office taking over case .DON stated CR#1 was found in ants around 4:30 a.m. and aides were instructed to give CR#1 a shower to rinse off ants. Record review of Facility's Daily Maintenance Log revealed: [DATE] Ants coming through a/c; [DATE] ants infestation; and [DATE] ants on the floor by refrigerator. Record review of LVN A's General Orientation Checklist for Training dated [DATE] revealed training in Abuse, Incidents/Accidents Reporting, Emergency 911, Resident Rights, HIPAA, and Reporting Safety Concerns. Interview on [DATE] at 10:24 a.m. LVN A said she was making her rounds and around 4 a.m. she was putting on CR #1's oxygen, foley and she left the room, but she came back because she forgot to get the dirty oxygen canula. LVN A said she went back to the room and CR#1 had some red on his face and she thought he threw up, so she went to get a towel to wash his face and she looked, and it was ants. LVN A said she started brushing the ants off his face and she saw there were more on the other side of his face. She said she went to get help and the other aides came in and started brushing his face. She said there were ants around CR#1's mouth, eyes, all over the bed, and there were a lot of ants. LVN A said she had just been in CR#1's room in under 45 minutes previously when she drained CR#1's foley drainage bag and changed the O2 canula. LVN A said she left the room and returned to CR#1's room to get the dirty canula and she said she went to CR#1's face to put the nasal cannula on and the lights were on, and she saw some ants in the residents bed. LVN A said she went to get help from LVN B and CNA A, and they got CR#1 out of the bed, showered him, and moved him to a different room. LVN A said there were a lot of ants, and it scared the hell out of her. LVN A said when they pulled CR#1's blanket back on his bed there were ants all in his bed. She said while they were brushing the ants off, LVN B was taking a video of the ants. She said LVN B sent the video to the DON to show her what was going on in the room. LVN A said she had to get the ants off of herself and after she made sure the ants were off of her, she called the DON to see how she would handle it. LVN A said the ants bit her too and she was standing in them, and she did not know she was standing in the ants. She said she was brushing the ants off of CR#1's face and they were crawling up her leg. LVN A said the ants came from under the air conditioner on the right side of the bed and the trail was long, and they were black ants. LVN A said LVN B, and all the resident CNA's came to assist them. She said the CNA's got the Hoyer lift to get CR#1 out of bed to get him into the shower. She said the CNA that worked the hall was CNA A, and she was PRN. LVN A said she has worked at the facility for about 2 weeks now. LVN A said the incident happened on [DATE] at around 5 a.m. LVN A said she started rounds at 2 a.m. and was in CR#1's room at 4:14 a.m. LVN A said CR#1 did not grimace like he was in pain, and she had just given CR#1 his [MEDICATION(S)]. LVN A said there were more ants around his mouth and eyes area. She said she did not get CR#1's face on the video and that was where the majority of the ants were. LVN A said CR#1 died on the next shift. LVN A said she called the DON, but she did not call the Doctor or CR#1's responsible party. LVN A said she called the DON and she said she would handle it when she came to work. Interview on [DATE] at 11:15 a.m. Maintenance said he came in the morning on [DATE], and he did not see any ants outside or inside the facility. Maintenance said there was 1 room this morning with 3 ants in one of the rooms. He said he sprayed and walked the entire perimeter. Maintenance said pest control came to the facility today, [DATE] and on [DATE]. He said they made rounds around the building. Observation and interview, around the physical environment of the facility, on [DATE] at 11:30 a.m. with Maintenance revealed this Surveyor found 1 untreated ant bed outside, near CR #1's room . Maintenance said Pest Control just left the facility this morning and he had also walked around the facility and did not see the ant mound. In a telephone interview on [DATE] at 12:57 p.m. with the local Pest Control, he said he found 3 or 4 ant mounds on the exterior of the facility which he treated, and 2 resident rooms that had 3 to 4 unknown species of ants, maybe fire ants. Pest Control said there were 3 or 4 fire ant mounds close to the building. He said when it rained, the ants made their way on the lawn or grass. He said he had never seen the mounds against the concrete or brick. He said he had never seen it happen where an ant would form a mound inside the a/c unit. He denied finding anything on the 400 Hall area. Pest Control said the Administrator asked him to come back to shoot the mound outside of the 400 hall, near CR#1's room. He said he would come back tomorrow, [DATE]. Interview on [DATE] at 3:41 p.m. the Hospice RN said when the hospice aide went to the facility on [DATE] at 5 a.m. he was actively transitioning after the ant bites, and she went for her normal routine. The Hospice RN said the hospice policy reflected if the resident was having an emergency, then the operate according to the facility's policy. The Hospice RN said the hospice policy was to notify the hospice provider before transport and to notify them before calling 911. The Hospice RN said the nurse did not arrive until the facility called to say CR#1 passed. Hospice RN said the nurse would have ordinarily come before CR#1 passed. Interview on [DATE] at 3:50 p.m. LVN A said she could not say CR#1 was actively dying but he was getting [MEDICATION(S)] every 4 hours. LVN A said the only change she saw in CR#1 that day was when she tried to feed him lunch, and he was not swallowing. LVN A said he was just lying in the bed, no problems breathing, and his eyes were open. She said he never talked to her. She said she made sure there was no food in his mouth. She said since she had been taking care of the resident, he had been same way, and there was no real change in the resident. She said she had never seen anyone visit the resident on her shift. LVN A said CR#1 was taking [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)] and that was what put CR#1 into a deep sleep, and she gave CR#1's med's at 2 a.m. LVN A said she called her DON and she told her she would handle everything with CR#1 when she came to the facility. LVN A said she did not call the doctor because the DON said she would take care of it when she got to the facility. She said LVN B was the one who called the DON originally and she did not call 911 because of the DON. LVN A said after the ant bites the resident changed in his breathing. She said she took CR#1's vitals, the oncoming nurse took over and the Hospice CNA came before she left. LVN A said she did not call 911 because he was on hospice, had a DNR and because her DON said she would handle it. She said CR#1's vitals were the same as they had always been before the ant bites when she came to work between 6 p.m. and 8 p.m. CR#1's temperature was 97.2 degrees Fahrenheit, pulse 96, respirations were 20 (breaths per minute), and blood pressure was ,d+[DATE]. She said after the ant bites CR#1's vitals were temperature was 97.4 degrees Fahrenheit, pulse was 84, respiration were 18, blood pressure was ,d+[DATE] and his pulse was 95. LVN A said the original vitals were in the computer, but she did not record the 2nd set of vitals. LVA said after the bites, when they moved CR#1 from room [ROOM NUMBER] and placed him in room [ROOM NUMBER], CR#1 started breathing different like he was going to die. She said she did not call 911 or the doctor because she followed her chain of command who told her what to do. Interview on [DATE] at 4:05 p.m. the facility Doctor said she heard CR#1 passed away. She said the DON did not call her about CR#1 until this morning, [DATE] after 9 a.m. The Facility Doctor said she was coming into this incident after the fact. She said hospice stopped the daily visits with CR#1, but they were doing daily visits until Friday, [DATE]. The Facility Doctor said she had not seen the resident, normally she would expect that the resident would stop breathing because of the ant bites venom. The Doctor said she did not want to give an opinion about whether the fire ants caused CR#1's death. She said when she talked with the DON, the DON said he had some trailing around his face and a few covering his legs. The Facility Doctor said she did not get the impression that he was covered in ants. The Facility Doctor said since the coroner was involved, he would give the Surveyor a better assessment. The Facility Doctor said what the DON described was not that he was completely covered with ants. The Facility Doctor said she did not want to answer this Surveyor if CR#1 could have died from the fire ant bites or if CR#1 should have been sent to the hospital. She said if she had someone with a broken bone, she would send them to the hospital. She said if a resident were covered from head to toe with ants, she would probably have sent the resident to the hospital. The Facility Doctor said she did not recall a message on her answering service, and she checked her messages and found that no one had called to report the incident. The Facility Doctor said she spoke with the hospice nurse who saw CR#1 and she was horrified at what she saw. The Facility Doctor said as best as she could tell she was not notified. The Facility Doctor said CR #1 was on scheduled [MEDICATION(S)] and was on hospice. She said she asked this morning and was told hospice was doing frequent visits and then they took him off of frequent visits because he was no longer actively dying. In an interview on [DATE] at 8:47 p.m. with CR#1's family member 1 (RP), she said Hospice called her after the incident with CR#1 saying that CR#1 had passed away. Hospice called her right after he passed at about 9:20 a.m. The family member said the facility did not call her until after hospice called her. She said if the facility would have called her, she would have wanted CR#1 to go to the hospital or to even call the doctor. The family member said the facility should have called the Doctor right away for the Doctor to see CR#1. The family member said what happened to CR#1 was horrible. She said the DON called her about 10 or 15 minutes after Hospice called. Family member 1 said Hospice told her about the ant bites on CR#1's face. The DON called and said the resident passed away and that she was sorry and that they checked on him at about 5 or 5:30 a.m. and they discovered ants, the cleaned him up and took him a shower. She said CR#1's other family member 1 wanted to know why the facility did not call the doctor. She says she does not think it's right and CR#1's family cannot understand how this happened. The family member said CR#1 had not been eating and he started eating again. The family member said she wondered if CR#1 ate by himself or did they clean him up after eating for the ants to be around his mouth. In an interview on [DATE] at 8:56 p.m. with CR#1's family member 1 (main RP) and family member 2 family member #2 said he was very sad and disappointed about how the facility took care of CR#1. Family member 2 said they felt the facility bated (made him [NAME] for the ants) CR#1 and put him back in the bed and he thought they would have called the doctor because CR#1 might have gone into shock with all the fire ant bites. Family member 2 said someone needed to be responsible for that. Family member 1 said the hospice nurse told them they were evacuating 2 other rooms because they found ants in those other rooms, too. Both family members said that was not acceptable for them and the hospice nurse said it was so much worse than what they told her on the phone. Family member 1 said the hospice nurse said it was pretty bad and that CR#1's face was all swollen with ant bites all over his face. Family member 2 said when they found CR#1 with those ants it was 4:30 a.m. and he died at 9:15 a.m., and he felt the facility should call the doctor or take him to the emergency room . Family member 2 said CR#1 could not use his hands so he could not swipe the ants from his face. In an interview on [DATE] at 11:37 a.m. with LVN B she said she was on her hallway on 300 hall doing rounds on the date of the incident. LVN B said LVN A from the 400 hall came looking for help, asking LVN B to come, and she pulled CNA B with her, too. LVN B said she took a short video of the ants that were on CR#1 because she wanted her supervisor, the DON, and maintenance to see. LVN B said they took CR#1's clothes off and brought CR#1 out of the room. LVN B said she called the DON and sent her the video. LVN B said the DON said to make sure the residents (CR#1 and his roommate, Resident #1) get a shower and don't take any of the clothes into the new room. LVN B said Resident #1 was not bitten, but they did find ants in his bed and on the sheets. LVN B said the ants were headed to Resident #1's bed. LVN B said she got CR#1 and Resident #1 out the room and out of the situation. LVN B said there were hundreds of ants on the floor and on [CR#1]. LVN B said CR#1 was actively dying already from the night before. LVN B said she did not call hospice because LVN A said she could handle it. This Surveyor asked why the doctor or 911 was not called LVN B said she let LVN A handle her resident. LVN B said if it was on her hall, she would have called the doctor, hospice and CR#1's family to let them know. LVN B said she did not see the reason to call 911 because she did not know what they would have done because he was already actively dying. LVN B said she had not seen the resident until after he was bitten, and he was breathing like he was actively dying. She said the CNA's were CNA A and CNA B on her hall. In an Interview on [DATE] at 12:53 p.m. with the Administrator she said she woke up to a text message sent on [DATE] at 4:30 a.m., but she did not see it until 6 a.m. or 6:30 a.m. She said she called the nurses at the facility and asked who the resident was, and they said they already spoke to DON and she gave them orders to get CR#1 and Resident #1 up, showered and change their rooms. The Administrator said LVN A said she had already talked to the DON and gotten all of LVN A and LVN B's orders and instructions from the DON. The Administrator said when the staff told her that they already talked to the DON, she did not question it. She said on a hospice patient they usually don't send anyone out on a 911 emergency and when she talked to everybody, they said everything was done. She said she was not aware of the severity of the situation. The Administrator said she would have sent the resident to the hospital if she had known the severity of the ant bites, but that was not communicated to her. She said she could not answer what the outcome would be if someone was bitten by hundreds of ants. The Administrator said it was so unbelievable and she thought about it a thousand times of how to even prepare for something like that. She said the facility had exterminators coming in, they got the treatments, and they did not miss any. She said, How do you prevent something like that?. The Administrator said the facility in-serviced the staff on what they were doing for their room rounds, to look more closely by the window seals, make sure they notified the Maintenance Director, the DON and the Administrator. They had the exterminator to come out twice already to spray inside and outside the building twice now. The Administrator said she also included notifying the doctor as a part of the in-service. In an interview on [DATE] at 1:15 p.m. with the DON she said she was notified of the incident at on [DATE] at 4:21 a.m. by text and phone call by LVN B that there were ants on CR#1. She said she told the staff to get CR#1 up, showered and to another room. The DON said she asked if there were bites and they said there were not a lot of bites and that there was a little red around CR#1's mouth and eyes. DON said she asked the color of the ants and they said they were black. She said the nurses would do as she instructed and she would notify the doctor and family in the morning. She said LVN B sent her the video she took of the ants on CR#1, but not any pictures, so she could not see CR#1's face on the video. The DON said LVN A and LVN B did not explain that it was an emergency, so she followed normal protocol and she bathed the resident, but in hindsight she would not have said to go to the hospital because they don't send hospice residents out to the hospital. The DON said if they fall and break their arm and they are actively dying they would notify the doctor. The DON said the facility had the exterminators coming and spraying since the incident. She said if any residents had bites on them, they should let the doctors know immediately. She said she did not see it, but she should have let the nurse call the doctor. The DON said she did not call the family because she was not told about the severity of the ant bites. The DON said LVN C called hospice at 6:30 a.m. and that was why they came, and CR#1 passed away at 9:19 a.m. The DON said, she does not feel she did anything wrong. She said she felt that the movement from the ambulance would have killed CR#1 and when she saw CR#1's face she still would not have sent the resident to the hospital because he did not look like the picture that hospice took when she saw him. She said she did not know if the ant bites turned that way after CR#1 passed. She said she had this to happen to her before, not to this degree, they had sugar ants in the bed, so they got the resident up and showered the resident and moved them to a different room. The DON said, she probably would have asked the doctor for a Benadryl, but that is not what she saw. The DON said she did not get to the facility until after he died at about 9:30 a.m. The DON said she spoke with LVN A and asked her why she would call her when they should call the doctor and follow what their procedures were. In an interview on [DATE] at 4:02 p.m. with Local Pest Control he said the ant mound this Surveyor found by CR#1's room was imported fire ants and they were a biting species. He said he never found mounds inside the building, but the facility called him for unscheduled visits for a couple of rooms they found ants in on [DATE]. He said he could not really answer as to why the ants came in. Pest Control said the window seals in the facility were not sealed perfectly and ants did not need a lot of space to be able to come into the facility. He said they found 1 or 2 mounds touching on the building or really close to the building. Pest Control said he thought the ant mounds were outside of the 300 Hall, and he did find a mound on the outside of the 400 hall and there was one about 15 feet from the building. He said the a/c units could be entry points, but the facility had him go into all the rooms, but he did not see where the ants came in. Pest Control said some of the rooms had residents so he could not spray, so he put clear gel in the rooms to treat the ants. In an interview on [DATE] at 4:32 p.m. with Hospice Nurse she said her aide arrived at the facility on [DATE] at 5:25 a.m. after CR#1 had been bitten by ants, completed care, exited the facility at 6:23 a.m. and CR#1 was still alive. She said her nurse attended CR#1's death at 9:15 a.m. and left the facility at 9:50 a.m. She said on Friday, [DATE] CR#1 was alert and talking and at that time the facility reported to the hospice nurse that CR#1 was actively dying, but according to their triage no one from the facility reported CR#1 was actively dying. Hospice said, hospice clearly communicated that she was taking the resident off of actively dying status. She said CR#1 was taking 2 ml of [MEDICATION(S)] concentrate every 4 hours scheduled, and had an order of .25 ml up to 1 ml every hour as needed, and that was based off of symptom management. She said the [MEDICATION(S)] was started on [DATE]. Hospice said the facility should have immediately notified the attending physician, hospice, and the family regarding the incident. Hospice said the facility should have completed an incident report. She said hospice would have agreed to send the resident to the hospital because the family had every right. In an interview on [DATE] at 2:10 p.m. with the Housekeeping Supervisor she said she received a text at 4:23 a.m. to come to spray for ants, and she was already at the facility so she went to get the spray. She said there were a bunch of ants in CR#1 's room behind the nightstand, but nothing under the a/c. The Housekeeping Supervisor said she did not see any food in the room, but they had already taken all of CR#1's things out of the room. She said the ants were still in the room and she had not seen so many ants, so she sprayed everything from privacy curtains to everything. The Housekeeping Supervisor said she did not know how the ants got into the facility and that maybe they had little cracks outside from between the brick. She said now she and Maintenance were walking the building twice a day checking for ants. The Housekeeping Supervisor said the housekeepers were also looking for ants and as soon as they saw something they called her. The Housekeeping Supervisor said the housekeepers were going to be checking more and doing deep cleaning. The Housekeeping Supervisor said they were using a little bit stronger stuff to keep the ants out. The Housekeeping Supervisor said they would check the privacy curtains up and down and in the closets. Interview on [DATE] at 2:30 p.m. with CNA A she said she worked 10 p.m. to 6 a.m. shift and she started her first round checking the residents close to midnight. She said she goes back at 2 a.m. to start here 2nd round. She said usually, the residents were not wet at that time, but she did check their beds. CNA A said at 4 a.m. the nurse would go in before she did. She said she started from the back of 400 to the front. She said on the date of the incident she heard some commotion in CR#1's room. CNA A said LVN A found the resident with all the fire ants at that point, they panicked, and they got scared and could not to see what to do. CNA A said it was very ugly and she could not get what happened out of her head. She said she saw the fire ants in his mouth, and everywhere, and CNA B started helping her. She said they stripped the bed, stripped CR#1, bathed him, put a fresh brief on him and moved CR#1 to a different hall. CNA A said CNA B checked CR#1's penis and found 4 or 5 fire ants inside the skin of CR#1's penis. CNA A said CR#1 had a foley catheter. She said CR#1's eye lids were swollen, and his eyes were so red. CNA A said CR#1 had to be bleeding because when they touched his eyes with a wipe, she was afraid the skin would come off and the wipe was red, and CR#1 did not make any sounds. She said his breathing remained the same. CNA A said the way CR#1 was breathing they thought he was about to expire right then. She said when they got off their shift at 6 a.m. CR#1 was still alive. She said before the incident CR#1 was not breathing bad and she believed that CR#1's breathing changed after the incident. CNA A said maybe CR#1 was in pain and could not tell them. CNA A said she had to clean his buttocks because he had a large bowel movement, and she could see some ant bites and it looked scary. CNA A said at one point she kept scrubbing his behind and then she realized that it was ant bites. She said she thought it was bowel movement, but it was ant bites so she started just dabbing him because common sense says he was in pain and could not tell them. CNA A said she thought CR#1's skin was going to fall off and it looked like he was in pain. CNA A said CR#1's skin was red and bumpy from the ant bites, and she saw blood, but not dripping. CNA A said CR#1's bottom was swollen with little bumps. She said the ants bit everywhere inside CR#1's mouth even his tongue. She said she and LVN A was cleaning the outside of his mouth and they did not know where to start because the ants were everywhere. CNA A said the ants were all around CR#1's mouth and they realized they could not wipe because blood was smeared on his face, she started shaking she was so scared. CNA A said LVN B called the DON, but she did not know what was mentioned there. She was there with another CNA, and they did the best they could. CNA A said she went to get the Hoyer lift to transfer him out of the room ASAP. She said the trail of ants was by the window, so she started stepping on them and then she saw the bed. CNA A said they had previously moved CR#1 and Resident #1 from 200 Hall because there were fire ants on the 200 Hall and the 100 hall had a problem with ants in room [ROOM NUMBER] and they moved those 2 residents (Resident #2 and Resident #3). CNA A said she did not believe Resident #2 and Resident #3 were bitten and the only one that was bitten was CR#1. Record Review and interview on [DATE] at 10:40 a.m. with the DON of CR#1's MAR and Treatment Notes dated [DATE] revealed LVN A did not document oxygen as administered. DON said they were supposed to hit the button on the computer as soon as they administered medication or treatments, and oxygen was not documented. She said Sundays were the days they changed the canula, but she did not know if she did change the canula. The DON said the last time LVN A documented that she was in the room was 2 a.m. when [MEDICATION(S)] and [MEDICATION(S)] were administered. She said the administrations were: 12 a.m.- [MEDICATION(S)], 1 a.m. - [MEDICATION(S)], 2 a.m.- [MEDICATION(S)] and 2 a.m.- [MEDICATION(S)]. The DON said LVN C called the Hospice Nurse at 6:30 a.m. to inform them that CR#1 was dying. The DON said if she had been the nurse on duty at the time of the incident, she would have gotten the patient to safety and called the doctor. She said they should have called the doctor and hospice before calling her and notified her what they were doing. The DON said LVN A said she went back into the resident's room to change the canula because the resident was on oxygen and that is when LVN A saw the ants. The DON said they

Based on observation, interview, and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest, practicable physical, mental, and psychosocial well-being of each resident for 1 of 8 residents (CR #1) reviewed for residents administration. The Administrator failed to: -- Implement the facility's Abuse, Neglect, and Exploitation prohibition policy to prevent neglect of CR#1. --Supervise the DON to ensure the DON was performing her duties and supervising the nurses. The DON failed to: - Supervise LVN A to ensure she followed facility's instructions of contacting 911, the facility doctor, hospice nurse, Responsible Party after LVN A and LVN B noticed CR#1 had a decline and change in condition. - Supervise the nursing staff to ensure they were consulting with physicians regarding CR#1's change of conditions. The facility failed to contact CR#1's physician, hospice Nurse or Responsible Party for guidance or direction after he sustained numerous ant bites which left open wounds around and inside CR#1's mouth, eyes, and ear. CR#1 died at the facility within 4 hours after sustaining the ant bites. An Immediate Jeopardy (IJ) was identified on [DATE] at 3:19 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that is not an Immediate Jeopardy and a scope of isolated as the facility continued to monitor the implementation and effectiveness of their plan of removal. These failures placed residents who are totally dependent on Staff for ADL's with communication deficits at risk of experiencing pain, physical and emotional distress, and possible death. Findings include: Record review of a Face Sheet for CR #1 revealed an [AGE] year-old male admitted on [DATE] and readmitted [DATE]. CR#1 was diagnosed with senile degeneration of brain (mental decline), cognitive communication, [CONDITION(S)] (hardening of the arteries in the heart), [CONDITION(S)] and [CONDITION(S)] (complete loss of strength and weakness on one side of the body), hypertension (high blood pressure), ataxia (loss of full control of body movements) and [CONDITION(S)] (high cholesterol). Record review of CR#1's Minimum Data Set, dated dated dated [DATE] revealed his BIMS Summary score was 8 indicating his cognition was mildly impaired; walking in room and corridor did not occur; he was totally dependent with two staff for transfers, and dressing; totally dependent with one staff for locomotion on and off unit, eating, toilet use, and personal hygiene and he needed extensive assistance with two staff for bed mobility. CR #2 was totally dependent on staff for bathing with one staff assisting; urinary continence was not rated, and he was frequently incontinent of bowel. Record review of CR#1's Care Plan dated [DATE] revealed CR#1 was incontinent of bowel and bladder with intervention was to check as required for incontinence, wash, rinse and dry perineum, change clothing PRN after each incontinent episode; Activities of Daily Living (ADL) self-care performance deficit with intervention was bathing required physical help of ,d+[DATE] staff participation with bathing, bed mobility required ,d+[DATE] staff participation to reposition and turn in bed, dressing required limited-extensive assistance of ,d+[DATE] staff participation to dress, eating required limited extensive assist of 1 staff participation to eat, Geri chair for positioning, comfort and proper body alignment, hygiene/oral care required limited-extensive assist of ,d+[DATE] staff participation with personal hygiene and oral care , and toilet use required limited-extensive assist of ,d+[DATE] staff participation to use toilet; transfer required extensive assist of 2 staff participation with Hoyer lift transfers; impaired cognitive function or impaired thought processes r/t dementia with intervention as BIMS 10, administer medications as ordered, ask yes/no questions in order to determine the resident's needs; cognitive deficit as evidenced by trouble concentrating with interventions was administer anti-anxiety medication, Evaluate for side effects of medications, monitor for non-verbal signs of anxiety: restlessness, trembling, rocking and pacing, indwelling suprapubic Catheter and is at risk for increased Urinary tract infections; pressure ulcers with interventions was the resident has a 16 FR catheter. Position catheter bag and tubing below the level of the bladder and away from entrance room door and check tube for kinks. Record review on [DATE] of video #1 revealed CR#1 was covered with black ants. Observation revealed hundreds of ants all over CR#1. The nurses were saying they were all over him, his mouth, and that he was still breathing. Record review on [DATE] of Video #2 revealed a trail of hundreds of black ants leading from the wall by the outside by the nightstand leading to CR#1. Record review of Local Hospice Nurses notes dated [DATE] revealed, Integumentary Assessment was pale and poor turgor, no abnormal respiratory findings identified, his appetite was poor eating bite sizes, and no imminent signs of death noted. Record review of Hospice notes dated [DATE] revealed 2 pictures of CR#1 revealing the ants had eaten CR#1's flesh all around his mouth, eyes, the inside of his cheek, ear and possibly bites on his tongue. Hospice notes further revealed, This RN received call from DON that CR#1 had passed. After assessment including auscultation of chest for 1 minute, no signs of life noted. Confirmed time of death of on [DATE] at 9:19 a.m. CR#1 was found covered in ant bites from an ant infestation in his room at the facility .Medical examiner's office taking over case .DON stated CR#1 was found in ants around 4:30 a.m. and aides were instructed to give CR#1 a shower to rinse off ants. Record review of Job Descriptions for Director Of Nursing Reports to Executive Director of Operations dated ,d+[DATE] revealed, The primary purpose of this position is to plan, organize, develop and direct the overall operation of the Clinical Services department in accordance with current federal, state, and local standards. The DCO will work collaboratively with the administrative support team to establish an effective and efficient work environment to provide excellent quality of care to residents while embracing a culture of empowerment and educational development .Essential functions: Responsible for developing and overseeing the staffing schedule for the department. Develop and participate in the planning, conducting, and scheduling of timely in-service trainings as needed Assess the quality of care rendered. Helps development of policies and procedures that govern nursing services and other services under his or her position control. Responsible for staff performance, staff recruitment, staff retention and staff development to achieve resident outcomes. Attempted Record review of Job Descriptions for Administrator revealed the document was requested, but it was not received. Interview on [DATE] at 10:24 a.m. LVN A said she was making her rounds and around 4 a.m. she was putting on CR #1's oxygen, foley and she left the room, but she came back because she forgot to get the dirty oxygen canula. LVN A said she went back to the room and CR#1 had some red on his face and she thought he threw up, so she went to get a towel to wash his face and she looked, and it was ants. LVN A said she started brushing the ants off his face and she saw there were more on the other side of his face. She said she went to get help and the other aides came in and started brushing his face. She said there were ants around CR#1's mouth, eyes, all over the bed, and there were a lot of ants. LVN A said she had just been in CR#1's room in under 45 minutes previously when she drained CR#1's foley drainage bag and changed the O2 canula. LVN A said she left the room and returned to CR#1's room to get the dirty canula and she said she went to CR#1's face to put the nasal cannula on and the lights were on, and she saw some ants in the residents bed. LVN A said she went to get help from LVN B and CNA A, and they got CR#1 out of the bed, showered him, and moved him to a different room. LVN A said there were a lot of ants, and it scared the hell out of her. LVN A said when they pulled CR#1's blanket back on his bed there were ants all in his bed. She said while they were brushing the ants off, LVN B was taking a video of the ants. She said LVN B sent the video to the DON to show her what was going on in the room. LVN A said she had to get the ants off of herself and after she made sure the ants were off of her, she called the DON to see how she would handle it. LVN A said the ants bit her too and she was standing in them, and she did not know she was standing in the ants. She said she was brushing the ants off of CR#1's face and they were crawling up her leg. LVN A said the ants came from under the air conditioner on the right side of the bed and the trail was long, and they were black ants. LVN A said LVN B, and all the resident CNA's came to assist them. She said the CNA's got the Hoyer lift to get CR#1 out of bed to get him into the shower. She said the CNA that worked the hall was CNA A, and she was PRN. LVN A said she has worked at the facility for about 2 weeks now. LVN A said the incident happened on [DATE] at around 5 a.m. LVN A said she started rounds at 2 a.m. and was in CR#1's room at 4:14 a.m. LVN A said CR#1 did not grimace like he was in pain, and she had just given CR#1 his [MEDICATION(S)]. LVN A said there were more ants around his mouth and eyes area. She said she did not get CR#1's face on the video and that was where the majority of the ants were. LVN A said CR#1 died on the next shift. LVN A said she called the DON, but she did not call the Doctor or CR#1's responsible party. LVN A said she called the DON and she said she would handle it when she came to work. Interview on [DATE] at 3:41 p.m. with Hospice RN she said when the hospice aide went to the facility at 5 a.m. he was actively transitioning after the ant bites, and she went for her normal routine. Hospice policy says if the resident is having an emergency its according to the facility's policy. Hospice policy is to notify them before transport and to notify them before calling 911. The nurse did not arrive until the facility called to say he passed. Interview on [DATE] at 3:50 p.m. with LVN A she said she cannot say CR#1 was actively dying but he was getting [MEDICATION(S)] every 4 hours. The only change she saw in CR#1 that day was when she tried to feed him, and he was not swallowing. He was just lying in the bed, no problems breathing, his eyes were open. He never talked to her. She made sure there was no food in his mouth. Since she had been taking care of the resident, he has been same way, and there was no real change in the resident. She had never seen anyone visit the resident on her shift. LVN A said CR#1 was taking [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)] and that is what put CR#1 into a deep sleep, and she gave CR#1's med's at 2 a.m. She did not give CR#1's 6 am dose. LVN A said she called her DON she said she would handle it when she came to the facility. LVN A said she did not call the doctor because the DON said she would take care of it when she got to the facility. She said LVN B is the one who called the DON originally and she did not call 911 because of the DON. LVN A said after the ant bites the resident changed in his breathing. She said she took CR#1's vitals, the oncoming nurse took over and the Hospice CNA came before she left. LVN A said she did not call 911 because he was hospice and a DNR and because her DON said she would handle it. She said CR#1's vitals had not changed before the ant bites because when she came to work between 6 p.m. and 8 p.m. CR#1's temperature was 97.2 pulse 96 and 20 respiration blood pressure ,d+[DATE] and his pulse was 95, but after the ant bites CR#1's vitals were temperature 97.4, pulse 84,respiration 18, blood pressure ,d+[DATE] and pulse 95. The Original ones were in the computer, but she did not record the 2nd set of vitals. After the bites, when they moved CR#1 from room [ROOM NUMBER] to room [ROOM NUMBER], CR#1 started breathing different. She did not call 911 or the Doctor because she followed her chain of command who told her what to do. Interview on [DATE] at 4:05 p.m. with Facility Doctor she said she heard CR#1 passed away. She said the DON did not call her until this morning, [DATE] after 9 a.m. The Doctor said she is coming into this after the fact. She said Hospice stopped the daily visits with CR#1, but they were doing daily visits until Friday. The Doctor said she had not seen the resident, normally she would expect that the resident would stop breathing because of the ant bites. The Doctor said she did not want to give an opinion about whether the fire ants caused CR#1's death. She said when she talked with the DON, she said he had some trailing around his face and a few covering his legs. The Doctor said she did not get the impression that he was covered in ants. Since the coroner is involved, he will give the Surveyor a better assessment. The Facility Doctor said she did not find out about CR#1 until this morning and what the DON described was not that he was completely covered with ants. The facility Doctor said she did not want to answer this surveyor if CR#1 could have died from the fire ant bites or if CR#1 should have been sent to the hospital. She said if she had someone with a broken bone, she would send them to the hospital. If a resident were covered from head to toe with ants, she would probably have sent the resident to the hospital. The facility Doctor said she did not recall a message on her answering service, and she checked her messages and found that no one had called to report the incident. The Facility Doctor said she spoke with the hospice nurse who saw CR#1 and she was horrified when she saw it. The Facility Doctor said as best as she could tell she was not notified. CR #1 was on scheduled [MEDICATION(S)] and was on hospice. She said she asked this morning and was told hospice was doing frequent visits and then they took him off of frequent visits because he was no longer actively dying. In an interview on [DATE] at 8:47 p.m. with CR#1's family member she said Hospice called her after the incident with CR#1 saying that CR#1 had passed away. Hospice called her right after he passed at about 9:20 a.m. The family member said the facility did not call her until after hospice called her. She said if the facility would have called her, she would have wanted CR#1 to go to the hospital or to even call the doctor. The family member said the facility should have called the Doctor right away for the Doctor to see CR#1. The family member said what happened to CR#1 was horrible. She said the DON called her about 10 or 15 minutes after Hospice called. The Family member said Hospice told her about the ant bites on CR#1's face. The DON said the resident passed away and that she was sorry and that they called and checked on him at about 5 or 5:30 a.m. and they discovered ants, the cleaned him up and took him a shower. She said CR#1's other family member 1 wanted to know why the facility did not call the doctor. She says she does not think it's right and CR#1's family cannot understand how this happened. The family member said CR#1 had not been eating and he started eating again. The family member said she wondered if CR#1 ate by himself or did they clean him up after eating for the ants to be around his mouth. In an interview on [DATE] at 8:56 p.m. with CR#1's family member 1 (main RP) and family member 2 family member #2 said he was very sad and disappointed about how the facility took care of CR#1. Family member 2 said they felt the facility bated (made him [NAME] for the ants) CR#1 and put him back in the bed and he thought they would have called the doctor because CR#1 might have gone into shock with all the fire ant bites. Family member 2 said someone needed to be responsible for that. Family member 1 said the hospice nurse told them they were evacuating 2 other rooms because they found ants in those other rooms, too. Both family members said that was not acceptable for them and the hospice nurse said it was so much worse than what they told her on the phone. Family member 1 said the hospice nurse said it was pretty bad and that CR#1's face was all swollen with ant bites all over his face. Family member 2 said when they found CR#1 with those ants it was 4:30 a.m. and he died at 9:15 a.m., and he felt the facility should call the doctor or take him to the emergency room . Family member 2 said CR#1 could not use his hands so he could not swipe the ants from his face. In an interview on [DATE] at 11:37 a.m. with LVN B she said she was on her hallway on 300 hall doing rounds on the date of the incident. LVN B said LVN A from the 400 hall came looking for help, asking LVN B to come, and she pulled CNA B with her, too. LVN B said she took a short video of the ants that were on CR#1 because she wanted her supervisor, the DON, and maintenance to see. LVN B said they took CR#1's clothes off and brought CR#1 out of the room. LVN B said she called the DON and sent her the video. LVN B said the DON said to make sure the residents (CR#1 and his roommate, Resident #1) get a shower and don't take any of the clothes into the new room. LVN B said Resident #1 was not bitten, but they did find ants in his bed and on the sheets. LVN B said the ants were headed to Resident #1's bed. LVN B said she got CR#1 and Resident #1 out the room and out of the situation. LVN B said there were hundreds of ants on the floor and on [CR#1]. LVN B said CR#1 was actively dying already from the night before. LVN B said she did not call hospice because LVN A said she could handle it. This Surveyor asked why the doctor or 911 was not called LVN B said she let LVN A handle her resident. LVN B said if it was on her hall, she would have called the doctor, hospice and CR#1's family to let them know. LVN B said she did not see the reason to call 911 because she did not know what they would have done because he was already actively dying. LVN B said she had not seen the resident until after he was bitten, and he was breathing like he was actively dying. She said the CNA's were CNA A and CNA B on her hall. In an Interview on [DATE] at 12:53 p.m. with the Administrator she said she woke up to a text message sent on [DATE] at 4:30 a.m., but she did not see it until 6 a.m. or 6:30 a.m. She said she called the nurses at the facility and asked who the resident was, and they said they already spoke to DON and she gave them orders to get CR#1 and Resident #1 up, showered and change their rooms. The Administrator said LVN A said she had already talked to the DON and gotten all of LVN A and LVN B's orders and instructions from the DON. The Administrator said when the staff told her that they already talked to the DON, she did not question it. She said on a hospice patient they usually don't send anyone out on a 911 emergency and when she talked to everybody, they said everything was done. She said she was not aware of the severity of the situation. The Administrator said she would have sent the resident to the hospital if she had known the severity of the ant bites, but that was not communicated to her. She said she could not answer what the outcome would be if someone was bitten by hundreds of ants. The Administrator said it was so unbelievable and she thought about it a thousand times of how to even prepare for something like that. She said the facility had exterminators coming in, they got the treatments, and they did not miss any. She said, How do you prevent something like that?. The Administrator said the facility in-serviced the staff on what they were doing for their room rounds, to look more closely by the window seals, make sure they notified the Maintenance Director, the DON and the Administrator. They had the exterminator to come out twice already to spray inside and outside the building twice now. The Administrator said she also included notifying the doctor as a part of the in-service. In an interview on [DATE] at 1:15 p.m. with the DON she said she was notified of the incident at on [DATE] at 4:21 a.m. by text and phone call by LVN B that there were ants on CR#1. She said she told the staff to get CR#1 up, showered and to another room. The DON said she asked if there were bites and they said there were not a lot of bites and that there was a little red around CR#1's mouth and eyes. DON said she asked the color of the ants and they said they were black. She said the nurses would do as she instructed and she would notify the doctor and family in the morning. She said LVN B sent her the video she took of the ants on CR#1, but not any pictures, so she could not see CR#1's face on the video. The DON said LVN A and LVN B did not explain that it was an emergency, so she followed normal protocol and she bathed the resident, but in hindsight she would not have said to go to the hospital because they don't send hospice residents out to the hospital. The DON said if they fall and break their arm and they are actively dying they would notify the doctor. The DON said the facility had the exterminators coming and spraying since the incident. She said if any residents had bites on them, they should let the doctors know immediately. She said she did not see it, but she should have let the nurse call the doctor. The DON said she did not call the family because she was not told about the severity of the ant bites. The DON said LVN C called hospice at 6:30 a.m. and that was why they came, and CR#1 passed away at 9:19 a.m. The DON said, she does not feel she did anything wrong. She said she felt that the movement from the ambulance would have killed CR#1 and when she saw CR#1's face she still would not have sent the resident to the hospital because he did not look like the picture that hospice took when she saw him. She said she did not know if the ant bites turned that way after CR#1 passed. She said she had this to happen to her before, not to this degree, they had sugar ants in the bed, so they got the resident up and showered the resident and moved them to a different room. The DON said, she probably would have asked the doctor for a Benadryl, but that is not what she saw. The DON said she did not get to the facility until after he died at about 9:30 a.m. The DON said she spoke with LVN A and asked her why she would call her when they should call the doctor and follow what their procedures were. Record review of Change in a Resident's Condition or Status Policy revised [DATE] revealed, Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): accident or incident involving the resident; discovery of injuries of an unknown source; A significant change of condition is a major decline or improvement in the resident's status that: Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is-not self-limiting); Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: The resident is involved in any accident or incident that results in an injury including injuries of an unknown source; There is a significant change in the residents physical, mental, or psychological status; There is a significant change in the resident's room assignment . Record review of the facility's policy on Identifying Neglect dated [DATE] revealed, Preventing resident neglect is a priority throughout all levels of this organization. Preventing neglect includes recognizing and understanding how neglect is defined and how it can occur with residents. Neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical pain, mental anguish, or emotional distress. Any situation in which the resident's care needs are known (or should be known) by staff (based on assessment and care planning), and those needs are not met to other circumstances, can be defined as neglect. Record review of Facility's policy on Hospice Program dated [DATE] revealed, In general, it is the responsibility of the facility to [NAME] the resident's personal care and nursing needs in coordination with the hospice representative and ensure that the level of care provided is appropriately based on the individual resident's needs. These include .Notifying the hospice about the following: A significant change in the resident's physical, mental, social, or emotional status. Clinical complications that suggest a need to alter the plan of care. A need to transfer the resident from the facility for any condition. The resident's death. Communicating with the hospice provider (and documenting such communication) to ensure that the needs of the resident are addressed and met 24 hours per day; and Reporting any alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of resident property by hospice personnel, to the hospice administrator immediately upon awareness of the alleged violation. On [DATE] at 3:19 PM, an Immediate Jeopardy (IJ) was identified. The Administrator was notified. The Administrator was provided with the IJ template, and a Plan of Removal (POR) was requested at that time. The POR, submitted by the Administrator, was accepted on [DATE] at 9:27 AM. The POR revealed: A follow up interview on [DATE] at 10:40 a.m. with the DON revealed if she had been the nurse, she would have gotten the patient to safety and called the doctor. The DON said the Nurses should have called the Doctor and hospice before calling her and notified her what they were doing. LVN A said she went back into the residents room to change the canula because the resident was on oxygen. In an emergency, they are supposed to call the doctor first, she does not know why LVN A called her first. Interview with DON on [DATE] at 10:30 a.m. she said the training the nurses had in order to care for CR#1 she said in July they had a hospice in-service on when to notify hospice by calling their on-call number and they have their hospice nurse to call them back and the Hospice Nurse will contact their Doctor and Responsible Party. The DON said post IJ they did an in-service when to notify hospice, emergency situations, and they gave them the policy on hospice. The Nurse would go in to assess the patient and if she feels it is an emergency she can call 911 right then. After the ER come, she will notify the doctor and RP. The DON said if they have another nurse who can call hospice and everyone they can. She said their rule is Patient is first. She has called 911 in her career for someone on hospice. The DON said if someone is having a heart attack you are not going to call the Dr. you will call 911. When the DON was asked, How did she ensure the nurses were competent in their skills for in caring for a resident such as CR#1 she said their nurses have called 911 when a resident falls and their head is bleeding profusely and they did more in-dept training after the incident with CR#1, but they have been educated and it is part of your nursing education when they go to school. She has ADON's and MDS nurses who educate the CNA's. The DON said the CNA's have competencies they do; they have to notify the Nurse with anything going on with a Resident. If the Nurse does not call and the CNA feels it's not taken care of, they can call 911 and they have in-services and testing on what to do in emergency situation, what to do if the nurse does not take care of something appropriately, follow the chain of command they can call 911 and they can call the State if it's appropriate. The DON was asked how you think this incident came about and the DON said the Nurse on the floor caring for the resident should have called hospice and the Dr and given them her assessment. She said that should have been LVN A's first phone call and that is where the disconnect was. The DON said there was nothing she could do about ants and if they would have called hospice and the Dr and gave them their assessments then everybody would have known and not been in shock. The DON said the resources the facility had available to them is Policy and Procedures, consultants, sister facilities, medical director. She said the facility had policies in place, MD who is on-call ,d+[DATE] if they cannot reach a primary care, regional nurse, tele-nurse from corporate they can call at any time, team Help with the Doctor and hospice. The DON said the RP may have felt that they just wanted to know sooner about CR#1, they may be emotional and the resident she cannot say how he was affected because from what she was told he was passing so she could not answer that on how the ants impacted resident. The DON said she could not say CR #1 was in pain, or if he died 15 minutes earlier, she cannot say because she does not know. In an interview on [DATE] at 1:12 p.m. with the Administrator she said her job responsibility is to oversee the operation or the day-to-day operation of the facility and that they have policy and procedures for all the residents they accept in their facility to meet the needs to ensure that we are properly taking care of them. The Administrator said she monitor the DON to ensure the systems they monitor are being done sufficiently by following up on specific situation that to significant change in conditions to ensure they are following policy and regulations. The Administrator said the staff notify her about significant change and conditions and emergency situations. She said when they notify her of ER situations it depends on what it is. She said she would talk to the DON or talk to her Regional Nurse and staff and if it is a reportable then she reports it. The Administrator said she could not make anything out of what was being said that morning of the incident on the video and they said that CR#1 was a hospice patient that was actively dying. She said they said he had ants on him, but they already took care of him and that they talked to the DON and showered him, moved him, and that DON would reach out to the Doctor. The Administrator said had she known the severity of it she would have done something different, but it did not raise a red flag on why the DON was calling the Doctor because they were busy with the resident. She said in Hindsight knowing the severity of it she would have absolutely called the Doctor and 911. The Administrator said she told them they call her for everything, but they did not call her about the ER. She said they have to use their Nursing judgment because they are not in the building. She said if you would call 911 for your child then you know to call 911. The Administrator said she ensured competency of the staff by continuing to in-services, do the skills check off and competency test. She said skills check off is putting the staff in different situations and see what steps they would take, and they have done assessment check offs with the staff. The Administrator said she does evaluate policy and procedures with the staff and a lot of times they use their policy and procedures to make their in-services and competency tests. She ensured effectiveness of facility processes by doing weekly meetings where they go over processes, and again with QAPI they go over the process weekly and monthly depending on what processes there are and as needed PRN, daily, weekly and monthly depending on the process. When asked how the Administrator thought the incident came about, she said the facility failed to follow the [TRUNCATED]

Based on interview and record review, the facility failed to promptly communicate and collaborate with hospice representatives in coordinating hospice care planning following a significant change in condition of a resident that suggested a need to alter the plan of care and treatment for one of eight residents (CR#1) reviewed for hospice services in that: -The facility failed to immediately contact and communicate with CR#1's hospice provider after he sustained numerous ant bites which left open wounds around and inside CR#1's mouth, eyes, and ears and all over his body. CR#1 died at the facility within 4 hours after sustaining the ant bites. These failures placed residents who were on hospice at risk of experiencing pain and physical and emotional distress. Findings include: CR#1 Record review of a Face Sheet for CR #1 dated [DATE] at 10:22 a.m. revealed an [AGE] year-old male admitted on [DATE] and readmitted [DATE]. CR#1 was diagnosed with senile degeneration of brain (mental decline), cognitive communication, [CONDITION(S)] (hardening of the arteries in the heart), [CONDITION(S)] and [CONDITION(S)] (complete loss of strength and weakness on one side of the body) and , hypertension (high blood pressure), ataxia (loss of full control of body movements) and [CONDITION(S)] (high cholesterol). Record review of CR#1's Minimum Data Set, dated dated dated [DATE] revealed his BIMS Summary score was 8 indicating his cognition was mildly impaired; walking in room and corridor did not occur; he was totally dependent with two staff for transfers, and dressing; totally dependent with one staff for locomotion on and off unit, eating, toilet use, and personal hygiene and he needed extensive assistance with two staff for bed mobility. CR #2 was totally dependent on staff for bathing with one staff assisting; urinary continence was not rated, he was frequently incontinent of bowel and Hospice care identified. CR#1 was usually able to make self-understood and was usually able to understand others. Record review of CR#1's Care Plan dated [DATE] revealed CR#1 had a terminal diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] determine the resident's needs; cognitive deficit as evidenced by trouble concentrating with interventions was administer anti-anxiety medication, Evaluate for side effects of medications, monitor for non-verbal signs of anxiety: restlessness, trembling, rocking and pacing, indwelling suprapubic Catheter and is at risk for increased Urinary tract infections; pressure ulcers with interventions was the resident has a 16 FR catheter. Position catheter bag and tubing below the level of the bladder and away from entrance room door and check tube for kinks. Interview on [DATE] at 10:40 a.m. with DON revealed, DON said if she had been the Nurse, she would have gotten the patient to safety and called the doctor. The DON said the Nurses should have called the Doctor and hospice before calling her and notified her what they were doing. LVN A said she went back into the residents room to change the canula because the resident was on oxygen. In an emergency, they are supposed to call the doctor first, she does not know why LVN A called her first. Record review on [DATE] of video #1 by LVN B revealed CR#1 was covered with black ants. Observation revealed hundreds of ants all over CR#1. The nurses were saying they were all over him, his mouth, and that he was still breathing. Record review on [DATE] of Video #2 by LVN B revealed a trail of hundreds of black ants leading from the window and wall by the nightstand leading to CR#1. Record review of Local Hospice Nurses notes dated [DATE] revealed, Integumentary (skin) Assessment was pale and poor turgor (dehydration), no abnormal respiratory findings identified, his appetite was poor eating bite sizes, and no imminent signs of death noted. Record review of Hospice notes dated [DATE] revealed 2 pictures of CR#1 revealing the ants had eaten CR#1's flesh all around his mouth, eyes, the inside of his left cheek, ears and possibly bites on his tongue. Hospice notes further revealed, This RN received call from DON that CR#1 had passed. After assessment including auscultation (listening to the sounds ) of chest for 1 minute, no signs of life noted. Confirmed time of death of on [DATE] at 9:19 a.m. CR#1 was found covered in ant bites from an ant infestation in his room at the facility .Medical examiner's office taking over case .DON stated CR#1 was found in ants around 4:30 a.m. and aides were instructed to give CR#1 a shower to rinse off ants. Interview on [DATE] at 10:24 a.m. LVN A said she was making her rounds and around 4 a.m. she was putting on CR #1's oxygen, foley and she left the room, but she came back because she forgot to get the dirty oxygen canula. LVN A said she went back to the room and CR#1 had some red on his face and she thought he threw up, so she went to get a towel to wash his face and she looked, and it was ants. LVN A said she started brushing the ants off his face and she saw there were more on the other side of his face. She said she went to get help and the other aides came in and started brushing his face. She said there were ants around CR#1's mouth, eyes, all over the bed, and there were a lot of ants. LVN A said she had just been in CR#1's room in under 45 minutes previously when she drained CR#1's foley drainage bag and changed the O2 canula. LVN A said she left the room and returned to CR#1's room to get the dirty canula and she said she went to CR#1's face to put the nasal cannula on and the lights were on, and she saw some ants in the residents bed. LVN A said she went to get help from LVN B and CNA A, and they got CR#1 out of the bed, showered him, and moved him to a different room. LVN A said there were a lot of ants, and it scared the hell out of her. LVN A said when they pulled CR#1's blanket back on his bed there were ants all in his bed. She said while they were brushing the ants off, LVN B was taking a video of the ants. She said LVN B sent the video to the DON to show her what was going on in the room. LVN A said she had to get the ants off of herself and after she made sure the ants were off of her, she called the DON to see how she would handle it. LVN A said the ants bit her too and she was standing in them, and she did not know she was standing in the ants. She said she was brushing the ants off of CR#1's face and they were crawling up her leg. LVN A said the ants came from under the air conditioner on the right side of the bed and the trail was long, and they were black ants. LVN A said LVN B, and all the resident CNA's came to assist them. She said the CNA's got the Hoyer lift to get CR#1 out of bed to get him into the shower. She said the CNA that worked the hall was CNA A, and she was PRN. LVN A said she has worked at the facility for about 2 weeks now. LVN A said the incident happened on [DATE] at around 5 a.m. LVN A said she started rounds at 2 a.m. and was in CR#1's room at 4:14 a.m. LVN A said CR#1 did not grimace like he was in pain, and she had just given CR#1 his [MEDICATION(S)]. LVN A said there were more ants around his mouth and eyes area. She said she did not get CR#1's face on the video and that was where the majority of the ants were. LVN A said CR#1 died on the next shift. LVN A said she called the DON, but she did not call the Doctor or CR#1's responsible party. LVN A said she called the DON and she said she would handle it when she came to work. Interview on [DATE] at 3:50 p.m. LVN A said she could not say CR#1 was actively dying but he was getting [MEDICATION(S)] every 4 hours. LVN A said the only change she saw in CR#1 that day was when she tried to feed him lunch, and he was not swallowing. LVN A said he was just lying in the bed, no problems breathing, and his eyes were open. She said he never talked to her. She said she made sure there was no food in his mouth. She said since she had been taking care of the resident, he had been same way, and there was no real change in the resident. She said she had never seen anyone visit the resident on her shift. LVN A said CR#1 was taking [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)] and that was what put CR#1 into a deep sleep, and she gave CR#1's med's at 2 a.m. LVN A said she called her DON and she told her she would handle everything with CR#1 when she came to the facility. LVN A said she did not call the doctor because the DON said she would take care of it when she got to the facility. She said LVN B was the one who called the DON originally and she did not call 911 because of the DON. LVN A said after the ant bites the resident changed in his breathing. She said she took CR#1's vitals, the oncoming nurse took over and the Hospice CNA came before she left. LVN A said she did not call 911 because he was on hospice, had a DNR and because her DON said she would handle it. She said CR#1's vitals were the same as they had always been before the ant bites when she came to work between 6 p.m. and 8 p.m. CR#1's temperature was 97.2 degrees Fahrenheit, pulse 96, respirations were 20 (breaths per minute), and blood pressure was ,d+[DATE]. She said after the ant bites CR#1's vitals were temperature was 97.4 degrees Fahrenheit, pulse was 84, respiration were 18, blood pressure was ,d+[DATE] and his pulse was 95. LVN A said the original vitals were in the computer, but she did not record the 2nd set of vitals. LVA said after the bites, when they moved CR#1 from room [ROOM NUMBER] and placed him in room [ROOM NUMBER], CR#1 started breathing different like he was going to die. She said she did not call 911 or the doctor because she followed her chain of command who told her what to do. Interview on [DATE] at 4:05 p.m. the facility Doctor said she heard CR#1 passed away. She said the DON did not call her about CR#1 until this morning, [DATE] after 9 a.m. The Facility Doctor said she was coming into this incident after the fact. She said hospice stopped the daily visits with CR#1, but they were doing daily visits until Friday, [DATE]. The Facility Doctor said she had not seen the resident, normally she would expect that the resident would stop breathing because of the ant bites venom. The Doctor said she did not want to give an opinion about whether the fire ants caused CR#1's death. She said when she talked with the DON, the DON said he had some trailing around his face and a few covering his legs. The Facility Doctor said she did not get the impression that he was covered in ants. The Facility Doctor said since the coroner was involved, he would give the Surveyor a better assessment. The Facility Doctor said what the DON described was not that he was completely covered with ants. The Facility Doctor said she did not want to answer this Surveyor if CR#1 could have died from the fire ant bites or if CR#1 should have been sent to the hospital. She said if she had someone with a broken bone, she would send them to the hospital. She said if a resident were covered from head to toe with ants, she would probably have sent the resident to the hospital. The Facility Doctor said she did not recall a message on her answering service, and she checked her messages and found that no one had called to report the incident. The Facility Doctor said she spoke with the hospice nurse who saw CR#1 and she was horrified at what she saw. The Facility Doctor said as best as she could tell she was not notified. The Facility Doctor said CR #1 was on scheduled [MEDICATION(S)] and was on hospice. She said she asked this morning and was told hospice was doing frequent visits and then they took him off of frequent visits because he was no longer actively dying. In an interview on [DATE] at 8:47 p.m. with CR#1's family member she said Hospice called her after the incident with CR#1 saying that CR#1 had passed away. Hospice called her right after he passed at about 9:20 a.m. The family member said the facility did not call her until after hospice called her. She said if the facility would have called her, she would have wanted CR#1 to go to the hospital or to even call the doctor. The family member said the facility should have called the Doctor right away for the Doctor to see CR#1. The family member said what happened to CR#1 was horrible. She said the DON called her about 10 or 15 minutes after Hospice called. The Family member said Hospice told her about the ant bites on CR#1's face. The DON said the resident passed away and that she was sorry and that they called and checked on him at about 5 or 5:30 a.m. and they discovered ants, the cleaned him up and took him a shower. She said CR#1's other family member 1 wanted to know why the facility did not call the doctor. She says she does not think it's right and CR#1's family cannot understand how this happened. The family member said CR#1 had not been eating and he started eating again. The family member said she wondered if CR#1 ate by himself or did they clean him up after eating for the ants to be around his mouth. In an interview on [DATE] at 8:56 p.m. with CR#1's family member 1 (main RP) and family member 2 family member #2 said he was very sad and disappointed about how the facility took care of CR#1. Family member 2 said they felt the facility bated (made him [NAME] for the ants) CR#1 and put him back in the bed and he thought they would have called the doctor because CR#1 might have gone into shock with all the fire ant bites. Family member 2 said someone needed to be responsible for that. Family member 1 said the hospice nurse told them they were evacuating 2 other rooms because they found ants in those other rooms, too. Both family members said that was not acceptable for them and the hospice nurse said it was so much worse than what they told her on the phone. Family member 1 said the hospice nurse said it was pretty bad and that CR#1's face was all swollen with ant bites all over his face. Family member 2 said when they found CR#1 with those ants it was 4:30 a.m. and he died at 9:15 a.m., and he felt the facility should call the doctor or take him to the emergency room . Family member 2 said CR#1 could not use his hands so he could not swipe the ants from his face. In an Interview on [DATE] at 12:53 p.m. with the Administrator she said she woke up to a text message sent on [DATE] at 4:30 a.m., but she did not see it until 6 a.m. or 6:30 a.m. She said she called the nurses at the facility and asked who the resident was, and they said they already spoke to DON and she gave them orders to get CR#1 and Resident #1 up, showered and change their rooms. The Administrator said LVN A said she had already talked to the DON and gotten all of LVN A and LVN B's orders and instructions from the DON. The Administrator said when the staff told her that they already talked to the DON, she did not question it. She said on a hospice patient they usually don't send anyone out on a 911 emergency and when she talked to everybody, they said everything was done. She said she was not aware of the severity of the situation. The Administrator said she would have sent the resident to the hospital if she had known the severity of the ant bites, but that was not communicated to her. She said she could not answer what the outcome would be if someone was bitten by hundreds of ants. The Administrator said it was so unbelievable and she thought about it a thousand times of how to even prepare for something like that. She said the facility had exterminators coming in, they got the treatments, and they did not miss any. She said, How do you prevent something like that?. The Administrator said the facility in-serviced the staff on what they were doing for their room rounds, to look more closely by the window seals, make sure they notified the Maintenance Director, the DON and the Administrator. They had the exterminator to come out twice already to spray inside and outside the building twice now. The Administrator said she also included notifying the doctor as a part of the in-service. In an interview on [DATE] at 1:15 p.m. with the DON she said she was notified of the incident at on [DATE] at 4:21 a.m. by text and phone call by LVN B that there were ants on CR#1. She said she told the staff to get CR#1 up, showered and to another room. The DON said she asked if there were bites and they said there were not a lot of bites and that there was a little red around CR#1's mouth and eyes. DON said she asked the color of the ants and they said they were black. She said the nurses would do as she instructed and she would notify the doctor and family in the morning. She said LVN B sent her the video she took of the ants on CR#1, but not any pictures, so she could not see CR#1's face on the video. The DON said LVN A and LVN B did not explain that it was an emergency, so she followed normal protocol and she bathed the resident, but in hindsight she would not have said to go to the hospital because they don't send hospice residents out to the hospital. The DON said if they fall and break their arm and they are actively dying they would notify the doctor. The DON said the facility had the exterminators coming and spraying since the incident. She said if any residents had bites on them, they should let the doctors know immediately. She said she did not see it, but she should have let the nurse call the doctor. The DON said she did not call the family because she was not told about the severity of the ant bites. The DON said LVN C called hospice at 6:30 a.m. and that was why they came, and CR#1 passed away at 9:19 a.m. The DON said, she does not feel she did anything wrong. She said she felt that the movement from the ambulance would have killed CR#1 and when she saw CR#1's face she still would not have sent the resident to the hospital because he did not look like the picture that hospice took when she saw him. She said she did not know if the ant bites turned that way after CR#1 passed. She said she had this to happen to her before, not to this degree, they had sugar ants in the bed, so they got the resident up and showered the resident and moved them to a different room. The DON said, she probably would have asked the doctor for a Benadryl, but that is not what she saw. The DON said she did not get to the facility until after he died at about 9:30 a.m. The DON said she spoke with LVN A and asked her why she would call her when they should call the doctor and follow what their procedures were. Record review of Facility's policy on Hospice Program dated [DATE] revealed, In general, it is the responsibility of the facility to [NAME] the resident's personal care and nursing needs in coordination with the hospice representative and ensure that the level of care provided is appropriately based on the individual resident's needs. These include .Notifying the hospice about the following: A significant change in the resident's physical, mental, social, or emotional status. Clinical complications that suggest a need to alter the plan of care. A need to transfer the resident from the facility for any condition. The resident's death. Communicating with the hospice provider (and documenting such communication) to ensure that the needs of the resident are addressed and met 24 hours per day; and Reporting any alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of resident property by hospice personnel, to the hospice administrator immediately upon awareness of the alleged violation. Record review of Change in a Resident's Condition or Status Policy revised [DATE] revealed, Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): accident or incident involving the resident; discovery of injuries of an unknown source; A significant change of condition is a major decline or improvement in the resident's status that: Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is-not self-limiting); Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: The resident is involved in any accident or incident that results in an injury including injuries of an unknown source; There is a significant change in the residents physical, mental, or psychological status; There is a significant change in the resident's room assignment .

Based on interview and record reviews the facility failed to ensure residents were free from neglect for 1 of 12 residents (CR #1) reviewed for neglect, in that; The facility did not notify CR #1's physician of the contaminated urine culture and sensitivity laboratory report. Seven days later CR #1 was transferred to the hospital and diagnosed with [CONDITION(S)] (life-threatening complication of an infection). CR # 1 died on e month later her cause of death was [CONDITION(S)]. This deficient practice could place residents at risk of decline in health from not having their laboratories identified and addressed promptly. Findings included: CR #1 Record review of CR #1's face-sheet revealed an [AGE] year-old female, admitted to the facility on [DATE], her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Face-sheet also revealed CR #1 was discharged to the hospital on [DATE]. Record review of CR #1's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 3 out of 15, indicating severe cognitive impairment. Review also revealed CR #1 required extensive assist of two persons for bed mobility, dressing, toilet use and personal hygiene. CR #1 was always incontinent of bowel and bladder. Record review of CR #1's care plan revealed: -Focus: I have Urinary Retention/Hematuria (Date initiated: [DATE]). Interventions: encourage adequate fluid intake. Give antibiotic therapy as ordered. -Focus: I am on Anticoagulant therapy (Date initiated: [DATE]). Interventions: Labs as ordered. Report abnormal labs to the Medical Doctor. Record review of CR #1's death certificate dated [DATE] revealed: - Legal name of deceased : CR#1. - date of death : [DATE]. - Underlying cause (disease or injury that initiated the events resulting in death: [CONDITION(S)]. Approximate interval onset to death: 2 weeks. Record review of CR #1's Progress note dated [DATE] revealed in part .Patient in room with call-light at bedside. Patient on day 3 of fall, and the patient was not herself today. CNA noticed during shower that the patient seem to have pain. Pain pill was given to the patient and the patient was asked if she was in pain, and she replied she had some discomfort in her left hip when she touched it MD was called and an x-ray and labs of CBC and BMP was ordered. Awaiting results. Author: LVN #1 . Record review of CR #1's Licensed Nurse MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . For 1 day. Further review revealed order completed on [DATE]. (Add physician orders) Record review of CR #1's lab report (Complete Blood count with auto, with PLT and Comprehensive Metabolic panel) with order date: [DATE] and approved date: [DATE]), revealed in part . white blood cells 10.9 High (reference range: 3.6 - 10.2). RDW-SD 60.40 High (reference range: 36.5 0 45.9). RDW-CV 18.5 High (reference range: 11.0 - 15.0) Urea [MEDICATION(S)] (BUN) 29 High (reference range: ,d+[DATE]). BUN/Creatinine Ratio 49 High (reference range: ,d+[DATE]). Further review revealed MD AWARE was noted on the lab report . Record review of CR #1's Licensed Nurse MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed Order date: [DATE] and order status: completed. Record review of CR #1's Progress note dated [DATE] revealed in part .CR #1 has had a decrease in intake and has been increasingly confused and agitated since fall on ,d+[DATE]. Vitals remain WNL, neuros WNL, full ROM noted with no signs or symptoms of any injuries. No complaints of pain at this time. MD aware, got new order for stat UA with C&S. Urine collected by this nurse and picked up by the lab this afternoon. CBC and BMP done on resident and was sent to the NP. No new orders regarding lab results at this time. Will notify oncoming shift of pending UA results .Author: RN #2 Record review of CR #1's undated Medication review report revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Order date: [DATE]. Record review of CR #1's lab results (collected:[DATE] and reported: [DATE]) revealed in part .Test name: Urinalysis. Color: yellow. Leukocyte: 2+. Bacteria: Many. Culture: Result: Growth of mixed flora was isolated, suggesting probable contamination . In an interview with RN#2 on [DATE] at 3:00 PM, she stated on [DATE] she collected the UA and it was picked-up by the lab, however; the following day she fell ill and was out for 2 weeks. RN #2 stated when she returned to work she looked at CR #1's lab report and saw it was contaminated. RN#2 stated normally when a lab comes back contaminated, the MD is notified, and the MD orders the lab to be re-done, but she was not in the facility at the time and was unsure if the labs were re-done. Record review of CR #1's Lab report ( CBC- complete blood count w/auto, W/PLT) order date: [DATE] and final approved date: [DATE] revealed in part .RDW-SD 62.60 High (reference range: 36.5 0 45.9). RDW-CV 18.9 High (reference range: 11.0 - 15.0). Lymphocytes 4.6 High (reference range: 1.0 - 3.2). BUN/Creatinine ratio 60 High (reference range: ,d+[DATE]). Further review revealed Faxed to MD [DATE] by LVN #2 . In an interview with RN #1 on [DATE] at 12:19 PM, she stated the MD and NP are notified via phone calls. She further stated when lab results are received by the facility, the MD and NP are notified via phone regarding the results. In an interview with the facility ADON on [DATE] at 1:40 PM, she stated at the change of each shift the out-going and in-coming nurses do a walk through the facility and review each resident and the out-going nurse lets the incoming nurse know of any change in condition, labs that are new for the residents. Attempted interview on [DATE] at 2:58 PM, [DATE] at 11:20 AM, and 3:10 PM, with LVN #2 indicated all attempts were unsuccessful, messages left but no calls were returned. Record review of CR #1's Progress note dated [DATE] revealed in part .Patient in room with call light at bedside, patient had labs done and sent to MD, no new orders were ordered, patient has been talking more and asking for water, ate some of her breakfast, will continue to monitor. Author: LVN #1 . In an interview with LVN #1 on [DATE] at 3:39 PM, she stated she called the MD with CR #1's lab and x-ray results but could not remember the UA. LVN #1 further stated she remembered that a UA had to be done, but she was off after that and was not in the facility when the UA was drawn. Record review of CR #1's Progress note dated [DATE] revealed in part .UA result faxed to MD. C &S result pending. Author: LVN #2 . Record review of CR #1's Progress note dated [DATE] revealed in part .Resident ate less than 25% of meal. Author: LVN #3 . Record review of CR #1's Progress note dated [DATE] revealed in part .Ate less than 50% or less for 2 or more meals in the day, offered med pass and alternate meal. Author: LVN #3 . In an interview with CNA #1 on [DATE] at 1:54 PM, she stated around the day CR #1 was sent to the hospital she was not herself, she had stopped eating and just slept a lot which was not her norm because she liked to be up. CNA #1 stated she reported the change to the nurse, but could not recall which nurse it was. In an interview with CNA #2 on [DATE] at 2:06 PM, she stated CR #1 usually would talk a lot and liked to be up in her wheel-chair and roll around, but during her last week in the facility the resident was not eating. CNA #2 stated she even tried to feed the resident, but she would not eat. CNA #2 stated she informed the nurse (could not remember which nurse) of the change in the resident, and the nurse stated they were waiting on lab results. In an interview with CMA #1 on [DATE] at 2:22 PM, she stated CR #1 was hard of hearing, confused and loved getting out of bed after breakfast. CMA #1 stated the last time she gave CR #1 medication, the resident was sitting in a geri-chair, seemed very confused, and did not seem like herself. CMA #1 stated the resident would not look at her, which was not normal. She stated she informed the nurse (cannot remember the name of the nurse she told or the exact date she informed the nurse), and the nurse went to the resident's room. CMA #1 stated she did not know what happened after that point. In an interview with LVN #3 on [DATE] at 2:55 PM she stated she only worked with CR #1 a couple of times, and was not very familiar with the resident, but the resident was very quiet and was not eating much, which was not her norm. Tried to encourage her to eat and even offered alternatives. Record review of CR #1's Progress note dated [DATE] revealed in part .Lab results for CMP, TSH and Vitamin D. Total faxed to MD. No new orders given at this time. Author: LVN #2 . Record review of CR #1's NP progress note dated [DATE] revealed in part .History of present illness: [AGE] year-old female seen today for follow-up of reports of change in behavior. Elevated WBC has resolved. However, urinalysis shows large amount of bacteria and large amount of leukocyte. Urine culture is pending. Patient is stable and in no acute distress. Vitals are within target range. Potassium level slightly elevated and will increase P.o. fluids X 72 hours and repeat potassium levels. Staff to report any acute changes . In an interview with the NP on [DATE] at 11:34 AM, she stated she visited the facility on [DATE]. She further explained that CR #1 would normally be out of bed and up in the wheel-chair, however; during the visit, CR #1 did not want to get out of bed. NP stated she proceeded to order CBC, BMP, UA and C&S. NP stated that CR #1's results came in on [DATE] and showed elevated WBC and [MEDICATION(S)]. UA results showed potassium level was high. NP stated she was not called about the culture sensitivity being contaminated, and had she been made aware of it, she would have started the resident on an antibiotic and re-ordered the C&S. Record review of CR #1's Progress note dated [DATE] revealed in part .New order from NP. Repeat K levels and increase p.o. fluids 250cc/shift times 72 hours. Author: LVN #2 . Record review of CR #1's Progress note dated [DATE] revealed in part .lab results for UA and C&S faxed to MD. Author: LVN #2 . Record review of CR #1's Progress note dated [DATE] revealed in part .resident has decreased appetite and is very tired, not wanting to talk or speak. Contacted the MD and sent all previous labs. Author: LVN #3 . In an interview with LVN #3 on [DATE] at 4:29 PM, LVN #3 stated she remembered a UA and C&S was taken, and the results sent to the MD, but she could not recall if the MD was called about the contaminated culture and sensitivity. Record review of CR #1's Progress note dated [DATE] revealed in part .while trying to get readings for resident's vital signs, it was difficult to read her blood pressure therefore a manual blood pressure performed readings of ,d+[DATE] p:56, ,d+[DATE] p:55, ,d+[DATE] p:59. Oxygen was 99, respirations 18, resident began to mouth breathe and respiration increased to 21. Contacted MD and she stated to contact [family member] to inform her resident will be sent out. Called 911 to come for resident. Resident sent to hospital. Author: LVN #3 . In an interview with the MD on [DATE] at 2:45 PM, she stated the last time she visited the facility and saw CR #1, the resident was in bed and she did not examine her. The MD stated the facility did not make her aware of any UA and C&S results. Had she been informed of the labs, she would have started to treat for the resident with ABT and IV fluids. The MD stated the facility was to call her office with results or any change of condition for the residents that are under her care. Interview with LVN #3 on [DATE] at 4:29 PM, she stated on [DATE], CR #1 was very sleepy in the morning and did not want her vital signs or blood pressure checked. However; later in the day, CR #1 got up and was showered, while up in the wheel-chair, LVN #3 stated she proceeded attempt to get CR#1's blood pressure, but it was reading very low, she proceeded to call the MD. She was given orders to send the resident out, and CR#1 was sent out via 911. Record review of CR #1's hospital record dated [DATE] revealed in part: -Re-examination/Reevaluation. [DATE]. Patient presents to the Emergency Department via Emergency Medical Services due to tachycardia onset PTA. Patient was seen and examined with physical exam findings as above. I ordered further studies according to patient's condition. Awaiting results at this time; will continue to monitor patient. Labs noted for significant signs of dehydration, will continue to fluid resuscitate. Urine positive for UTI. Will cover with antibiotics. Given patient's tachycardia elevated white count and elevated lactic acid level, patient meeting criteria for [CONDITION(S)]. Blood cultures ordered. IV [MEDICATION(S)] also ordered. -Impression and Plan. Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . -Lab results [DATE]: Creatinine Lvl 1.50 (HIGH) -BUN 73MG/dl (High) -B/C Ratio 47 (High) -Sodium Lvl 152 mEq/L (High) -TSH 0330 uIU/ML (Low) -WBC 11.5 K/CMM (High) -PT 15.5 seconds (High) -INR 1.22 (High) -UA WBC > 182/HPF (High) -UA RBC 58/HPF (High) -[MEDICATION(S)] Acid Lvl 3.0 [NAME]/L (High) In an interview with the facility's ADON on [DATE] at 1:32 PM, she stated the facility's protocol is that lab results are to be called or faxed to the MD upon receipt. The MD reviews it and lets the facility know of new orders. ADON further stated she was unsure of what occurred with CR #1's C&S lab report. In an interview with the facility's administrator on [DATE] at 1:50 PM, he stated he was aware of a few hick-ups regarding labs and that the DON was working on an action plan along with a complete audit of labs. The administrator further stated that the lab issues had not been addressed in QA, but were being addressed by the DON. In an interview with the facility's DON on [DATE] at 3:49 PM she stated when the facility receives lab results, the nurses were responsible for forwarding the results to the MD and following the MD's orders. DON further explained that when a lab is contaminated, the MD usually orders it to be re-done. DON stated that every day in the clinical morning meeting the nurse managers discuss labs and follow up to make sure lab orders were followed, and she remembered reviewing CR #1's contaminated culture and sensitivity report in the clinical meeting, however; she was unable to see documentation of the lab being re-ordered. DON stated she remembered discussing it with CR #1's labs with the NP, but she did not follow-up with the NP to inquire about any new orders, the nurse would have been the one to follow up with the NP. On [DATE] at 4:17 PM, surveyor requested the facility's policy on labs, however, per the administrator, the facility did not have a lab policy and procedure. Record review of the facility's policy titled Recognizing signs and symptoms of Abuse/Neglect (Revised [DATE]) revealed in part: Policy interpretation and Implementation: 2. Neglect is defined as failure to provide goods and services as necessary to avoid physical harm, mental anguish, or mental illness. 3. B. Signs of actual physical neglect: (6): Inadequate provision of care.

Based on observation, interview, and record review, the facility failed to offer and/or provide sufficient fluid intake to maintain proper hydration and health for 2 of 9 Residents (Resident #8 and CR #5) reviewed for sufficient hydration in that- -CR #5 was admitted to the hospital on [DATE] with dehydration, [MEDICAL CONDITION] and [MEDICAL CONDITION]. -The facility failed to follow physician orders [REDACTED].#8 These failures affected one former resident and one resident and had the potential to affect 5 other residents who were receiving tube feedings and dependent on the facility to meet their hydration needs by causing dehydration, decline in health and hospitalization . Findings Include: CR #5 Record review of CR #5's clinical record revealed he was a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of CR #5's Care Plan initiated 1/3/18 revealed the following in part: *Problem. Resident on tube feeding *Goal. Resident will maintain adequate nutrition status; Resident will have no signs and symptoms of dehydration throughout stay Interventions. Monitor for signs of complications *Problem. Resident is at risk for dehydration *Goal. Resident will not be dehydrated during stay at facility *Problem. I am on diuretic therapy ([MEDICATION NAME]) related to hypertension *Goal. I will be free of any discomfort or adverse side effects of diuretic therapy through the review date *Interventions. Report pertinent lab results to MD. According to his admission MDS assessment dated , 1/6/18, his BIMS score was 13 indicating minimal cognitive impairment. He required total assistance with eating and drinking. Record review of CR #5's Care Plan initiated 1/12/18 revealed the following in part: *Problem. Requires transmission-based precautions isolation (Contact), [MEDICAL CONDITION] *Goal. Will not exhibit any psychosocial concerns or unintended weight loss over the next 30 days -Strict isolation will be maintained to protect visitors, staff, and other residents *Interventions. Contact Precautions: Gown and gloves required when providing direct care and if anticipating coming into contact with surfaces and materials potentially contaminated by the resident Record review of CR #5's Care Plan initiated 1/17/18 revealed the following in part: *Problem. I am at risk for dehydration related to feeding tube status. *Goal. My risk for dehydration will be minimized every day and ongoing through the next review date *Interventions. Monitor/document/report to MD signs and symptoms of dehydration including dry mucus membranes, reduced urine output, lethargy; -Notify physician if persistent symptoms of diarrhea, nausea/vomiting unresolved past 48 hours Record review of CR #5's MAR for January 2018 revealed the following medications were given in part: -Start 1/2/18 [MEDICATION NAME] Tablet 20mg tablet (A diuretic medication) via PEG tube one time a day. -Start 1/12/18 [MEDICATION NAME] Sequels Capsule extended release 500mg (A diuretic medication). every 8 hours. This medication was discontinued on 1/29/18. Record review of admission orders [REDACTED]. Record review of CR #5's Nutrition Service Note dated 1/8/18 revealed the following in part: *Assessment/Recommendations: Resident's family member hopes resident will be able to eat by mouth and stop tube feeding before taking home. Micro and macronutrient needs increased related to wound healing, need for gradual weight gain 2/2 underweight status (less than 90% IBW). Recommend to change tube feeding formula to avoid overloading gut with hypo caloric formula. Discontinue Fibersource HN at 75ml/hr x22 hours. Start [MEDICATION NAME] 1.5 at 70ml/hr x 22hours via PEG tube (bowel rest 10a-12p). No flush orders per MAR, start 50cc water before and after medications plus 125cc water every 8 hours. Record review of CR #5's Communication between the Dietician and the Attending Physician and Physician order [REDACTED]. -Discontinue Fibersource HN at 75ml/hr -[MEDICATION NAME] 1.5 at goal rate 70ml/hr x22 hours via PEG tube (bowel rest 10a-12p) -50cc free water before and after medications -125cc free water every 8 hours Record review of a physician's orders [REDACTED]. Record review of CR #5's progress notes revealed the following in part: *1/1/18 10:02 [MEDICATION NAME]. Held resident complained of loose stools. Need order clarification. Orders for [MEDICATION NAME] and [MEDICATION NAME] scheduled twice daily. *1/1/18 14:10 Dr. G came to see resident, discontinued orders for [MEDICATION NAME] scheduled and [MEDICATION NAME] scheduled. Gave order for CBC and BMP every Monday. *1/11/18 08:46 Resident is feeling weak and having several episodes of loose stools, notified Dr. G and received new orders for CBC, stool for culture and [MEDICAL CONDITION]. *1/12/18 08:51 Called Dr. G for [MEDICAL CONDITION] result and got order for [MEDICATION NAME] 500mg three times daily for 10 days and isolate resident. Medication started. *1/21/18 16:41 Continues [MEDICATION NAME] through today for [MEDICAL CONDITION]. Resident still having loose stools several per shift. Denies pain or discomfort at this time. Continues on [MEDICATION NAME] 1.5 at 70cc/hr. [DEVICE] is patient. *1/29/18 10:30 Stool collected for follow up for [MEDICAL CONDITION] *1/29/18 12:50 Left for appointment with cardiologist. *1/29/18 18:35 Resident brought order recommendations for cardiologist. The following was approved by Dr. G: discontinue [MEDICATION NAME] .Change [MEDICATION NAME] to 20mg every day. * 1/30/2018 08:33 - Shift Level Administration: Noted residual of 230cc. spoke to Dr. G new order to hold feeding for 4 hours until 1230pm then restart and recheck residual at dinner. Resident is stable at this time. BP 100/66 p 99. * 1/30/2018 13:55 Resident c/o left side abdominal pain. Checked residual again it was zero. Also resident has some confusion. Notified Dr. G new order for stat KUB, hold feeding until results of Stat KUB received. Insert peripheral IV and give 0.9% normal saline x 700cc, then 0.45%Normal Saline for 300cc additional * 1/30/2018 16:09 Residents AMS not improving. Spoke to Dr. G , New order to send to ER Family requested (local hospital). * 1/30/2018 16:41 Resident picked up by EMT via stretcher for transport to Patients med center. Vital signs 100/60, 98.2, 98%, r20. Family member at bed side at time of transfer and took all residents belongings with her. * 1/30/2018 16:53 Received results for Stool culture after Discharge to Hospital, resident remains + for [MEDICAL CONDITION] Record review of CR #5's Lab results revealed the following: 1/7/18 -BUN--H 28 (Reference range 6-25) -Creat--0.60 (Reference range 0.30-1.2) -HGB--L 13.1 (Reference range 13.8-17.2) -HCT--42.0 (Reference range 41.0-50.0) 1/11/18 -[MEDICAL CONDITION]---Positive 1/11/18 -BUN--H 41 (Reference range 7-18) -Creat--0.9 (Reference range 0.6-1.3) -HGB--13.5 (Reference range 12.5-16.9) -HCT--39.3 (Reference range 37.5-50.7) 1/14/18 -BUN--H 44 (Reference range 6-25) -Creat--0.64 (Reference range 0.30-1.2) -HGB--L 13.1 (Reference range 13.8-17.2) -HCT--42.5 (Reference range 41.0-50.0) 1/29/18 -[MEDICAL CONDITION]---Positive 1/20/18 -BUN--H 32 (Reference range 6-25) -Creat--0.54 (Reference range 0.30-1.2) -HGB--L 12.6 (Reference range 13.8-17.2) -HCT--L 39.4 (Reference range 41.0-50.0) 1/28/18 - BUN--H 82 (Reference range 6-25) -Creat-- H 1.36 (Reference range 0.30-1.2) -HGB--L 11.9 (Reference range 13.8-17.2) -HCT--L 37.8 (Reference range 41.0-50.0) Record review of a physician progress notes [REDACTED].#5 had diarrhea and was found to be C.Diff positive. Diarrhea got better but then reappeared. Dr. G reviewed lab results from 1/7/18, 1/14/18 and 1/20/18. There was no notes regarding dehydration nor high/low lab values. Record review of physician orders [REDACTED]. Record review of CR #5's History and Physical Information from a local hospital, dated 1/30/18 revealed the following in part: *Free Text: [AGE] year old presents to the emergency department complaining of abdominal pain that began today. Paramedics state the nursing home reports altered mental status and lethargy. *Focused Physical exam: Mouth-mucus membranes dry *Lab Tests: -Potassium-5.9 H (Reference range 3.5-5.1) -BUN-123 H (Reference range 7-18) -Creat-1.60 H (Reference range 0.7-1.3) -[MEDICATION NAME]-2.2 L (Reference range 3.4-5.0) *Dictation Note: Patient now hypotensive. Will bolus IV fluids. Appears to be dehydrated based on labs. CT scan shows [MEDICAL CONDITION]. Nursing home reports patient has [MEDICAL CONDITION]. Patient also report diarrhea. Will admit for IV fluid and antibiotics. Potassium is high but likely due to dehydration. Will not give kaexalate due to [MEDICAL CONDITION]. Will give IV fluids. Interview on 2/21/18 at 11:33am LVN C revealed that CR #5 was on contact isolation and had diarrhea upon admission. She revealed that she notified the physician on 1/30/18 because the resident had increased residual volume from tube feeding. She said she call again because she thought Resident #5 may be dehydrated. She received orders for IV fluids. The last time she called the physician because Resident # 5 became more confused, received order to send to the hospital. Interview on 2/21/18 at 12:05pm ADON L revealed that CR #5 became lethargic and the physician notified, orders received for IV fluids and to send CR #5 to the hospital. She revealed that he had [MEDICAL CONDITION] with loose stools since admission. Interview on 2/21/18 at 1:56pm Dr. G revealed that CR #5's hydration was not addressed by her because his hemoglobin was stable, his cardiologist had made changes in his medications, and his vital signs were stable. When asked did she review that labs with elevated BUN, creatinine, and decreased hemoglobin on 1/28/18 she replied yes. Resident #8 Record review of Resident #8's clinical record revealed Resident #8 was an [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #8's care plan with an admitted on 2/5/18 revealed the following Problems: -I require tube feeding related to dysphagia -Resident requires assisted nutrition/hydration. Interventions included-Tube feeding per MD order -Resident at risk for dehydration due to failure to thrive diagnosis, impaired physical mobility, and impaired cognition. -The resident has a swallowing problem related to Oropharyngeal Dysphagia -The resident has potential nutritional problem related to diet restrictions and failure to thrive. Record review of Resident #8's Nutrition Services Note dated 2/13/18 revealed the following; -Assessment/Recommendations: Borderline underweight per 90% ideal body weight (IBW). Current tube feeding providing less than 70% estimated energy needs, at risk for weight loss. Recommend to increase goal rate of tube feeding to 75ml/hr x 22 hours to provide 1650ml formula volume, 1980 kilocalories Record review of Resident #8's Communication between the Dietician and the Attending Physician and Physician order [REDACTED]. -Discontinue Fibersource HN at 50ml/hr continuous -Fibersource HN at 75ml/hr for 22 hours via PEG tube Resident #8's admission MDS dated [DATE] revealed that he required total assistance with feeding. Observation on 2/21/2018 at 10:10 a.m. revealed Resident 8 was in his bed. Fibersource HN was hanging, but was not connected to Resident # 8. There was no water flush connected with tube feeding. There were no fluids in his room. Interview on 2/21/2018 at 10:10 a. m. Resident # 8 revealed that he had been unhooked from his feeding since breakfast. Observation on 2/21/2018 at 1:11 p.m. revealed Resident #8 was in his bed. Fibersource HN was hanging, but was not connected to Resident # 8. There was no water flush connected with tube feeding. There were no fluids in his room. Observation on 2/21/2018 at 2:01 p.m. revealed Resident #8 was in his bed. Fibersource HN was hanging, but was not connected to Resident # 8. There was no water flush connected with tube feeding. There were no fluids in his room. Interview on 2/21/2018 at 2:01 p. m. Resident # 8 revealed that he did not recall being hooked up to tube feeding since the breakfast. Interview on 2/21/18 at 2:05 p.m. LVN D revealed that Resident #8 was unhooked from his tube feeding for lunch and she had not had a chance to resume feeding. Interview on 2/21/18 at 2:06 p.m. ADON J revealed that Resident #8 should be hooked up to feeding continuously for 22 hours a day per MD orders. Record review of the facility's Hydration policy with effective date 11/2018 revealed the following: *Policy: Based on comprehensive assessment, each resident receives adequate fluids to maintain proper hydration and health based on their estimated needs, preferences and clinical condition. .Calculate residents' estimated hydration needs as part of the nutrition assessment. Report to physician on residents that may have fluid and electrolyte imbalance for possible treatment and/or adjustment to current treatment. Record review of the facility's Enteral and [MEDICATION NAME] Feedings policy with effective date 11/2017 revealed the following. *Policy: Enteral or [MEDICATION NAME] feedings will be indicated for residents who are unable to obtain adequate nutritional intake orally and whose clinical condition demonstrates that enteral/[MEDICATION NAME] feedings are unavoidable. .Enteral feeding orders are noted in the physician orders. Nursing services is responsible for the administration of enteral feedings. According to list provided by facility staff on 2/21/18 there were 6 residents on tube feedings.