Every finding on record at Fort Worth Transitional Care Center

Based on interview, observation, and record review the facility failed to immediately inform the resident, consult with the resident's physician, and notify, consistent with his or her authority, the resident's representative when there was a significant change in the resident's physical, mental, or psychosocial status for 1 of 5 residents (Resident #1) reviewed for notifying the RP when there was a need to add a new medication due to a change in condition. The facility failed to notify Resident #1's RP on 08/07/26 when Resident #1 developed a rash on the top of his scalp and required a new order for hydrocortisone cream to treat it. The facility did not contact Resident #1's RP until three days later on 08/10/26. This failure could result in the RP not being aware of change in conditions that may require them to make medical decisions.Based on interview, observation, and record review the facility failed to immediately inform the resident, consult with the resident's physician, and notify, consistent with his or her authority, the resident's representative when there was a significant change in the resident's physical, mental, or psychosocial status for 1 of 5 residents (Resident #1) reviewed for change in condition. The facility failed to notify Resident #1's RP on 08/07/26 when Resident #1 developed a rash on the top of his scalp and required a new order for hydrocortisone cream to treat it. The facility did not contact Resident #1's RP until three days later on 08/10/26. This failure could result in the RP not being aware of change in conditions that may require them to make medical decisions. Findings include: Record review of Resident #1's, undated, face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Chronic kidney disease (kidneys are damaged and cannot filter blood the way they should), Dementia (loss of memory, language, problem-solving, and other thinking abilities that interferes with daily life), Diabetes (high blood sugar that affects how your body turns food into energy), Parkinson's Disease (progressive brain disorder that causes problems with movement, balance, and other body functions when nerve cells stop making enough dopamine), Respiratory Failure with Hypoxia (life-threatening condition where the respiratory system cannot transfer enough oxygen into the bloodstream), Squamous Cell Carcinoma of Skin (skin cancer, caused by the abnormal, accelerated growth of squamous cells in the outer layer of the skin), Schizophrenia (chronic mental health disorder that affects how a person thinks, feels, and behaves, often making it difficult to distinguish between reality and imagination). Record review of Resident #1's Quarterly MDS, dated [DATE], did not reflect a BIMS score as he was rarely or never understood. Record review of Resident #1's Care Plan, dated 08/21/2026, reflected he had limited physical mobility r/t debility/weakness, dementia, Parkinson's disease, bedbound majority of the time; tracheostomy status, and under interventions to Inform the resident/family/caregivers of any new area of skin breakdown. Record review of Resident #1's Progress Notes, dated 08/21/2026, reflected the following: Effective Date: 08/07/2026 21:01 Type: NURSING - Nurse NoteNote Text: Upon assessing resident writer noted a rash or abrasion to the top of scalp, unknown origin. Wound reported to hospice by previous nurse. No new orders at this time wound monitored. Author: [LVN A] Effective Date: 08/08/2026 10:30 Type: NURSING - Nurse NoteNote Text: contacted on call [Company Name] Hospice nurse regarding treatment order for rash to scalp. hospice nurse contacted Dr. [Name], awaiting new orders to be faxed. Author: [LVN A] Effective Date: 08/08/2026 15:48 Type: NURSING - Nurse NoteNote Text: n/o received via fax for hydrocortisone ointment to be applied to scalp q 12h for 7 days rt rash. orders queued. Author: [LVN A] Effective Date: 08/10/2026 13:10 Type: SW - Skin Issues.Skin issue education: Dressing change(s). Skin issue education: Signs and symptoms of infection. Skin issue education: Treatment of skin issue. Skin issue education: Change clothing / briefs. Skin issue education: Moisture barrier. Skin issue education: Care of skin issue(s). Skin issue notification: Provider. Skin issue notification: Manager. Skin issue notification: Family. Skin issue notification: Dietitian. Author: [WCN]. Record review of Resident #1's Change of Condition Communication Form, dated 08/07/2026 by LVN A, reflected rash to middle of scalp. Under nursing notes reflected, Received report from night nurse that hospice aid noticed onset of rash to [Resident #1] front scalp. Contacted hospice for potential treatment of skin issue. Reported to Primary Care Clinician. Record review of Resident #1's Weekly Skin Assessment, by LVN A, dated 08/08/26, reflected a new issue to the front scalp (rash) that was acquired in-house. Record review of Resident #1's Physician Orders, dated 08/08/26, reflected a new order for Hydrocortisone Ointment every 12 hours for 7 days. Record review of Resident #1's MAR Schedule for August 2026 reflected the Hydrocortisone Topical Ointment 1% (Hydrocortisone (Topical)) was applied on the below dates: 8/8: 08:00 PM8/9: 08:00 AM and 08:00 PM8/10: 08:00 AM and 08:00 PM8/11: 08:00 AM and 08:00 PM8/12: 08:00 AM and 08:00 PM8/13: 08:00 AM and 08:00 PM8/14: 08:00 AM and 08:00 PM8/15: 08:00 AM In an observation on 08/21/26 at 10:50 AM, Resident #1 was observed laying in bed. Resident #1 was observed with his eyes opened; he was clean with clear and smooth skin. Resident #1's scalp was clear and there were no signs of a rash. In an interview on 08/21/26 at 1:30 PM, HN F stated she took over Resident #1's care on 08/17/26. HN F stated his prior hospice nurse, HN G mentioned that there was a rash on his head. HN F stated she assumed HN G gave the family a call. HN F stated to her; it looked like a small circular shape on the top of his head. HN F stated HN G told her they were applying hydrocortisone cream. HN F stated she assessed the top of his head and it was dry and covered with hydrocortisone cream. HN F stated the facility was taking care of the rash. HN F stated that the RP told her that hospice nor the facility notified her. HN F stated the rash was never opened, bleeding or showed signs of abuse or neglect. HN F stated Resident #1 was a chronic wound care hospice patient. In an interview on 08/21/26 at 2:00 PM, LVN A stated she was informed during the Shift Change Report that Resident #1 had developed a rash. LVN A stated there was no bleeding or broken skin. LVN A stated she completed a Change in Condition Report in PCC (an electronic health record and practice management software) and informed the DON during the morning meeting. LVN A stated she contacted hospice, but where she messed up was that she did not notify the RP. LVN A stated hospice put in a new order for Hydrocortisone every 12 hours. LVN A stated there were no concerns with the rash and it was already resolved. LVN A stated she wished they knew what caused it; however, he had a history of skin cancer. LVN A stated regardless if the resident was on hospice or not, the facility was still supposed to contact the family with any changes in condition. LVN A stated she should had contacted the RP and not relied on hospice. LVN A stated she previously received in-services on Abuse and Neglect and any Change in Conditions regarding what forms to complete and who to notify. In an interview on 08/21/26 at 2:28 PM, the WCN stated Resident #1 developed a rash on his scalp on 08/07/26 according to the Skin Assessment. The WCN stated currently Resident #1 did not have any skin issues, but he had a history of blisters and wounds that staff kept resolving. The WCN stated she saw Resident #1 on 08/10/26 as he showed up on the Skin Issue Report in PCC under new skin issues. The WCN stated she assessed Resident #1 and reviewed his notes to see what had been done. The WCN stated LVN A had already notified hospice and Hydrocortisone had been ordered to be applied every 12 hours for 7 days. The WCN stated she called the RP and informed her about the new skin issue on 08/10/26 and that orders were already in place. The WCN stated she informed the RP that she would continue to treat and monitor the rash closely until it was resolved. The WCN stated she saw Resident #1 Monday through Friday and yesterday (08/20/26), she went in with the NP. The WCN stated they cleaned off the dry skin on the scalp and the skin was normal with no redness. The WCN stated the rash started on 08/07/26 and it dissolved on 08/20/26 (within 2 weeks). The WCN stated she spoke with the RP this morning (08/21/26) and did a video call to show her the rash had been resolved. The WCN stated Resident #1 had a history of skin cancer. The WCN stated Resident #1 could have a skin issue today and next week it would be resolved. The WCN stated if there was any skin issues, she completed a full skin assessment to confirm. The WCN stated she checked PCC to confirm if any interventions had been initiated. The WCN stated if not, she contacted hospice, the doctor and the family. The WCN stated you contacted hospice first, then the doctor and the RP. The WCN stated if there were any issues, they always contacted hospice about what was going on. The WCN stated Hospice would speak with their doctor and then get back to the facility. The WCN stated they shared all feedback from hospice with the facility's doctor. The WCN stated all communication was always documented in PCC and they discussed concerns during clinicals and the morning meetings. In an interview on 08/21/26 at 3:05 PM, the ADON stated Resident #1 developed a rash on his head on 08/07/26 and it was reported to Hospice by LVN A. The ADON stated LVN A completed a skin evaluation, and contacted hospice. The ADON stated the hospice nurse contacted the doctor and a new order was put in for Hydrocortisone every 12 hours for 7 days and the rash had resolved. The ADON stated if a resident had a change in condition, they communicated with hospice and the family so that they both were aware. In an interview on 08/21/26 at 3:40 PM, the ADM stated he had worked at the facility since 06/15/2026. The ADM stated during the morning meeting on 08/10/26, it was discussed that Resident #1 had a rash on his head and they were treating it. The ADM stated hospice was notified and the WCN notified the family. The ADM stated that they would complete in-services on change in conditions and notifications. The ADM stated that LVN A should had contacted the family too. The ADM stated his expectations was if there was a change in condition, the family should be notified as soon as possible. The ADM stated it was important for the family to know what was going on with the resident. Record review of the facility's Notification of Changes policy, revised 10/24/22, reflected, Policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification.Compliance Guidelines: The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification.3. Circumstances that require a need to alter treatment. This may include:a. New treatment.

Based on observation, interview, and record review the facility failed to provide or obtain laboratory services to meet the needs of its residents, including the quality and timeliness of the services, for one (Resident #1) of three residents reviewed for laboratory services. The facility failed to ensure Resident #1 received a re-draw of lab work following her refusal for services on 07/02/26. This failure could result in residents not receiving timely interventions and care.Findings included: Record review of Resident #1's Face Sheet, dated 07/08/26, reflected she was a [AGE] year-old female, who admitted to the facility on [DATE], with diagnoses including liver cell carcinoma (liver cancer), acute kidney failure (a sudden and rapid decline in kidney function that occurs within hours or days), and gastrointestinal hemorrhage (an upper gastrointestinal bleed that occurs in the esophagus, stomach, or the first part of the small intestine). Record review of Resident #1's MDS Assessment, dated 07/03/26, reflected she had a BIMS score of 9, which indicated moderate cognitive impairment. Record review of Resident #1's Care Plan, dated 06/27/26, reflected no documented information related to her low hemoglobin levels or the need for repeat lab work. Record review of Resident #1's Lab Results Report, dated 07/01/26, reflected a critically low result for hemoglobin at 6.8 g/dL. Normal limits were between 11.2-15.7 g/dL. Record review of Resident #1's Nurse's Notes, dated 07/01/26 and signed by LVN A, reflected, .critical hemoglobin results sent to [Nurse Practitioner]. n/o for iron BID, and sodium 1gm BID. pt admitted for anemia, per hospital report pt received [2 units of] blood prior to discharge with post hgb of 7.7. redraw ordered for 7/2. Observation of Resident #1 at the hospital (sent on 07/06/26 due to abdominal pain) on 07/08/26 at 1:00PM, revealed she was sitting upright in her bed. She displayed no obvious signs or symptoms of distress. During an interview with Resident #1 on 07/08/26 at 1:00PM, she stated she was admitted to the hospital due to her stomach and rectum hurting. She said she was feeling better since she had been admitted and she did not recall anything related to lab work at the facility. During telephone interviews with LVN A on 07/08/26 at 11:20AM and 11:48AM, she stated she was the assigned Charge Nurse for Resident #1 on 07/01/26, when her lab work initially returned as being critically low for hemoglobin. LVN A stated she notified Resident #1's Nurse Practitioner, who ordered iron and sodium supplements, and labs to be re-drawn the following day. LVN A stated she input the new orders into the electronic medical charting system, which automatically notified the mobile lab company to come back the next day to re-draw the lab on 07/02/26. LVN A stated she worked on 07/02/26, but she did not see anyone from the lab at the facility. She said she was not aware that a lab technician had been to the facility or that Resident #1 refused to have the lab drawn. She was not aware that Resident #1's lab work was not completed. She stated it was her mistake that she did not follow up on the repeat lab work or notify Resident #1's physician/Nurse Practitioner of the missed re-draw. She stated the risk of not notifying Resident #1's physician/Nurse Practitioner was that the facility would remain unaware of the resident's current status and any directives that needed to be followed. During an interview with DON on 07/08/26 at 11:40AM, she stated the expectation was for the assigned Charge Nurse to follow-up on any necessary lab work, including lab re-draws. She stated LVN A should have followed up with the mobile lab work company when Resident #1's lab re-draw was not taken on 07/02/26, as well as to notify Resident #1's physician/Nurse Practitioner. She stated the risk of not doing so included missed lab work and directives. During a telephone interview with a representative from the Client Services department at the mobile lab company (assigned to complete Resident #1's lab work re-draw) on 07/08/26 at 11:50AM, it was reported that a technician from the company went to the facility on [DATE] for the purpose of re-drawing Resident #1's labs, but Resident #1 refused the lab draw. The technician went back to the facility on [DATE] (reported this date was likely chosen by the mobile lab company due to the holiday weekend) to complete the lab work, but Resident #1 was at the hospital. The representative stated she did not have any additional information pertaining to whether or not the lab technician notified the facility that Resident #1 refused the lab draw, and she stated that she was unable to provide the name or contact information of the technician who came to the facility. During a telephone interview with the Nurse Practitioner for Resident #1 on 07/08/26 at 11:56AM, she stated Resident #1 had numerous comorbidities that had contributed to her overall decline in status. She stated on 07/01/26, Resident #1's lab work showed she had a critical low (a test result that falls so far outside the normal range that it indicates an immediate health risk) hemoglobin, so she ordered labs to be re-drawn the following day to determine whether her numbers continued to drop and if she needed to go to the hospital for further evaluation and treatment. The Nurse Practitioner stated she was not notified that Resident #1 refused to have her labs re-drawn on 07/02/26. She stated the facility should have notified her; she would have educated the resident and attempted to get the family involved to encourage Resident #1 to have her lab work completed. She stated the facility should have ensured the lab work was completed in a timely manner; they should not have allowed the mobile lab company to wait through the weekend to return to the facility. During an interview with the assigned nurse for Resident #1 at the hospital on [DATE] at 1:10PM, she stated Resident #1 was admitted to hospital due to abdominal pain. She stated the pain was very likely due to her diagnosis of liver cancer. She stated Resident #1's hemoglobin upon admission was relatively stable to the results of the most recent lab draw at the facility, as the results upon admission to the hospital were 6.7 g/dL. She stated the low levels of Resident #1's hemoglobin were likely a direct result of her multiple comorbidities; Resident #1's prognosis was very low due to her comorbidities. Record review of the facility's Notification of Changes policy, dated 10/24/22, reflected, .The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. and Circumstances requiring notification include . 2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status.

Based on observations, interviews, and record review, the facility failed to ensure respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, for 2 of 4 residents (Resident #71, Resident #8) reviewed for respiratory care.1.The facility failed to provide tracheostomy care and tracheal suctioning for Resident #71 when she experienced shortness of breath and was transferred to the hospital and had her trache replaced in the emergency room2.The facility failed ensure an Ambu bag (a handheld, self-inflating device that forces air or oxygen into the lungs during emergencies) an emergency equipment was available in Resident #8's room.3.The facility failed to monitor the Resident #8 oxygenation status during high-risk procedure when suctioning.4. The facility failed to ensure timely response to Resident #8 when he required suctioning.On 04/07/26 at 3:20 PM, an Immediate Jeopardy (IJ) was identified, and the Administrator was notified. While the Administrator was notified that the IJ was removed on 04/08/26 at 6:00 PM, the facility remained out of compliance at a severity level of potential for more than minimal harm and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.This failure could placed residents at risk of serious harm, respiratory compromise, and death.Findings included: Record review of Resident #71's Comprehensive MDS assessment, dated 01/11/2026, reflected She was a [AGE] year-old female admitted to the facility on [DATE]. No BIMs score was recorded indicating no interview was conducted. Her diagnoses included dysphagia(is a physical difficulty or discomfort with swallowing, often aphasia (muscle weakness or neurological issues like stroke), aphasia(a language disorder caused by brain damage), and respiratory failure (a critical condition where the respiratory system fails to perform its basic function of gas exchange, resulting in too little oxygen in the blood). Section K0520 was coded for feeding tubes. Record review of Resident #71's care plan initiated 03/27/2024 reflected Resident #71's has a tracheostomy. Interventions Ensure that trach ties are secured at all times. Monitor/document for restlessness, agitation, confusion, increased heart rate Provide good oral care daily and PRN. Record review of Resident #71's active physician dated 04/06/2026 reflected Change disposable trach 6.4mm inner cannula one time a day for mucous plugs, minimize secretions order start date 01/30/2025. Record review of Resident #71's active physician dated 04/06/2026 reflected Change trach collar and tubing with oxygen condensation trap at bedtime every 7-day(s) order start Date 01/01/2025. Record review of Resident #71's active physician dated 04/06/2026 reflected Suction trach every shift for copious secretions order start Date 03/31/2025. Record review of Resident #71's active physician dated 04/06/2026 reflected Trach care - Cleanse with normal saline with 4X4 around trach stoma, pat dry, apply T-drain sponge (pre-cut sponges that provide a snug fit around catheters), and secure with trache collar order start date 01/31/2026. Record review of Resident #71's nurses notes dated 4/5/2026 at 7:15 PM reflected the following approximately 12:15 PM, pt FM present, came to this nurse stating pt appeared to have a hard time breathing and states he would like her sent to hospital. This nurse went to assess, pt observed with labored breathing. V/S 158/79,95 bpm,20 RR , 153, glucose, 96%, o2 8L trach. Pt suctioned and administered scheduled albuterol nebulizer treatment (used to prevent and treat difficulty breathing, wheezing, shortness of breath, coughing, and chest tightness caused). No distress noted pts breathing improved post suctioning. Pt's FM continues to request pt be sent out. This nurse called NP and notified her. EMS called, EMS arrived and assessed pt. EMS states pt's FM would like pt sent out r/t large abdomen transported to [hospital]. This entry was written by LVN F. Record review of Resident #71's hospital nurses notes dated 4/5/2026 at 2:32 PM reflected the following Pt from NH with abdominal pain. Trach dependent patient, on 35% trach collar, 7 cuffless old style (? fenestrated) (a specialized airway device with holes in the outer cannula that allows air to pass through the upper airway, enabling speech and improved breathing, especially during weaning). Pt trach had foul smelling. Took the inner cannula out to clean, inner cannula was fully clogged with dry secretion, as soon as trach was out pt started to cough up blood. Decision made to change the trach. Trach exchanged to #7.0 Protex (tubes made from siliconized PVC to be soft yet kink-resistant) cuff less, placement verified with B/L BS, positive color change. ED attending and resident at the bedside. Placed on 28% trach collar Spo2 98%. During an interview 04/07/2026 at 10:21 AM, the hospital case manager revealed that Resident#71 was admitted to the hospital on [DATE] with complications of trache and clogged g-tube. She stated the resident had trache replacement in the emergency room and family had requested placement to a different facility after she discharged from the hospital. Observation on 04/07/2026 at 10:30 AM of Resident #71 in the local hospital Resident #71 was awake with eyes open, but she was uninterviewable. She was receiving oxygen via tracheostomy. During an interview on 04/07/2026 at 10:46 AM, the Hospital RN revealed that Resident #71 arrived at the hospital by Ems. She stated the family had concerns that she had shortness of breath and her abdomen was distended. She stated when the respiratory therapist attempted to suction Resident #71 the Respiratory therapist could not advance the suction catheter. She stated Resident #71 oxygen levels started to drop, attempts to hyper oxygenate the resident were unsuccessful, then the attending physician ordered to remove inner canula. She stated the inner cannula had a strong foul smell, it was completely occluded (when mucus or secretions form a plug inside a tracheostomy tube, restricting airflow) and calcified (accumulation of calcium deposits of the inner cannula often due to long-term use) the entire length of the tracheostomy. She stated when they removed the inner cannula had a foul smell that was so bad staff had to exit the room. She stated Resident #71 she was bleeding from the stoma, and the Respiratory therapist had to replace the trache ostomy. She stated that she reported to APS because per her assessment the tracheostomy was not being taken care of. During an interview 04/07/2026 at 10:50 AM, the hospital Respiratory therapist stated while Resident #71 was in the emergency room she had a lot of secretion. She stated when she attempted to suction the resident, there was difficulty advancing the suction catheter because the inner cannula was occluded. She stated she took the inner cannula out then Resident #71 coughed a large amount of blood. She stated the trache had a lot of dried mucous, it had a foul smell, so they had to replace the entire trache. She stated based on her assessment the inner cannula had not changed in a long time. She stated the inner cannula was supposed to be replaced at least daily and, in some cases, twice a day, while the actual trache needed to be replaced every three months. She stated the trache ties were dirty, indicating they had not been changed in a while. During an interview on 04/7/2026 at 12:45 PM, LVN F revealed she was Resident #71 the nurse she was transferred to the hospital. She stated the weekend supervisor asked her to replace the humidification water on Resident #71 tracheostomy. LVN F stated she suctioned Resident #71 and changed the water then she went down the hall. She stated Resident #71 FM then told her he wanted Resident #71 sent out to the hospital. LVN F stated the resident presented with signs of shortness of breath labored breathing. She stated she assessed the resident and suctioned the resident with positive result, Resident #71's breathing improved and she was not showing signs of respiratory distress, but the FM insisted he wanted her sent to the hospital. LVN F stated she notified the NP then and called EMS. She stated she gave EMS report and they went to take vital signs. She stated that whenever she was scheduled to work with the resident, she always changed the inner canula. She changed her cannula every time she was here. She stated the risk of not following physician order to trache care was infection, the resident could experience respiratory distress and even death. Record review of Resident #8's Comprehensive MDS assessment, dated 02/27/2026, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. BIMs score was recorded was 00 indicating no interview was conducted. His diagnoses included encounter for attention to tracheostomy (attention to tracheostomy, which includes cleaning, care, and changing or removing tracheostomy tubes). Section O -was coded for trache care, suctioning, and oxygen therapy. Record review of Resident #8's care plan Date Initiated: 02/23/2026 reflected Resident# 8has a tracheostomy. Interventions Monitor/document respiratory rate, depth, and quality. Check and document q shift/as ordered. Suction, as necessary. Record review of Resident #8's active physician orders 04/06/2026 revealed Change Trach Monthly on the 15th one time a day starting on the 15th and ending on the 15th every month order start date 02/21/2026. Record review of Resident #8's active physician orders 04/06/2026 revealed Suction trach as needed for copious secretions order start date 02/21/2026. Record review of Resident #8's active physician orders 04/06/2026 revealed Suction trach every shift order start 02/21/2026. Observation and interviews on 04/06/26 at 11:40 AM, during initial pool the surveyor noted that Resident #8 did not have an Ambu bag in his room, which was a requirement in the event the resident needed resuscitation. The surveyor observed Resident #8 FM suctioning Resident #8 using the non-sterile suctioning tube that connects to the cannister. Resident #8 was observed coughing thick mucus with audible rattling/gurgling noises. During an interview Resident #8's FM reported she frequently had to wait for a long time for his call light to be answered. Resident #8's FM stated she had not been trained on trache care, but when she suctioned his tracheostomy, it helped Resident #8 breath better. The surveyor activated the call light at 11:40 AM. At 11:49 AM, a CNA M entered the room, turned off the call light, and walked out of the room. When asked by the surveyor why the CNA M turned off the call light and did not ask what was needed, the CNA M stated she would be right back. The surveyor notified CNA M that Resident #8 needed to be suctioned. At 11:58 AM, the surveyor left the room to locate a nurse, as it had been 18 minutes since the call light had initially been activated. The surveyor met with ADON R on the hallway and notified her that Resident #8 was coughing up a lot of mucous. Resident #8 continued to cough thick mucus, audible rattling/gurgling noises, and thick/yellowish phlegm on the trach tie. At 12:00 PM the ADON R and LVN B entered Resident #8 room. During an interview at 12:03 PM with the ADON Q revealed every resident with trach there must have an Ambu bag in room in case they require resuscitation. She stated the risk to the resident was the staff would not be able to perform resuscitation to the resident and it could lead to serious harm including death. The surveyor observed the ADON R brought an Ambu bag and placed it in Resident# 8 room. Observation on 04/06/25 at 12:04PM, LVN B changed the trach tie and gauze for Resident #8. The resident was observed to continuously cough yellowish, thick phlegm. The nurse did not assess the resident's oxygen saturation after changing the trach tie, LVN B started to doff PPE without suctioning the resident. The surveyor asked if LVN B was going to suction the resident, and she stated she had suctioned the resident in the morning; the surveyor asked the nurse, per her assessment, the resident needed suctioning due to all the phlegm he had that his family member was cleaning with gauze. LVN B proceeded to suction the resident using sterile technique. The nurse did not hyper oxygenate the resident prior to suctioning, nor did the nurse did not check the resident's oxygen saturation before, during and after suctioning the resident. LVN B performed suctioning using inappropriate technique including applying suction while advancing the catheter and using a back-and-forth motion, which is inconsistent with accepted standards of care. During an interview with LVN B on 04/06/26 at 12:23 PM, she stated it was her first time working with Resident #8. She stated she was not aware of the physician order to suction trach as needed for copious secretions. She stated she had suctioned Resident #8 in the morning, and he was suctioned every shift. She stated she should have checked Resident#8 oxygen saturation before, during and after suctioning him. She could not identify what an Ambu bag was and or its purposes. She stated she had not been in serviced on trach care at this job but at her other job she had been in serviced. During an interview on 04/07/26 at 12:33 PM, RT H stated she sees the residents with traches weekly but due to increased work assignment she has been seeing the residents every two weeks. She stated she last saw Resident #71 and Resident # 8 three weeks ago at that time there were no issues noted. She stated the nurses provided respiratory care such as suctioning, tracheostomy, ventilator, and/or emergency care. She stated procedures used to monitor the resident's respiratory status included change checking oxygen saturation, checking for changes in secretion, blood pressure, and auscultation of breath sounds. She stated that if there was a mucus plug the staff would know because they would not be able to pass the suction catheter and they would know to take out the inner cannula out. She stated she had classes on respiratory care and tracheostomy every two weeks on trache care, but she had no control on what nurses showed up for training. She stated if a trache was observed to have dried hard secretions, dirt and fouls smell would be indication of infection and not proper care of the trache. She stated the risk if not having an Ambu bag would be the resident would suffer serious harm respiratory distress to include death. Record review of an unnamed, undated, scanned book submitted by Regional Clinical Specialist as the facility policy, reflected: Tracheal suction involves the removal of secretions from the trache by means of a catheter inserted through the mouth or nose or a tracheal stoma, a tracheostomy tube. Before suctioning determine whether your facility requires a physician's order and obtain one if necessary Assess the patients' vital signs, breath sounds and general appearance to establish a baseline for comparison after suctioning. Use sterile technique, open suctions catheter kit, and put on the gloves. Using your sterile hand gently insert the suction catheter into the artificial airway. Advance the catheter, without applying suctions until you meet resistance. If the patients' coughs pause briefly and then resume advancement. After inserting the catheter, apply suction intermittently by removing and replacing the thumb of your non dominant hand over the control valve simultaneously, use your dominant hand to withdraw the catheter as you roll it between your thumb and for finger. Never suction more than 10 seconds at a time to prevent hypoxia. On 04/07/26 at 3:20 PM, an Immediate Jeopardy (IJ) was identified, and the Administrator was notified. While the Administrator was notified that the IJ was removed on 04/08/26 at 6:00 PM, the facility remained out of compliance at a severity level of potential for more than minimal harm and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. The facility POR for immediate jeopardy was accepted on 04/08/2026 at 9:31 AM and reflected the following: On April 7, 2026, the surveyor notified the Facility that immediate jeopardy had been called, and the Facility needed to submit a letter of removal. The Facility respectfully submits this Letter for a Plan of Removal pursuant to Federal and State regulatory requirements. The alleged Immediate Jeopardy allegations are as follows: Issue: F695 - Respiratory/Tracheostomy Care and Suctioning Actions for Residents Involved: Resident #71: On 04/06/2026, Resident #71 was transferred to the hospital for evaluation and treatment of respiratory distress. Upon notification, the facility initiated a review of respiratory care provided. The DON/Designee will review admission orders and documentation upon return during the clinical meetings and through rounding to ensure that all physician orders and assessments related to tracheostomy care are followed, and licensed nurses will inspect and document presence of Emergency respiratory equipment to include Ambu bag at bedside every shift. Resident #8: On 4/7/26, Resident # 8 was assessed by Respiratory Therapists, provided trach care and suctioning. On 4/7/2026 Resident #8 was assessed by Respiratory Therapist and received physician's order to send resident out to hospital to change current tracheostomy to cuffless tracheostomy. Identify residents who could be affected: On 04/07/2026 , a 100% audit of all residents with tracheostomies and respiratory care needs was conducted by the Director of Nursing and/or designee. This audit included respiratory assessment, verification of physician orders, presence of emergency equipment at bedside including Ambu bag, and review of documentation for respiratory care and suctioning. Any identified concerns were immediately addressed. Action Taken / System Change: The Director of Nursing was immediately reeducated by Respiratory Therapist on 04/07/2026 regarding oversight of respiratory care services, including ensuring staff competency, adherence to physician orders, and availability of emergency equipment. LVN B was reeducated on 04/07/2026 by the Respiratory Therapist and received 1:1 education with return demonstration on the following: - Proper tracheostomy care and maintenance - Proper suctioning technique (including no suction upon insertion and correct withdrawal method) - Requirement to assess oxygen saturation before, during, and after suctioning - Recognition of signs and symptoms of respiratory distress - Proper use and purpose of emergency equipment, including Ambu bag By 04/08/2026, 100% of licensed nurses will be reeducated by the Director of Nursing, Respiratory Therapist and/or designee and pass return demonstration prior to start of next scheduled shift. - Tracheostomy care and infection control practices - Proper suctioning techniques and frequency based on resident need - Monitoring and documentation requirements, including oxygen saturation - Emergency response procedures for respiratory distress - Identification, location, and use of emergency equipment, including Ambu bag Beginning 4/7/26, Licensed nurses who are on PRN status/PTO/FMLA/Leave of absence will have the re-education completed and return demonstration prior to the start of next scheduled shift. Beginning 04/07/2026 and ongoing, licensed nurses are required to verify each shift and document on the MAR and replace supplies if not present at bedside. - Presence of emergency equipment at bedside including Ambu bag Beginning 04/07/2026, newly hired and agency staff will receive required training and must demonstrate competency prior to providing care to residents with tracheostomies. On 4/7/2026, Family members will be educated by the Respiratory Therapist that clinical procedures, including suctioning, are not to be performed by non-trained individuals. Completion Date: 04/07/2026 Monitoring: Beginning 04/07/2026 and ongoing, the Director of Nursing and/or designee will conduct monitoring and daily audits to ensure: - Compliance with tracheostomy care and suctioning procedures - Presence of required emergency equipment at bedside - Proper documentation of respiratory assessments and interventions The Director of Nursing, Respiratory Therapist and/or designee will conduct random observations of tracheostomy care and suctioning procedures to validate competency, and verification of presence of emergency medical equipment including ambu bag at bedside by rounding on residents with tracheostomy. Results of audits will be reviewed in the Quality Assurance Performance Improvement (QAPI) Committee, and additional interventions will be implemented as needed to sustain compliance. On 04/07/2026, an Ad Hoc QAPI meeting was held with the Medical Director, Facility Administrator, Director of Nursing, and interdisciplinary team to review the Immediate Jeopardy and approve the Plan of Removal. Monitoring the facility's Plan of Removal included the following: Interviews with the following staff from 04/8/25 at 9:46 AM to 4:04 PM who worked all shifts and all days of the week revealed they had been in-serviced on tracheostomy care and infection control, and taken the competency assessment: LVN B, RN D, RN E, LVN F, LVN G, RN I, LVN K, RN L, ADON R. Record review of an QAPI Agenda, IJ F-695 Respiratory Tracheostomy Care/Suctioning, dated 04/7/26 reflected Administrator. DON and MD were in attendance. Record review of Resident #8 respiratory assessment revealed on 4/7/26, Resident # 8 was assessed by Respiratory Therapists, provided trach care and suctioning. On 4/7/2026 Resident# 8 received physician's order to send resident out to hospital to change current tracheostomy to cuffless tracheostomy. Record review of in-service sign-in sheets, dated 04/07/26 and titled Tracheostomy Care reflected the DON had signed and completed Tracheostomy Competency Assessment. Record review of in-service sign-in sheets, dated 04/07/26 and titled Tracheostomy Care reflected the LVN B had signed and completed Tracheostomy Competency Assessment. Record review of daily audits and monitoring reflected the Director of Nursing conducted audits on 04/07/2026 and 04/08/2026 on all three residents with tracheostomies. The audits included monitor nurse competency for trach q day, monitoring suctioning for trache care q day, monitoring emergency supplies at bedside q day. Record review of Respiratory assessments dated 04/07/2026 and 04/08/2026 reflected the Respiratory therapist conducted assessments were completed on three residents with tracheostomy's. Record review of residents with tracheostomy reflected licensed nurses documented required to verify and presence of emergency equipment at bedside (including Ambu bag and suction equipment). Record review of tracheostomy care in-service, dated 04/07/26-04/08/2026, reflected 18 nursing staff had been in-serviced. Record review of in-service titled Call light Response dated 04/07/26-04/08/2026, reflected 53 staff members had been in-serviced. Observation on 04/08/2026 at 8:05 AM of residents with tracheostomies revealed that all requires emergency equipment and suction apparatus were present and readily available at the bedside, emergency equipment included an ambu bag, extra tracheostomy inner cannula(appropriate sizes), and suction supplies was observed to be set up and accessible for immediate use. During an interview 04/08/2026 at 10:05 AM, the MD Revealed Resident #71 was a long-term resident, the NP would see her monthly. He stated because of her neurological issues and trache she seemed to have a lot of medication issues see was seen on average on at least twice a month. He stated trache care is primarily by the nurses overseen by the respiratory therapist and if there were any issues with the trache they would call the respiratory therapist and she would communicate with him. He stated the times he saw the resident he had no concerns. He stated the risk when the trache was not cared for per physician's order to include suctioning and changing inner cannula as schedule was mucus plugs occluding the inner cannula which could lead to respiratory emergencies including hospital transfer. He stated he was notified of the immediate jeopardy and agreed with the plan of correction. He stated the retraining of the nursing staff and daily monitoring by the DON would ensure residents with trach are well taken care of. Interview 4/08/2026 at 10:55 AM, RT H stated, she assessed Resident #8 on 04/07/2026 and provided trach care and suctioning. She stated she received physician's order to send resident out to hospital to change current tracheostomy to cuffless tracheostomy which would make speaking much easier because it would allow air to flow around the tube, up through the vocal cords, and into the mouth, enabling sound production. She stated that she reeducated the Director of Nursing on 04/07/2026 regarding oversight of respiratory care services, including ensuring staff competency, adherence to physician orders, and availability of emergency equipment. She stated on 4/07/2026, she educated Resident #8 Family members that clinical procedures, including suctioning, are not to be performed by non-trained individuals. During an interview on 4/08/2026 at 11:03 AM, the DON stated she had been in serviced by the respiratory therapist and had completed the tracheostomy care competency assessment. She stated when Resident #71 returned to the facility she would ensure that all physician orders related to tracheostomy care are followed, including respiratory assessment. She stated she would monitor routine care and cleaning, suctioning, monitoring for complications and verify presence of Emergency respiratory equipment to include Ambu bag at bedside daily. She stated she would do random checks when the nurses were suctioning the residents with traches and will ensure all new staff are in- serviced and complete the tracheostomy competency assessment. She stated that she will audit PCC daily to make sure the nurses are documenting the availability of emergency equipment. She stated on 04/07/2026 LVN B was reeducated received 1:1 education with return demonstration on tracheostomy care. She stated Beginning 04/07/2026, all CNAs were reeducated on: Timely response to call lights, Immediate reporting of respiratory distress to licensed nursing staff, Infection control practices related to respiratory care. She stated that any new issues will be reviewed in QAPI meetings. She stated that no nurse will be allowed to work the floor before completing the tracheostomy Inservice and the competency assessment. During an interview on 4/08/2026 at 11:30 AM with Resident #8 FM revealed she was educated by the respiratory therapist on 04/07/2026 to only let the nursing staff suctions and care for the resident's tracheostomy. During an interview on 4/08/2026 at 11:45 AM 2026 LVN B stated she received 1:1 education on tracheostomy care and she was able to verbalize the steps and procedures in tracheostomy care and suctioning. During an interview on 4/08/2026 at 11:55 AM 2026 LVN F stated she received in-service on tracheostomy care and she was able to verbalize the steps and procedures in tracheostomy care and suctioning Observation on 4/08/2026 12:13 PM, trache care LVN G assessed Resident #8 oxygen saturation was assessed before, during, and after suctioning. Suctioning was performed using sterile technique. LVN G demonstrated appropriate tracheostomy and assessed the resident's respiratory status, Emergency equipment including an Ambu bag and suction set up was observed to be present and readily available at the bedside. The nurse completed hand hygiene after the procedure and documented the care provided including the resident's response and findings. No concerns were identified during this observation. On 04/07/26 at 3:20 PM, an Immediate Jeopardy (IJ) was identified, and the Administrator was notified. While the Administrator was notified that the IJ was removed on 04/08/26 at 6:00 PM, the facility remained out of compliance at a severity level of potential for more than minimal harm and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.

Based on observations and interviews, and record reviews the facility failed to ensure residents receiving enteral nutrition (g tube) received appropriate care, treatment and service to maintain nutritional status to prevent complications and ensure safe feeding practices consistent with professional standards of practice for 2 (Residents #71 and Resident #8) of 4 residents reviewed for enteral feeding. The facility failed to monitor for complications related to Resident #71 feeding tube and tube feeding when Resident #71 was transferred to the hospital and had part of the g-tube replaced. The facility failed to ensure LVN F allowed Resident's #8 medication to flow by gravity while administering through G-Tube on 04/07/2026 and not using force.This failure could put residents at risk of inaccurate delivery of prescribed nutrition and medication administration.Findings included: Record review of Resident #71's Comprehensive MDS assessment, dated 01/11/2026, reflected She was a [AGE] year-old female admitted to the facility on [DATE]. No BIMs score was recorded indicating no interview was conducted. Her diagnoses included dysphagia(is a physical difficulty or discomfort with swallowing, often caused by muscle weakness or neurological issues like stroke), aphasia(a language disorder caused by brain damage), and respiratory failure (a critical condition where the respiratory system fails to perform its basic function of gas exchange, resulting in too little oxygen in the blood). Section K0520 was coded for feeding tubes. Record review of Resident #71's care plan initiated 03/27/2024 Resident #71's requires tube feeding r/t dysphagia following CVA; G-tube in place and ordered NPO. Interventions Monitor/document/report PRN any s/sx of: Aspiration- fever, SOB, Tube dislodged, Infection at tube site, Tube dysfunction or malfunction, Abnormal breath/lung sounds, Abnormal lab values, Abdominal pain, distension, tenderness, Constipation or fecal impaction, Diarrhea, Nausea/vomiting, Dehydration. Record review of Resident #71's active physician dated 04/06/2026 revealed Enteral Feed Order every shift for Aspiration Prevention Check for residual. If residual is greater than 100 cc call MD start date 03/31/2026. Record review of Resident#71's hospital records dated 04/06/2026 reflected: Sound Progress Note DOS: 4/6/2026 Chief Complaint: Abdominal Pain (Family reports abdominal distention x 2 days.) 76 y.o. with a PMH of seizure disorder, psychiatric disorder, chronic trach and PEG,nonverbal patient coming from nursing home as family was worried that she had abdominal distention and respiratory distress. Assessment & Plan Status post insertion of percutaneous endoscopic gastrostomy (PEG) tube (CMS/HCC) Present on admission: Not Applicable Abdominal distention in setting of PEG obstruction/complication- [hospital] report filed to nursing home as patient had clogged trach and G-tube was not being cared for. Case manager consulted for placement to a different nursing home strict bowel regimen will also need to be initiated as patient has moderate constipation noted on CT Patient is having bowel movements. Trach dependent -IR for PEG replacement on April 6, 2026 Continue with gentle fluids. Holding medicines and tube feeds we have PEG tube. Focused H&P Exam dated 04/06/2026 CC: Preoperative anesthesia evaluation HPI : Resident#71 is a 76 y.o. female with h/o seizure disorder, psychiatric disorder, chronic trach, and PEG. Patient is non-verbal at baseline. G-tube is clogged and malfunctioning. Patient presents to IR for gastrostomy tube exchange. H&P by [MEDICAL DOCTOR]at 4/6/2026 3:16 PM (continued) 4. Status post insertion of percutaneous endoscopic gastrostomy (PEG) tube (CMS/HCC) Case request interventional radiology: IR GASTRIC TUBE REPLACEMENT/EXCHANGE Case request interventional radiology: IR GASTRIC TUBE REPLACEMENT/EXCHANGE IR GASTRIC TUBE REPLACEMENT/EXCHANGE IR GASTRIC TUBE REPLACEMENT/EXCHANGE 4/6/2026 3:16 PM Procedure aborted post physician consultation with family the entry was written by Hospital MD. An attempt on 04/06/2026 at 4:00 PM to observe Resident #71 at the hospital was unsuccessful surveyor was notified that the Resident#71 was in the operating room to replace her G-tube. During an interview 04/07/2026 at 10:21 AM the hospital case manager stated Resident #71 was admitted to the hospital on [DATE] with complications of trache and clogged g-tube. She stated the resident was scheduled to have the g tube replaced on 04/06/2026 but the decision was receded after consultation with MD and family. Observation on 04/07/2026 at 10:26 AM of Resident #71 at the local hospital revealed G-tube feeding infusing via g-tube and resident was observed to have trache. Resident#71 was in bed alert with eyes open. resident un-interviewable. An attempt on 04/07/2026 at 10:26 AM to interview Resident #71 FM was unsuccessful, left voicemail with call back number. During an interview 04/07/2026 at 10:46 AM, RN N (hospital staff) stated Resident#71 arrived at the hospital by Ems. She stated the family was concerned her abdomen was distended. She stated that when she went to assess the resident's G-tube it was occluded. She said the [NAME] valve (a three-way stopcock device, used with PEG or gastro-jejunostomy tubes to provide safe, closed-system access for feeding and medication administration) had no caps, it was dirty and occuled with dried brownish substance. She stated they attempted to de-clog the g-tube with no success. She stated they had to hold the residents medication and the resident was scheduled to have her g-tube replacement. She stated she reported to APS per her assessment the g-tube was not being taken care of by the nursing home. During an interview 04/07/2026 at 1:24PM, the DON stated Resident #71 was transferred to the hospital per family request. She stated she was notified by the nurse that Resident #71's FM wanted the resident sent to the hospital for shortness of breath. During an interview 04/08/2026 at 2:40 PM, LVN F stated she was the nurse that discharged Resident #71 to the hospital. She stated Resident #71 was transferred to hospital by EMS after the FM was concerned that she had shortness of breath. She stated she always flushed Resident #71's G-tube. Record review of Resident #8's Comprehensive MDS assessment, dated 02/27/2026, reflected He was a [AGE] year-old male admitted to the facility on [DATE]. BIMs score was recorded was 00 indicating no interview was conducted. His diagnoses included encounter for attention to gastrostomy (encounter for attention to a gastrostomy, covering routine care, cleaning, and tube changes/replacements). Section K0520 was coded for feeding tubes. Record review of Resident #8's care plan initiated 03/27/2024 Resident #8 requires tube feeding r/t dysphagia. Interventions Monitor/document/report PRN any s/sx of: Aspiration- fever, SOB, Tube dislodged, Infection at tube site, Tube dysfunction or malfunction, Abnormal breath/lung sounds, Abnormal lab values, Abdominal pain, distension, tenderness, Constipation or fecal impaction, Diarrhea, Nausea/vomiting, Dehydration. Record review of Resident #8's active physician orders dated 04/08/2026 revealed NPO diet NPO texture, NPO (Nothing by Mouth) Active 02/21/2026 Record review of Resident #8's active physician orders dated 04/08/2026 revealed Enteral Feed Order every shift Osmolite 1.5 (a high-protein, low-residue, complete enteral tube-feeding formula designed for patients with increased calorie/protein needs, or those with limited volume tolerance) at 70mL/hr x20hr provides: Verbal Active 02/27/2026. Record review of Resident #8's active physician orders Enteral Feed Order every shift Flush feeding tube with 35 ml of water before and after medication administration. An observation on 04/07/2026 at 7:30 AM medication administration for Resident #8, LVN F was observed force-flushing 7 of 13 medication individually through the G tube. During an interview 04/07/2026 at 7:40 AM, LVN F stated it was her first time working with Resident #8 and stated she did not know how his g-tube worked. She stated g tube medication administration should be administered by gravity, but she pushed because there was difficulty with gravity flow and the resident needed his medication. She stated she should have stopped and notified the physician. During an interview 04/07/2026 at 8:24 AM, the DON revealed that G-tube medication should be administered by gravity and if the g tube was not patent while administering medication attempts should be made to de-clog the g tube and if attempts to de-clog were unsuccessful, the medication should be held and MD notified. Review of the facility's policy Enteral Tube Medication Administration Revised 10/01/2019 reflected the following:Put 15 - 30ml of water in syringe and flush tubing using gravity flow. Clamp tubing after the syringe is empty, allowing water to remain in the tube.Pour dissolved/dilute medication in syringe and unclamp tubing, allowing medication to flow by gravity.Clogged tube - Clogging can occur from kinking of the tube or from internal blockage.Check first to see that the tube is not kinked.If clog is still present gently milk the tube from top to bottom to release any clog that may be in this part of the tube.Do NOT force-flush the tube or use a rigid object in an attempt to clear the tube. If the clog is persistent, contact the MD if the above techniques fail.

Based on observation, interview, and record review, the facility failed to label and store Drugs and biologicals under proper temperature controls in accordance with State and Federal laws on two residents (Resident#13,Resident# (300 and 200 hall nurses medication cart) of 4 medication carts reviewed for medication storage. 1.The facility failed to ensure Resident#13's opened vial of Lorazepam was not refrigerated and was stored in the medication cart.2. The facility failed to ensure opened Lantus SoloStar Subcutaneous Solution Pen-injector 100 UNIT/ML (a long-acting human insulin) was properly labeled with resident name before it was stored in the medication cart.3. The facility failed to ensure two bottles of nystatin were properly labeled with patients label after opening and before it was stored in the medication cart.4. The facility failed to ensure a tube of ammonium lactate 12% was properly labeled after opening and before it was stored in the medication cart. These failures could place residents at risk for compromised medication efficacy, unsafe administration, and increased harm to residents.Finding IncludedObservation of 300 short hall nurses medication cart on [DATE] at 10:10 AM revealed the following:*Resident #13 Lorazepam Oral Concentrate 2 MG/ML was stored unrefrigerated in the medication cart, two bottles of nystatin100,000units/gram (anti-fungal medication use to treat skin infections caused by candida yeast) with no prescription labels and *ammonium lactate 12%(a prescription- strength medication designed to treat dry scaly skin conditions and server itching) with no prescription labels. During an interview on [DATE] at 10:13 AM with RN D, she stated she was not aware that lorazepam was supposed to be refrigerated and the nystatin bottles and ammonium lactate 12% did not have patients' labels. She stated the risk of not refrigerating medication that required refrigeration was that the drug would lose its potency and would not be effective to treat the residents' symptoms. She stated failure to have medication with labels was a risk for medication error. She stated the risk to the resident was medication error and medication not being effective if it was expired. She stated that she had been in-serviced on medication storage. 2.Observation of 300 long hall on [DATE] at 10:20 AM on the, revealed an opened Lantus Solostar Subcutaneous Solution Pen-injector 100 UNIT/ML (a long-acting human insulin) was not labeled with resident name before it was stored in the medication cart. During an interview on [DATE] at 10:22 AM with RN D revealed she was not aware the Lantus did not have the required label. She stated that all medications were supposed to have a label from pharmacy. She stated having insulin in the medication cart that did not have the proper label could result in administering insulin to the wrong resident which may result in hospitalization. She stated the nurses and medication aides had been serviced on medication administration and storage. During an interview on [DATE] at 10:20 AM with ADON R, revealed nurses and MAs were responsible for ensuring the medication carts were clean, all medications were labelled and stored per manufacturer's recommendation. She stated lorazepam should always be refrigerated because it loses its effectiveness when it was stored in temperatures higher than recommended, making it ineffective in treating the residents' symptoms. She stated the risk of having medication without labels was a medication error. She stated she audited the carts weekly and the pharmacists audited the carts monthly. She stated the nurses and medication aides had been serviced on medication administration and storage in the room. During an interview on [DATE] at 3:00 PM with the DON, revealed nurses and MAs were responsible for ensuring the medication was properly labeled and stored per manufacturer's recommendations. The DON stated the risk of unlabeled medications included the potential for medication error and unrefrigerated lorazepam would not be effective in treating the residents' symptoms. She stated the nurse and medication aides had been serviced on medication administration and storage in the room. Review of the facility's policy Medication Administration Revised [DATE] reflected the following: Whenever you are preparing to give someone medication, it is important to understand the 10 rights of medication administration. Safety should be the first thing on your minds with medications. There is always a risk of giving the wrong pill, the wrong dose, or the wrong person's medication. If this happens, harm to the person can occur and some reactions can be deadly. While there has always been protocol for giving drugs, it is important for everyone to always know the safety rules for medication. IN THE PAST, YOU MAY have heard of the 5 rights of medication administration: right patient, right drug, right route, right time, and right dose. Medical practice have changed to include a few more rights.Right patient - make sure you are giving the right medication to the right person. Check the name, the order, and the patient. Use 2 identifiers. Always ask the patients name, check an ID band, pictures or whatever form of identification is being used and check the medication bottles/cards/tubes to compare before giving a medication.

Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that included instructions and services needed to provide effective and person-centered care for the resident that met professional standards of care within 48 hours of the resident's admission for one (Resident #119) of five residents reviewed for baseline care plans. The facility failed to complete a baseline care plan for Resident #119 within 48 hours of her admission. This failure could place newly admitted residents at risk of not receiving effective and person-centered care and services.Findings included: Review of Resident #119's Face Sheet, dated 04/08/26, reflected she was a [AGE] year-old female, who admitted to the facility on [DATE], with diagnoses including chronic multifocal osteomyelitis of the left ankle and foot (a rare inflammatory bone condition characterized by multiple sites of bone infection), type 2 diabetes mellitus (a chronic condition characterized by insulin resistance and high blood sugar levels), and acute kidney failure (a sudden loss of kidney function that occurs when the kidneys suddenly lose their ability to filter waste, excess fluids, and electrolytes from the blood). Review of Resident #119's electronic medical record on 04/08/26 reflected no evidence that a baseline care plan had been completed. There was a notification which indicated the baseline care plan was overdue. During an interview with the Interim DON on 04/08/26 at 12:17 PM, she stated she was responsible for overseeing the completion of baseline care plans. She said while the admitting nurse was required to initiate the baseline care plan, she reviewed to ensure completion within two days (48 hours) of a resident's admission to the facility. The Interim DON confirmed there was no evidence that Resident #119 had a baseline care plan completed within 48 hours of her admission. She stated the risk of baseline care plans not being completed included the potential for facility staff to not follow the resident's necessary plan of care. Review of the facility's Baseline Care Plan policy, dated 06/06/25, reflected, .1. The baseline care plan will: a. Be developed within 48 hours of a resident's admission. b. Include the minimum healthcare information necessary to properly care for a resident.

Based on interviews 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 7 residents (Resident #14) reviewed for comprehensive care plans. The facility failed to ensure Resident #14's comprehensive care plan identified bed rail use as an intervention for mobility assistance. This deficient practice could place residents at risk for not receiving proper care and services due to inaccurate care plans. Findings included: Record review of Resident #14's MDS assessment dated [DATE], reflected a [AGE] year-old female, originally admitted to the facility on [DATE], with a BIMS score of 14 which indicated intact cognitive impairment and diagnoses that included: Cerebral infarction (a type of stroke caused by a blocked blood vessel in the brain, leading to brain tissue damage), Atrophy (when a part of the body, like a muscle or tissue, shrinks or wastes away from lack of use or disease), Morbid (severe) Obesity (extremely overweight which significantly increases health risks, daily care, and mobility) Anxiety Disorder (ongoing uncontrollable, and excessive worry, fear, or dread that significantly interferes with daily life), Depression (feelings of severe sadness and inability to initiate activity), and Schizoaffective Disorder (a serious mental illness blending symptoms of schizophrenia - psychosis like hallucinations/delusions, with mood disorders like depression or bipolar mania involving extreme mood swings, disorganized thinking, and disrupted reality perception.), and Functional Quadriplegia (inability to move arms and legs due to severe weakness or illness). Record Review of Resident #14's comprehensive care plan initiated on 11/27/2023, revealed the care plan did not address the use of one or both bed rails as a mobility intervention. Record review of Resident #14's Physician Orders dated 04/06/2026, revealed an active order with a start date of 02/07/2026 authorizing the use of one or both bed rails every shift for mobility assistance and repositioning. In an interview on 04/06/2026 at 10:17 AM with Resident #14, she reported she used the side rails on her bed every day. She reported she used them mostly to help her reposition herself. She reported the side rails are very helpful and denied the rails prevented her ability to get out of bed. During an interview on 04/08/2026 at 11:00 AM with MDSC F, she reported the resident had new orders for the side rails entered in February at the resident's re-admission. She reported the side rail use should have been added to the resident's care plan. She stated it not being added was an oversight on her part. The MDSC F reported the risk to residents who do not have accurate care plans was that staff would not know the side rails are to be used by the resident. During an interview on 04/08/2026 at 11:55 AM with DON, she reported there are two MDS nurses who complete the Baseline and Comprehensive Care Plans. She stated the MDSC F reviews Care Plans to ensure the information was accurate. She stated the risk to residents who do not have accurate care plans was that interventions may not be followed. Record Review of the facility Comprehensive Care Plan policy dated 10/24/2022, reflected in part: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs. The comprehensive care plan will describe at minimum the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on observations, interviews, and record review the facility failed to ensure correct use of bed rails and to assess the resident for risk of entrapment from bed rails for 1 (Resident #7) of 4 residents whose records were reviewed for the use of side rails. The facility failed to complete a quarterly bed rail assessment and have a current physician's order for the continued use of Resident #7's siderails. This failure could place residents at risk of entrapment or injury.Findings included: Record review of Resident #7's face sheet, dated 04/06/25, revealed she was admitted to the facility on [DATE] with diagnoses including Age-Related Physical Debility (geriatric syndrome characterized by a gradual decline in physiological reserve, muscle strength, and functional capacity), Functional Quadriplegia (a patient cannot move their limbs due to extreme physical frailty or advanced chronic illness), Hemiplegia and Hemiparesis following Cerebral Infarction (one-sided body impairments caused by brain or spinal cord damage, often from stroke, tumors, or trauma), Muscle Wasting and Atrophy (loss of muscle tissue) and Vascular Dementia (decline in thinking skills caused by conditions that block or reduce blood flow to the brain). Record review of Resident #7's quarterly MDS assessment dated [DATE], revealed her BIMS score was 13 indicative of minimal cognitive impairment. Resident #7 required partial to moderate assistance with rolling left and right, from sitting to lying, and from lying to sitting on side of bed. Under Section P - Restraints and Alarms, revealed Resident #7 used a bed rail daily. Record review of Resident #7's Care Plan, reflected the following: Problem: [Resident #7] uses side rails to both sides of bed for bed positioning/mobility. Date Initiated: 01/30/25 Interventions: Discuss and record with the resident/family/caregivers, the risks and benefits of side rail use, when the side rails should/will be applied, routines while side rails are in use and any concerns or issues regarding side rail use. Date Initiated: 01/30/25Ensure valid consent on chart prior to initiating side rails. Date Initiated: 01/30/25 Problem: [Resident #7] has an ADL self-care performance deficit r/t debility, impaired cognition (having trouble with mental processes like memory, thinking, concentration, or decision-making), dementia (loss of memory, language, problem-solving and other thinking abilities), SAH (Subarachnoid Hemorrhage), functional quadriplegia. Date Initiated: 08/04/22 Interventions: Assist rails to both sides of bed for bed mobility. Date Initiated: 12/11/24 Record review of Resident #7's Side-Rail Use Assessment Form revealed under Section C - Recommendations, was not completed and there was no signature or date. Record review of Resident #7's Nursing - Side Rail Evaluation dated 12/12/24 revealed it was completed. Record review of Resident #7's Bed Rails/Device Informed Consent for Use was completed and signed on 12/17/24. Record review of Resident #7's Order Review Report dated 04/06/26 revealed a physician's order for Assist rails to both sides of bed for bed mobility, every shift with a start date of 01/12/26, an end date of 04/02/26 and an order status of Discontinued. Under the notes section it revealed, No longer has side rails. Observation and interview on 04/06/26 at 09:55 AM revealed Resident #7 in her room sitting in her wheelchair. Resident #7 stated she was doing okay and staff took good care of her. Resident #7 had half bedrails on both sides of her bed. Resident #7 stated she used the bedrails every day to reposition herself in bed. In an interview on 04/08/26 at 11:20 AM, MDSC F stated that nursing staff completed bed rail assessments. MDSC F stated the DON or ADON completed the assessments quarterly. MDSC F stated whoever completed any form that required a signature was responsible for obtaining the signature. MDSC F stated Resident #7's Physician's Order was initiated on 01/12/26 and discontinued on 04/02/26. MDSC F stated Resident #7 not having a fully completed assessment or current physician's order on file could result in harm. In an interview on 04/08/26 at 1:10 PM the MD stated that Resident #7 was not bedbound and she ambulated using a wheelchair. The MD stated if Resident #7 attempted to get out of bed during the middle of the night, nursing staff may use the side rails as a precautionary basis. The MD stated staff must have a physician's order to start or discontinue the use of bed rails. In an interview on 04/08/26 at 1:50 PM the DON stated nursing staff completed Side Rail Evaluations in PCC. The DON stated the evaluations should be completed in PCC at admission, quarterly, or as needed. The DON stated the risk of not having a fully completed assessment or current physician's order could affect Resident #7's care by causing harm or entrapment. The DON stated the physician's order would be discontinued based on the resident's assessment if bed rails were no longer needed. The DON stated if a resident had bed rails, they needed a current doctor's order. The DON stated there was risk to the resident if the assessment was not completed entirely. The DON stated for example, if the resident needed a bed rail you were not helping the resident with their independence, being able to reposition themselves in bed if bed rail usage was not captured on the assessment. The DON said the purpose of having the evaluation and order for bedrails for a resident was to make sure they were appropriate for the resident. The DON said the nursing department was responsible for ensuring there was an order and assessment for the bedrails. In an interview on 04/08/26 at 2:30 PM LVN A stated that Resident #7 had bed rails because she was able to pull herself up in bed. LVN A stated Resident #7 had two different sized bed rails because her left side was weaker than her right side. LVN A stated nursing evaluated residents for bed rail usage. LVN A stated she was not made aware that Resident #7's bed rails would be removed. LVN A stated Resident #7 easily used both bed rails. An attempt was made on 04/08/26 at 2:55 PM to speak with RN E prior to exit. Review of facility policy, Restraints, dated 8/15/22 revealed the following: Policy Statement: It is the policy of this facility that each resident shall attain and maintain his/her highest practicable well being in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints. Physical Restraint refers to any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Physical restraints may include, but are not limited to: . - Using bed rails to keep the resident from voluntarily getting out of bed. 2. Physical restraints may be used in emergency care situations for brief periods to permit medically necessary treatment that has been ordered by a practitioner unless the resident has previously made a valid refusal of the treatment in question. 4. A physician's order alone is not sufficient to warrant the use of a physical restraint. The facility is responsible for the appropriateness of the determination to use a restraint.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, administering and disposition of all controlled drugs for 2 (Resident #79, and Resident #3) of 10 residents reviewed for pharmacy services.1. The facility failed to ensure proper disposal of Resident#79's Tylenol 300/30mg (controlled medication) by taping the blister pack of a narcotic medication.2. The facility failed to ensure nursing staff reconstituted Resident#3's IV medication prior to administration.This failure could place residents at risk of drug diversion, medication errors, and risk of pills contamination due to broken seals.Findings Included1.Record review of Resident #79's Quarterly MDS Assessment, dated 01/20/26, reflected Resident #79 was a [AGE] year-old female, admitted [DATE] and readmitted [DATE].She had a BIMS score of 12, indicating moderate cognitive impairment. The resident had diagnoses including chronic pain syndrome, other low back pain. Record review of Resident #79's active Comprehensive Care Plan, revised 09/25/2024, reflected Resident #79 has acute/chronic pain r/t back pain. Interventions included Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Monitor/document for side effects of pain medication.Record review of Resident #79's active physician orders, dated 04/06/2026, reflected the resident had orders for Acetaminophen-Codeine Oral Tablet 300-30 MG (Acetaminophen w/ Codeine) Give 1 tablet by mouth every 4 hours as needed for breakthrough pain DO NOT ADMINISTER IS LESS THAN 2 HOURS OF SCHEDULED NORCO. Order start date 04/02/2026. An observation on 04/06/26 at 9:30 AM with RN C of the 300 Hall nurses' medication Cart, revealed Resident #79's Tylenol 300/30mg (controlled medication) had a damaged blister bubble and the capsule still inside, secured with taping the blister pack. During an interview with on 04/06/26 at 9:30 AM RN C revealed she did not notice the blister was damaged before the surveyor brought it to her attention. She stated the nurses and medication aides were responsible for inspecting the blister packs at every shift change when they did the narcotic count. She stated the risk was drug diversion and medication error because there was no evidence that the medication in the blister. 2. Record review of Resident# 3's Comprehensive MDS Assessment, dated 03/06/2026, reflected the Resident #3 was a [AGE] year-old male, admitted [DATE]. She had a BIMS score of 03, indicating severe cognitive impairment. The residents had diagnoses including SEPSIS UNSPECIFIED ORGANISM( systemic response to infection where the specific bacteria, virus, or fungus has not been identified) , and Multidrug-Resistant Organism ( bacteria or fungi resistant to one or more classes of antimicrobial drugs, making infections difficult to treat) and Urinary Tract Infection (a bacterial infection in the urinary system, commonly causing burning pain, frequent urges to urinate, and cloudy or strong-smelling urine).Record review of Resident #3's Comprehensive Care Plan, dated 03/05/2026, reflected* The Resident has infection of UTI with E. coli, ESBL. Interventions included Administer antibiotic as per MD orders.* The resident is on IV Medications (SPECIFY medications) r/t UTI, MDRO (a medical term for germs (typically bacteria) that are resistant to three or more types of antimicrobial agents), sepsis. Intervention included Monitor/document/report PRN s/sx of infection at the site: Drainage, Inflammation, Swelling, Redness, Warmth. Monitor/document/report PRN s/sx of leaking at the IV site: Edema at the insertion site, Taut, shiny, or stretched skin, whitening/blanching, or coolness of the skin, slowing or stopping of the infusion, leaking of I.V. fluid out of the insertion site.Record review of Resident 3's active physician orders, reflected Ertapenem Sodium Solution Reconstituted 1 GM (a broad-spectrum carbapenem antibiotic used to treat serious bacterial infections, including pneumonia, urinary tract infections, and abdominal infections) Use 1 gram intravenously at bedtime for infection related to SEPSIS, UNSPECIFIED ORGANISM. Active 04/02/2026. Observation and interview on 04/06/26 at 9:45 AM of Resident#3 revealed there was completed IV medication Ertapenem Sodium Solution Reconstituted 1 GM Use 1 gram hanging on the IV pole. The normal saline solution was completed but the medication was still in the vial. Resident stated he got his IV medication the previous night. During an interview on 04/06/26 at 10:15 AM with LVN B revealed she was Resident#3's nurse. She stated she did not notice that the IV Medication was still in the vial. She stated she did noted the saline was completed and thought the medication was properly administered. She stated the risk to the residents as ineffective treatment and medication error. During an interview on 04/06/26 at 9:50 AM with DON stated the medication should have been reconstituted with the normal saline prior to administering to the resident. She stated she would complete a medication error and notify the MD and inservice the nursing staff. She stated the risk to the resident was missing a dose of antibiotics and ineffective treatment of the resident infection. The DON stated once a narcotic blister pack seal was broken it should not be taped. The pill should be disposed witnessed by two nurses. The DON stated the risk would be losing the medication because the seal was broken. She stated nurses and Medication Aides were responsible for checking the medication blister packs for broken seals during the count on the change of shifts. The DON stated the ADON audits the medication carts weekly, then the pharmacy consultant audits the medication room, and the medication carts every month. She stated the nurses and the MAs had been in-serviced on medication storage, and narcotics were not to be taped if the blister seal was broken. Review of facility documentation dated 04/06/2026 at 11:27 AM reflected documentation of Resident#3 medication error. Review of the facility's policy Medication Administration Revised 10/01/2019 reflected the following: Medications are administered as prescribed in accordance with good nursing principled and practices and only by the persons legally authorized to do so.Medication are administered in accordance with written orders of the prescriber. Review of the facility's policy Parenteral Administration Revised 10/01/2019 reflected the following: To provide for the safe and accurate reconstitution of parenteral medications prior to administration manufacturer information is reviewed and aseptic technique is observed.Read medication package literature, medication label, or other appropriate reference to determine the correct diluent and quantity of diluent to be used. Note any special steps required (such as shaking).Review of the facility's policy Parenteral Administration Revised 03/22/2023 reflected the following: When a dose of control medication is removed from the container for administration but refused by the resident or not given for any reason, it is not placed back in the container. It is destroyed in the presence of two licensed nurse, and the disposal is documented on the accountability record/book on the line representing that dose. The same process applies to the disposal of unused partial tablets and unused portions of single ampules and doses of controlled substances wasted for any reason.

Based on observation, interview, and record review, the facility failed to must provide each resident with the necessary care and services to attain or maintain the highest practicable, physical, mental, and psychosocial well-being consistent with the resident's comprehensive assessment and care plan by ensuring a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal hygiene for 1 of 4 residents (Resident #1) reviewed for ADL care. The facility failed to provide Resident #1 assistance with timely incontinence care for at least 4 hours on 10/23/25, which resulted in Resident #1 being soaked with urine and soiled through her brief, draw sheet, and bed sheets. This failure could place the residents at risk for decreased feeling of self-worth, skin breakdown, and infection. Findings included: Record review of Resident #1's face sheet, dated 10/23/25, reflected Resident #1 admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #1's Significant Change in Status MDS assessment, dated 09/25/25, reflected Resident #1 had moderate cognitive impairment, with a BIMS of 09. Resident #1 was noted to be dependent on staff for all transfers and substantial/maximum assistance with toileting. The MDS noted that Resident #1 was always incontinent of bowel and bladder. The resident's active diagnoses included hemiplegia (paralysis that affects one side of the body), seizure disorder (condition causing repeated seizures from abnormal brain activity), anxiety disorder (excessive fear or worry that can disrupt daily life), depression (condition causing persistent sadness and loss of interest), bipolar disorder (condition causing extreme mood swings between mania and depression), and cerebral palsy (disorder caused by brain damage that affects movement, muscle control, and coordination). Record review of Resident #1's care plan, dated 10/01/25, reflected Resident #1 had bowel and bladder incontinence. The care plan reflected: Intervention: Check resident every two hours and assist with toileting as needed. Problem: [Resident #1] has an ADL self-care performance deficit r/t weakness, impaired decision-making ability, impaired mobility, left sided weakness, cerebral palsy. Goal: The resident will improve current level of function in ADL's through the review date. Intervention:. Personal Hygiene/Oral Care: The resident requires max/total assist x 1 or 2 staff for personal hygiene and oral care. Toilet Use: The resident requires max/ total assist of 1 or 2 staff for toilet use. Transfer: The resident requires max/total assist of 1 or 2 staff for transferring. Observation and interview on 10/23/25 at 9:39 AM revealed a strong smell of urine in Resident #1's room. Resident #1 revealed she was currently wet and needed to be changed. Resident #1 stated the last time she had been changed was around 4:00 AM. Resident #1 stated she could not recall if she let a staff member know that she needed to be changed or the last time a staff member was in her room. Resident #1 stated she knew how to use the call light but preferred not to bother the staff. Observation and interview on 10/23/25 at 10:45 AM, revealed CNA A pulled back the sheets on Resident #1. CNA A stated the urine had soaked through the sheets. CNA A asked RN B to get new sheets before starting incontinence care. Interview on 10/23/25 at 10:50 AM, CNA A revealed night shift had changed Resident #1 last. CNA A stated she started her shift at 6:00 AM, but it was difficult to check on residents every 2 hours. She stated she had not checked on Resident #1 yet. Observation on 10/23/25 at 11:00 AM, revealed CNA A and RN B providing Resident #1 with incontinence care. When Resident #1 was turned onto her side during incontinence care, it was noted that urine had soaked through the resident's brief, draw sheet, fitted sheet, and was wet up to Resident #1's back and gown. When the fitted sheet was removed, there was a pool of urine on the mattress. No skin issues or redness was noted to Resident #1's perineal area. Interview on 10/23/25 at 11:07 AM, Resident #1 revealed she did not typically soak through the sheets. Resident #1 stated she had not been changed yet this shift, but she understood because staff got busy. Resident #1 stated she was happy with the care she received in the building and did not have concerns. Interview on 10/23/25 at 1:08 PM, CNA A revealed she was expected to perform rounds on all residents every 2 hours. CNA A stated she tried to check on residents every 2 hours, but that it could be hard to do that. She stated her assignment had changed which caused a delay. CNA A stated residents, who could use their call light, got incontinence care more frequently. CNA A stated dependent residents unable to use their call light still got incontinence care, but it could take longer. CNA A stated it was not normal for Resident #1 to have urine soaked through the sheets. She stated it was due to the resident lying in urine for a longer period. CNA A stated she had not changed Resident #1 on her shift yet, and Resident #1 told her the last time she had been changed was 4:00 AM. CNA A said it could have been around 7 hours since the last time she had been changed, but she could not confirm for sure. CNA A stated Resident #1 would usually let her know when she was wet, but she did not today. CNA A stated Resident #1 was fully incontinent and dependent upon staff to be changed. CNA A stated if Resident #1 was lying in urine or not being checked on every 2 hours, it put her at risk to have skin breakdown and get pressure sores. CNA A stated she had been employed at the facility for 2.5 weeks and had been trained during orientation to round on residents every 2 hours and to provide care as needed. Interview on 10/23/25 at 2:24 PM, RN B revealed she expected her CNAs to complete their rounds at least every 2 hours. RN B stated she did her own rounds to ensure that the CNAs rounds were completed. RN B stated it was not normal for Resident #1 to have urine wet through the sheets and up her back. RN B revealed Resident #1 was dependent and always incontinent of bladder and bowel. RN B stated she checked on Resident #1 around 7:00 AM, and Resident #1 was dry. RN B stated not changing Resident #1's brief when she was wet, put her at risk of urinary tract infections and skin breakdown. Interview on 10/23/25 at 3:52 PM, ADON C revealed she expected staff to complete rounds as frequently as possible, but at least every 2 hours. ADON C stated she did do frequent spot rounds at random times to ensure that staff rounds were completed. ADON C stated she did skin rounds earlier and checked Resident #1 around 7:00 AM and the resident was dry. ADON C stated Resident #1 should have been checked on again before 11:00 AM, since it was over 2 hours. ADON C revealed it was everyone's job to round on residents. ADON C stated leaving Resident #1 wet placed her at risk of skin breakdown and infections. Interview on 10/23/25 at 4:10 PM, the DON revealed she expected the staff to conduct rounds on residents at least every 2 hours. She stated residents with incontinence should be changed as often as possible and at a minimum of every 2 hours. The DON stated it was all staff's job to ensure that residents were being checked on every 2 hours. The DON stated leaving Resident #1 wet placed her as risk of developing pressure sores, infections, and skin breakdown. Record review of the facility's Perineal Care policy, implemented 10/24/22, reflected: It is the practice of this facility to provide perineal care to all incontinent residents during routine bath and as needed in order promote cleanliness and comfort, prevent infection to the extent possible, and to prevent and assess for skin breakdown.

Based on observations, interviews, and record reviews the facility failed to ensure residents were provided an environment that was free from accident hazards for 1 of 5 residents (Resident #1) reviewed for accidents. The facility failed to ensure Resident #1's mattress overlay was properly secured to prevent her from falling out of bed. This failure could place residents at risk of falls and resulting injuries. Findings included:Record review of Resident #1's quarterly MDS, dated [DATE], reflected the resident was admitted to the facility on [DATE] with diagnoses which included stroke affecting her left side, dysphasia (inability to swallow), aphasia (inability to speak), and breathing difficulty requiring the placement of a tracheostomy (breathing tube in her neck). Her BIMS score was not completed due to her medical conditions. Her Functional Ability assessment indicated she was totally dependent on staff for all her ADLs. Record review of Resident #1's care plan, dated 06/16/25, reflected she was a fall risk with actual falls with interventions which included staff ensuring the resident had safe and proper positioning in bed on her air mattress. Record review of Resident #1's Fall Risk assessment, dated 05/31/25, reflected she was at high risk for falls with a score of 13. Observation of video footage submitted by Resident #1's family member, dated 08/20/25, revealed Resident #1 lying on her bed with her head to the left side of the bed. The resident then fell off the bed headfirst, landing on the fall mat beside the bed. The video footage also showed the resident's mattress overlay sliding off the bed with her. Record review of Resident #1's nursing progress notes reflected LVN A documented the following entries:- 08/20/25 at 8:30 AM: Observed patient lying on floor to left side of the mat. Lying on left side. No signs of distress observed. Assessed patient for injuries. No injuries visible at the time. Carefully, transferred patient from floor to the bed with coharts [sic]. Vitals checked. [Family] notified. Patient transferred to [hospital] at family's request. DON informed of most recent events.- 08/20/25 at 9:30 AM family informed of pick up time.Observation on 09/03/25 at 10:35 AM revealed Resident #1 was positioned in her bed with her left side tilted up with pillows. There were fall mats on both sides of the resident's bed, and the resident's bed was in the low position. The air mattress had bolsters built into it to help keep the resident from sliding out of bed. The resident had no bruising to her head or face. Interview on 09/03/25 at 12:35 PM with Resident #1's Family Member revealed the facility had notified the Family Member about Resident #1's fall. The Family Member was informed the resident had no obvious injury. The Family Member stated they requested the resident be sent to the hospital for evaluation. The Family Member stated the resident was seen in the ER, where she diagnosed with a UTI (an infection in any part of the urinary system which includes the kidneys, ureter, bladder, and urethra). The Family Member stated the resident was sent back to the facility the same day. Interview on 09/03/25 at 10:37 AM with LVN B revealed at the time of Resident #1's fall on 08/20/25 her mattress was fitted with an overlay, with built-in bolsters that went on top of her air mattress, which was secured to the bed frame with several straps. LVN B stated one of the straps was not secured, which allowed the overlay to slide with the resident, when she slid off the bed instead of staying in place and preventing the resident from sliding out of bed. She stated the air mattress was now fitted with a different type of cover that was more secure than the previous one. Interview on 09/03/25 at 10:40 AM with the DON revealed his investigation into Resident #1's fall revealed the resident's mattress overlay did not have the top right strap secured. When the resident began to slide to her left, the overlay slid with her instead of staying in place, which prevented the built-in bolsters from doing their job of making it harder for her to slide out of bed. The DON stated it was the responsibility of the nurses and CNAs to check the overlay and make sure it was properly secured. He stated he initiated an in-service on proper use of the overlays, as well as resident neglect. The DON stated there was only one other resident in the facility with the type of overlay Resident #1 had. Observation on 09/03/25 at 10:55 AM of Resident #1's mattress overlay revealed it was properly secured to the bed frame with three straps on each side of the mattress. Interview on 09/03/25 at 12:50 PM with CNA C revealed she was familiar with the residents, who were at risk for falls, and she rounded on them more frequently. She stated the fall risk residents were also in a binder at the desk and on the Kardex (a documentation system that summarizes important details and quick access for essential patient data) for those not familiar with the residents. She stated Resident #1 was known to move about a little and work her way to one side of the bed or the other. Interview on 09/03/25 at 1:00 PM with CNA D revealed the nurses told the CNAs when there was a new resident, who was a fall risk, and the residents were also in a binder on the desk. She stated those residents were rounded on more frequently. She stated Resident #1 was particularly prone to sliding out of bed. She stated no matter how often she was positioned in the middle of the bed, with pillows behind her, she would eventually end up on one side of the bed. Interview on 09/03/25 at 2:35 PM with the DON revealed the resident fall risk assessments were conducted on admission and then quarterly thereafter unless there was a fall, in which case an assessment would be completed at that time. He stated Resident #1 should have had a fall risk assessment completed in June 2025 for her quarterly assessment and definitely after her fall on 08/20/25. He stated he did not know why neither one had been conducted. Interview on 09/03/25 at 3:41 PM with LVN A via telephone revealed on 08/20/25 she positioned herself outside Resident #1's room because she liked to keep a closer eye on the resident. She stated she had returned to her desk outside Resident #1's room, after assisting another resident, and she saw the resident had fallen out of bed. She called for help, and several staff came to assist her with the resident. LVN A stated when she found the resident she noted the mattress overlay had slid off the bed with her. She stated she had found the overlay unsecured before and had to secure it. She stated when she assessed the resident there were no bruises or obvious injuries. The resident was non-verbal but did not grimace when she felt the resident for any injury or deformity. When she notified the Resident #1's Family Member, the Family Member insisted the resident be sent to the hospital to be assessed for any injuries. Record review of the facility's Fall Prevention Program policy, dated 08/15/22, reflected: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls.2. Upon admission, the nurse will complete a fall risk assessment along with the admission assessment to determine the resident's level of fall risk 4 . g. Complete a fall risk assessment every 90 days and as indicated when the resident's condition changes.

Based on observations, interviews and record reviews the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for 1 of 9 residents (Resident #1) reviewed for accidents. RN A and CNA B failed to monitor/supervise Resident #1 on 05/27/25 who suffered a fall and laid on the floor for 3 hours before being found. The resident sustained a broken leg as a result of the fall. The noncompliance was identified as past noncompliance that began on 05/27/25 and ended on 05/28/25. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of injury. Findings included: Record review of Resident #1's undated admission Record reflected Resident #1 was admitted to the facility on [DATE] with diagnoses which included liver failure, dementia, and repeated falls. Record review of Resident #1's quarterly MDS, dated [DATE], revealed a BIMS score of 9 indicating she had moderate cognitive impairment. Her Functional Ability assessment indicated she required staff assistance with her ADLs. The resident uses a walker to transfer from her bed to her chair. Record review of Resident #1's care plan, dated 06/10/25, indicated she had an ADL self-care deficit requiring assistance from staff, she had impaired cognitive function related to liver failure, and she was at risk for falls related to her disease processes. Interventions included bed in lowest position, and call light within reach. The resident's care plan was updated on 04/13/25 to include fall risk interventions. After the fall on 05/27/25 the plan was again updated to add frequent rounding. Record review of the facility's Accident and Injury report from April to June of 2025 revealed Resident #1 had suffered unwitnessed falls on 04/13/25 and 05/27/25. The resident suffered no injury with the fall on 04/13/25. Record review of the facility's investigation report revealed in the early morning hours of 05/27/25 around 6:00 AM RN C entered Resident #1's room while making her morning rounds and found Resident #1 lying on the floor of her room. Resident #1 stated she had been trying to get to her chair when she fell, and she complained of right shoulder pain. The resident was assisted back to bed, the physician was contacted and an order for a shoulder x-ray was ordered. The family was also contacted. Resident#1's family member reviewed video footage from the camera in her room and discovered the resident fell at 3:20 AM and RN C discovered the resident at 6:20 AM. The resident could be heard calling for help, but her door was closed. The x-ray of her shoulder was negative for any injury. Later that afternoon the resident complained of right knee pain. The x-ray of her knee indicated she had broken her lower leg bone just below he knee. The resident refused to go to the Emergency Room, instead followed up with an orthopedist the next week. The resident was ordered to not bear weight on her right leg for 4 weeks. Record review of RN C's nursing progress note from 05/27/25 reflected: This nurse was doing rounds and checking on residents when I hear a this resident call for help, this nurse went into the room and found resident laying on the floor with a pillow under her head, resident stated that she needed help getting up and that she slipped out of her chair and onto the floor, resident stated that she believes she slipped out of her chair as she was sleeping, resident states she did not hit her head and could not reach her call light to ask for help so she was calling out for someone, this nurse assessed vitals and began neuro checks, this nurse had aid help resident up into wheelchair, resident then wanted to lay in bed, this nurse assisted resident into bed, residents neck range of motion within normal limits, this nurse contacted NP, and DON, this nurse called family member and left voicemail. Observation and interview on 06/24/25 at 10:00 AM revealed Resident #1 was in her bed. The bed was in the lowest position, and a fall mat was on the floor. The resident could not answer questions about her fall, other than to say she fell. The resident's conversation was very scattered. The resident's room was located directly across from the nurses sta'tion. In an interview on 06/24/25 at 10:40 AM, the Administrator stated Resident #1's family had called back after reviewing the video footage from her room and reported the resident fell at 3:20 AM and was not discovered until the day nurse came in at 6:20 AM. The family member reported the resident was using her walker to transfer to her recliner, where she preferred to sleep, when she fell. The Administrator stated the resident's room was the last room at the end of the hallway, and her door was closed at her request, so it would have been difficult for staff to hear her call for help from the nurse's station. CNA B stated she had last checked on the resident around 2:30 AM. RN A and CNA B were both suspended and CNA B was eventually terminated and RN A resigned. The resident was moved to a room closer to the nurse station for closer monitoring and so she could be heard if she called out instead of using her call light. In an interview on 06/24/25 at 1:20 PM, CNA B stated she had checked on Resident #1 throughout the evening of 05/26/25. She last saw the resident around 2:30 AM when the resident requested some water. CNA B stated she did not check on Resident #1 the rest of the shift because her door was closed, and she did not want to wake her up. CNA B stated she knew she was supposed to check on the residents every two hours. She stated she should have checked on the resident, but she just did not want to wake her up. She stated the risk to the residents was just what happened to Resident #1, they could fall and no one would know. Phone interview attempts on 06/24/25 at 2:00 PM and 2:32 PM with RN A were unsuccessful. Phone interview attempts on 06/24/25 at 2:05 PM and 3:38 PM with RN C were unsuccessful. In an interview on 06/24/25 at 1:30 PM, RN D stated she had been recently in-serviced by the ADON on abuse and neglect. She stated the in-service covered reducing fall risks by ensuring call lights were within reach, frequent rounding on the residents, and what to do if a resident did fall. They also discussed frequent rounding on at risk residents. In an interview on 06/24/25 at 1:25 PM, CNA E stated she had been recently in-serviced by the ADON on abuse and neglect. The in-serviced covered reducing fall risks by ensuring the residents needs were met, and the call light was within reach. It also covered what to do if a resident was found on the floor. They also discussed frequent rounding on at risk residents. In an interview on 06/24/25 at 1:35 PM, LVN F stated she had been in-serviced by the ADON recently on abuse and neglect. The in-service addressed fall prevention and what to do when a resident falls. Staff needed to check on the residents frequently, make sure their call lights were within reach, and offer toileting at least every two hours. They also discussed frequent rounding on at risk residents. In an interview on 06/24/25 at 1:40 PM, CNA G stated she had been in-serviced recently on abuse and neglect. She stated the focus was on fall prevention and what to do if a resident fell. Staff had to check on the residents frequently, offer toileting and keep their call light within reach. They also discussed frequent rounding on at risk residents. In an interview on 06/24/25 at 1:45 PM, CNA H stated she had been in-serviced on abuse and neglect. She stated staff had to try to prevent falls by keeping the call light within reach and checking on the residents frequently. They also discussed frequent rounding on at risk residents. In a phone interview on 06/24/25 at 1:50 PM, CNA I stated she had been in-serviced on abuse and neglect. She stated they covered fall prevention actions and what to do if a resident falls. They also discussed frequent rounding on at risk residents. In a phone interview on 06/24/25 at 2:00 PM, LVN J stated she had been in-serviced on abuse and neglect recently. She stated they discussed fall prevention and frequent rounding on the residents. and what to do when a resident falls. They also discussed frequent rounding on at risk residents. In a phone interview on 06/24/25 at 2:10 PM, RN K stated he had been in-serviced on abuse and neglect. They discussed what to do if a resident fell, and fall prevention methods. They also discussed frequent rounding on at risk residents. In a phone interview on 06/24/25 at 2:15 PM, CNA L stated she had been in-serviced on abuse and neglect. The in-service covered fall prevention, frequent rounding, and what to do if a resident falls. They also discussed frequent rounding on at risk residents. In a phone interview on 06/24/25 at 2:18 PM, Resident #1's Responsible Party stated he had been contacted by the Administrator the morning of the resident's fall, and again later that day when they had x-rayed her knee and found the fracture. They discussed the resident's refusal to go to the hospital and he was ok with waiting until she could she the orthopedist in the office. He stated the resident had been getting more confused but she refused to take the medication to lower her ammonia levels. He stated the other family member, who monitored the camera, was very ill and would not be able to be interviewed. He was satisfied with the resident's overall care and the communication with the Administrator. In an interview on 06/24/25 at 2:55 PM, the ADON stated she had in-serviced staff immediately after the event on 05/27/25. She emphasized that the facility's expectation was for staff to round on the residents at least every two hours, and that rounding could be done by the nurse or the CNA. She covered the need to coordinate rounding times, fall prevention actions such as low beds, call lights within reach, post-fall assessment, and frequent toileting. In-servicing of all staff had been completed by 05/28/25. Resident #1 had also been moved to a room next to the nurse's station because she sometimes would not use the call light, but yell for help instead. She stated shechecks with the residents to confirm frequent rounding is being done. She stated the resident's confusion has been improving since she agreed to start taking her lactulose again, her amonia levels are lowering. In an interview on 06/24/25 at 5:30 PM, the Administrator stated he did not have a policy addressing rounding on the residents. He stated it was his expectation that staff round at least every two hours, and more frequently on residents at higher risk of falling.

Based on observation, interview, and record review, the facility failed to ensure residents fed by enteral means received treatment to prevent complications of enteral feedings for 1 of 1 resident (Resident #2) reviewed for enteral feedings. CNA H paused the resident's feeding pump for perineal care and failed to re-start the pump after the care was completed, or ask a nurse to re-start it. This failure could place the resident at risk of not receiving the prescribed nutritional calories she required. Findings included: Record review of Resident #2's undated admission Record reflected Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included stroke affecting her left side, inability to swallow requiring the placement of a gastric tube, and difficulty maintaining her airway requiring the placement of a tracheostomy. Record review of Resident #2's quarterly MDS, dated [DATE], reflected a BIMS score not calculated based on her medical conditions. Her Functional Ability assessment reflected she required total assistance of staff for her ADLs. Record review of Resident #2's care plan, dated 06/16/25, reflected she had an ADL self-care deficit, and she received all nutrition via her gastric tube. Record review of Resident #2's physician orders reflected an order dated 06/01/25 every shift for nutrition Glucerna 1.5 @ 70mL/hr x 20hrs/day (1680 kcal, 84 g pro) via stationary pump. Observation on 06/24/25 at 3:32 PM revealed CNA H and CNA E providing incontinence care to Resident #2. CNA H paused the resident's feeding pump prior to initiating incontinence care. The incontinence care was provided appropriately, and the CNAs exited the room leaving the feeding pump paused. Both CNAs then continued to round on other residents. In an interview on 06/24/25 at 3:45 PM with CNA H and ADON M, CNA H admitted she had paused the feeding pump for Resident #2 and did not re-start it or alert a nurse to re-start it. ADON M stated CNAs were not allowed to start, stop, or pause feeding pumps because the formula was considered a medication. ADON M stated the fact the pump was not restarted proved why CNAs should not pause the pump. CNA H did not answer when asked if this was a normal action for her to pause feeding pumps. ADON M was observed to immediately pull CNA H to her office to in-service her. In an interview on 06/24/25 at 5:30 PM, the Administrator stated he could not locate a policy addressing gastric tube feedings or gastric tube management.

Based on interview and record review, the facility failed to provide or obtain laboratory services to meet the needs of its residents and failed to be responsible for the quality and timeliness of the services for one (Resident #1) of five residents reviewed for laboratory services. The facility failed to complete Resident #1's lab order for a urinalysis with C&S (a diagnostic test that involves analyzing a urine sample to detect and identify potential infections and determine their susceptibility to antibiotics) as ordered by the physician. The failure could place residents at risk for delays in the provision of treatment for laboratory abnormalities and acute exacerbation of clinical conditions. Findings included: Record review of Resident #1's Face Sheet dated 03/27/25 revealed the resident was a [AGE] year-old male who admitted to the facility on [DATE] and readmitted on [DATE] from an acute stay at the hospital. Resident #1's diagnosis included a fracture of the left femur (upper leg bone), orthopedic aftercare following surgical amputation, dysphagia (difficulty swallowing foods or liquids), cirrhosis of liver (late-stage liver disease where healthy liver tissue is replaced by scar tissue, hindering the liver's ability to function properly), gangrene (a condition where tissue dies due to a lack of blood supply), peripheral vascular disease (a condition that affects the blood vessels outside of the heart and brain), repeated falls, hypertension (a condition where the force of blood pushing against the artery walls is consistently too high), sepsis (a life-threatening condition that occurs when the body's immune system overreacts to an infection, leading to widespread inflammation and organ damage), atrial fibrillation (irregular heart rhythm) and urinary tract infection (an infection of the urinary system, which includes the kidneys, ureters, bladder, and urethra). Record review of Resident #1's admission MDS assessment dated [DATE] revealed a BIMS score of 09, which indicated moderately impaired cognition and a mood score of 13 with negative mood issues of fatigue, depression, difficulty concentrating and issues with sleep. Resident #1 had no signs of psychosis, delirium or behaviors that affected his care. Resident #1 had range of motion impairment on one side of his lower extremities and used a walker and wheelchair for mobility. Resident #1 was always incontinent of bowel and bladder and required staff assistance for all his ADLs. Resident #1 had six unstageable pressure ulcers and one deep tissue injury. All skin issues were present upon admission to the facility. Record review of Resident #1's care plan initiated on 02/10/25 reflected, Problem: Resident has dehydration or potential fluid deficit r/t diuretic use; Goal: The resident will be free of symptoms of dehydration and maintain moist mucous membranes, good skin turgor; Interventions: Administer medications as ordered, Monitor/document for side effects and effectiveness, Monitor/document/report PRN any s/sx of dehydration: decreased or no urine output, concentrated urine, strong odor, tenting skin, cracked lips, furrowed tongue, new onset confusion, dizziness on sitting/standing, increased pulse, headache, fatigue/weakness, dizziness, fever, thirst, recent/sudden weight loss, dry/sunken eyes. Record review of a progress note written by the NP dated 03/16/25 reflected that on 03/14/25, Resident #1 had complained of a sore throat, no fever or shortness of breath and he tested negative for COVID. He was started on throat lozenges as needed and Claritin 10 mg po. On 03/16/25, the NP documented the facility nurse reported that per family, Resident #1 was confused the nurse was not able to collect UA. During the visit, the NP stated Resident #1 was observed to be in bed not in distress and answered questions appropriately, denied pain, and had no complaints of health issues. The NP documented there were no new concerns voiced by nursing staff. His vitals were reviewed and a physical exam completed with no new concerns. Record review of Resident #1's nursing progress notes reflected the following: - 03/16/25 6:09 PM [written by RN A]: Resident family request to check his UA C&S. They feel he seems confusion [sic]. NP made aware. - 03/25/25 7:58 PM [written by RN A]: Family member called EMS to transport pt to the hospital because they thought he seemed more confused. Nurse attempted to give EMS face sheet and order summary, but they declined stating that they already had the information. Record review of Resident #1's physician orders reflected: -03/16/25 reflected an order for, Urinalysis reflex***Sent to lab 3/16/25 6:08 PM Verbal CT***one time only related to urinary tract infection [status reflected completed]. -03/25/25 reflected an order for, Urinalysis to C/S if indicated***Sent to lab 3/25/25 7:14 PM CT***one time only related to urinary tract infection [status reflected completed]. Review of Resident #1's clinical chart from 03/16/25 through 03/25/25 revealed no evidence of a lab collection for urine or a lab result for the urinalysis ordered on 03/16/25 or 03/25/25. Record review of Resident #1's hospital records reflected he admitted to the hospital on 03/25/25 for antibiotic therapy, trending of creatine values, IV fluids and monitoring of his neurological statis as well as wound care for a chronic decubitus ulcer on his sacrum. Resident #1 was placed on empiric Cefepime; however, the urinalysis did not show any definite infection. His chest x-ray did not reveal any infiltrates and his urine culture showed no growth. Resident #1's white blood cell count at the time of the hospital admission was 7.3 [reference range value is 4-11]. An interview with ADON D on 03/27/25 at 1:36 PM revealed it was important to act on a concern that a resident had a UTI to prevent it from worsening. He stated Resident #1 had no changes in his behavior but was transferred to the hospital on 03/25/25 when his family called 911 to have him sent out. ADON D stated he looked at Resident #1's orders on the e-chart and saw there was an order on 03/16/25 for a UA and another on 03/25/25 for a UA, but Resident #1 got sent out before the latter one could be collected. ADON D said the 03/16/25 UA reflected it was not collected on the facility's lab report, but it did not indicate why. ADON D stated he knew when it was first ordered because one of the charge nurses let him know it was difficult to collect Resident #1's urine due to his fluctuating continence. ADON D stated if a resident was retaining urine, a nurse could do a straight cath as long as the resident agreed or use a foley catheter if the resident already had one and do a clean catch. ADON D said the nurse could also use a specimen cup or a urine collection hat if the resident used a urinal or the toilet. ADON D stated, I know the charge nurse would check on him but I guess bad timing. ADON D stated he was not sure which options were used to try and collect urine for Resident #1. He stated RN A was Resident #1's usual daytime nurse and RN B was his usual night nurse. An interview with RN B on 03/27/25 at 2:40 PM revealed from what she could remember, the order for Resident #1's UA came on the night shift when RN A was working and it was passed to the next shift and they were not able to collect it, so then it was passed to her morning/afternoon shift the next day. RN B stated she got Resident #1 a new urinal that morning and told him she needed a urine sample and if he could please press the call light. When Resident #1 pressed the call light, RN B said she went in but he had already urinated in his brief so she could not collect the sample. RN B stated Resident #1 did not use the urinal during her shift and she left around 6:00 PM. When the night nurse arrived, RN B said she told him she could not collect the urine specimen. RN B stated when the nurse cannot collect a urine specimen, they should write a progress note to chart it, and she should have done one but did not. RN B stated if Resident #1 was not allowing the nurses to help him get the urine into his urinal, then she could have told the doctor after so many attempts and then done a straight cath. RN B said Resident #1 would have been a candidate for that, but we didn't' go that route. RN B stated she was not working when Resident #1 was sent out 911 by his family but read the progress note that reflected he was sent out due to family noticing increased confusion. RN B said she last saw Resident #1 on Sunday 03/23/25 and he was acting normal, at his baseline and did not present as confused. She stated Resident #1 usually slept a lot, ate a lot of snacks and normally complains of pain but that day he didn't. RN B said Resident #1 did not present as confused. RN B stated it was important to follow physician orders because if the doctor was asking for it, then they were trying to see if the resident had an infection and it was important to catch it so the resident could heal and the infection did not worsen. An interview with the DON on 03/27/25 at 3:05 PM revealed Resident #1's cognition waxed and waned, for example, when he admitted to the facility his BIMS was zero and six days later it was a 13 when he was re-assessed. The DON stated the only thing mentioned by Resident #1's family member was that he was having increased confusion. The DON said she did not see any change other than the normal ups and downs with his mood. The DON stated RN B was a newer nurse to the facility and what she should have done was reach out to the doctor and straight cath Resident #1. The DON stated, That is going to be something she [RN B] has to learn, to reach out and get an order to obtain it. The DON additionally stated, Yes, we should have called the doctor and done a straight cath, I just wound have done it, but these nurses are new and maybe they didn't realize that should be done versus waiting on him to urinate. She stated the facility did complete a CBC and CMP three days before the UA was ordered and all values were towards the bottom of norm, with his white blood cell count being 6.5. The DON said she would have been more concerned if his white blood cell count had been elevated but it was not. The DON stated, I am saying within three days he would not have gotten an infection of a UTI to the extent of showing any change in his vitals and mentation. The DON stated if the specimen had been collected and the UA with C&S completed and showed Resident #1 had a UTI, she would have contacted the physician with the results and placed him on antibiotics based on the culture and sensitivity. The DON stated any labs ordered for residents in the facility were reviewed on a daily basis by the charge nurses who are on the front line and supposed to check on labs throughout their shift. She said there were clinical meetings every day with herself, ADON D, the MDS nurse, social worker, director of rehab and the administrator. During those meetings, the charge nurses came in and presented on their assigned residents where they went over new orders, nursing notes, changes in condition, discharges, admissions and labs. The DON stated with labs, she wanted to know during those meetings which ones were abnormal. When a lab could not be completed, the DON said the charge nurse should document it and bring it up during the daily clinical meetings. She said the nurses could only document on a specimen attempt three times and that was why the nurses placed an order for another UA on 03/25/25 which she did believe they got before Resident #1 was sent out to the hospital. The DON stated Resident #1 was expected to return back to the facility in a few days and the hospital updated the facility that he admitted with a diagnosis of encephalophagy (a medical condition that affects the brain's function, leading to changes in mental state and cognitive abilities) and a preliminary UTI, but they did not have a C&S on it for growth yet. An interview with Resident #1's family member on 04/11/25 at 10:05 AM revealed the concern the family had was during a visit on 03/14/25, he appeared to be talking about random things that did not make sense to his situation and environment. When they came back to visit him a week later, he seemed to be in the same state of mind. Since Resident #1 had a UTI in his past, the family member stated they figured he had one again or was developing one. The family member stated Resident #1 did have intermittent confusion as a baseline, however, they felt his confusion was more pronounced than before. An interview with the MD on 04/11/25 at 11:11 AM revealed Resident #1's family had requested a UA because they thought he had some increased confusion. The MD stated according to his NP, the UA request was not pursued because there was no clinical indication it was needed and Resident #1 did not have any signs or symptoms of a UTI and appeared fine. However, because the family was concerned, the MD said an order was written for a UA, but the nurses were not able to obtain a specimen. The MD stated to use a straight cath was not a routine technique and an aggressive procedure that could introduce an infection into his system just trying to get a sample. The MD stated he had reviewed Resident #1's hospital records after the family had him sent out but did not see any indicated he had an infection. The MD stated he did not give an order to get a urine sample via a straight cath as that was not their routine way to handle a urine collection. The MD stated We wanted to wait until we could get one [urine sample] and if we believed from a clinical assessment he was showing signs and symptoms of an infection, especially a UTI, we will get a sample whatever it takes. If the nurses could not get it [urine sample], maybe they should have called us and let us know there was no clean catch and we could have said wait 12 hours and try the next day or to a straight cath. The MD stated, My nurses are my eyes and ears, family is important, but I rely on the NP and the nurses int he facility to give clinical judgement of signs and symptoms, which he did not present with any. They are capable. And with the vital signs prior, there was nothing going on with the patient. An interview with the NP on 04/11/25 at 11:30 AM revealed she remembered a facility nurse reported that Resident #1's family members were concerned he was more confused and requested a UA because he had fallen twice in three days. The NP told the facility they could get a UA, but she did not know they could not get a urine specimen. The NP stated, however, that Resident #1 did not have a change in his mental status from what she could tell during her last visit on 03/16/25. She stated the concern at the time of her visit was that the nurses were reporting he would not call for staff help for transfers and had fallen. The NP stated not completing an ordered lab could cause an abnormal lab value to go missed. The NP said if a nurse could not get a urine specimen through a clean catch, they could do a straight cath, but they would have to call and get an order for that procedure because there was not a standing order for it. Record review of the facility's policy titled, Laboratory Services and Reporting dated 04/08/2023 reflected, Policy: The facility must provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with state law .2. The facility is responsible for the timeliness of the services .

Based on observation, interview and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status for one (Resident #28) of ten residents reviewed for nutrition. The facility failed to ensure Resident #28 maintained an acceptable weight causing her to trigger a -7.75 percent weight loss. The facility failed to provide weekly weight checks for Resident #28 beginning 12/19/24 with missing dates of 12/19/24, 12/26/24, 01/02/25, 01/09/25, 01/17/25, 01/23/25. These failures placed residents at-risk for weight loss and inadequate nutrition. Findings included: Review of Resident #28's quarterly MDS assessment, dated 12/11/24 revealed the resident was an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #28 had a BIMS score of 6 which indicated severe cognition impairment. The resident's diagnoses included Anemia (not having enough red blood cells to carry oxygen), High Blood Pressure (pressure inside arteries are higher than it should be) , End Stage Renal Disease (kidney failure), Dysphagia Oropharyngeal Phase (difficulty swallowing which involves the movement of food or liquid from the mouth to the esophagus) and non-Alzheimer's dementia. Resident #28 required supervision or touching assistance with eating. Resident #28's MDS indicated no signs or symptoms of a swallowing disorder. Resident #28's weight indicated 111 with a weight loss/gain of 5% or more in the last month or loss/gain of 10% or more in the last 6 months. Review of Resident #28's care plan, initiated on 1/19/24, reflected Resident #28 had a swallowing problem related to complaints of difficulty or pain with swallowing. Holding food in mouth/cheeks (pocketing), Dysphagia. Goal: Resident #28 will have no chocking episodes when eating. Interventions included All staff to be informed of resident's special dietary and safety needs. Check mouth after a meal for pocketed food and debris. Report to nurse. Provide oral care to remove debris. Monitor for shortness of breath, choking, labored respirations, lung congestion. Record review of Resident #28's care plan, initiated on 03/18/24, revised 12/12/24 also reflected the resident had unplanned or unexpected weight loss. 12/12/24 30-day weight loss. Goal: Resident's weight will return to baseline range by review date. Interventions included: Alert dietician if consumption is poor for more than 48 hours. Give Resident supplements as ordered. Alert nurse/dietician if not consuming on a routine basis. If weight decline persists, contact physician and dietician immediately. Labs as ordered. Report results to physician and ensure dietician is aware. Monitor and evaluate any weight loss. Determine percentage loss and follow facility protocol for weight loss. Monitor and record food intake at each meal. Record review of Resident #28's orders included: orders: 1.Weekly weights related to weight loss; one time a day every Thursday Other Active 12/19/2024 06:00 12/17/2024 2.Regular diet, Mechanical Soft texture, Regular Liquids consistency for diet Diet Active 12/4/2024 09:10 12/4/2024 3.Omeprazole Oral Capsule Delayed Release 20 MG (Omeprazole) Give 1 capsule by mouth one time a day for GERD Do not crush. Pharmacy Active 1/17/2024 07:30 11/8/2024 4.Monday weekly weight; No directions specified for order. Other Active 5/1/2024 5.Megestrol Acetate Oral Suspension 400 MG/10ML (Megestrol Acetate) Give 10 ml by mouth one time a day for Appetite Stimulant Pharmacy Active 1/11/2024 08:00 1/10/2024 Record review of Resident #28's weight chart revealed: 1/10/2025 15:31 113.0 Lbs Wheelchair E1533283 (Manual) 12/12/2024 11:55 111.0 Lbs Standing E1534238 (Manual) 12/8/2024 15:57 101.5 Lbs Standing E1533969 (Manual) 12/12/2024 11:55 by ADON Z Incorrect Documentation 11/6/2024 12:56 118.0 Lbs Standing E1535678 (Manual) 10/7/2024 10:05 105.0 Lbs Wheelchair E1535415 (Manual) 9/9/2024 12:43 104.9 Lbs Wheelchair E1534238 (Manual) Observation and interview on 01/28/25 at 10:43 AM revealed Resident #28 was sitting in her bed. According to Resident #28 she was under the impression that she weighed 110 pounds or more. Resident #28 stated she may be losing weight however felt she still had her hips, which made it hard for her to tell if she was losing weight. Observation and interview of Resident #28 on 01/29/25 at 12:30 PM revealed she ate at least 25-50 percent of her lunch. Resident #28 stated she had enough to eat and was not going to complete her meal. Resident #28 was observed going to her room. Interview on 01/30/25 at 9:56 AM with LVN A revealed she was working with Resident #28, when asked about orders, LVN A stated she was to be weighed every Thursday. LVN A stated Resident #28 had missed weight checks dates of 12/19/24, 12/26/24, 01/02/25, 01/09/25, 01/17/25, 01/23/25. LVN A stated she could not be sure why Resident #28's physician orders had not been followed. LVN A stated aides were responsible for weighing residents, LVN A stated she was also able to weigh residents. LVN A stated Resident #28 had Dementia which led to a diagnosis of Anxiety. LVN A stated Resident #28 would forget that she had not eaten. LVN A stated Resident #28 was on a puree diet and at times would not eat because she did not like the texture, currently on mechanical soft diet. LVN A stated Resident #28 went through a spell of having to be encouraged to eat in the dining room where she could be monitored and encouraged to eat. LVN A stated she could complete a weight check for Resident #28. Observation and interview on 01/30/25 at 10:19 AM of LVN A completing a weight check with Resident #28 revealed LVN A pushing wheelchair to the scale, asking Resident #28 if she was able to stand on the scale. Resident #28 stated yes, I can stand and preceded to hold the handlebars on the scale. The scale was observed to read 102.4. Surveyor asked if resident could also be weighed while sitting in her wheelchair; that weight revealed to be 144.8. LVN A relocated Resident #28 to sit on the couch so that she could weigh the wheelchair. The wheelchair weight revealed to be 40.6 on the scale. According to LVN A she did the math 144.8-40.6=104.2, LVN A stated she was not sure where the 2 pounds resulted from. LVN A stated she was not aware of the weight loss and had Resident #28 been weighed according to physician orders the weight loss could have been noted prior to today. LVN A stated the aides were supposed to weigh according to schedule and alert her so she could enter the weekly weight. LVN A stated she was responsible to ensure the weight checks were done by the aides or herself, not doing so placed Resident #28 at risk of weight loss. Interview on 01/30/25 at 10:30 AM with the Physician revealed he had not been alerted to Resident #28 losing weight, as he noted her to be on a trend upwards. The Physician stated the facility should be following orders and weighing Resident #28 weekly and reporting any concerns. The Physician stated Resident #28 was on a supplement. The Physician stated the nursing staff was responsible for monitoring resident weights, and not doing so placed residents at risk of weight loss without staff knowing. The Physician stated, if we are monitoring the weekly weights correctly something may have come up and we could have consulted nutrition to come up with a plan to prevent weight loss. The Physician stated he was not concerned with Resident #28's weight because she does what she wants to do, and she will tell you what she is not going to do. The Physician stated not following orders for Resident #28 to be weighed placed her at risk of weight loss, and not monitoring her appropriately for maintaining her weight. Interview on 01/30/25 at 11:05 AM with Dietician revealed Resident #28 was on a puree diet and was doing well, however she did not like it. The Dietician stated a speech evaluation was completed and she was able to upgrade to a mechanical soft diet. The Dietician stated I checked in with her on 12/04/24 and noted she was doing fine but needed to get used to the mechanical soft texture. Resident #28's last assessment with me was 01/23/24 and she weighed 113 pounds, I see that her weight was taken today, and she has dropped to 102.4 pounds. The Dietician stated, I am at the facility weekly, when I returned to the facility I would do an assessment, check with her to see how she was doing, and make any recommendations as I saw fit. According to The Dietician the facility has not notified her of the weight loss yet, and further stated since she was there weekly, she would have seen the drop in Resident #28's weight on her own. The Dietician stated if Resident #28 had orders to be weighed weekly, then she should have been weighed weekly. I was concerned she did not like the diet when she was on the puree diet and wondered how she was doing with the mechanical soft diet, being weighed weekly could have given us knowledge if she was maintaining a consistent weight. According to the Dietician she was not concerned at this time because her baseline weight was in the 90's. Observation and Interview on 01/30/25 at 12:39 PM with ADON Z revealed Resident #28's lunch was 25 percent eaten, according to ADON Z although Resident #28 only ate 25 percent of her lunch she ate better during breakfast. ADON Z stated, Resident #28 is a snacker and really enjoyed salads and sandwiches. ADON Z stated, Resident #28 was on puree diet, and did not do well on it but now she was on a mechanical soft diet, which was preferred, which was a process that we had been watching. ADON Z stated weight checks were completed by CNAs, nurses were responsible for ensuring this task was being done. ADON Z stated, not following physician orders to weigh Resident #28 on a weekly basis placed her at risk of weight loss, skin breakdown, and dehydration. Interview on 01/31/25 at 3:32 PM with the DON revealed Resident #28 was on a puree diet but recently changed to mechanical soft and was doing better. The DON stated Resident #28 was a big snacker and will continue to improve. The DON stated she was notified by ADON Z Resident #28 was measured with weight loss, and this was definitely a process they had been watching. According to the DON at the end of the day it was me and nursing leadership's responsibility to make sure physician orders to complete weekly rates were being done, not doing so placed residents at risk of weight loss, skin breakdown, dehydration and not being able to have early intervention. Record review of the facility's undated policy titled Weight Monitoring revealed Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise. Weight can be useful indicator of nutritional status. Significant unintended changes in weight (loos or gain) or insidious weight loss (gradual unintended loss over a period of time) may indicate a nutritional problem. 1. The facility will utilize a systemic approach to optimize a resident's nutritional status to included monitoring the effectiveness of interventions and revising them, as necessary. 2. Assessments should include weight, food, and fluid intake. 3. Interventions will be identified, implemented, monitored, and modified as appropriate. 4. A weight monitoring schedule, residents with significant weight loss, monitor weight weekly.

43791 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 resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and psychosocial needs that are identified in the comprehensive assessment that describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 5 of 16 residents (Residents #26, #32, #37, #54, and #194) reviewed for care plan accuracy. 1. The facility failed to develop and implement care plans for Residents #26, #32, #37, and #54, which addressed the residents' physician orders to be weighed weekly. 2. The facility failed to develop and implement a care plan for Resident #194, which addressed his need for a mechanical lift to be used for transfers. The failure placed residents at risk for potential weight loss and nutrtional decline. Findings included: 1. Record review of Resident #26's undated Admission Record reflected the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included prostate cancer, bone cancer, and diabetes. Record review of Resident #26's admission MDS, dated [DATE], reflected a BIMS score of 3, indicating severely impaired cognitive impairment. The MDS reflected Resident #26 required partial assistance with bed mobility and transfers. Record review of Resident #26's care plan, dated 01/16/25, reflected he required assistance with his ADLs, he was known to wander, and had a cognitive impairment. The care plan did not address weekly weights. Record review of Resident #26's physician orders, dated 01/06/25, reflected the following order: Weekly weights x 4 weeks, then monthly and prn. Record review on 01/30/25 of Resident #26's weights reflected the following weights: 01/06/25 171.2 pounds, 01/07/25 171.2 pounds, and 01/14/25 167.3 pounds. Record review of Resident #32's undated Admission Record reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included traumatic brain injury, kidney disease, difficulty swallowing requiring the placement of a feeding tube. Record review of Resident #32's annual MDS dated [DATE] reflected her BIMS score was not calculated. The MDS reflected Resident #32 required total assistance with all her ADLs. Record review of Resident #32's care plan, dated 12/02/24, reflected she had a self-care deficit, impaired cognition, and required a feeding tube, and unplanned/unexpected weight loss with an intervention to monitor and evaluate any weight loss. She was not care planned for weekly weights. Record review of Resident #32's physician orders, dated 10/21/24, reflected the following order: Weekly weights related to gastric tube status. Record review on 01/30/25 of Resident #32's weights reflected the folloiwng weights: 11/08/24 130.4 pounds, 11/13/24 124.3 pounds, and 12/08/24 123.9 pounds. The 12/08/24 weight was a 4.98% weight loss for Resident #32. Record review of Resident #37's undated Admission Record reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included stroke affecting her left side, difficulty swallowing requiring a feeding tube, and tracheostomy placement. Record review of Resident #37's quarterly MDS assessment, dated 01/10/25, reflected her BIMS score was not calculated. The MDS reflected Resident #37 required total assistance with all her ADLs. Record review of Resident #37's care plan, dated 01/15/25, reflected she had a self-care deficit, required a feeding tube for all nutrition, and requires a tracheostomy for breathing. She is not care planned for weekly weights. Record review of Resident #37's physician orders, dated 12/31/24, reflected the following order: Weigh weekly x 4 weeks, then monthly and as needed. Record review of Resident #37's weights reflected the following weights: 12/31/24 158.0 pounds, and 01/10/25 162.1 pounds. Record review of Resident #54's undated Admission Record reflected the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included diabetes, chronic respiratory failure requiring a tracheostomy, and Parkinson's disease. Record review of Resident #54's quarterly MDS reflected his BIMS score was not calculated. The MDS reflected Resident #54 required total assistance with all his ADLs. Record review of Resident #54's care plan, dated 01/24/25, reflected he had a self-care deficit, limited physical mobility, potential for fluid deficit related to dehydration, and a nutritional problem related to NPO status. He was not care planned for weekly weights. Record review of Resident #54's physician orders, dated 10/21/24, reflected the following order: Weigh weekly related to feeding tube status. Record review of Resident #54's weights reflected the following weights: 11/13/24 175.1 pounds, 12/16/24 170.9 pounds, and 01/10/25 176.4 pounds. Interview on 01/30/25 at 2:45 PM with the DON revealed residents with feeding tubes should be weighed weekly to monitor for weight loss and nutritional status. She stated she did not know why the residents had not been weighed as ordered by the physician. She stated she would have to educate the staff on weighing residents as ordered. 2. Record review of Resident #194's Face Sheet dated 01/31/25 reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE]. Record review of Resident #194's quarterly MDS dated [DATE] reflected Resident #194 was cognitively intact with a BIMS score of 15. Functional limitation in range in motion indicated there was no impairment for upper and lower extremities and a mobility device of a wheelchair. Resident #194 was dependent on 2 or more staff for chair/bed-to-chair transfers, sit to lying, lying to sitting on side of the bed, toilet transfer, and tub/shower transfer. His active diagnosis included abnormalities of gait and mobility, muscle wasting and atrophy (wasting or loss of muscle tissue), lack of coordination, Type 1 Diabetes (chronic condition where the pancreas produces little or no insulin), Stroke (blood flow to an area in the brain is cut off), Renal Insufficiency/Failure or End Stage Renal Disease (poor function of the kidneys). Record review of Resident #194's Care Plan reflected Resident #194 was moderate risk for falls related to deconditioning and gait/balance problems. The care plan goals reflected Resident #194 would be free of minor injury. The care plan interventions included: Be sure 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. Provide resident with mobility device: Wheelchair, walker, or cane. Physical therapy evaluate and treat as ordered or as needed. The Care Plan did not address how much assistance was required for transferring the resident. Observation and interview on 01/28/25 at 1:07 PM with Resident #194 revealed he returned from therapy and was in his room sitting in his wheelchair. The resident had a mechanical lift sling under him in his wheelchair. According to Resident #194 he had a fall, he further stated there was a male aide that was helping him transfer to bed and he fell between the nightstand and the bed. Resident #194 stated he did not hit his head or go to the hospital but did have a skin injury to his elbow which was observed to be losing scab. Resident #194 stated he did not have any further injuries and staff assessed him for pain and injury. Resident #194 stated since the failed transfer he was now transferred by mechanical lift with two people.

Based on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice for 2 of 3 residents (Residents #44 and #54) reviewed for oxygen. 1. The facility failed to have accurate physician orders for Resident #44's oxygen use. 2. The facility failed to ensure Resident #54, who was ventilator dependent, was repositioned every two hours to assist the resident in expectorating secretions. This failure could place residents who received oxygen therapy at risk for inadequate or inappropriate amounts of oxygen delivery and possible infection. Findings included: 1. Review of Resident #44's Admission Record dated 01/08/25 reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident #44's quarterly MDS, dated [DATE], revealed the resident was not able to completed the BIMS due to cognitive impairment. The resident's diagnoses included severe intellectual disabilities (limitations in mental abilities affecting intelligence, learning, and everyday life skills), dysphagia (difficulty swallowing), epilepsy (brain disorder that causes recurring, unprovoked seizures), muscle wasting and atrophy (wasting or loss of muscle tissue), contracture (permanent tightening of the muscles), other lack of coordination. The MDS reflected Resident #44 had no shortness of breath, and she used oxygen therapy. Review of Resident #44's undated care plan reflected Resident #44 had continuous oxygen therapy ordered. The care plan goal reflected: will have no signs and symptoms of poor oxygen absorption. The care plan interventions included: Give medications as ordered by physician. Monitor/document side effects and effectiveness. Suction as needed. The care plan reflected Resident #44 had altered respiratory status/difficulty breathing related to excessive secretions; requires frequent oral suctioning, scopolamine patch ordered. The care plan goal reflected: Resident will maintain normal breathing pattern as evidenced by normal respirations, normal skin color, and regular respiratory rate/pattern. The care Interventions: Administer medication/puffers as ordered. Monitor for effectiveness and side effects. Monitor for signs and symptoms of respiratory distress and report to physician as needed. Increased Respirations; Decreased Pulse oximetry; Increased heart rate; Restlessness; Headaches; Lethargy; Confusion; Cough; Pleuritic pain; Monitor /document/report abnormal breathing patterns to physician; increased rate; decreased rate, periods of apnea (sleep disorder), prolonged inhalation, prolonged exhalation, prolonged shallow breathing, prolonged deep breathing, use of accessory muscles, pursed-lip breathing, nasal flaring. Record review of Resident #44's physician orders revealed: has continuous oxygen therapy ordered. Oxygen at 2LPM via nasal cannula. Date Initiated: 07/09/2021 Revision on: 10/13/2021 Record review of Resident #44's Medication and Treatment Administration Record for the month of January 2025 indicated staff were administrating: Oxygen at 2 liters are needed for shortness of breath every shift started 07/08/21 discontinued 01/27/25. Oxygen at 2 liters per nasal canula continuous every shift start 01/27/25 Observation and interview on 01/28/25 at 12:12 PM revealed Resident #44 was on 3 liters of oxygen by nasal canula. Resident #44 was wake and alert, when speaking to Resident #44 revealed she was unable to communicate with the ability to be understood. Observation of Resident #44 on 01/30/25 at 9:15 AM revealed oxygen rate at 3 liters water bottle dated 01/30/25. Observation and interview on 01/30/25 at 1:07 PM with LVN A revealed she worked with Resident #44 on 6:00 -2:00 PM shift on rotating days. LVN A stated Resident #44 is on 2 liters of oxygen per her order. LVN A checked the order and confirmed she was on 2 liters. When asked to observe Resident #44, LVN A stated Resident #44 was currently on 3 liters of oxygen. LVN A stated Resident #44 was having a cough that was concerning, I did not adjust the oxygen, LVN A then lowered Resident #44's oxygen and checked her pulse oxidation stating she is low at 91 when on 2 liters, and 99 on 3 liters. According to LVN A whomever increased the oxygen to 3 should have had an order to do so and documented about it. LVN A stated she did not see any documentation on the order being increased. LVN A pointed out the progress note and stated she reached out to the Hospice to have a nurse come and assess her, and followed up with ADON Z, and she did not recall if the nurse came in. LVN A stated not following the physician order and increasing oxygen without an order, and not documenting on Resident #44's coughing or need for increased oxygen placed her at risk for decline, something missed or lost, and not getting the treatment she needed. Interview on 01/30/25 at 2:39 PM with the DON revealed nurses were responsible for assessing residents and contacting physician for orders. The DON stated she was not aware Resident #44 was currently administered 3 liters of oxygen with an order for 2 liters. The DON stated her expectation was that the nurse staff who increased the oxygen should have gotten an order to maintain Resident #44's oxygen level to 3liters, not communicating with staff, hospice and family placed Resident #44 at risk of not getting the treatment she needed. On 01/31/25 at 4:00 PM the DON was asked for a policy on following physician orders, and oxygen use the facility revealed after reaching out to their corporate office they did not have a policy. 2. Record review of resident #54's undated Admission Record reflected the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included diabetes, chronic respiratory failure requiring a tracheostomy, and Parkinson's disease. Record review of Resident #54's quarterly MDS reflected his BIMS score was not calculated. His Functional Status indicated he required total assistance with all his ADLs. Record review of Resident #54's care plan, dated 01/24/25, reflected he had a self-care deficit, limited physical mobility, and facility acquired pressure ulcer. Record review of Resident #54's physician orders reflected an order to reposition the resident every two hours. Observation on 01/28/25 at 10:28 AM revealed Resident #54 was positioned on his back, and his legs were contracted to the left. Resident #54 had pillows between his knees. Observation on 01/28/25 at 12:05 PM revealed Resident #54 remained in the same position on his back. Observation on 01/29/25 at 8:10 AM revealed Resident #54 remained in the same position on his back. Observation on 01/29/25 at 12:18 PM revealed Resident #54 was positioned on his left side after wound care was provided. Interview on 01/28/25 at 11:33 AM with LVN K revealed repositioning Resident #54 to his right side induced a lot of secretions and coughing. LVN K would not agree the order to turn the resident every two hours was for that reason, to expectorate secretions. When asked why Resident #54 was never taken out of bed and put into a chair, LVN K stated it would be difficult to do so as the resident would have to be disconnected from his ventilator to move him. LVN K stated she did not do passive ROM with bedridden residents because she needed training by Physical Therapy, so she did not cause any further injury to the resident. LVN K would not answer if she had been trained on ROM during her LVN training. Interview on 01/29/25 at 12:21 PM with the DON revealed getting a resident out of bed and into a chair should not be prevented just because it was difficult to do. The DON stated she was not aware Resident #54 had an order to reposition every two hours. The DON would not agree placing pillows to offload pressure was different from turning or repositioning the resident side to side. Observation on 01/29/25 at 1:15 PM revealed Resident #54 was transferred to a reclining chair using a lift device with three staff members assisting. The resident was transferred without having to be removed from his ventilator.

Based on observation, record review and interview, the facility failed to ensure any drug regimen irregularities reported by the Pharmacist Consultant were acted upon, for one resident (Resident #56) of five residents whose medications were reviewed. The facility's Pharmacy Consultant recommended the physician should consider a gradual dose reduction for Resident #56's Duloxetine (used to treat depression) and Zolpidem (used to treat insomnia) on 08/19/24. The facility failed to ensure this was communicated to the resident's primary care physician regarding the recommendation. This failure could place residents receiving medications at risk for adverse consequences and could cause a decline in their physical, mental, and psychosocial condition. Findings included: Review of Resident #56's Admission Record, dated 01/30/25, reflected she was a [AGE] year-old female who admitted to the facility on [DATE]. Review of Resident #56's Quarterly MDS Assessment, dated 12/03/24, reflected she had a BIMS score of 13 indicating no cognitive impairment. Her active diagnoses included anxiety disorder, depression, and psychotic disorder. The medications she had taken were antipsychotics, antidepressants, and hypnotics. For the medication review, it was noted Resident #56 received antipsychotics on a routine basis, but a gradual dose reduction had not been attempted or documented by a physician as clinically contraindicated. Review of Resident #56's undated care plan, reflected the following: Problem: The resident is on sedative/hypnotic therapy r/t primary insomnia .Goal: The resident will be free of any discomfort or adverse side effects of hypnotic use through the review date .Interventions: Administer sedative/hypnotic medications as ordered by physician .Problem: The resident uses antidepressant medication r/t major depressive disorder .Goal: The resident will be free from discomfort or adverse reactions related to antidepressant therapy through the review date .Interventions: Administer Antidepressant medications as ordered by physician. Review of Resident #56's Order Summary Report reflected the following: - Duloxetine HCI Oral Capsule Delayed Release Particles 60 MG (Duloxetine HCI), Give 60 mg by mouth one time a day for major depressive disorder unspecified - Zolpidem Tartrate Oral Tablet 10 MG (Zolpidem Tartrate), Give 10 mg by mouth at bedtime for insomnia Review of Resident #56's January 2025 MAR reflected she received duloxetine and zolpidem every day as ordered. Review of Resident #56's Medication Regimen Review Report, dated 08/19/24, reflected: Resident is receiving the following psychoactive medications that are due for review. Per CMS regulations, please evaluate resident for trial dose reduction. Duloxetine 60mg QD -> Duloxetine 40mg QD Zolpidem 10mg QHS If dose reduction is contraindicated or resident failed previous reduction attempt, please document below. Review of Resident #56's Consultant Pharmacist/Physician Communication form, dated 08/19/24 reflected: [At the top right corner of the page had a message of 'Not our patient'] Dear [Physician J], Resident is receiving the following psychoactive medications that are due for review. Per CMS regulations, please evaluate resident for trial dose reduction. Duloxetine 60mg QD -> Duloxetine 40mg QD Zolpidem 10mg QHS If dose reduction is contraindicated or resident failed previous reduction attempt, please document below. [The bottom part of the form was blank where the Physician/Prescriber Response]. Observation and interview on 01/28/25 at 11:00 AM with Resident #56 revealed she was in her room laying in her bed; she was fully dressed and groomed. Resident #56 said she was doing okay today. Interview on 01/30/25 at 3:21 PM with ADON G revealed she vaguely remembered seeing something in the pharmacy recommendations regarding Resident #56's medications. ADON G said a lot of times doctors will write notes about the recommendations and sometimes they agreed with the pharmacy recommendations and sometimes they did not. ADON G said there should have been a note that the facility received back from them and the facility followed whatever was needed for the resident. ADON G said the doctor would write they disagreed for this reason on the note. ADON G said she was not sure if she was the only one responsible for checking and following up on the pharmacy recommendations. ADON G said the purpose of the pharmacy recommendations was to try and see if some of the medications could be weaned down or if they were still necessary for the resident to keep taking. ADON G said she had a file that the pharmacy recommendations go into so the doctors could review them when they came to the building. ADON G said she looked for any notes that came from the pharmacy recommendations and followed up to see what the doctor decided on. ADON G said the attending physician or NP were notified when there was paperwork that needed to be reviewed or required their signature, and they were responsible for checking and following up on the paperwork in the folder for them. ADON G said if a GDR was not completed timely or assessed for a lot of things could happen. ADON G said if pharmacy recommendations were not followed up on her answer was pharmacy recommendations [did] not always mean the doctor would agree to it. ADON G said that while the pharmacist completed their review and made a recommendation, the attending physician was the one who would give the order to change a medication. ADON G was not sure how often a GDR was supposed to be considered. ADON G said she just went off the list of when a GDR needed to be considered. Interview on 01/31/25 at 8:59 AM with the DON revealed she found no evidence that the doctor reviewed Resident #56's medications for a GDR or that it was noted to be contraindicated. The DON said the only thing she could say was that ADON G was still learning the process and since then has improved. The DON said it appeared that the GDR was not attempted, and she had no further information other than that. A follow-up interview on 01/31/25 at 12:06 PM with the DON revealed she was not sure when ADON G took over the pharmacy recommendations responsibility, but at the end of the day as the DON for the building she was ultimately responsible. The DON said the purpose of following up on the pharmacy recommendations was that the medications needed to be reviewed and GDRs attempted. The DON said any resident on a psychotropic or anti-psychotic needed to have a GDR attempted if possible or at least reviewed for a GDR attempt. The DON said GDR attempts were done annually if not contraindicated. The DON said if a pharmacy recommendation was not followed up on or a GDR was not attempted, a resident would continue on that medication regimen. The DON said the doctor reviewed the medications as well as the pharmacist. The DON said the pharmacist would also follow up for the next month on any recommendations that were missed by the doctor or facility because the recommendation would still reappear to the next month. Review of the facility's policy, revised 01/16, titled Psychoactive Medications and Behavior Monitoring reflected: 4. Drug Regimen reviews will be conducted by the pharmacist for unnecessary use, excessive doses or duration in absence of acceptable medical diagnosis according to standard of practice. Recommendations will be communicated to the attending physician with recommendations either reduce or eliminate drug usage as appropriate.

Based on observation, interviews and record reviews, the facility failed to ensure residents who use psychotropic drugs receive gradual dose reductions unless clinically contraindicated, in an effort to discontinue these drugs for 1 (Resident #56) of 3 residents reviewed for unnecessary medications/ gradual dose reduction. The facility failed to ensure a gradual dose reduction (GDR) was attempted or to document contraindication for a gradual dose reduction for Resident #56's ordered Duloxetine (an antidepressant used to treat depression) and Zolpidem (a sedative-hypnotic used to treat insomnia). This failure could place residents at risk for possible psychotropic medication side effects, adverse consequences, decreased quality of life and dependence on unnecessary medications. Findings included: Review of Resident #56's admission Record, dated 01/30/25, reflected she was a [AGE] year-old female who admitted to the facility on [DATE]. Review of Resident #56's Quarterly MDS Assessment, dated 12/03/24, reflected she had a BIMS score of 13 indicating no cognitive impairment. Her active diagnoses included anxiety disorder, depression, and psychotic disorder. The medications she had taken were antipsychotics, antidepressants, and hypnotics. For the medication review, it was noted Resident #56 received antipsychotics on a routine basis but a gradual dose reduction had not been attempted or documented by a physician as clinically contraindicated. Review of Resident #56's undated care plan, reflected the following: Problem: The resident is on sedative/hypnotic therapy r/t primary insomnia .Goal: The resident will be free of any discomfort or adverse side effects of hypnotic use through the review date .Interventions: Administer sedative/hypnotic medications as ordered by physician .Problem: The resident uses antidepressant medication r/t major depressive disorder .Goal: The resident will be free from discomfort or adverse reactions related to antidepressant therapy through the review date .Interventions: Administer Antidepressant medications as ordered by physician. Review of Resident #56's Order Summary Report reflected the following: - Duloxetine HCI Oral Capsule Delayed Release Particles 60 MG (Duloxetine HCI), Give 60 mg by mouth one time a day for major depressive disorder unspecified - Zolpidem Tartrate Oral Tablet 10 MG (Zolpidem Tartrate), Give 10 mg by mouth at bedtime for insomnia Review of Resident #56's January 2025 MAR reflected she received duloxetine and zolpidem every day as ordered. Review of Resident #56's Medication Regimen Review Report, dated 08/19/24, reflected: Resident is receiving the following psychoactive medications that are due for review. Per CMS regulations, please evaluate resident for trial dose reduction. Duloxetine 60mg QD -> Duloxetine 40mg QD Zolpidem 10mg QHS If dose reduction is contraindicated or resident failed previous reduction attempt, please document below. Review of Resident #56's Consultant Pharmacist/Physician Communication form, dated 08/19/24 reflected: [At the top right corner of the page had a message of 'Not our patient'] Dear [Physician J], Resident is receiving the following psychoactive medications that are due for review. Per CMS regulations, please evaluate resident for trial dose reduction. Duloxetine 60mg QD -> Duloxetine 40mg QD Zolpidem 10mg QHS If dose reduction is contraindicated or resident failed previous reduction attempt, please document below. [The bottom part of the form was blank where the Physician/Prescriber Response]. Observation and interview on 01/28/25 at 11:00 AM with Resident #56 revealed she was in her room laying in her bed; she was fully dressed and groomed. Resident #56 said she was doing okay today. Interview on 01/30/25 at 3:21 PM with ADON G revealed she vaguely remembered seeing something in the pharmacy recommendations regarding Resident #56's medications. ADON G said a lot of times doctors will write notes about the recommendations and sometimes they agreed with the pharmacy recommendations and sometimes they did not. ADON G said there should have been a note that the facility received back from them and the facility followed whatever was needed for the resident. ADON G said the doctor would write they disagreed for this reason on the note. ADON G said she was not sure if she was the only one responsible for checking and following up on the pharmacy recommendations. ADON G said the purpose of the pharmacy recommendations was to try and see if some of the medications could be weaned down or if they were still necessary for the resident to keep taking. ADON G said she had a file that the pharmacy recommendations go into so the doctors could review them when they came to the building. ADON G said she looked for any notes that came from the pharmacy recommendations and followed up to see what the doctor decided on. ADON G said the attending physician or NP are notified when there is paperwork that needed to be reviewed or required their signature, and they were responsible for checking and following up on the paperwork in the folder for them. ADON G said if a GDR was not completed timely or assessed for a lot of things could happen. ADON G said if pharmacy recommendations were not followed up on her answer was pharmacy recommendations [did] not always mean the doctor would agree to it. ADON G said that while the pharmacist completed their review and made a recommendation, the attending physician was the one who would give the order to change a medication. ADON G was not sure how often a GDR was supposed to be considered. ADON G said she just went off the list of when a GDR needed to be considered. Interview on 01/31/25 at 8:59 AM with the DON revealed she found no evidence that the doctor reviewed Resident #56's medications for a GDR or that it was noted to be contraindicated. The DON said the only thing she could say was that ADON G was still learning the process and since then has improved. The DON said it appeared that the GDR was not attempted, and she had no further information other than that. A follow-up interview on 01/31/25 at 12:06 PM with the DON revealed she was not sure when ADON G took over the pharmacy recommendations responsibility, but at the end of the day as the DON for the building she was ultimately responsible. The DON said the purpose of following up on the pharmacy recommendations was that the medications needed to be reviewed and GDRs attempted. The DON said any resident on a psychotropic or anti-psychotic needed to have a GDR attempted if possible or at least reviewed for a GDR attempt. The DON said GDR attempts were done annually if not contraindicated. The DON said if a pharmacy recommendation was not followed up on or a GDR was not attempted, a resident would continue on that medication regimen. The DON said the doctor reviewed the medications as well as the pharmacist. The DON said the pharmacist would also follow up for the next month on any recommendations that were missed by the doctor or facility because the recommendation would still reappear to the next month. Review of the facility's policy, revised 01/16, titled Psychoactive Medications and Behavior Monitoring reflected: 4. Drug Regimen reviews will be conducted by the pharmacist for unnecessary use, excessive doses or duration in absence of acceptable medical diagnosis according to standard of practice. Recommendations will be communicated to the attending physician with recommendations either reduce or eliminate drug usage as appropriate.

Based on observations and interviews, the facility failed to ensure the menus were followed for 1 (the lunch meal on 01/28/25) of 2 meals reviewed for menus. The facility did not serve the posted lunch menu of roast beef, red cabbage, dill potatoes, or ice cream on 01/28/25. This failure could affect all residents in the facility, who eat from the kitchen, by placing them at risk of not knowing what was going to be served for that meal. Findings included: Observation on 01/28/25 at 12:00 PM of the monthly menu posted near the dining room reflected for Tuesday, January 28th the following: Roast Beef, Dill Potatoes, Red Cabbage, Wheat Bread, Margarine, Ice Cream, Coffee or Tea, Garnish Parsley Sprig. Observation on 01/28/25 at 12:17 PM revealed an unknown dietary aide brought the daily menu posting to the 3rd floor dining room area which listed the following: beef tips, season potatoes, cabbage, roll with butter, and pears. Interview on 01/28/25 at 12:22 PM with Resident #22 revealed the menu was not usually posted or followed. Resident #22 said she never knew what was going to be served for the day. Observation and interview on 01/28/25 at 12:45 PM with the Head [NAME] revealed the following items were being served for lunch today: beef tips, green cabbage, rosemary potatoes, a roll, and pears. Interview on 01/28/25 at 2:07 PM with the Head [NAME] revealed she knew the DM would not be at the facility today but his absence did not interrupt anything with the lunch service earlier. The Head [NAME] said the beef tips, rosemary potatoes, red cabbage, and pears were all substituted during the lunch meal service because the other items were not provided by the supplier from the week's order. The Head [NAME] said the menu was posted upstairs to let residents know what they were going to be served for that meal. The Head [NAME] said normally the DM makes sure the daily menu was posted at the beginning of the day but if he was not at the facility one of the dietary aides could post it instead. The Head [NAME] said the residents did not know what they were being served until they received their plate today because it did not match the posted menu. The Head [NAME] said the purpose of following the menu was so that residents would know what they were being served for that day and if they were going to like it or not. The Head [NAME] said that substitutions happen on the fly sometimes and sometimes they knew about them in advance. Interview on 01/31/25 at 1:04 PM with the DM revealed while he was not here on Tuesday (01/28/25) his staff should have still been able to continue the normal procedures of the kitchen and meal service. The DM said the menu should be posted daily and if things on the menu were not available that needed to be communicated to the residents. The DM said the posted menu should always match what was being cooked for the residents for that meal. The DM said the purpose of serving what the menu said was so the residents know what they were being served so if they did not like something they can ask for something else. The DM said if residents were not served what was posted on the menu it could be misleading to them .

Based on interviews and record reviews the facility failed to ensure, based on the comprehensive assessment of a resident, that residents received treatment and care received care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 4 residents (Resident #1) reviewed for quality of care. The facility failed to ensure LVN A followed proper procedure during wound care for Resident #1, and caused Resident #1's wound to start bleeding uncontrollably. This led to Resident #1 being transported to the hospital via EMS and Resident #1 was admitted to the hospital, required 4 blood transfusions due to blood loss, and was at risk of death. This failure placed the resident at risk of not receiving treatment and care in accordance with professional standards of practice which could lead to serious injury, hospitalization or death and resulted in actual harm to Resident #1. An Immediate Jeopardy situation was identified on 7/20/23. While the IJ was removed on 7/21/23 the facility remained out of compliance at a scope of isolated with actual harm that is not immediate, due to the facility's need to evaluate the effectiveness of the corrective systems. Findings include: Record review of Resident #1's Admission Record revealed she was a [AGE] year-old female admitted to the facility on [DATE] and discharged to the hospital on 7/04/23. Resident #1 had diagnoses that included abscess to her buttocks and upper thigh requiring surgical intervention, diabetes, and obesity. Record review of Resident #1's admission MDS assessment, dated 7/02/23, revealed she had a BIMS score of 10, which indicated moderate cognitive impairment. Her Functional Status indicated she required extensive assistance with all her ADLs. Record review of Resident #1's baseline care plan, dated 6/28/23, revealed she was at risk for skin impairment related to a wound on the buttocks and upper thigh. Record review of the EMS report, dated 7/04/23, revealed: Upon EMS arrival pt was found lying in her hospital bed right lateral recumbent in a pool of her own blood . Staffing reported that pt was getting her wound vac changed when the nurse pulled it too hard and pt started hemorrhaging, staffing reported that it took 2 hrs for staffing to call 911. The nurse doing t care reported that pt was bleeding significantly and that she tried for 2 hrs to fix pt prior to calling EMS. Pt is being transported to the hospital for further evaluations. PT is [AGE] year old female Alert mostly spontaneously, but once b/p got low pt was alert to painful stimuli and then once it raised again pt was spontaneously alert and oriented X 4. Upon initial assessment EMS noted that pt was pale, cool, and moist. That pt was pouring out blood from her wound vac EMS patched up pt's wound, then IV access was obtained. EMS gave pt 4mg of Zofran and 10mcg of push dose epinephrine X 4 EMS noted along the way that IV access was positional and would not push drugs or fluids well. IO access was obtained then fluids was given wide open. Pt was monitored and transported. ALS assessment was performed by EMT-P. All vitals and other evaluations can be found in charts.Pt is being transported to [hospital] due to severe hemorrhaging. EMS vital signs were as follows: 10:46 PM Respirations 16, Pulse 118 [high], O2 saturation Room Air 98% , Blood pressure 92 / 62 [low], Shock Alert 10:50 PM Pulse 121 [high], Respirations 16. O2 Saturation 99%, Blood pressure 88/64 [low], Shock Alert EMS Dispatched at 10:30 PM Arrived at facility at 10:34 PM Left the facility at 11:11 PM Arrived at hospital 11:16 PM Record review of hospital ER records revealed on 07/04/23 Resident #1 was taken to a trauma resuscitation room on arrival. Blood pressure was low, 103/67, pulse 109, pain 10/10. Bedside hemoglobin was 6.9 (normal is 11-15), resident had an order to transfer two units of blood and was transfused with two units of O negative while waiting for crossmatch to be done. Post transfusion her Hgb was 11.2. Resident received an addition two units of cross matched blood after admission. Wound was treated with quick clot, trauma dressings and direct pressure to control bleeding. ER physician documented Large wound to left lateral posterior thigh with wound VAC in place, significant blood clots present underneath the clear dressing Resident's admitting diagnoses: hemorrhage (loss of blood) from wound, hemorrhagic shock (significant blood loss that causes a lack of oxygen to cells and leads to shock), transient hypotension (sudden drop in blood pressure). ER Vital signs: 11:25 PM 103/67 109 1:30 AM 107/66 82 Record review of LVN-A's nursing note on 7/04/23 at 11:20 PM revealed: went to change pt wound vac. while removing and wetting previous sponge from wound, wound beginned [sic] to bleed. i attempted to stop the bledding[sic] and resumed with applying the wound vac.after two failed attempts wound vac would suction but would loose [sic] it attachment do [sic] to bleeding.after holding preesure [sic] and observing how much blood was being lost i got help from the other nurse that was on duty to help control the bleeding from the wound vac.vitals was taking and where stable 120/80. after failed attemps [sic] MD was called and explained what was going on and told me to send pt out [hospital] emt arrivied [sic] and worked with us with getting pt transfer to stretcher to transfer pt out to [hospital] Interview on 7/19/23 at 11:37 AM, the family member of Resident #1 stated she was notified on the evening of 7/04/23 that Resident #1 was being sent to the hospital because she was bleeding from her surgical cite. The family member arrived and was told that a nurse had pulled Resident#1's dressing off too fast and the wound started to bleed and would not stop. Resident #1 was sent to the ER where she received two blood transfusions. Interview on 7/20/23 at 2:35 PM, LVN-A stated she was changing Resident #1's wound vac as a scheduled change. She removed the plastic cover, wet the sponge and was removing the sponge when the wound began to bleed. The wound was bleeding from the wound bed itself, not from the edges of the wound. She attempted to stop the bleeding with direct pressure. When the bleeding would not stop, she contacted the physician and received an order to send the resident to the ER. LVN-A stated from the time of wound vac removal to EMS arrival was about 45 minutes. She stated Resident #1 left the facility by 10:30 PM. LVN-A stated Resident #1's vitals were stable, and the resident was awake and alert. Interview on 07/20/23 at 3:40 PM, CNA-B stated she assisted LVN-A with changing Resident #1's wound vac. She stated the wound vac was turned off when they rolled the resident to her right side to start the procedure. CNA-B stated she helped the wound care nurse with multiple wound vac changes in the past, and this one was not done properly. CNA-B stated LVN-A pulled the wound vac cover and sponge off very roughly, the resident was saying ouch and that hurts. She stated the nurse did not wet the sponge before taking it off, and the wound began to bleed like a faucet. She stated the sponge was not soaked with blood or drainage like she had seen with other wound vac changes. CNA-B stated LVN-A tried to use pressure to stop the bleeding, and then tried to reapply the wound vac but it would not stick because of the bleeding. CNA-B stated she went to retrieve another nurse, LVN-C, to help LVN-A because she did not seem like she knew what she was doing. CNA-B stated they began the procedure around 9:00 PM and EMS got there around 10:30 PM. CNA-B stated Resident #1 was very pale and sweaty when EMS arrived. Interview on 7/20/23 at 3:50 PM, the ADON stated she conducted interviews with the staff involved and determined there was a need for re-education on wound vacs. She would not say if LVN-A's actions were incorrect, but she needed to be re-educated. Education had been scheduled for the end of the month. On-going education was a provided as wound vacs came into the facility. ADON provided the in-service documentation for LVN-A that had been completed on 07/05/23. Interview on 07/20/23 at 3:30 PM, LVN-C stated she was called to the room by the CNA-B because Resident #1 was bleeding everywhere. When she entered the room LVN-A was trying to put the wound vac back in place. LVN-C stated when she turned on the wound vac a lot of blood came out of the suction tubing, and it started bleeding around the tape. LVN-C stated she told LVN-A that was not normal and to call the ADON. LVN-C stated she did not see any vitals taken while she was involved, but based on her experience and the resident's appearance, she would have expected her blood pressure to be on the low end and not normal ranges. Interview on 7/20/23 at 5:10 PM with the RN at hospital ER, she stated she had cared for Resident #1 in the ER previously and on this visit, she was not in her normal state. Resident #1 arrived minimally responsive, pale, and sweaty, with the dressing and wound vac in place to her posterior thigh/buttock, nursing home sheets, and EMS sheets were all soaked with blood. Resident #1 had an IO in place and was rapidly transfused with 2 units of O negative blood. Interview on 7/21/23 at 10:21 AM, the Wound Care Nurse stated if the wound vac was working properly, one would hear a quiet humming and if it was turned off there would be no alarm or alert other than the green light being off. It would alarm if there was an issue such as loss of suction, or full canister. The normal procedure for a wound vac change was to pre-medicate the resident for pain, slowly remove the outer dressing, use alcohol wipes if it was adhering to the skin, and removed the foam from the wound. If the wound vac was working, there was usually drainage on the sponge which kept it from sticking to the wound. If there was scant or no drainage you would wet it with normal saline and slowly remove it, otherwise it would pull off tissue, clots, etc. and cause bleeding. In most cases if the procedure was done right, there was little to no bleeding. The Wound Care Nurse stated the facility did not get a lot of wound vacs, so when one was expected she or the ADON would update staff on the care of wound vacs, and the physician also wrote an order on how to care for the wound vac. The Wound Care Nurse was on vacation while Resident #1 was in the facility, so the ADON handled the education. The type or model of wound vac they got depended on what was applied at the hospital if they are coming from one, or what type the supply company sent if it was being placed at the facility for the first time. This was determined to be an Immediate Jeopardy (IJ) on 07/20/23 at 5:00 PM. The Administrator was notified. The Administrator was provided with the IJ template on 07/20/23 at 5:00 PM. The following Plan of Removal submitted by the facility was accepted on 7/21/23 at 4:00 PM: LETTER OF CREDIBLE ALLEGATION FOR REMOVAL OF IMMEDIATE JEOPARDY Issue: F-Tag 684: Quality of Care. The facility failed to ensure a resident with a wound vac, used to treat a surgical wound, receive treatment and care in accordance with professional standards of practice. Done for those affected: Resident #1 no longer resides at the facility. Identify residents who could be affected: The Director of Nursing/ designee reviewed on 7/20/23 if there were any other residents with negative pressure devices in the center and none were identified. The Director of Nursing/ designee will evaluate residents on 7/21/23 with surgical wounds to ensure that treatments are provided as ordered. Action Taken: The nurse was provided 1:1 re-education on the use of negative pressure on 7/5/23 by the Assistant Director of Nursing. Effective immediately on 7/20/2023, the Administrator/ DON and/ or designee began reeducation to all licensed nurses on the following: o Abuse and Neglect o Orders needed for Negative Pressure Wound Care o Procedures for Negative Pressure Wound Dressings Remove old dressing Clean as ordered Assess skin/ wound characteristics Apply A side layer on affected area Apply black sponge cut to wound size Apply B side layer on affected area Close wound Ensure adequate seal & vac function The DON/Designee will check each negative pressure machine daily to ensure the machine is applied and running as ordered. The Charge Nurses will assess each negative pressure machine each shift to ensure it is applied and running as ordered. All CNAs will be trained on 7/21/23 to report to the Charge Nurse immediately if a negative pressure machine becomes o Disconnected from the resident; o Begins to beep; o Is turned off; o If power is lost; o If the Resident complains of pain Staff will be re-educated prior to the start of their next scheduled shift. Any Licensed Nursing/CNA Staff on FMLA, Leave of Absence or PTO will be reeducated prior to the start of their next scheduled shift. To monitor, the Director of Nursing/ designee will review in the Clinical Morning Meeting, attended Monday - Friday, the new orders for residents. Should orders for Negative Pressure be present they will validate the orders are present for the site, dressing, pressure and how often to change. Should orders not contain the necessary components, the ordering physician will be notified. Director of Nursing/ designee will monitor that surgical wound treatments are performed as ordered by observing licensed nurses who perform them each day for 72 hours and then three times per week for four weeks. Trends from monitoring will be reported to the QAPI Committee weekly for four weeks and then monthly for three months. Involvement of Medical Director: The Medical Director was notified about the immediate jeopardy on 7/20/2023. Who is responsible for the implementation of the process? The Director of Nursing for the implementation of the process. Who is responsible for the monitoring of the process? The Facility Administrator will be responsible for monitoring the implementation of the process. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy issued on 7/20/2023. Monitoring of the POR included the following. Interview on 7/21/23 at 10:35 AM, CNA-D stated she did not hear of any issues with Resident #1's wound vac not working on her shift on 7/04/23. She stated Resident #1 was usually awake during the day when she cared for her. Interview on 7/21/23 at 2:00 PM, LVN-E stated she was in-serviced on wound vacs when she came to work. She stated they discussed how to place the wound vac on the wound, the orders that should be in place for the care of the wound vac, and to document the output in a progress note. Interview on 7/21/23 at 2:05 PM, CNA-D stated she had been in-serviced on wound vacs before work. She stated they covered wound vac care, physician orders, how to change the vac, and what to document. Interview on 7/21/23 at 3:23 PM, LVN-A stated she had been in-serviced on wound vacs this afternoon. She stated they covered physician orders, changing schedule, who was responsible for changing it. Document in a wound note about the output every shift. LVN-A also stated Resident #1 never asked her to stop, did not complain of pain. Interview on 7/21/23 at 3:27 PM, LVN-E stated she was in-serviced on wound vacs this afternoon. She stated they covered how to change the wound vac, the physician orders that needed to be in place, how to trouble shoot it, and to document output in a wound note. Interview on 7/21/23 at 3:36 PM, LVN-G stated she had been in-serviced on wound vacs this afternoon. She stated they covered how to check the vac for operation, how to trouble shoot it, when to change the vac, and to document the output. Interview on 7/21/23 at 3:39 PM, LVN-C stated she had been in-serviced on wound vacs this afternoon. She stated they covered who was responsible for wound vac care, the setting for the psi, placement of the vac, troubleshooting it, how to put a wet to dry dressing on if it stops working, document output in a progress note. Interview on 7/21/23 at 3:42 PM, LVN-H stated he had been in-serviced on wound vacs this afternoon. He stated they covered the procedures for changing a vac, physician orders, troubleshooting the vac, to put a wet to dry dressing if wound vac stopped, and to document output in a nurse progress note. Interview on 7/21/223 at 4:35 PM, the DON stated the facility did not have a policy on negative pressure devices (wound vacs) specifically. She stated she checked the facility, there are no negative pressure devices on any residents. She reviewed all residents receiving wound care with the wound care nurse and checked their orders for completeness. She will round twice a week with the wound care nurse to monitor residents receiving wound care and enter a progress note on her observations. The Administrator was informed the Immediate Jeopardy was removed on 07/21/23 at 5:00 PM. The facility remained out of compliance at a severity level of actual harm that is not immediate and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview and record review the facility failed to ensure pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences, for one (Resident #14) of six residents reviewed for pain management. 1. The facility did not give Resident #14 pain medication as requested and ordered, causing Resident #14 to experience unnecessary pain for at least 10 days. 2. The facility failed to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. The facility failed to ensure that Resident #14's PRN pain medication, [MEDICATION(S)], was available for administration. These failures affected one resident and placed all residents who require pain management at risk for further decline in their mental and/or physical functioning, unnecessary pain, and discomfort. Findings included: Review of Resident #14's face sheet, dated 10/19/22, revealed the resident was an [AGE] year-old male, admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #14's quarterly MDS Assessment, dated 08/02/22, reflected a BIMS score of 15, which indicated the resident was cognitively intact. Resident #14 had presence of frequent pain. Record review of Resident #14's care plan, revised on 03/02/22, reflected the resident was on pain medication therapy related to chronic pain. Resident #14's interventions included: administering analgesic medications as ordered by the physician, monitoring and documenting the side effects and effectiveness every shift, asking the physician to review medication if side effects persisted, and monitoring and documenting adverse reactions to medications. Record review of Resident #14's physician orders, dated 04/17/22, reflected an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #14's physician orders, with a start date of 01/21/22, reflected an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #14's September 2022 MAR reflected Resident #14 received his [MEDICATION(S)] patch every 72 hours all month, with the last one being topically applied on 09/29/22 and scheduled to be removed and replaced on 10/02/22. Review of Resident #14's October 2022 MAR reflected Resident #14 did not have a [MEDICATION(S)] patch topically applied until 10/11/22. Review of Resident #14's October 2022 MAR reflected Resident #14 did not receive any PRN [MEDICATION(S)] until 10/08/22, and his pain level was documented as a 10. Resident #14 continued to get PRN [MEDICATION(S)] on 10/09/22 with pain level documented at a 10 and on 10/10/22 with pain level documented at a 5. Interview and observation on 10/17/22 at 9:15 AM with Resident #14 revealed he was sitting his wheelchair talking to his roommate. Resident #14 was dressed and well [NAME] with no visible marks or bruises. Resident #14 was not grimacing and did not indicate being in any pain at the time. He stated he was currently doing well; however, he had been in a lot of pain approximately three weeks prior. Resident #14 stated one of the nurses had a miscommunication with the physician and informed the nursing staff that all of resident's pain medication was to be held per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . He stated after the misunderstanding was cleared up, the physician came to personally apologize to him. Record review of Resident #14' EHR reflected a nurses' note written by RN H, dated 10/08/22 at 5:21 PM, which reflected: As reported to this nurse, all of resident's pain medication is held until he sees a pain management specialist, upon checking residents' vitals, a marked increase in BP is noted as well as resident c/o pain. This nurse contacted Dr. about his pain medication being held. Dr. made it very clear that residents can continue current pain medications, resident asked for his medications to be increased, Dr. is refusing to INCREASE until resident sees a pain management specialist. At this time per Dr. orders, continue with current pain medicine regimen. Interview on 10/18/22 at 1:36 PM with RN H revealed she only worked during the weekend and had worked at the facility since March 2022. RN H stated she worked as charge nurse on the 300 hall on 10/08/22, and when she arrived on shift, she found the medication nurse passing medications, who then informed her that Resident #14 did not have any [MEDICATION(S)] patches available. RN H stated that was when RN I told them that Resident #14's pain medications had been placed on hold, so he did not need any. RN H stated she looked at the documentation to find an order from the doctor and to see who received it, but she could not find anything. RN H stated she proceeded to check Resident #14's vitals and found that his blood pressure was high. She stated Resident #14 told her that the nurses had been holding his pain medications all week, and he had been in pain. RN H stated that was when she decided to contact the doctor and found that there was never an order to hold pain medications. RN H stated she was able to pull [MEDICATION(S)] from the emergency supply/med bank; however, there were no [MEDICATION(S)] patches to pull. RN H stated she informed the doctor that Resident #14's [MEDICATION(S)] patches needed to be reordered. RN H stated she went ahead and administered the [MEDICATION(S)], and it provided resident some relief. Record review of Resident #14' EHR reflected a nurses' note written by RN I, dated 10/12/22 at 6:54 PM, which reflected: Resident has been off his usual medications for over two weeks now. Nurse called DR, and dr stated that he did not d/c his medication. Medication was reordered and resident back to his medication routine. Now resident is back on his regime of pain medication after two weeks and he became very drowsy. Interview on 10/18/22 at 5:35 PM with RN I revealed she had worked at the facility since May 2022. She stated she worked the 2:00 PM - 10:00 PM shift on the 300 Hall and had worked with Resident #14. RN I stated she received report on 10/03/22 from the morning shift informing the doctor had held all of Resident #14's pain medications. RN I stated the facility used a lot of agency nurses, and she could not remember exactly who gave her report that morning. RN I denied ever having a conversation with the doctor regarding Resident #14's pain medications and stated she was just passing along the report that she had received. RN I stated usually when a doctor held any medication, there would be a hold order and stop date on the MAR. RN I could not recall whether she confirmed seeing an order in Resident #14's records. RN I admitted that she dropped the ball by not confirming whether there was a hold order in place. She also admitted that she could have used her nursing judgement to contact the doctor when Resident #14 continued to express being in pain. RN I stated Resident #14 did not have any [MEDICATION(S)] or [MEDICATION(S)] patches in the medication cart at that time. She denied trying to reorder either of the medications due to thinking that all pain medications had been placed on hold. RN I stated when her shift started on 10/12/22, she was informed that RN H had confirmed with the doctor that there had been a miscommunication, and the doctor never said to hold all of Resident #14's pain medications. RN I stated they were told to immediately continue all pain medications as ordered. RN I stated at that time, Resident #14's [MEDICATION(S)] patches and [MEDICATION(S)] were back in supply at the facility, and he was able to receive them as ordered. RN I denied ever being in-serviced or trained by the facility on when to contact the physician or how to document or communicate clear orders. She stated those were all typical nursing practices that all nurses just knew. Interview on 10/17/22 at 5:11 PM with the Interim DON revealed she was aware of the miscommunication regarding Resident #14's pain medication. The Interim DON admitted there was no documentation to show which nurse had communication with the doctor and misunderstood the order. The Interim DON stated the notes that were documented were from nurses who received the information second-hand, and it did not indicate who the information was received from. The Interim DON looked at Resident #14's October 2022 MAR and acknowledged that Resident #14 was given PRN [MEDICATION(S)] on 10/08/22-10/10/22, 10/12/22-10/13/22, and 10/15/22-10/17/22, and that he had not had a [MEDICATION(S)] patch placed since 09/29/22. The Interim DON recalled a clinical team meeting held on 10/04/22 where Resident #14's pain management was discussed. The Interim DON recalled the team stating Resident #14 needed to see a pain management specialist; however, she was unsure if that appointment had been completed. At that time, the error with Resident #14's pain medication had not been discovered. The Interim DON admitted the nursing staff should have contacted the physician sooner, when Resident #14 expressed being in pain, which would have led to the miscommunication being cleared up sooner. The Interim DON stated this mistake placed Resident #14 at risk of being in continuous pain. Interview on 10/18/22 at 9:56 AM with MD F revealed he recalled speaking with a nurse during the second weekend of October, but he could not recall the exact day or the nurse he spoke with. MD F stated the call was regarding Resident #14's pain medication being held. MD F stated he informed the nurse that he did not give an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . MD F stated he informed the nurse that Resident #14 wanted his pain medications increased; however, he refused to do so until resident had a consultation with a pain management specialist. After finding that there had been an error with Resident #14's pain medication, MD F stated the nurse also told him the facility did not any [MEDICATION(S)] patches in supply and that they needed to be reordered by a physician due to an issue with the insurance. MD F stated he contacted the pharmacy on the same day, which was over the weekend, with no resolve. MD F stated he visited the facility on 10/10/22, when he contacted the pharmacy again and was informed that due to Resident #14's payor source, the [MEDICATION(S)] patches could only be sent out in a 30-day supply at one time. MD F stated he was able to reorder the [MEDICATION(S)] patches on that day and Resident #14 was able to receive the medication on the following day. MD F denied being aware that the facility did not have PRN [MEDICATION(S)] available for Resident #14. MD F stated it was his medical opinion that Resident #14 was more reliant on the euphoric feeling of pain medication than for the management of his pain, and therefore he referred Resident #14 to a pain management specialist. MD F stated clinically he did not believe that Resident #14 was in as much pain as he claimed, and this was based on reports from the staff that resident slept well, maintained a good appetite, and did not complain much of pain. MD F stated Resident #14 had not yet been seen by a pain management specialist due to issues with his payer source. Record review of Resident #14's controlled substance log, undated, revealed a quantity of two [MEDICATION(S)] patches were filled on 09/25/22. The first patch was topically applied on 09/26/22 and the second one was topically applied on 09/29/22. The last log showed there were zero patches remaining on 09/29/22. Record review of Resident #14's controlled substance log, dated 10/10/22, revealed that a quantity of five [MEDICATION(S)] patches were filled on 10/09/22. The first patch was topically applied on 10/10/22, a second patch was topically applied on 10/14/22 and a third one was topically applied on 10/17/22. The last log showed that there were two patches remaining on 10/17/22. Record review of Resident #14's controlled substance log, undated, revealed a quantity of 57 [MEDICATION(S)] was filled on 07/24/22. The first dose was given on 08/20/22 with 56 remaining. The last dose was given on 09/28/22 with zero remaining. Record review of Resident #14's controlled substance log, undated, revealed a quantity of 57 [MEDICATION(S)] was filled on 10/11/22. The first dose was given on 10/10/22 with 56 remaining. The last dose was given on 10/18/22 with 44 remaining. Record review of Resident #14's EHR revealed no significant changes in ADLs including eating/drinking, bathing, and behavior symptoms. Resident #14's vitals were mostly normal with approximately nine days of elevated blood pressure between the dates of 10/02/22 and 10/12/22. Interview on 10/18/22 at 3:39 PM with ADON D revealed she had only worked at the facility for 90 days, and was the ADON for the 300 hall. ADON D stated she was informed by RN I that Resident #14's pain medication was placed on hold by the doctor. ADON D stated RN I was unable to tell her who reported it to her, and it was not documented anywhere in the nursing notes. ADON D stated she had also received a text message from MD F informing her of the miscommunication regarding Resident #14's pain medications and the issue with the [MEDICATION(S)] patches. ADON D looked over Resident #14's MAR and acknowledged that he last received a PRN [MEDICATION(S)] on 09/28/22. ADON D stated Resident #14 was out of his supply of both [MEDICATION(S)] and [MEDICATION(S)] patches, and there was not any in the emergency bank to her knowledge. ADON D stated the process for reordering medications was to get triplicate from the doctor to reorder medications if there were refills on the prescription. She stated if there were no refills left, the doctor would have to send a new order. ADON D stated there was a place on the medication cards that indicated to the nurses when it was time to reorder. ADON D stated it was her responsibility to monitor the charge nurses and ensure that medications were reordered in a timely manner. ADON D stated she was new to the facility and still learning her role; however, she planned on implementing documentation training for the nurses. Interview on 10/19/22 at 3:31 PM with the Administrator revealed it was his expectation for the nurses to call the physician and accurately document all information received during the conversion. The Administrator stated he also expected for the nurses to know when to contact the physician, especially when there was a need for clarification. He stated the miscommunication regarding Resident #14's pain medication placed the resident at risk of being in unnecessary pain. Review of the facility's policy titled Pain Management, dated 08/15/22, revealed in part the following: Policy explanation and Compliance Guidelines: The facility will utilize a systematic approach for recognition, assessment, treatment and monitoring of pain. Recognition: 1. In order to help a resident, attain or maintain his/her highest practicable level of physical, mental, and psychological well-being and to prevent or manage pain, the facility will: -Recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated. -Evaluate the resident for pain upon admission, during ongoing scheduled assessments, and when a significant change in condition or status occurs. -Manage or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences.

Based on observations, record review and interviews, the facility failed to ensure an environment that was free of accident hazards and that each resident received adequate supervision to prevent elopement for one (Resident #1) of four residents reviewed for elopements. The facility failed to ensure Resident #1, who had dementia and a history of wandering, was provided with adequate supervision to prevent elopement when the resident was admitted on [DATE]. Due to the facility's WanderGuard alarm system not being audible at the nurses' station, the resident was able to elope 3.7 miles from the facility and was not found until approximately 15 hours later. An Immediate Jeopardy (IJ) was identified on 04/29/22 at 4:00 PM. While the IJ was lifted on 04/30/22, the facility remained out of compliance at a severity level of potential for more than minimal harm and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. This failure placed the residents at risk of eloping without detection by the staff. Findings included: Record review of Resident #1's EHR revealed the resident was an [AGE] year-old male admitted to the facility on [DATE] at approximately 3:30 PM with diagnoses including dementia, high blood pressure, and [CONDITION(S)]. Record review of Resident #1's Wandering Evaluation, dated 04/18/22, revealed the resident was at moderate risk for wandering with a score of 11.The facility used a Wandering Evaluaation tool to evaluate a resident's risk of elopment, with the following scoring:- 0-5 was Low Risk, 6-15 was Moderate Risk, and 16-35 was High Risk. Record review of Resident #1's EHR revealed nursing progress notes documented by the DON: 04/18/22 at 3:50 PM - Resident admitted .accompanied by family members. Resident appears very upset, agitated and requesting to leave. Resident was pacing down the halls, seems confused, attempting to open all doors. Staff instructed to keep resident in line of sight at all times. This nurse discussed with [family member] about placement in a locked memory care unit that maybe more appropriate for current level of functioning. [Family member] stated she was helpless at this point since [Resident #1] has been wandering quite a lot and was not sure what to do. 04/18/22 at 4:55 PM - Resident served dinner in the living room and ate 100%. Family still present with patient. He was insisting to leave to go outside but nursing staff redirected him frequently 04/18/22 at 6:59 PM - Resident was taken to his room but he kept attempting to open elevator doors and every door. Nursing staff placed a Wanderguard on R [right] lower leg for tracking. Resident was offered fluids and snacks at the time and went to his room. 04/18/22 at 7:15 PM - This nurse heard the exit door alarm beeping and went to check, it was open and was reset. This nurse inquired about the resident and no one had seen him in the search began in the building and outside for resident. 04/18/22 at 7:38 PM - 911 was called about 19:36 [7:36 PM] .Police Incident Report#- 7352. 04/18/22 at 10:05 PM - This nurse notified family, physician and called 911 to report resident missing. All areas in and around the facility have been searched and continues at this time. 04/18/22 at 10:27 PM - [Famiy member] of resident states he has always been a wanderer and would exit their home frequently and be missing for periods of time. [Police Officer] spoke with family and states they were understanding and have had to experience his eloping frequently. Family sent picture of resident to [Police Department] for assistance in identifying him, and flyers are being made. Employees are assisting in driving around to help locate resident. 04/19/22 11:19 AM - This nurse was notified that resident had been located and family was aware. This nurse called and spoke with [family member], discussed several other options about placement for the safety of the resident. [Family member] stated they would discuss the issue with other family members before making a decision. Review of facility's Provider Investigation Report, dated 04/19/22, revealed Resident #1 was admitted to the facility and was unhappy about his admission to facility and wanted to leave and go back home. The resident was able to ambulate independently, and a WanderGuard device was placed on the resident with the family's permission. The report reflected Resident #1's family stayed for approximately one and a half hours to settle the resident. The resident was observed going to the elevator several times and was redirected. The DON heard an alarm going off and went to the elevator and discovered it was not that alarm that was activated but a stairwell alarm. The DON went to reset the alarm and looked for the resident and could not find him. The facility immediately engaged elopement procedures, the police and family were notified. The report reflected the resident was found safely. The PIR revealed staff were in-serviced on elopement policy and procedures after the event. Interview on 04/28/22 at 1:30 PM with Resident #1's family member revealed he had been living independently prior to being admitted to the facility, but his ability to care for himself had deteriorated, including episodes of him wandering away from his apartment and not being found for hours. The family member revealed they were made aware the facility did not have a locked unit and agreed to allow the resident to be fitted with a WanderGuard ankle monitor. The family stated they stayed with the resident until about 5:30 PM or 6:00 PM to get him settled in. The family member revealed the resident was anxious about being there and wanted to go home. The family member stated they notified by the DON around 7:30 PM that night that the resident was missing, staff were searching for him, and the Police Department had been notified. The family member revealed the resident was eventually found by a distant family member at a restaurant 3.7 miles from the facility around 10:30 AM the next morning (04/19/22, approximately 15 hours later). The family member stated that Resident#1 had suffered no obvious injuries, he was still wearing his WanderGuard ankle bracelet, and the family opted to keep him with them until they could locate a facility with a locked unit. Interview on 04/28/22 at 4:00 PM with the DON revealed on 04/18/22 she had been working on the unit and had admitted Resident #1on 04/18/22. She revealed that she was not aware of the extent of the resident's wandering behaviors until admission when the resident was adamant about going home, that is why she offered the Wanderguard monitor to the family. She stated around 7:00 PM, she heard the alarms for the Wanderguard and exit door going off when she came to the nurse's station. She asked staff present if they heard the alarm, and no one had noticed the alarms. Staff searched the floor and located an exit door leading to a stairway was ajar. DON went down the stairway, which lead from the second floor to an external exit, outside and around to the front of the building but did not see any residents. Staff performed a head count and discovered Resident #1 was missing. Staff immediately began to search the grounds. A staff member (RN A) approached Resident #2, who was outside smoking and asked if he had seen anyone walking away from the facility. Resident #2 revealed someone had walked past him and towards a major roadway. She stated a staff member (RN A) walked down to the road, approximately 800 feet from the facility, without seeing the resident. She stated other staff members and the police department searched the immediate areas, including local hospitals, without locating the resident. The DON revealed she had discussed with Resident #1's family her concerns about his desire to go home and had proposed the WanderGuard system as an option to help monitor the resident in case he did try to elope. She stated that Resident #1 was fitted with an ankle bracelet. She stated that after the family had left the facility, staff had to redirect the resident away from the elevators several times when he set off the alarm. She revealed distraction techniques were used to redirect Resident #1's focus, such as offering snacks and watching television in the common area by the nurses' station. She revealed Resident #1 would go back to wandering the unit from his room to the nurses' station and back to his room. The DON revealed the WanderGuard system would sound an alarm when a resident wearing the monitor was within five feet of the exit. She stated the exit doors would alarm as soon as the door-release bar was depressed after 15 seconds, the door was able to be opened. She stated the alram changed from a beeping alarm to a continuous alarm until the door was closed and the reset code was entered. Interview on 04/28/22 at 4:34 PM with Resident #2 revealed on the day of Resident #1's elopement he had been sitting on a bench located next to the road in front of the facility and had noted an elderly male walk past him in the direction of a nearby street. He revealed he did not speak to the male and did not realize that he was a resident because he was wearing regular clothing and seemed to know where he was going. He described the male's pace as slightly faster than a normal walking pace. Interview on 04/28/22 at 3:55 PM with RN A revealed she was working on 04/18/22 when Resident #1 eloped. She revealed she was standing at the nurses' station when the DON asked her if she heard the alarm going off. She told the DON that she had not noticed the alarm. RN A stated she was aware of the alarm after it was pointed out by the DON, but she could barely hear it. She revealed staff searched for the source of the alarm, and once they knew that Resident #1 was missing, they began to search for him. She revealed she spoke with Resident #2 and walked down towards the road he indicated and did not see the resident. She revealed she was not aware of the resident being an elopement risk because he was new to the facility, and she had not been involved with his admission. RN A stated residents with elopement risks were discussed during report between shifts, and so the information had not been relayed to her yet. Interview attempts via telephone on 04/29/22 at 1:00 PM with CNAs working the second floor on 04/18/22 when Resident #1 eloped were unsuccessful. Interview on 04/29/22 at 1:15 PM with the Administrator revealed the cameras located around the facility, including cameras positioned to see the door that Resident #1 eloped from, were not monitored, or recorded. He did not have an exact time of when Resident #1 eloped from the facility. The facility had been aware Resident #1 had wandered away from his apartment in the past, but he thought the WanderGuard system would keep him safe as they had other residents with exit-seeking behaviors. The Administrator revealed he was not aware the alrams could not be heard at the nurses' station. Observation on 04/29/22 at 2:00 PM of the WanderGuard alarm activation, with the Maintenance Director, revealed the WanderGuard alarm would begin to sound when a monitor worn by a resident was within about five feet of the alarm. The exit door would alarm when the push bar was depressed. The WanderGuard alarm was a rapid beeping alarm. The exit door was a slower beeping sound for 15 seconds while the bar was depressed and then a steady alarm once the door was opened and continued until the door was closed and the reset code was entered. When both systems were activated at once, there were two different sounding alarms sounding at once, one did not override the other. The surveyor was standing at the nurse's station, 160 feet from the door Resident #1 eloped from, and the alarms were barely audible. The Director of Medical Records was standing in the hall, closer to the alarm than the surveyor, and she revealed she heard something but did not know what it was. Observation of staff on the second floor revealed none had alerted to, or seemed concerned about, the alarm sounding. The surveyor stood at the DON's office, which was located directly behind the nurses' station, and the alarm was not audible. Interview on 04/29/22 at 2:10 PM with the Maintenance Director revealed he was not aware the alarms could not be heard very well at the nurses' station. He revealed he tested the alarms monthly, and the alarm was very loud when you were standing there testing it. He revealed it had not occured to him that it was not audible at the nurses' station. He revealed he would see if he was able to turn the volume up on either one of the alarms. Record review of facility's Elopement Binder revealed Residents #3, #4, and #5 were listed as elopement risks. Review of resident's care plans revealed they were not care planned for elopement risk initially, but their care plans had been updated since Resident #1's elopement to reflect they were at risk for elopement. Observation on 04/29/22 from 2:30 PM to 3:10 PM of Residents #3, #4, and #5 revealed they were wearing WanderGuard ankle bracelets. Review of facility's current, undated Elopements policy reflected the following: It is the responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing, to the charge nurse as soon as practical. The policy did not address elopement prevention and techniques to use to distract the resident. It did not address what steps to take if a resident was eloping from the facility. On 04/29/22 at 4:00 PM, the Administrator was notified that an Immediate Jeopardy had been identified, and he was provided the Immediate Jeopardy template. The facility submitted the following acceptable Plan of Removal on 04/30/2022 at 7:28 AM: Issue: The Facility failed to ensure a resident with known exit-seeking behavior was provided with adequate supervision to prevent him from eloping. FACILITY'S PLAN OF REMOVAL o Resident #1 is no longer a resident in this facility. discharged [DATE] o On 4/28/22, Director of Nursing (DON) .audited all wandering resident care plans to ensure proper interventions are in place. All care plans were updated and proper interventions in place. o On 4/18/22, All staff were re-educated by DON .regarding facility's elopement policy and protocols in place if there is an elopement to return a resident safely to the facility. All staff not present will be called via phone and re-educated and will sign in-service prior to next shift. o On 4/29/22, DON .re-educated all staff on the sound of the elopement alarm and what to listen for and for staff to respond immediately. All staff not present will be called via phone and re-educated and will sign in-service prior to next shift. o On 4/29/22, DON .reviewed all elopement assessments for wandering residents. Completed 4/29/22. These assessments are completed at admission and quarterly. o On 4/29/22 Maintenance Director .installed an additional alarm on the exit doors o On 4/19/22, Interdisciplinary Team reviewed elopement binders to ensure documentation is complete. Re-reviewed 4/29/22 o On 4/29/22 Administrator .and DON .to review all wander risk residents for appropriate placement to a secure unit. Review completed today. o Elopement Risk system will be reviewed weekly for four weeks and monthly thereafter o Any resident assessed as being at risk for elopement will be considered for transfer to another facility. If residents start to exhibit exit seeking behaviors, they will be re-evaluated by physician and medications reviewed. On 4/29/2022, an AdHoc Quality Assurance Performance Improvement Meeting was held with the Management Team to discuss the incident and procedures to help ensure that residents are safe in the facility. Elements of the above plan were discussed at the QAPI meeting. Monitoring of the IJ included: Observation on 04/30/29 at 9:00 AM revealed the Maintenance Director had installed temporary alarm system on all external doors of both second and third floors with an alarm speaker mounted in the nurses' station. Observation on 04/30/22 between 9:00-9:30 AM of testing of the new system revealed it functioned on all exit points and was audible throughout the floor on both 2nd and 3rd floors. Interview on 4/30/22 at 9:30 AM with the Maintenance Director revealed a work order had been placed to install a more permanent upgrade to the WanderGuard system as well as the door alarm. Interview on 04/30/29 at 9:30 AM with the DON and the Administrator revealed they had provided education to staff on the facility's WanderGuard system, to include recognizing the sound of the alarm and the facility's resident elopement policy and procedure. They revealed education had been done in-person and via phone with all staff. The DON revealed Wandering Evaluations would be updated weekly for four weeks, and then monthly for three months, and quarterly thereafter and updates would be done by herself and the MDS Coordinator. The DON revealed current residents identified as elopement risks were evaluated for transfer to a facility with a locked unit. Residents #3 and #5 were identified as meeting admission criteria, The DON stated she would coordinate a care plan meeting with family to discuss possible transfers. The DON stated she wouldl work with an IDT to include social workers, MDS Coordinator and administration to craft guidelines for assessing future residents for appropriate placement in the facility in relation to elopement risk and exit-seeking behaviors. Interviews on 04/30/22 from 9:30 AM through 9:50 AM with RN B, LVN C, LVN D, LVN E, LVN F, CNA G, CNA H, CNA I, CNA J, Housekeeper K, Housekeeper L, and Director of Medical Records, who worked on the second and third floors, revealed they were able to identify the WanderGuard alarm and responded immediately when it was activated. They were also educated on the Elopment Binders and where to locate them. Interviews conducted via telephone on 04/30/22 from 10:00 AM through 10:30 AM with LVN M, LVN N, LVN O, RN P, CNA Q, CNA R, and MA S, who were not present in the facility, revealed they were also able to verify education was provided by the Administrator and the DON on how to identify the WanderGuard alarm and to respond immediately when it was activated. They were also educated on the Elopment Binders and where to locate them. Record review of care plans on 04/29/22 revealed the DON had updated the care plans for Residents #3, #4, and #5 currently in the facility and identified as elopement risks. Residents #3, #4, and #5 Wandering Evaluations were also updated. Review on 04/30/22 of the facility's Elopement Binders revealed they were updated to include photos of Residents #3, #4, and #5. Elopment Binders were observed to be posted at each nurses' station and at the receptionist's desk. The Immediate Jeopardy was lifted on 04/30/22 at 10:36 AM when the facility was found to be in compliance with the Plan of Removal. While the IJ was lifted on 04/30/22, the facility remained out of compliance at a severity level of potential for more than minimal harm and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview, and record review, the facility failed to ensure that residents who had pressure sores received necessary treatment and services to promote healing, prevent infection, and prevent new sores from developing for seven (Residents #1, #2, #4, #5, #6, #7 and #8) of 19 reviewed for pressure ulcers. 1. The facility failed to off-load Resident #2's heels when she had an unstageable pressure ulcer to her right heel. 2. The facility failed to keep pressure off Resident #8's left leg when she had an unstageable pressure ulcer to her left calf. The staff failed to recognize the device to off-load the resident's heels created pressure to her left calf pressure ulcer until surveyor intervention. 3. RN A failed to follow proper infection techniques when providing treatment to Resident #1's multiple pressure ulcers. 4. LVN B failed to follow proper infection control techniques when providing treatment to Resident #5's Stage II pressure ulcer. 5. ADON E failed to follow proper infection control techniques when providing treatment to Resident #4's Stage IV pressure ulcer. 6. The facility failed to provide treatment to Resident #6's unstageable pressure ulcer on 03/26/16 and 03/27/16. 7. The facility failed to provide treatment to Resident #7's Stage III pressure ulcer on 03/26/16 and 03/27/16. These failures could affect the 10 residents in the facility with identified pressure ulcers by placing them at risk for deteriorating pressure ulcers, infections, pain, and development of additional pressure ulcers. Findings included: 1. Resident #2's MDS assessment, dated 02/02/16, reflected she was a [AGE] year-old female, who was initially admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. The resident had moderately impaired cognition and required extensive assistance with all of her ADLs to include bed mobility. The resident was at risk for pressure ulcer development and had one unstageable pressure ulcer measuring 1.0 cm x 1.0 cm with eschar. Resident #2's comprehensive care plan dated 10/05/15 reflected Resident #2 was at risk for skin breakdown due to recent surgery and limited mobility. Interventions included assisting with repositioning every two hours. The Braden Scale for Predicting Pressure Sore Risk dated 10/19/15 and 11/02/15 reflected Resident #2 was identified as at severe risk for developing pressure ulcers. An update to the plan of care on 12/02/15 identified the resident as having actual skin breakdown to the right heel which was unstageable (the base of the ulcer was not visible). A secondary care plan also dated 12/02/15 reflected Resident #2 was at risk for alterations related to bilateral deep tissue injury to bilateral heels. The care plan reflected interventions which included, Assist resident to a position of comfort, utilizing pillows as appropriate positioning devices. A progress note from the contracted wound-care company dated 01/06/16 reflected Resident #2 was seen for an unstageable wound of the right heel which measured 1 cm x 1.4 cm and was greater than 32 days in duration. Weekly progress notes by the Wound Care Physician reflected the Resident's wounds had deteriorated on 02/03/16, 02/10/16, and 02/24/16. On 02/24/16, Resident #2's right heel pressure ulcer was unstageable and measured 2.5 cm x 4 cm. The note reflected the wound had deteriorated and recommended off-loading of the pressure ulcer (pressure ulcer not touching a surface). Resident #2's comprehensive physician's orders [REDACTED]. No order for off-loading of the heels was reflected. An interview on 03/02/16 at 11:30 a.m. with CNA K revealed Resident #2 had a pressure ulcer on the right heel, and the resident's heels were supposed to be off-loaded with her feet elevated. The CNA stated she received frequent in-servicing on topics related to turning and repositioning. An observation on 03/02/16 at 12:25 p.m. of Resident #2 revealed her heels were resting on the pillow. At that time, the Wound Care Physician measured the pressure ulcer on the resident's right heel, and he stated it measured approximately 1.6 cm x 1.8 cm.; the wound bed was approximately half covered with a dark brown necrotic tissue; and the surrounding skin was intact. After assessment, the Wound Care Physician positioned the resident's heels in the same position as when he entered, resting on the pillow. An observation on 03/16/16 at 10:05 a.m. revealed Resident #2 was lying flat on her back with her heels touching a pillow, which created pressure on her heels. An observation on 03/16/16 at 11:30 a.m. revealed Resident #2 was lying flat on her back with her heels touching a pillow, which created pressure on her heels. Resident #2 revealed staff always placed her heels on a pillow, and her heels were never floated (heels not touching a surface). An observation on 03/16/16 at 4:30 p.m. revealed the resident was lying flat on her back with socks covering her feet, and her heels were resting directly on top of a pillow. An observation on 03/16/16 at 6:10 p.m. revealed the resident was lying flat on her back with socks covering her feet, and her heels were resting directly on top of a pillow. An observation on 03/16/16 at 6:25 p.m. with LVN D revealed Resident #2 lying on her back in bed with her heels resting on a pillow. LVN D stated the resident's heels were not off-loaded, and there was no point in using a pillow if the heels were just going to rest on the pillow. LVN D left the room without repositioning the resident or off-loading her heels. Review of Resident #2's ADL sheet dated 03/31/16 reflected the CNAs were to assist with repositioning every two hours. No direction related to off-loading of the heels was reflected. 2. Resident #8's MDS assessment, dated 02/25/16, reflected the resident was an [AGE] year-old female admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident was at risk for pressure ulcer development and had one unstageable pressure ulcer measuring 5.0 cm x 4.0 cm with eschar. The skin and ulcer treatments included pressure reducing device for chair and bed. The Wound Care Specialist Initial Evaluation dated 01/13/16 reflected Resident #8 had an unstageable pressure ulcer to her right heel which measured 5.0 cm x 4 .0 cm and an unstageable pressure ulcer to her left heel which measured 2.0 cm x 2.0 cm. The comprehensive care plan for Resident #8, dated 01/14/16, reflected she had been identified for actual skin breakdown to the right heel which was unstageable due to pressure. Interventions included float heels while in bed and instruct/assist resident in methods of reducing friction and shear. The weekly wound care progress notes reflected on 01/27/16 the left heel ulcer had resolved. An update to the care plan on 03/17/16 reflected Resident #8 had a wound to the left calf. The updated intervention was to cleanse the left lateral lower leg with normal saline or wound cleanser, pat dry with gauze, apply Santyl (a [MEDICATION NAME] agent to remove dead tissue)/calcium alginate (an antimicrobial to prevent infection), and cover with a dry dressing daily. The care plan continued to reflect the previous interventions of floating heels while in bed and instruct/assist resident in methods of reducing friction and shear. The weekly wound care progress notes reflected on 03/23/16 the right heel wound had resolved. An unstageable wound of the left calf was initially evaluated on 03/23/16 which measured 2 cm x 2 cm. Surgical debridement of muscle (cutting out dead tissue) was performed by the physician on that date. An observation on 03/30/16 at 10:20 a.m. revealed Resident #8 lying in bed with her heels floated. A gauze dressing was on the resident's left calf where the calf rested on a foam off-loading device. CNA F stated at that time the device was to keep the resident's heels from touching the mattress. When asked if the device was appropriately positioned, she straightened the device out slightly and positioned it where the resident's calf wound again rested directly on the off-loading device. The CNA confirmed the resident's heels were not touching the mattress and the off-loading device was appropriately positioned. CNA F acknowledged the Resident had a dressing to the left calf and stated she was unsure of any additional information about, or care needs for the pressure ulcer. The CNA indicated the primary concern for off-loading was to keep pressure off of the heels. An observation on 03/30/16 at 1:45 p.m. revealed Resident #8 lying in bed in the same position. The DON and LVN G agreed the resident's calf pressure ulcer was resting directly on the off-loading device. The DON stated Resident #8 scooted in bed and could have moved her legs down onto the device. After attempting to reposition the resident using the off-loading device, the LVN and DON stated the device was not appropriate for off-loading due to the location of the calf pressure ulcer and would instead utilize pillows to position the Resident #8. An interview on 03/30/16 at 3:45 p.m. with the DON revealed she was able to successfully off-load Resident #8's heels with pillows while keeping pressure off of the pressure ulcer on the resident's calf. An observation on 03/31/16 at 4:55 p.m. revealed Resident #8 lying in bed with pillows placed under her lower legs with the pressure ulcer on her calf resting directly on the pillow. The DON stated at that time she did not know why the pressure ulcer was resting directly on the pillow, and not the way she had positioned the resident the previous day. The DON folded the pillow in half and repositioned the resident to prevent pressure to the area. She removed the dressing to the left calf and exposed the wound which measured approximately 2.5 cm x 1.5 cm x 0.5 cm. The wound bed was pink and the surrounding tissue was pink. (Note: pressure ulcer was debrided on 03/23/16 and pink tissue was consistent with procedure performed) 3. Resident #1's MDS assessment, dated 02/05/16, revealed he was a [AGE] year-old male admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident had modified independence with his cognitive skills for daily decision making and required extensive assistance with bed mobility. The resident was at risk for pressure ulcer development and had two unstageable pressure ulcers with slough/eschar and two unstageable pressure ulcers that were deep tissue. The largest of these pressure ulcers measured 8.0 cm x 7.0 cm x 0.2 cm with eschar. Observation of the consulting wound care physician's treatment of [REDACTED]. These pressure ulcers were as follows: - left ischium, 5 cm x 5 cm x 1 cm with 30 percent of the wound being necrotic; - right hip measured 7 cm x 6 cm x 1.5 cm and was 50 percent necrotic; - right buttock measured 8 cm x 6 cm x 1.5 cm and the wound base was covered with granulation tissue; and - coccyx the final wound measured 3 cm x 2.5 cm x 0.7 cm. An observation on 03/16/16 at 1:20 p.m. revealed RN A donned a pair of gloves without washing/sanitizing his hands. He then picked up the trash can and moved it closer to Resident #1's bed. Next, he applied an antiseptic to the four pressure ulcers with 4 x 4 gauze. Wearing the same gloves, he covered the pressure ulcers with ABD pads and tape. An interview on 03/02/16 at 1:30 p.m. with RN A revealed he recently graduated from nursing school and was not very experienced with wounds and pressure ulcers. RN A stated he had not received any wound-specific training since he began his employment at the facility. 4. Resident #4's MDS assessment, dated 02/28/16, reflected the resident was an [AGE] year-old male admitted to the facility on [DATE]. Review of Resident #4's comprehensive plan of care, initiated on 01/20/16, revealed the resident had actual skin breakdown to his right heel related to contractures, a history of pressure ulcer, limited mobility, and [MEDICAL CONDITION]. Interventions to address the skin breakdown included providing wound treatment as ordered. A progress note by the consulting wound care physician dated 02/24/16 reflected Resident #4 was seen for a stage IV pressure ulcer to the right heel which measured 2.0 cm x 2.5 cm x 0.3 cm. The physician ordered ongoing treatment with Santyl and calcium alginate, daily. Resident #4's progress note by the consulting Wound Care Physician dated 03/02/16 reflected the pressure ulcer on the resident's right heel measured 1.5 cm x 2 cm and had improved since the previous week. An observation on 03/02/16 at 12:35 p.m. revealed ADON E entered Resident #4's room to provide treatment his Stage IV pressure ulcer treatment on his right heel. She did not wash her hands upon entering the resident's room. The resident was sitting up in a chair and ADON E lifted the resident's right leg onto the bed to clean the pressure ulcer. ADON E donned clean gloves and cleaned the wound with four by four gauze. The pressure ulcer's wound bed was pink and the surrounding skin was dry and intact. She then applied the wound treatment as ordered by the consulting physician, without donning new gloves or washing her hands. She then applied a clean sterile dressing without donning new gloves or washing her hands. An interview on 03/02/16 at 4:00 p.m. with ADON E revealed the facility's protocol was to wash hands upon entering a resident's room, put on gloves, remove a dressing, remove the dirty gloves, put on clean gloves, cleanse the wound, change gloves, apply the dressing, and wash hands before leaving the resident's room. The ADON revealed she could have changed her gloves more frequently during wounds rounds with the wound care physician. ADON E further revealed the facility was experiencing some staffing changes and was in between wound care nurses at the time. 5. Review of Resident #5's face sheet, dated 03/16/16, revealed a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses, including [MEDICAL CONDITION], pressure ulcer of the sacral region, [MEDICAL CONDITION], pressure ulcer of the buttock, type 2 diabetes, and obesity. The comprehensive care plan for Resident #5 dated 03/04/16 revealed she admitted to the facility with a pressure ulcer to the sacrum. Interventions included, Cleanse sacral wound with wound cleanser, pat dry with four by four gauze, apply collagen to wound bed, cover w/ (with) Duoderm (a gel filled dressing) q (every) 3 days and PRN (as needed). Resident #5's MDS assessment, dated 03/08/16, reflected an alert and oriented resident who required extensive two person assistance with bed mobility, and totally dependent upon staff with transferring, dressing, toileting, and personal hygiene. The assessment reflected a Stage II pressure ulcer to her sacral region. On 03/16/16 at 12:30 p.m., the Wound Care Physician measured Resident #5's sacrum pressure ulcer and stated it was 0.5 cm x 0.7 cm. LVN B did not wash her hands before cleaning the wound on Resident #5's sacrum. LVN B cleaned the sacral wound with wound cleanser and 4x4 gauze and then applied the treatment as ordered by the physician without donning new gloves or washing her hands. 6. Resident #6's MDS assessment, dated 03/17/16, revealed she was an [AGE] year-old female, admitted to the facility on [DATE]. An admission nurses note dated 03/17/16 reflected Resident #6 had been assessed for pressure ulcer risk by a Braden scale and was identified as at severe risk. A Social Services admission note dated 03/21/16 reflected a cognition screen had been conducted and the resident was cognitively intact. The Wound Care Specialist Initial Evaluation for Resident #6 dated 03/23/16 reflected she was seen for an unstageable pressure ulcer to her right buttock which measured 2 cm x 1.5 cm. Resident #6's Physician's Telephone Order dated 03/24/16 reflected to cleanse the sacral wound with normal saline or wound cleanser, pat dry apply [MEDICATION NAME] (a foam dressing) with dry dressing every day shift. The treatment order for the Resident's coccyx wound dated 03/24/16 was to cleanse with normal saline or wound cleanser, pat dry with four by four gauze, then apply santyl, calcium alginate, and dry dressing every day shift. The March, 2016 Treatment Administration Record for Resident #6 reflected RN H conducted pressure ulcer treatment on Friday, 03/25/16. On 03/26/16, LVN I signed she completed the treatment. No signature was reflected on Sunday, 03/27/16. An interview with Resident #6 on 03/29/16 at 3:50 p.m. revealed she had a sore on her rear end that had been treated every day the previous week by RN H. Resident #6 stated no one did anything to the sore over the weekend and RN H resumed treatment on Monday (03/26/16). Resident #6 believed the RN had informed her she would receive wound treatments over the weekend, but since no one had conducted treatment, she wondered if she misunderstood the RN. Resident #6 stated her wound was getting better. A telephone interview on 03/30/16 at 4:35 p.m. with LVN I revealed she completed Resident #6's pressure ulcer treatment on Saturday, 03/26/16. The LVN could not recall the location of the ulcer nor the treatment provided. She did not know why Resident #6 would say she had not completed the treatment. 7. Resident #7's MDS assessment, dated 03/18/16, reflected she was a [AGE] year-old female, admitted to the facility on [DATE]. The comprehensive care plan for Resident #7 dated 03/21/16 revealed she had been identified as at risk for skin breakdown as evidenced by impaired sensation, moisture/excessive perspiration, history of pressure ulcer, limited mobility, incontinence, and vascular disease. Preventative interventions included assisting the resident with repositioning and monitor skin for signs of breakdown. No actual breakdown was reflected in the plan of care. A Social Services admission note dated 03/21/16 reflected a cognition screen had been conducted and the resident was cognitively intact. Review of the Wound Care Specialist Evaluation dated 03/23/16 revealed Resident #7 had a Stage III pressure ulcer of the right buttock, which measured 3 cm x 2 cm x 0.1 cm and was evaluated by the physician for the first time on this date. The recommendations were for collagen dressing once daily. Review of Resident #7's treatment administration record for March 2016 revealed on 03/25/16, pressure ulcer treatment was completed by RN H. On 03/26/16, LVN I signed she completed the treatment and on 03/27/16, LVN J signed she completed the treatment. An interview with Resident #7 on 03/30/16 at 2:25 p.m. revealed she had been seen by the wound care physician and was receiving treatments to her buttock. The resident stated staff had changed the gauze on her bottom every day the previous week, but no dressing changes had been conducted over the weekend. A telephone interview with LVN I on 03/30/16 at 4:35 p.m. revealed she completed Resident #7's pressure ulcer treatment over the weekend of 03/26/16 - 03/27/16. The LVN could not recall the location of the ulcer nor the treatment provided. She did not know why Resident #7 would say she had not completed the treatment. A telephone interview with LVN J on 03/30/16 at 5:00 p.m. revealed she completed the pressure ulcer treatment for [REDACTED]. 8. During an interview with the Wound Care Physician on 03/29/16 at 3:00 p.m., the physician was informed of the observed infection control issues. He stated he did not see infection control concerns during rounds with facility staff, but he was not surprised. He explained there was inconsistency in who conducted pressure ulcer treatments and there was no one at the top watching or monitoring. During a telephone interview with the DON on 03/29/16 at 1:35 p.m., she revealed it had been a struggle to supervise the wound care program at the facility partly because of change in staff. When asked how she ensured pressure ulcer treatment was provided appropriately, she stated she did random spot checks and the wound care physician conducted weekly rounds. She stated, however, it had been a challenge and at some point she just had to trust her nurses. An interview with RN H on 03/29/16 at 12:50 p.m. revealed she had been the wound care nurse for a short period and this was her second full week of work at the facility. RN H stated wound care had not been done over the weekend (03/26/16 and 03/27/16) by the charge nurses as ordered. RN H stated the dressings she applied and dated on Friday 03/25/16 were the same dressings she observed on Monday morning (03/28/16). The RN stated she reported to the Administrator on 03/28/16 that dressing changes had not been conducted over the weekend. During an interview with the Administrator and the DON on 03/30/16 at 9:30 a.m. they revealed the wound care nurse (RN H) had resigned without notice the previous day and they found her allegation that weekend pressure ulcer care was not conducted to be invalid. The Administrator and DON stated the treatment record reflected that care was conducted and they could not get a hold of RN H, so no further investigation could or would be conducted into the concern. 9. The facility's current Skin Integrity Management policy, dated 03/15/16, reflected the following: .4. Develop comprehensive, interdisciplinary plan of care including prevention and wound treatments, as indicated The facility's current Infection Control - Standard Precautions policy, dated 10/01/13, reflected the following: .3. Change gloves between tasks and procedures on the same individual and after contact with material that may contain a high concentration of microorganisms. 4. Remove gloves promptly after use before touching non-contaminated items and environmental surfaces, and before going to another individual. The facility's current Hand Hygiene policy, dated 10/01/13, reflected the following: .2.1 Before any direct contact with patient; 2.2 Before putting on gloves; . 2.5 After contact with blood, body fluids or excretions, mucous membranes, non-intact skin, or wound dressings (if visibly soiled, must wash hands); 2.6 When moving from contaminated body site to clean body site during patient care; 2.7 After contact with inanimate objects in the immediate vicinity of the patient; . 2.8 After removing gloves 10. The Resident Census and Conditions of Residents Form CMS-672, dated 03/30/16, reflected 10 residents had pressure ulcers.

Based on interview and record review, it was determined the facility failed to immediately consult the resident's physician when there was a significant change in the resident's physical status for one (Residents #2) of six residents reviewed for notification of changes in condition. 1) Staff failed to consult with Resident #2's physician when the resident, who had a heart stent placed prior to admission to the facility on [DATE] and was without chest pain until [DATE], had a significant change in condition when he complained of chest pain "generating" to his left arm and he rated the pain an eight out of 10. His physician was not notified until [DATE] and the pain continued through [DATE]. Resident #2 became unresponsive on [DATE], staff initiated CPR and the resident expired in the facility on [DATE]. An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because the facility was still monitoring the effectiveness of the Plan of Removal. These failures could affect the 41 residents, who resided on the Express Recovery Unit (Station 2), by placing them at risk for delayed medical care and treatment, continued pain, anxiety, fear, and/or death. Findings included: Resident #2's hospital History and Physical, dated [DATE], reflected,"...history of [MEDICAL CONDITION] with recent stent on RCA. On February 4th went to rehab, (name of rehab) last night. Again this morning, the patient had a sharp chest pain...PAST MEDICAL HISTORY: 1. Right middle cerebral artery stroke. 2. Critical stenosis of right internal carotid artery. 3. Occluded right distal MCA. 4. Hypertension...ASSESSMENT AND PLAN: ...recent stent 3 days back with right coronary artery...1. Chest pain...cardiology evaluating...Closely monitor the patient, cardiac monitor...." Resident #2's MDS assessment, dated [DATE], reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The MDS assessment also reflected his cognition was moderately impaired, he needed extensive assistance of two or more persons for bed mobility, transfers, and for toileting, he was dependent on staff for eating and he needed extensive assistance of one person for dressing, personal hygiene and bathing. Further review of the MDS assessment revealed he had an indwelling catheter, he was occasionally incontinent of bowel, he had a feeding tube, and he was on a scheduled pain medication regimen. Resident #2 resided on the Express Recovery Unit (Station 2). Resident #2's admission orders [REDACTED]. The Orders also reflected [MEDICATION NAME] 0.25 mg every six hours as needed for anxiety, [MEDICATION NAME] ,[DATE] mg every four hours as needed for pain, [MEDICATION NAME] 40 mg before breakfast, for GERD, and [MEDICATION NAME] 10 mg daily and Carvedilol 12.5 mg daily for Hypertension. http://www.webmd.com/heart-disease/tc/using-[MEDICATION NAME]-for-sudden-chest-pain-topic-overview reflected, "[MEDICATION NAME] is a [MEDICATION NAME], a medicine that opens blood vessels to improve blood flow. It is used to treat [MEDICAL CONDITION], a type of chest pain or discomfort that happens when there is not enough blood flowing to the heart. To improve blood flow to the heart, [MEDICATION NAME] opens up (dilates) the arteries in the heart (coronary arteries), which improves symptoms and reduces how hard the heart has to work...Regardless of what happens, you should let your doctor know that you had an episode of [MEDICAL CONDITION]. If this is unusual for you, if your [MEDICAL CONDITION] episodes are occurring more frequently or [MEDICATION NAME] longer, or if you need more medicine to control them, tell your doctor. Report any change in your chest pain (unstable [MEDICAL CONDITION]) to your doctor...." (retrieved on [DATE]) Review of Resident #2's Nurse's Notes from [DATE] through [DATE] revealed he did not have any chest pain during that time. Resident #2's Nurse's Notes dated [DATE] at 4:30 PM reflected he complained of chest pain which was "generating" to his left arm. The Notes reflected he was given one dose of [MEDICATION NAME] 0.4 mg, and a reassessment of his chest pain at 4:35 PM revealed his pain was "gone." Resident #2's February 2013 MAR indicated [REDACTED]. Resident #2's Nurse's Notes dated [DATE] at 4:30 PM did not reflect his physician was notified of the new onset of chest pain radiating to his left arm, and the pain was rated at an eight out of 10, even though he had a recent history of heart problems. Resident #2's facility History and Physical, dated [DATE], reflected the resident was admitted to the facility for rehabilitation status [REDACTED]. The History and Physical also reflected, "c/o (complained of) heart burn. (No) chest pain...." Resident #2's facility History and Physical, dated [DATE], did not reflect the resident's significant chest pain which radiated to his left arm. Resident #2's Nurse's Notes, dated [DATE] at 9:00 PM, reflected he complained of chest pain and received two doses of [MEDICATION NAME] 0.4 mg, one dose every 5 minutes. Resident #2's Nurse's Notes dated [DATE] at 9:00 PM did not reflect his physician was notified of the chest pain, even though he had a recent history of heart problems. Resident #2's Nurse's Notes, dated [DATE] at 9:00 AM, reflected he complained of chest pain and received two doses of [MEDICATION NAME] 0.4 mg, one dose every five minutes, and stated he was "pain free" after receiving the second dose. Resident #2's Nurse's Notes, dated [DATE] at 9:00 AM, did not reflect his physician was notified of the chest pain, even though he had a recent history of heart problems. Resident #2's Nurse's Notes, dated [DATE] with no time recorded, reflected he complained of chest pain again and [MEDICATION NAME] 0.4 mg was given with good effects after five minutes. The Notes reflected the following vital signs: blood pressure ,[DATE]; pulse rate 71; respirations 18; temperature 98.1; and oxygen saturation level of 97% with Oxygen at 2 liters per minute via nasal cannula. Further review of the Notes revealed his physician was notified and ordered a STAT EKG and laboratory studies. Resident #2's Nurse's Notes dated [DATE] did not reflect his physician was notified of the chest pain, even though he had a recent history of heart problems. Resident #2's Comprehensive Metabolic Profile (laboratory study) Results dated [DATE] reflected his SGOT was high at 40 with a reference range of ,[DATE] and his SGPT was high at 57 with a reference range of ,[DATE]. The Results also reflected his previous results from [DATE] for SGOT was 19 and his SGPT was 20, which were both within the reference range. http://www.medicinenet.com/liver_blood_tests/page2.htm reflected, "AST (SGOT) and ALT (SGPT) are sensitive indicators of liver damage or injury from different types of diseases...For example, elevations of these enzymes can occur with muscle damage...." (retrieved on [DATE]). Resident #2's Nurse's Notes, dated [DATE] at 10:00 AM, reflected he complained of chest pain and [MEDICATION NAME] 0.4 mg tablet was given. Resident #2's Nurse's Notes, dated [DATE] at 10:00 AM, did not reflect his physician was notified of his chest pain, even though he had a recent history of heart problems. Resident #2's Physician's Progress Notes, dated [DATE] at 6:50 PM, reflected one episode of "chest discomfort" that morning that was sharp and not associated with exertion. The Notes also reflected the resident's chest pain was "atypical," and the results of the EKG were "nonspecific." Further review of the Physician's Progress Notes revealed the physician paged another physician regarding the resident's chest pain. Resident #2's Nurse's Notes, dated [DATE] not timed, reflected,"...res (resident) c/o chest pain PRN (as needed) pain meds (medications) for ,[DATE] pain... res now resting quietly (with) eyes closed. WCTM (Will Continue to Monitor)." Resident #2's Nurse's Notes, dated [DATE], did not reflect his physician was notified of the chest pain, even though he had a recent history of heart problems. Resident #2's Nurse's Notes, dated [DATE] at 10:00 AM, reflected he complained of chest pain and [MEDICATION NAME] 0.4 mg was given. The Notes also reflected his vital signs were checked, but not recorded. Resident #2's Nurse's Notes, dated [DATE] at 10:00 AM, did not reflect his physician was notified of his chest pain, even though he had a recent history of heart problems. Resident #2's Physician's Progress Notes dated [DATE] reflected the resident's "atypical CP (chest pain) - resolved." Resident #2's Nurse's Notes, dated [DATE] at 11:00 AM, reflected he complained of chest pain and [MEDICATION NAME] 0.4 mg tablets were administered at five minute intervals for a total of three doses. The Notes also reflected, "...pt (patient) states pain is below 4 45 minutes later from a previous 8/o-10 (8 out of 10). 1300 pt c/o (illegible) another chest pain (physician) was notified...Imdur ([MEDICAL CONDITION]) 30 mg BID (twice a day). Pt [MEDICATION NAME] ([MEDICATION NAME]). Pt verbalize absence of pain...1500 pt c/o of another chest pain pt did not exhibit any SOB (shortness of breath), restless or being diaphoretic, pt was stable lying in bed watching TV, vital signs stable ,[DATE], 96.6, 80, 20 o2 (oxygen) 98% 2 LNC (liters via nasal cannula). (Physician) [MEDICATION NAME] and pt state relief. continue to monitor...1700 pt was being monitored, pt states no chest pain at this time, pt was watching TV...2000...denies any chest pain at this time...." Resident #2's Physician's Telephone Order, dated [DATE], [MEDICATION NAME] mg one tablet twice a day due to [DIAGNOSES REDACTED]. An interview with RN M on [DATE] at 3:54 PM revealed he was the nurse who called the physician on [DATE] when Resident #2 continued to complain of chest pain after three doses of [MEDICATION NAME] were administered on [DATE]. RN M stated he did not call Resident #2's physician for past complaints of chest pain because "the pain was relieved with one or two doses of Nitrogycerin." RN M stated the physician [MEDICATION NAME] mg daily, and the medication was ordered, but not delivered by the pharmacy until the next day. He stated the first dose [MEDICATION NAME] given on [DATE], but he could not remember at what time. RN M revealed Resident #2 was pain free and interacting with his family at the end of his shift, (the facility's schedule dated [DATE] reflected he worked from 6:00 AM until 10:00 PM) and his family was "anxious" regarding the resident's chest pain. He stated the resident's family never requested Resident #2 be sent to the hospital for evaluation. RN M revealed he did not work on the hall, where Resident #2 resided, on the day he expired. An interview with Resident #2's family member on [DATE] at 3:30 PM revealed when he/she visited Resident #2 on [DATE], he was "in so much pain, he was crying." The family member stated he/she notified RN M, and he stated he was "aware of the pain, the physician was already notified and he could not do anything for him right now." Resident #2's Nurse's Notes, dated [DATE] timed 3:00 (PM or AM not indicated), reflected CNA A notified LVN J that the resident was having a [MEDICAL CONDITION]. The Notes reflected his vital signs were blood pressure ,[DATE], pulse 86 and respirations 21, and the ADON monitored Resident #2, while LVN J notified his physician and received orders to transport the resident to the hospital. According to Nurse's Notes, Resident #2 became unresponsive at 3:57 PM, 911 was called and staff began CPR. EMS arrived at 4:11 PM and continued CPR until Resident #2 was pronounced dead at 4:41 PM. An interview with LVN J on [DATE] at 4:00 PM revealed she was the nurse who assessed Resident #2 on [DATE]. LVN J also revealed she cared for Resident #2 on several occasions since his admission to the facility, and he complained of chest pain "constantly." LVN J stated she did not notify Resident #2's physician because it was always relieved with one or two doses of [MEDICATION NAME]. LVN J also stated Resident #2's physician was aware of the complaints of chest pain and visited the resident once or twice a week. LVN J stated at 3:00 PM she was notified by CNA A that Resident #2 was "having a [MEDICAL CONDITION]," and when she arrived in his room he was "staring upwards." She revealed Resident #2 was unresponsive when she called his name and did not respond to chest rubbing used for stimulation. LVN J stated Resident #2 was breathing, and she left the room to retrieve her blood pressure cuff. She said when she left the room, the resident's family and the CNA remained in his room. LVN J revealed on her way to retrieve her blood pressure cuff, she notified the ADON of the resident's condition and the ADON went to Resident #2's room to assess him. LVN J stated while she was at the Nurse's Station calling the physician, the ADON came to the Station and checked Resident #2's clinical record. LVN J said after "about ten minutes" CNA A called for assistance from Resident #2's room. LVN J revealed when she and the ADON returned to his room, he was no longer breathing, and she called Code Blue and additional staff came to the room within one minute to initiate CPR. LVN J stated she could not remember which staff member called EMS. She also stated the resident's family member was present in the room, while CPR was being performed on Resident #2. LVN J revealed EMS arrived 10 minutes after staff began CPR. LVN J stated the paramedics performed CPR for 40 minutes before Resident #2 was pronounced dead. An interview with CNA A on [DATE] at 4:30 PM revealed she was the CNA who discovered Resident #2 "having a [MEDICAL CONDITION]." She stated when she entered Resident #2's room, his family member was at the bedside and Resident #2 appeared to be asleep. CNA A revealed after she obtained vital signs, the resident began to "shake all over." CNA A stated she left the room to get the nurse and returned to the room with LVN J and the ADON within a "couple of minutes." CNA A revealed at this time Resident #2 was no longer "shaking" and was breathing. She stated LVN J and the ADON left the room to check his clinical record and call his physician. CNA A revealed she stayed in the room with Resident #2 and his family member. She revealed after "about 12 minutes, he began to shake again," and his family member "yelled" at her to get help. CNA A stated the ADON returned to Resident #2's room "within seconds," and at this time Resident #2 was no longer breathing. CNA A revealed the ADON called "Code Blue" and began CPR. CNA A stated she could not remember which staff member called EMS. A telephone interview with Resident #2's family member on [DATE] at 3:30 PM revealed he/she visited Resident #2 daily and arrived at the facility at about 3:30 PM on [DATE]. The family member stated Resident #2 was asleep when he/she arrived and CNA A walked in the room to obtain the resident's vital signs shortly after he/she arrived. The family member revealed Resident #2 woke and complained of chest pain and then began to "shake like he was having a [MEDICAL CONDITION]." The family member stated CNA A left the room to get help and returned with LVN J and the ADON after "about 3 minutes." The family member also stated LVN J and the ADON stood at the end of the bed and watched Resident #2 and after a few minutes the "shaking stopped." The family member revealed the ADON and LVN J never assessed Resident #2, and the ADON asked CNA A for vital signs. The family member stated then the ADON and LVN J left the room, and CNA A remained in the room. The family member revealed after a few minutes Resident #2 began to "shake again...his eyes rolled back...he took a big breath and then stopped breathing." The family member revealed CNA A called for help and multiple staff members came to the room and began CPR, and it took about 10 to 15 minutes for EMS to arrive. The family member stated EMS continued CPR for about 30 minutes until Resident #2 was pronounced dead. A telephone interview with Physician X, Resident #2's physician, on [DATE] at 1:00 PM revealed he was "aware" Resident #2 "complained of chest pain often." He stated he assessed Resident #2 on two occasions while he resided in the facility. The Physician revealed Resident #2 was on the appropriate medications for his [MEDICAL CONDITION] [DIAGNOSES REDACTED]." Physician X stated he consulted Physician Y on [DATE] after seeing Resident #2. He stated Physician Y said all medications were appropriate for Resident #2's heart condition and cardiac rehabilitation was recommended when Resident #2 "was stronger." He stated nursing staff should notify the physician if a resident complained of chest pain, but he was "not sure" if there was "anymore that could be done" regarding Resident #2's condition. An interview with the DON on [DATE] at 1:30 PM revealed she was not employed at the facility on [DATE] and was only aware of the incident from what she read in Resident #2's clinical record. The DON stated that she provided in-services to the staff on [DATE], [DATE] and [DATE] regarding recognizing resident's significant change in condition and the procedure for administration of medications. The DON revealed she was aware of documentation errors, and the facility had not had a Staff Development Coordinator for "several months." An interview with the Administrator on [DATE] at 9:05 AM revealed he was in the facility on [DATE], but was not aware of the incident with Resident #2 until [DATE]. He stated he was aware of the documentation errors, but he thought the appropriate "nursing judgment" was used when reporting Resident #2's change of condition. The Administrator revealed the facility had a pain protocol, and he was "not sure" if chest pain should be reported to the physician if the chest pain was "minor or relieved with medications." The facility's current policy Physician Notification of Change in Resident Condition, revised [DATE], reflected, "Policy It is the policy of this Center to notify the physician and inform the resident and resident's responsible party of a significant change in the resident's physical, mental, psychological status, including accidents and when there is a need to alter treatments significantly...Immediately notifying the attending physician and/or emergency service physician...Taking action to prevent the resident from further injury, illness, or death. Purpose To keep the physician, resident and resident's responsible party informed of changes in the resident's condition so that timely intervention can be obtained. To ensure the resident receives prompt medical treatment in an emergency, when indicated. Definition 'Change of Condition related to physician notification is defined as the physician should be notified of any sudden and marked adverse change in the resident's condition which is manifested by signs and symptoms different than usual denoting a new problem, complication or permanent change in status and requiring a medical assessment, coordination and consultation with the physician or physician extender and a change in the treatment plan. Procedure 1. It is the responsibility of the person observing the change to report that change to the licensed nurse. 2. The licensed nurse will assess the change of condition and determine what nursing interventions are appropriate. 3. The licensed nurse will be responsible for making all notifications of changes to physicians, the resident, and the resident representative. 4. Examples of changes may include, but not limited to...Changes in vital signs, abnormal findings Respiratory or cardiovascular changes...5. Before notifying the physician, the licensed nurse must observe and assess the overall condition utilizing physical assessment and chart review. Notification to physician will include a summary of the condition change and an assessment of the resident's vital signs and system review focusing on the condition and/or signs and symptoms for which notification is required...6. Emergency notification will be made immediately... 15. Assessment and documentation will continue once each shift for a minimum of 72 hours (or until stable) to monitor the resident's condition and response to treatment." An IJ was identified on [DATE]. The Administrator and DON were notified of the IJ on [DATE] at 4:45 PM, and a Plan of Removal was requested at that time. The facility's Plan of Removal, accepted on [DATE] at 5:00 PM, reflected, "...Nursing Administration was educated on identification of change of condition, physician notification and proper medication administration. This education was conducted by the Regional Quality Assurance Nurse Consultant. This education process was then repeated for the licensed nursing staff, medication aides, and certified nurses assistants (sic)...This education will include but not limited to: 1. Emergency notification will be made immediately. Notification of non-emergency changes will be made promptly on the shift in which it occurred. 2. If, based on an evaluation/assessment by the charge nurse, a resident exhibits such serious symptoms that failure to obtain the most rapid therapeutic interventions by the physician would place the resident in great jeopardy: Call 911 and prepare the resident for immediate transfer. Send via paramedics to the nearest emergency room . Notify the attending physician... DON/interim DON will directly oversee and/or conduct the education training to the facility licensed nursing staff, medication aides, and certified nurses assistants (sic)...b. Identification (Change of Condition/Physician Notification) - All residents in the facility were evaluated by licensed staff for vital signs, pain, chest pain, shortness of breath and any atypical symptoms. The licensed nurse will be responsible for notifying the physician, if a change of condition is identified that requires the coordination and consultation with the physician or physician extender and a change in the treatment plan... Identification (Medication Audit) - Facility has completed a review of resident medication administration records and compared to physician orders [REDACTED]. DON or designee will be responsible for this process. Daily review of new admission records and discharge records for accuracy and completeness. Daily review of physician orders. Daily review of 24 hour reports to identify any change of conditions. Review of S-Bar/Stop & Watch...The Quality Assurance Committee will review the progress of medication administration, identification of change of condition and physician notification monthly to ensure the monitoring of these systems and adjust as necessary based on audits from chart reviews...." Interviews conducted from [DATE] at 9:45 AM through [DATE] at 4:20 PM with LVN J, LVN K, LVN L, RN M, RN N, RN O, LVN P, LVN Q, LVN R, LVN S, LVN T, LVN U, LVN W and LVN V revealed they were to notify the physician promptly for significant changes in conditions, they were to recognize emergent and non-emergent significant changes in conditions and were to use the S-BAR and Stop & Watch forms as assessment tools. Interviews conducted from [DATE] at 9:45 AM through [DATE] at 4:40 PM with CNAs A, B, C, D, E, F, G, H and I revealed they were to recognize and notify their Charge Nurses if the residents exhibited any changes in condition and the proper use of Stop and Watch form. The IJ was removed on [DATE]. The Administrator, DON and Vice President of Clinical Operations were notified on [DATE] at 5:30 PM that the IJ was removed. While the IJ was removed, the facility remained out of compliance at scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because the facility was still monitoring the effectiveness of the Plan of Removal. The facility's resident roster dated [DATE] reflected 41 residents resided on the Express Recovery Unit (Station 2).

Based on interview and record review, it was determined the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one (Resident #2) of three residents reviewed for quality of care. 1) Staff failed to recognize a significant change in Resident #2, who had a heart stent placed prior to admission to the facility on [DATE] and was without chest pain until [DATE] when he complained of chest pain "generating" to his left arm and he rated the pain an eight out of 10. His physician was not notified until [DATE] and the pain continued through [DATE]. 2) LVN J failed to assess Resident #2 when he had [MEDICAL CONDITION] activity and failed to remain with the resident to determine his status. Resident #2 became unresponsive on [DATE], staff initiated CPR and the resident expired in the facility on [DATE]. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because the facility was still monitoring the effectiveness of the Plan of Removal. These failures could affect the 41 residents, who resided on the Express Recovery Unit (Station 2), by placing them at risk for delayed medical care and treatment, continued pain, anxiety, fear, and/or death. Findings included: Resident #2's hospital History and Physical, dated [DATE], reflected,"...history of [MEDICAL CONDITION] with recent stent on RCA. On February 4th went to rehab, (name of rehab) last night. Again this morning, the patient had a sharp chest pain...PAST MEDICAL HISTORY: 1. Right middle cerebral artery stroke. 2. Critical stenosis of right internal carotid artery. 3. Occluded right distal MCA. 4. Hypertension...ASSESSMENT AND PLAN: ...recent stent 3 days back with right coronary artery...1. Chest pain...cardiology evaluating...Closely monitor the patient, cardiac monitor...." Resident #2's MDS assessment, dated [DATE], reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The MDS assessment also reflected his cognition was moderately impaired, he needed extensive assistance of two or more persons for bed mobility, transfers, and for toileting, he was dependent on staff for eating and he needed extensive assistance of one person for dressing, personal hygiene and bathing. Further review of the MDS assessment revealed he had an indwelling catheter, he was occasionally incontinent of bowel, he had a feeding tube, and he was on a scheduled pain medication regimen. Resident #2 resided on the Express Recovery Unit (Station 2). Resident #2's admission orders [REDACTED]. The Orders also reflected [MEDICATION NAME] 0.25 mg every six hours as needed for anxiety, [MEDICATION NAME] ,[DATE] mg every four hours as needed for pain, [MEDICATION NAME] 40 mg before breakfast, for GERD, and [MEDICATION NAME] 10 mg daily and Carvedilol 12.5 mg daily for Hypertension. http://www.webmd.com/heart-disease/tc/using-[MEDICATION NAME]-for-sudden-chest-pain-topic-overview reflected, "[MEDICATION NAME] is a [MEDICATION NAME], a medicine that opens blood vessels to improve blood flow. It is used to treat [MEDICAL CONDITION], a type of chest pain or discomfort that happens when there is not enough blood flowing to the heart. To improve blood flow to the heart, [MEDICATION NAME] opens up (dilates) the arteries in the heart (coronary arteries), which improves symptoms and reduces how hard the heart has to work...Regardless of what happens, you should let your doctor know that you had an episode of [MEDICAL CONDITION]. If this is unusual for you, if your [MEDICAL CONDITION] episodes are occurring more frequently or [MEDICATION NAME] longer, or if you need more medicine to control them, tell your doctor. Report any change in your chest pain (unstable [MEDICAL CONDITION]) to your doctor...." (retrieved on [DATE]) Review of Resident #2's Nurse's Notes from [DATE] through [DATE] revealed he did not have any chest pain during that time. Resident #2's Nurse's Notes dated [DATE] at 4:30 PM reflected he complained of chest pain which was "generating" to his left arm. The Notes reflected he was given one dose of [MEDICATION NAME] 0.4 mg, and a reassessment of his chest pain at 4:35 PM revealed his pain was "gone." Resident #2's February 2013 MAR indicated [REDACTED]. Resident #2's Nurse's Notes dated [DATE] at 4:30 PM did not reflect his physician was notified of the new onset of chest pain radiating to his left arm, and the pain was rated at an eight out of 10, even though he had a recent history of heart problems. Resident #2's facility History and Physical, dated [DATE], did not reflect the resident's significant chest pain, which radiated to his left arm. Resident #2's Nurse's Notes, dated [DATE] at 9:00 PM, reflected he complained of chest pain and received two doses of [MEDICATION NAME] 0.4 mg, one dose every 5 minutes. Resident #2's Nurse's Notes dated [DATE] at 9:00 PM did not reflect his physician was notified of the chest pain, even though he had a recent history of heart problems. The Notes also did not reflect the times the [MEDICATION NAME] was administered or his vital signs. Resident #2's Nurse's Notes, dated [DATE] at 9:00 AM, reflected he complained of chest pain and received two doses of [MEDICATION NAME] 0.4 mg, one dose every five minutes, and stated he was "pain free" after receiving the second dose. Resident #2's Nurse's Notes, dated [DATE] at 9:00 AM, did not reflect his physician was notified of the chest pain, even though he had a recent history of heart problems. The Notes also did not reflect vital signs before or after the medication was administered or his pain level. Resident #2's February 2013 MAR indicated [REDACTED]. Resident #2's Nurse's Notes, dated [DATE] with no time recorded, reflected he complained of chest pain again and [MEDICATION NAME] 0.4 mg was given with good effects after five minutes. The Notes reflected the following vital signs: blood pressure ,[DATE]; pulse rate 71; respirations 18; temperature 98.1; and oxygen saturation level of 97% with Oxygen at 2 liters per minute via nasal cannula. Further review of the Notes revealed his physician was notified and ordered a STAT EKG and laboratory studies. Resident #2's Nurse's Notes dated [DATE] did not reflect his physician was notified of the chest pain, even though he had a recent history of heart problems. Resident #2's February 2013 MAR indicated [REDACTED]. Resident #2's Comprehensive Metabolic Profile (laboratory study) Results dated [DATE] reflected his SGOT was high at 40 with a reference range of ,[DATE] and his SGPT was high at 57 with a reference range of ,[DATE]. The Results also reflected his previous results from [DATE] for SGOT was 19 and his SGPT was 20, which were both within the reference range. http://www.medicinenet.com/liver_blood_tests/page2.htm reflected, "AST (SGOT) and ALT (SGPT) are sensitive indicators of liver damage or injury from different types of diseases...For example, elevations of these enzymes can occur with muscle damage...." (retrieved on [DATE]). Resident #2's Nurse's Notes, dated [DATE] at 10:00 AM, reflected he complained of chest pain and [MEDICATION NAME] 0.4 mg tablet was given. Resident #2's Nurse's Notes, dated [DATE] at 10:00 AM, did not reflect his physician was notified of his chest pain, even though he had a recent history of heart problems. The Notes also did not reflect his vital signs or his pain level. Resident #2's February 2013 MAR indicated [REDACTED]. Resident #2's Physician's Progress Notes, dated [DATE] at 6:50 PM, reflected one episode of "chest discomfort" that morning that was sharp and not associated with exertion. The Notes also reflected the resident's chest pain was "atypical," and the results of the EKG were "nonspecific." Further review of the Physician's Progress Notes revealed the physician paged another physician regarding the resident's chest pain. Resident #2's Nurse's Notes, dated [DATE] not timed, reflected,"...res (resident) c/o chest pain PRN (as needed) pain meds (medications) for ,[DATE] pain... res now resting quietly (with) eyes closed. WCTM (Will Continue to Monitor)." Resident #2's Nurse's Notes, dated [DATE], did not reflect his physician was notified of the chest pain, even though he had a recent history of heart problems. The Notes also did not reflect the time of his pain, if the [MEDICATION NAME] was administered, or any vital signs. Resident #2's February 2013 MAR indicated [REDACTED]. Resident #2's Nurse's Notes, dated [DATE] at 10:00 AM, reflected he complained of chest pain and [MEDICATION NAME] 0.4 mg was given. The Notes also reflected his vital signs were checked, but not recorded. Resident #2's Nurse's Notes, dated [DATE] at 10:00 AM, did not reflect his physician was notified of his chest pain, even though he had a recent history of heart problems. The Notes also did not reflect the resident's pain was reassessed. Resident #2's February 2013 MAR indicated [REDACTED]. Resident #2's Physician's Progress Notes dated [DATE] reflected the resident's "atypical CP (chest pain) - resolved." Resident #2's Nurse's Notes, dated [DATE] at 11:00 AM, reflected he complained of chest pain and [MEDICATION NAME] 0.4 mg tablets were administered at five minute intervals for a total of three doses. The Notes also reflected, "...pt (patient) states pain is below 4 45 minutes later from a previous 8/o-10 (8 out of 10). 1300 pt c/o (illegible) another chest pain (physician) was notified...Imdur ([MEDICAL CONDITION]) 30 mg BID (twice a day). Pt [MEDICATION NAME] ([MEDICATION NAME]). Pt verbalize absence of pain...1500 pt c/o of another chest pain pt did not exhibit any SOB (shortness of breath), restless or being diaphoretic, pt was stable lying in bed watching TV, vital signs stable ,[DATE], 96.6, 80, 20 o2 (oxygen) 98% 2 LNC (liters via nasal cannula). (Physician) [MEDICATION NAME] and pt state relief. continue to monitor...1700 pt was being monitored, pt states no chest pain at this time, pt was watching TV...2000...denies any chest pain at this time...." Resident #2's Physician's Telephone Order, dated [DATE], [MEDICATION NAME] mg one tablet twice a day due to [DIAGNOSES REDACTED]. An interview with RN M on [DATE] at 3:54 PM revealed he was the nurse who called the physician on [DATE] when Resident #2 continued to complain of chest pain after three doses of [MEDICATION NAME] were administered on [DATE]. RN M stated he did not call Resident #2's physician for past complaints of chest pain because "the pain was relieved with one or two doses of Nitrogycerin." RN M stated the physician [MEDICATION NAME] mg daily, and the medication was ordered, but not delivered by the pharmacy until the next day. He stated the first dose [MEDICATION NAME] given on [DATE], but he could not remember at what time. RN M revealed Resident #2 was pain free and interacting with his family at the end of his shift, (the facility's schedule dated [DATE] reflected he worked from 6:00 AM until 10:00 PM) and his family was "anxious" regarding the resident's chest pain. He stated the resident's family never requested Resident #2 be sent to the hospital for evaluation. RN M revealed he did not work on the hall, where Resident #2 resided, on the day he expired. An interview with Resident #2's family member on [DATE] at 3:30 PM revealed when he/she visited Resident #2 on [DATE], he was "in so much pain, he was crying." The family member stated he/she notified RN M, and he stated he was "aware of the pain, the physician was already notified and he could not do anything for him right now." A telephone interview with the facility's contracted Pharmacist on [DATE] at 10:15 AM revealed the physician's orders [REDACTED]. Resident #2's February 2013 MAR indicated [REDACTED]. Resident #2's Nurse's Notes, dated [DATE] timed 3:00 (PM or AM not indicated), reflected CNA A notified LVN J that the resident was having a [MEDICAL CONDITION]. The Notes reflected his vital signs were blood pressure ,[DATE], pulse 86 and respirations 21, and the ADON monitored Resident #2, while LVN J notified his physician and received orders to transport the resident to the hospital. According to Nurse's Notes, Resident #2 became unresponsive at 3:57 PM, 911 was called and staff began CPR. EMS arrived at 4:11 PM and continued CPR until Resident #2 was pronounced dead at 4:41 PM. An interview with LVN J on [DATE] at 4:00 PM revealed she was the nurse who assessed Resident #2 on [DATE]. LVN J also revealed she cared for Resident #2 on several occasions since his admission to the facility, and he complained of chest pain "constantly." LVN J stated she did not notify Resident #2's physician because it was always relieved with one or two doses of [MEDICATION NAME]. LVN J also stated Resident #2's physician was aware of the complaints of chest pain and visited the resident once or twice a week. LVN J stated at 3:00 PM she was notified by CNA A that Resident #2 was "having a [MEDICAL CONDITION]," and when she arrived in his room he was "staring upwards." She revealed Resident #2 was unresponsive when she called his name and did not respond to chest rubbing used for stimulation. LVN J stated Resident #2 was breathing, and she left the room to retrieve her blood pressure cuff. She said when she left the room, the resident's family and the CNA remained in his room. LVN J revealed on her way to retrieve her blood pressure cuff, she notified the ADON of the resident's condition and the ADON went to Resident #2's room to assess him. LVN J stated while she was at the Nurse's Station calling the physician, the ADON came to the Station and checked Resident #2's clinical record. LVN J said after "about ten minutes" CNA A called for assistance from Resident #2's room. LVN J revealed when she and the ADON returned to his room, he was no longer breathing, and she called Code Blue and additional staff came to the room within one minute to initiate CPR. LVN J stated she could not remember which staff member called EMS. She also stated the resident's family member was present in the room, while CPR was being performed on Resident #2. LVN J revealed EMS arrived 10 minutes after staff began CPR. LVN J stated the paramedics performed CPR for 40 minutes before Resident #2 was pronounced dead. An interview with CNA A on [DATE] at 4:30 PM revealed she was the CNA who discovered Resident #2 "having a [MEDICAL CONDITION]." She stated when she entered Resident #2's room, his family member was at the bedside and Resident #2 appeared to be asleep. CNA A revealed after she obtained vital signs, the resident began to "shake all over." CNA A stated she left the room to get the nurse and returned to the room with LVN J and the ADON within a "couple of minutes." CNA A revealed at this time Resident #2 was no longer "shaking" and was breathing. She stated LVN J and the ADON left the room to check his clinical record and call his physician. CNA A revealed she stayed in the room with Resident #2 and his family member. She revealed after "about 12 minutes, he began to shake again," and his family member "yelled" at her to get help. CNA A stated the ADON returned to Resident #2's room "within seconds," and at this time Resident #2 was no longer breathing. CNA A revealed the ADON called "Code Blue" and began CPR. CNA A stated she could not remember which staff member called EMS. A telephone interview with Resident #2's family member on [DATE] at 3:30 PM revealed he/she visited Resident #2 daily and arrived at the facility at about 3:30 PM on [DATE]. The family member stated Resident #2 was asleep when he/she arrived and CNA A walked in the room to obtain the resident's vital signs shortly after he/she arrived. The family member revealed Resident #2 woke and complained of chest pain and then began to "shake like he was having a [MEDICAL CONDITION]." The family member stated CNA A left the room to get help and returned with LVN J and the ADON after "about 3 minutes." The family member also stated LVN J and the ADON stood at the end of the bed and watched Resident #2 and after a few minutes the "shaking stopped." The family member revealed the ADON and LVN J never assessed Resident #2, and the ADON asked CNA A for vital signs. The family member stated then the ADON and LVN J left the room, and CNA A remained in the room. The family member revealed after a few minutes Resident #2 began to "shake again...his eyes rolled back...he took a big breath and then stopped breathing." The family member revealed CNA A called for help and multiple staff members came to the room and began CPR, and it took about 10 to 15 minutes for EMS to arrive. The family member stated EMS continued CPR for about 30 minutes until Resident #2 was pronounced dead. A telephone interview with Physician X, Resident #2's physician, on [DATE] at 1:00 PM revealed he was "aware" Resident #2 "complained of chest pain often." He stated he assessed Resident #2 on two occasions while he resided in the facility. The Physician revealed Resident #2 was on the appropriate medications for his [MEDICAL CONDITION] [DIAGNOSES REDACTED]." Physician X stated he consulted Physician Y on [DATE] after seeing Resident #2. He stated Physician Y said all medications were appropriate for Resident #2's heart condition and cardiac rehabilitation was recommended when Resident #2 "was stronger." He stated nursing staff should notify the physician if a resident complained of chest pain, but he was "not sure" if there was "anymore that could be done" regarding Resident #2's condition. An interview with the DON on [DATE] at 1:30 PM revealed she was not employed at the facility on [DATE] and was only aware of the incident from what she read in Resident #2's clinical record. The DON stated that she provided in-services to the staff on [DATE], [DATE] and [DATE] regarding recognizing resident's significant change in condition and the procedure for administration of medications. The DON revealed she was aware of documentation errors, and the facility had not had a Staff Development Coordinator for "several months." An interview with the Administrator on [DATE] at 9:05 AM revealed he was in the facility on [DATE], but was not aware of the incident with Resident #2 until [DATE]. He stated he was aware of the documentation errors, but he thought the appropriate "nursing judgment" was used when reporting Resident #2's change of condition. The Administrator revealed the facility had a pain protocol, and he was "not sure" if chest pain should be reported to the physician if the chest pain was "minor or relieved with medications." The facility's current policy Physician Notification of Change in Resident Condition, revised [DATE], reflected, "Policy It is the policy of this Center to notify the physician and inform the resident and resident's responsible party of a significant change in the resident's physical, mental, psychological status, including accidents and when there is a need to alter treatments significantly...Immediately notifying the attending physician and/or emergency service physician...Taking action to prevent the resident from further injury, illness, or death. Purpose To keep the physician, resident and resident's responsible party informed of changes in the resident's condition so that timely intervention can be obtained. To ensure the resident receives prompt medical treatment in an emergency, when indicated. Definition 'Change of Condition related to physician notification is defined as the physician should be notified of any sudden and marked adverse change in the resident's condition which is manifested by signs and symptoms different than usual denoting a new problem, complication or permanent change in status and requiring a medical assessment, coordination and consultation with the physician or physician extender and a change in the treatment plan. Procedure 1. It is the responsibility of the person observing the change to report that change to the licensed nurse. 2. The licensed nurse will assess the change of condition and determine what nursing interventions are appropriate. 3. The licensed nurse will be responsible for making all notifications of changes to physicians, the resident, and the resident representative. 4. Examples of changes may include, but not limited to...Changes in vital signs, abnormal findings Respiratory or cardiovascular changes...5. Before notifying the physician, the licensed nurse must observe and assess the overall condition utilizing physical assessment and chart review. Notification to physician will include a summary of the condition change and an assessment of the resident's vital signs and system review focusing on the condition and/or signs and symptoms for which notification is required...6. Emergency notification will be made immediately... 15. Assessment and documentation will continue once each shift for a minimum of 72 hours (or until stable) to monitor the resident's condition and response to treatment." An IJ was identified on [DATE]. The Administrator and DON were notified of the IJ on [DATE] at 4:45 PM, and a Plan of Removal was requested at that time. The facility's Plan of Removal, accepted on [DATE] at 5:00 PM, reflected, "...Nursing Administration was educated on identification of change of condition, physician notification and proper medication administration. This education was conducted by the Regional Quality Assurance Nurse Consultant. This education process was then repeated for the licensed nursing staff, medication aides, and certified nurses assistants (sic)...This education will include but not limited to: 1. Emergency notification will be made immediately. Notification of non-emergency changes will be made promptly on the shift in which it occurred. 2. If, based on an evaluation/assessment by the charge nurse, a resident exhibits such serious symptoms that failure to obtain the most rapid therapeutic interventions by the physician would place the resident in great jeopardy: Call 911 and prepare the resident for immediate transfer. Send via paramedics to the nearest emergency room . Notify the attending physician... DON/interim DON will directly oversee and/or conduct the education training to the facility licensed nursing staff, medication aides, and certified nurses assistants (sic)...b. Identification (Change of Condition/Physician Notification) - All residents in the facility were evaluated by licensed staff for vital signs, pain, chest pain, shortness of breath and any atypical symptoms. The licensed nurse will be responsible for notifying the physician, if a change of condition is identified that requires the coordination and consultation with the physician or physician extender and a change in the treatment plan... Identification (Medication Audit) - Facility has completed a review of resident medication administration records and compared to physician orders [REDACTED]. DON or designee will be responsible for this process. Daily review of new admission records and discharge records for accuracy and completeness. Daily review of physician orders. Daily review of 24 hour reports to identify any change of conditions. Review of S-Bar/Stop & Watch...The Quality Assurance Committee will review the progress of medication administration, identification of change of condition and physician notification monthly to ensure the monitoring of these systems and adjust as necessary based on audits from chart reviews...." Interviews conducted from [DATE] at 9:45 AM through [DATE] at 4:20 PM with LVN J, LVN K, LVN L, RN M, RN N, RN O, LVN P, LVN Q, LVN R, LVN S, LVN T, LVN U, LVN W and LVN V revealed they were to notify the physician promptly for significant changes in conditions, they were to recognize emergent and non-emergent significant changes in conditions and were to use the S-BAR and Stop & Watch forms as assessment tools. Interviews conducted from [DATE] at 9:45 AM through [DATE] at 4:40 PM with CNAs A, B, C, D, E, F, G, H and I revealed they were to recognize and notify their Charge Nurses if the residents exhibited any changes in condition and the proper use of Stop and Watch form. The IJ was removed on [DATE]. The Administrator, DON and Vice President of Clinical Operations were notified on [DATE] at 5:30 PM that the IJ was removed. While the IJ was removed, the facility remained out of compliance at scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because the facility was still monitoring the effectiveness of the Plan of Removal. The facility's resident roster dated [DATE] reflected 41 residents resided on the Express Recovery Unit (Station 2).

Based on observation, interview, and record review, it was determined the facility failed to ensure one (Resident #3) of 13 current residents reviewed for falls and one (Resident #17) of three closed records reviewed received adequate supervision and assistance devices to prevent accidents. 1) Resident #3 was known by staff to want to go to bed after lunch and would attempt to transfer herself if left alone. On 05/24/12, the resident was left alone in her room. There was no intervention in place to potentially prevent the resident from falling. Resident #3 fell trying to transfer herself from the wheelchair to the bed and sustained fractures of both femurs. 2) Resident #17 eloped from the facility on two occasions as staff found her outside the building. These failures could affect the safety and security of 96 residents. Seven residents had a wanderguard. Findings included: 1) On 06/26/12 at about 11:00 a.m., Resident #3 was observed sitting in a Geri-chair in the television room across from the nurses station. At that time, LVN A stated Resident #3 had Dementia and required total care for her ADLss. He stated Resident #3 had fallen and fractured both her legs when she attempted to transfer herself. According to the facility's investigation, dated 05/25/12, Resident #3 had attempted to transfer herself from her wheelchair to her bed on 05/24/12 at about 2:00 p.m. She fell and fractured both her knees. The fall was not witnessed, however, HK B heard Resident #3 yelling and when she entered the room, Resident #3 was on her knees on the floor trying to pull herself up onto the bed. At the time of the incident, Resident #3 was able to tell staff she had fallen out of her wheelchair trying to transfer herself to the bed. The two CNAs on Resident #3's hall were CNA I and CNA H. CNA I's statement, dated 06/07/12, reflected, "Before lunch her family brought her lunch & she ate in her room. Her ___ (family member) was here. They were in there before lunch. '___ (Resident #3) not eating' family brought her something." CNA H's statement, dated 06/06/12, reflected "last time I saw her she was in the dining room. I didn't take her to her room." Resident #3's family members were called on 06/07/12 about Resident #3's fall. When asked if they were there at lunch on the day their mother fell , both family members said they were not at the facility on that date. According to the MDS assessment, dated 06/05/12, Resident #3 was a [AGE] year-old female, who was re-admitted on [DATE] with diagnoses, which included Anemia, Hypertension, Diabetes, Thyroid Disorder, Osteoporosis, Other Fracture, Alzheimer's Disease, Non-Alzheimer's Dementia, Depression, Chronic Obstructive Pulmonary Disease, Aftercare Trauma Fracture Bone, and Fall. Resident #3 required extensive to total assistance with her ADLs. The MDS assessment further reflected the resident had a history of [REDACTED]. The Alzheimer's/Dementia care plan for Resident #3, dated 11/16/11, reflected to "monitor resident's whereabouts in the facility to ensure safe environment." Resident #3's care plan for transfers, dated 03/15/12, reflected to "assist with transfers as needed." Resident #3's care plan, which addressed falls and was dated 11/04/11, was discontinued on 02/04/12. Nurse notes, dated 10/02/11, reflected "Resident slipped out of W/C (wheelchair)." The "Daily and Q Shift Charting" reflected Resident #3 was "found on room floor. Pt's (patient) roommate stated pt. slid out of chair to floor" on 11/03/11. Resident #3's nurse notes, dated 11/30/11, reflected "resident had a fall from W/C." The "Rehab Referral," dated 11/30/11, reflected recommendations had been made for Resident #3 to have a "Dycen" (non-slip pad) in her wheelchair. Resident #3's monthly nursing summary, dated 05/02/12, reflected under the therapy section "Pt very quiet, rarely speaks. Must be redirected from going back to room. Continuously asks to go back to her room to go to bed." The CNA daily care guides for 06/11/11 and 12/15/11 for Resident #3 were reviewed, which reflected a wheelchair press device was to be used and identified Resident #3 as being at risk for falls. LVN G was unable to locate any other CNA daily care guides. On 06/27/12 at 10:00 a.m., HK B was interviewed. She stated she heard Resident #3 yelling her "legs hurt" on 05/24/12 after lunch. When HK B entered the room, she found Resident #3 half on her bed and half on the floor. Her wheelchair was behind her. HK B stated she then saw LVN A and immediately reported Resident #3 was on the floor to the LVN. LVN A immediately went to the resident's assistance. HK B stated she did not hear or see a wheelchair alarm during this incident. HK B stated Resident #3 frequently tried to transfer herself. On 06/27/12 at 10:30 a.m., LVN A was interviewed. LVN A stated Resident #3 was supposed to have a wheelchair alarm, because she would try and get up to transfer herself from her wheelchair to her bed. The resident was not supposed to be left alone while in her wheelchair. The day she fell , her family brought her lunch. Then, they left without telling anyone, which left Resident #3 by herself. He was the person, who responded first when HK B found the resident and called him. The time was after lunch sometime between 1:00 p.m. and 2:00 p.m. LVN A stated he did not hear an alarm sounding at that time. On 06/27/12 at 3:30 p.m., Resident #3's family member was interviewed about her mother's fall. She stated neither she nor her sister were at the facility that day until after the facility called and informed them about Resident #3's fall. She stated no family member brought Resident #3 food that day. She stated during the February 2012 care planning meeting, a wheelchair alarm was discussed and was to be implemented. On 06/28/12 at 11:10 a.m., Previous DON B was interviewed via telephone. She stated Resident #3 did not have a wheelchair alarm or special grip pad in her wheelchair because she not fallen since November 2011. On 06/28/12 at 11:32 a.m., CNA C was interviewed. She stated she was one of Resident #3's caregivers even before her fall in May 2012 when Resident #3 was in a wheelchair. She stated she was not working the day Resident #3 fell on [DATE]. However, Resident #3 was able to independently wheel herself in the wheelchair, and after each meal, she wanted to be back in bed. She would slowly wheel herself towards her room. She (CNA C) and the other staff knew Resident #3 would attempt to transfer herself, so they would get her to her room and transfer her. CNA C did not remember Resident #3 having a wheelchair alarm or special pad in her wheelchair. CNA C stated Resident #3 was in a room closer to the nurses station before her fall, but then she was moved to a room at the end of the hall. That was the room she was in when she fell and fractured her knees. On 06/28/12 at 1:45 p.m., AD D was interviewed. The AD stated Resident #3 had a history trying to transfer herself, and she was a fall risk. AD D Staff knew Resident #3 needed to be transferred to bed after lunch. On 06/29/12 at 11:00 a.m., LVN G was interviewed. When LVN G was asked about Resident #3's fall care plan, she stated it should not have been discontinued as she was still a fall risk in May 2012. Upon reviewing Resident #3's entired clinical record, she stated she could not find where a wheelchair alarm or other devices to prevent falls was instituted. On 07/02/12 at 3:30 p.m., CNA I was interviewed via telephone. She stated she was not Resident #3's nurse aide the day she fell . CNA I stated she remembered not seeing her in the dining room at lunch and noticed her lunch tray was still on the cart. CNA I stated she just assumed Resident #3 did not come to the dining room and was going to eat in her room, espeicailly since she saw Resident #3's family members in the resident's room shortly after lunch. She stated Resident #3 would often wheel herself to her room and try to get in bed on her own. So, "the best thing to do with her was to toilet her and put her in the bed yourself," because she would otherwise try to transfer herself to the bed. During a telephone interview with CNA H on 07/02/12 at 3:40 p.m., she stated she was Resident #3's nurse aide on 05/24/12, the day she fell . She stated she did not take Resident #3 to her room after lunch as she was busy in the dining room. However, she did see Resident #3 in the dining room at lunch that day. CNA H stated the staff all knew Resident #3 would wheel herself to her room and try to transfer herself so "she stayed in the eye of the nurses and nurse aides." CNA H stated, "most likely," Resident #3 left the dining room and wheeled herself to her room without anyone realizing it. 2) Resident #17 was a [AGE] year-old female who was admitted to the facility on [DATE] according to a Quarterly MDS dated [DATE]. The MDS reflected her [DIAGNOSES REDACTED]. The resident had long- and short-term memory problems (C0600 and C0700). She was moderately impaired for cognitive skills for daily decision making (C1000). She had continuous disorganized thinking (C1300B). Wandering behavior occurred daily (E0900). The consolidated June 2012 orders reflected Resident #17 was to have a "wanderguard on at all times" and "check placement Q (every) shift." The orders reflected the initial date for the wanderguard was 04/01/11. Review of Routine Treatment Administration Record for June 2012 revealed the wanderguard placement was not checked for the following seven shifts: 06/11/12 the 6-2 and the 2-10 shifts, 06/12/12 the 6-2 shift, 06/16/12 the 10-6 shift, 06/17/12 the 6-2 and the 2-10 shifts, and 06/18/12 the 6-2 shift. An Interdiciplinary Plan of Care Review Form dated 05/17/12 was signed by the MDS Coordinator, ADON N, and the Dietitian. The HCP (Health Care Plan) dated 05/17/12 was a computer printout. The "problem" related to "Confusion, altered thought process, impaired memory" did not include an approach reflecting the resident had a wanderguard. The "problem" related to "Wandering" had a goal of "Have no injuries due to falls in the next 90 days." The approach reflected "Keep bed in the lowest position." It did not include any information reflecting the resident had a wanderguard. No problem/goal/approach was found related to the fact the resident had a wanderguard, that it was to be checked every shift, or that she was exit-seeking. A handwritten HCP note dated 05/20/12 reflected: "Potential for Elopement due to Hx (history) or wandering." The goal was "Resident will not leave prembses (sic.) Un attended in the next 90 days." Approaches included: "Wanderguard placed on Lower ext (extremity). Redirect res when exit seeking." Review of nurse's notes for Resident #17 revealed documentation of wandering, hallucinating, and "fighting to get out of the facility" on 05/14/12 at 11:00 p.m. The next note on 05/17/12 at "2-10pm" reflected "wandering in the hallway, pacing back and forth, not being friendly to other residents .... Con't (continue) to monitor very closely." The next note dated 05/20/12 at 4:45 p.m. reflected the resident eloped. LVN F documented, "I was notified by __ (LVN J) and __ (CNA K) on 3rd floor that __ (Resident #17) was seen by the CNA downstairs by the patio. The CNA helped resident to come back on 3rd floor. I notified __ (LVN K) the nurse on call and ... (started) 15-minute checks continuously." The next note on 05/21/12 at "10p-6a" reflected "continue to monitor resident for elopment (sic.) ... wanderguard in place/active" A note on the "2-10pm" shift reflected, "Resident (undecipherable) wandering back and forth in the hallway. Reluctant to follow simple commands .... Social Worker to find alternative method to keep pt (patient) safe." On 05/22/12 at "12" the note by ADON N reflected "Spoke _ (symbol for with) __ (daughter) R/T (due to) resident going down stairs verbalized understanding dementia." Review of facility incident reports for six months (January through June 2012) revealed one incident report related to an elopement. The incident report dated 05/21/12 for Resident #17 reflected the resident was "found outside PT (patient) patio." LVN E completed the report and noted the resident would be on "1 on 1 supervision." The report reflected the family was notified at 8:30 p.m. and the physician was notified at 8:15 p.m. Previous DON S had signed the report, but the Administrator had not signed it. A section was titled "List A" and a notation reflected: "Any "List A" events must be faxed to the legal department __(phone number) within 72 hours." The block on List A in front of "AMA (against medical advice)/Elopement" was gone because of the hole punch. It was unknown if the incident had been sent to the legal department. The back page of the incident report reflected "Wanderguard on at all times check for if working q (every) shift." The first page of the Witness Statement only the top part was completed: Resident's name, date and time of the incident, and type of incident was "attempted elopement." No information was filled as to what staff person was assigned to provide activities of daily living, or who the nurse reported the incident to. A Witness Statement continuation sheet was signed by Previous DON S. It reflected "Last night at approximately 8 pm I found Res __ (Resident #17) outside 1st floor patio trying to get back into the building. I ask her what she was doing but was unable to determine her response. She was very confused and disoriented. I took her back to 3rd floor where nurse completed head to to (toe) assessment on __ (Resident #17), (no) injuries were noted. She was placed on close observation by staff until her bed time around 9pm. Family member and physician were notified." No incident report for Resident #17 was found reflecting she had also eloped from the facility on 05/20/12 as noted in her nurse's notes. The 24-Hour Reports were reviewed for Resident #17: a) On 05/13/12 - ? "night" - "OK/wandering" ? "day" and "evening" - "confused resident, keep an eye on her and orient her" b) On 05/14/12 - ? "night" - "wandering/yelling/confused" c) On 05/20/12 - ? "day" and "evening" - "Q15 minute checks continuously for elopment (sic.) risk" d) On 05/21/12 - ? "night" - "continuous check while awake on WC (wheel chair)/use Wanderguard @ (at) all time (elopement risk)" ? "day" - no entry ? "evening" - "Social Worker to find alternative method to keep pt safe" e) On 05/22/12 ? "night" - "leaving the floor" ? "day" - no entry ? "evening" - "monitor for elopment (sic.)" The first In-Service Education provided by the facility relating to the elopement by Resident #17 was on 05/25/12. This was five days after the first documented elopement on 05/20/12. Social Worker (SW M) notes for 05/30/12, 10 days after the first incident, reflected, "Dr. __ spoke _ (symbol for with) SW concerning locked facility for res (resident). She doesn't feel that res can be kept safe d/t (due to) recent events _ (symbol for with) wanderguard system not working properly & res getting outside. She informed SW that she has spoken _ (symbol for with) dtr concerning progression of dementia ...." A Discharge Planning assessment dated [DATE] signed by SW M reflected "Dr. __ (resident's physician) had recommended a LTC (Long Term Care) locked/secure dementia facility." "...6/6 Dtr has chosen __ (name of facility)." A telephone interview was conducted on 6/28/12 11:15 a.m. with the Previous DON S. Surveyors asked if she remembered Resident #17. She replied, "Yes." Previous DON S reported she was aware the resident eloped when she got out of door by the gym. She said she was notified. She said she did not remember who told her. Surveyors asked if an incident report was completed. She said, " Yes." Surveyors asked if the facility notified DADS about the elopement. She said, "No." Previous DON S said she got out of the door and was only out 10-15 feet out of the building. She said she not recall how long the resident was gone. Previous DON S said she did not remember if Resident #17 had a wanderguard. She said there should be statements as ADON N interviewed staff. She said she could not recall who was interviewed. Surveyors asked how the resident got out. Previous DON S said she got out a door near the gym. She said she did not remember who found her. Surveyors asked her about wanderguards and whether they should be checked every shift. She stated that should be documented in MARs. Surveyors asked how the facility ensured the wanderguard was activating the alarm. She said when a nurse comes on duty, that should be part of her doc process and then document on the MAR. She said the 24-hour chart review should check that. She said if the MARs were not being completed, it should be brought to the attention of the ADON or DON. Surveyors asked if anyone was assigned to monitor the elevator. She said no one was assigned to monitor the elevator, "Everyone has to take care of residents." Surveyors asked if rounds were done to check on residents. She said rounds were scheduled every two hours by licensed nurse or CNA. She said "there should be no need to implement anything besides the wanderguard. Personnel respond to the wanderguard when they hear it." On 6/28/12 at 12:38 p.m. ADON N was interviewed. Surveyors asked ADON N if she recalled Resident #17. She said the resident started "roaming the doors and alarming them off in May (2012)." ADON N said the resident got on the elevator and went outside. She said the physic was notified and said the resident should be moved. Surveyors asked who found the resident. She said the Previous DON S found her. Surveyors asked if it was a Saturday or a Sunday in the evening. She said she was not sure as she was not working. ADON N reported Resident #17 had an order for [REDACTED]. She said the system kept alarming. Surveyors asked if she had done the investigation about the elopement. She said, "I did not do the investigation. __ (Previous DON S) did the investigation. She and the Administrator were both here. They came to do rounds on weekend." Surveyors asked when the Previous DON had come to the facility. ADON N said she came in 01/12 and left in 06/12. ADON N said she did not do any interviews related to that elopement. ADON N said Previous DON S was the one who brought Resident #17 upstairs. She said, "Apparently she was just gone a few minutes. LVN T and LVN E were working." ADON N again said she was not involved in the investigation. She said she heard they had given her a drink and it had not been extended time as far as what they told her. Surveyors asked if the elopement had been reported to DADS. She said, "No. Because she was still on our property." Surveyors asked if a person was assigned to the desk. She said, "No." On 06/28/12 at 1:28 p.m. Vice President (VP) U was interviewed. He was assisting the survey process while the Administrator was on vacation. He was interviewed about the wanderguard system. He stated the Maintenance Director tested the system with a device. The wanderguard that is put on residents have a light that flashes and enables staff to know it is working properly. If there is a solid light or no light then the wanderguard is not working properly. The wanderguard panel on Station 2 (on second floor) will alert if system was not working properly. This allows all staff to know the system is working. If sys not working then will staff notify the Maintenance Director. VP U did not know if inservices had been done. Surveyors asked if there were logs documenting checks of the system. Maintenance Director did have logs. Surveyors asked to review the logs. Surveyors asked if the facility had a system in place to man desk at all times. VP U said there was a unit secretary who worked 8-5 p.m. and after 5p.m. the nurses watch the desk. Surveyors expressed concern that the facility did not have a system to have someone at desk all times. Surveyors asked what would stop a resident from leaving. Surveyors advised during interviews, staff were saying they were all "busy." Surveyors asked if there had been a recent reduction in staffing. VP U said it was not reduced but changed. Station 3 (3rd floor) had three nurses and now have two nurses and one Medication Aide. He said no staff had approached him or the DON about staffing. Surveyors asked about so many new staff. He said they had people quit. The Previous DON left as of Monday (06/25/12), ADON N went to the second floor and had functioned as an interium ADON because ADON V was on sick leave. He said he was aware of who brought Resident #17 back in the building. He said the Acting DON said she did not know until about 15 minutes ago. VP U said he was aware the Previous DON and the Administrator were in the building. VP U told surveyors he oversaw 10 buildings and the Acting DON was a consultant for seven buildings. In an interview with ADON N on 6/28/12 at 2:30 p.m., while reviewing Resident #17 ' s chart, stated " I know there were more notes in this chart. They appeared to have been removed. I know that I saw them last week! " On 06/29/12 at 8:23 a.m. Resident #17's daughter was interviewed via telephone. Surveyors asked if she was aware her mother had eloped and asked if the wanderguard was working. She said, "She wanted to go home." The daughter said she had not been notified right away. She said she talked to nurses and CNAs a week later and they told her mother got out again within a 10 day period. She said she found out because she was visiting her mother. The Daughter said her mother was very confused that week. The daughter said ADON N told her that was the 2nd time her mother had gotten out. The DON never called her and she had not heard from Administrator. The Daughter said she visited four times or more a week and nurses and CNAs knew her. The Daughter reported the SW M casually mentioned, "Oh by the way, we want you know about her (Resident #17) leaving." She said the SW said she should find a facility with a locked unit. Surveyors asked if at any time the Admininistrator or the DON had called about Resident #17's elopement. She said, "No." The Daughter said her mother was always in the hallway because she wanted to be around someone. She said, "I felt I could not trust the system." The Administrator was interviewed via telephone on 06/29/12 at 9:54 a.m. He reported he came to the facility in late January 2012. He and the surveyor had a lengthy discussion specifically about the June 2012 Quality Assurance (QA) meeting and Resident #17's elopement. However, later that afternoon the Vice President assisting the survey team on site reported the facility had not had the June 2012 QA meeting yet. The Administrator advised one night he and the Previous DON came up to the building. He said he got there at 9:45 p.m. and the Previous DON arrived at separate times. The Previous DON told him Resident #17 was in the lobby (on the first floor). He said they told staff to monitor her frequently. Surveyors asked if the wanderguard was working. He related that night when they took Resident #17's wanderguard to the elevator it did activate the alarm. Surveyors asked if Resident #17 was out of the building. He said that was only time he was aware the resident had left the floor. Surveyors read the statement from the Previous DON on the Incident Report dated 05/21/12 that she had found the resident outside on the patio. Surveyors asked who was responsible to inservice staff. He said it was the Previous DON's job to inservice. He said she had not advised him of the second elopement. Surveyors asked if he had called the family about the elopement. He said he did not remember, but felt sure on the investigation the Previous DON had called the family. The surveyor asked if he reviewed investigations. He said, "Yes." The surveyor asked if staff were interviewed because there were no staff interviews. Surveyors asked if he had reviewed that investigation about Resident #17's elopement. He said he was sure he did. The surveyor advised the Investigation Report dated 5/21/12 was not signed by him. He again said he was not aware the resident was outside. Social Worker (SW) M was interviewed on 06/29/12 at 12:48 p.m. Surveyors asked if she was familiar with Resident #17. She said the resident was a "wanderer, was rarely oriented to other than self, and her mood fluctuates every day." Surveyors asked if she was aware of any problems with the resident. She said there were two times when she got off the floor. SW M said in the morning meeting staff discussed that the resident had gotten off the floor. She reported the DON, both ADONs, the Administrator, both SWs, the MDS Coordinator, the Director of Rehab, and the Dietitian attended the meetings. Resident #17's elopement was discussed only one of times was in the morning meeting. The second time she eloped she was advised by one of nurses the resident had gotten out again. She said both incidents happened within couple of days of each other. Surveyors asked if nursing investigated. She said she was not sure. SW M also said "nursing" should have done notification (of the family and the physician). She said the first elopement was after 5 p.m. SW M was not aware of a plan of action for Resident #17. SW M said the physician came in shortly after that and told the SW to find an alternate way to keep her safe. SW M said she talked with family about secure unit. SW M said the facility did check the wanderguards and check alarms. She said, "They took the keypad entry off doors around that time. They did say they were taking the keypad entries off a as safety measure." CNA K was interviewed via telephone on 07/01/12 at 7:51 p.m. She reported she worked the 2-10 shift on weekends. She said she knew Resident #17. The CNA said she remembered 05/2012 when she found Resident #17 in her wheelchair outside the back of the building on the parking area around 8:00 p.m. The CNA said she was coming from the break room and heard someone outside saying "Help me. Help me." She went out the door and brought the resident inside and up to the 3rd floor. The CNA said she told LVN J. The surveyor asked if she saw the resident's wanderguard. She said, "No." CNA K reported she wrote a statement and gave it to LVN F. She said the incident happened Saturday night (05/19/12), and they told her to write the statement on Sunday (05/20/12). LVN F was interviewed on the phone on 07/01/12 at 7:32 p.m. The surveyor asked if he completed a nurse's note for Resident #17 on 05/20/12 related to her elopement. He reported he did not remember exactly. He said he did not remember if he completed an incident report. LVN F stated he would call the surveyor back when he could review the chart. LVN F was interviewed on the phone on 07/02/12 at 11:33 a.m. after he had reviewed Resident #17's chart. He told the surveyor Resident #17 had eloped on Saturday 05/19/12 and CNA K had brought Resident #17 back. He stated, "I was busy in other rooms" when the resident was returned to the floor and the CNA told LVN L about the elopement. He said, "I found out about it on Sunday and called the Weekend Supervisor." LVN F said he had completed an incident report. He stated he also checked Resident #17's wanderguard on Sunday. LVN F said the wanderguard had "stopped working" when CNA K brought Resident #17 back and he had instituted 15-minute checks on her (on Sunday). He reported he did document them for Resident #17 "on a blank piece of paper." He related he had "two pages of 15-minute checks." The surveyor advised no documentation could be found for the 15-minute checks. The surveyor asked about whether 15-minute checks had been done for all residents who had wanderguards. He said, "No. Just __ (Resident #17)." The surveyor asked LVN F if he was Resident #17's nurse for May 19 and 20, 2012. He said "Yes." The surveyor asked about his documenting the incident dated 05/20/12 in nurse's notes when he said it happened on 05/19/12. He stated, "Usually when things happen I document." The surveyor asked LVN F about making a "late entry," how that should be done, and how that should be documented. He did not answer. LVN J was interviewed via telephone 07/01/12 at 8:05 p.m. She said she worked weekends on the 6-10 shift. She reported she did know Resident #17. She said one time the resident got in the elevator and got outside. She stated that she and LVN F were at the nurse's station when CNA K brought the up and said the resident had been outside. LVN J said Resident #17 had been seeking the elevator. She was not sure about someone being at the desk all the time. She said usually the alarm rings. LVN J said the wanderguard alarms sometimes and then did not alarm sometimes. She said she did not remember whether Resident #17's wanderguard was blinking or not. She said they were doing 15-minute checks on Resident #17. LVN J said she was not Resident #17's nurse, that LVN F was assigned to her. She said she thought LVN F did an incident report and the 15-minute checks. LVN J said, "We were shocked she got out." 3) 4) The facility's current policy for INCIDENT/ACCIDENT INVESTIGATION dated April 2004 was reviewed: "Purpose To investigate, study and evaluate any accident or incident too prevent a reoccurrence. Procedure: I. Accident/Incident Person(s) witnessing an accident or incident should: a) Render immediate assistance. Do not move the injured resident/person until examined by a nurse for possible injuries. b) If assistance is needed, depending on the condition of the resident/person, report to the nearest nurses' station or use the call button in the resident's room to summon help. c) If a resident/person is alleging an abuse, please refer to Abuse Manual for reporting, investigation, and follow-up. d) Report ALL accidents/incidents to the charge nurse as soon as practical. II. Medical Attention a) The charge nurse/supervisor will examine the resident/person for any signs of injury. b) Notify MD, family, responsible party and supervisor. If this is a reportable injury as noted in company policy for incident reports, the Administrator or his/her designee will be notified. c) Arrange for residents to be transferred to the acute (sic). d) Assisting visitors with direction from the Administrator to seek medical attention. If refused by visitor, document on the incident report. III. Investigation: a) Investigations are initiated immediately to involve those closest to the incident after completing the incident report as indicated. b) Include on the investigation form: i. All times and dates of the incident/accident invluding when family and MD were notified. ii. Circumstances surrounding the accident/incident including identiy of any medical devices involved in the accident. DO NOT make assumptions. Finding a person on the floor should be described, not an assumption that a person fell . iii. Place where the accident took place and possible condition of the area/environment. iv. Name and accounts of all witnesses. v. Injured person's or resident's account of the incident/accident. vi. Assessment of the resident/person including vital signs, pain level, cognitive level. vii. Final disposition of the injured. viii. Signature of the person completing the form. The investigation will be given to the Administrator and his or her designee to be attached to the Incident Report for follow-up as required by the reporting guidelines in Indicent Reporting Policy and Procedure." 5) The facility's current Wandering Device Policy dated May 2004 reflected, "When a resident has potential for elopement and is utilizing a wandering device, the device will be maintained in a manner

Based on interview and record review, it was determined the facility failed to ensure one (Resident #1) of 13 residents reviewed for accidents and injuries received adequate supervision and assistance devices to prevent accidents and injuries. Resident #1's hip was not maintained in proper alignment following the insertion of a hip prosthesis. An abductor pillow (a positioning device used to keep the hip and legs in proper alignment) was not maintained on the resident and the resident was diagnosed with [REDACTED]. These failures could affect the facility's 43 cognitively impaired residents by placing them at risk for preventable injuries, pain, and hospitalization s. Findings included: The Face Sheet dated 12/07/11 reflected Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] for aftercare following a fractured hip. The resident had additional [DIAGNOSES REDACTED]. Resident #1's facility History and Physical dated 11/09/11 reflected the additional [DIAGNOSES REDACTED]. The hospital Operation Report dated 10/31/11 reflected Resident #1 had placement of a prosthesis for the Subcapital Fracture of the right hip. The Physician's Discharge Orders dated 11/04/11 from the hospital reflected an abductor pillow was to be maintained for Resident #1 for the [DIAGNOSES REDACTED]. The Admission Nurse assessment dated [DATE] reflected the abductor pillow was in place on admission for Resident #1. Resident #1's facility admission orders [REDACTED]. A confidential interview revealed Resident #1 was transferred back to the hospital on [DATE] and required a second hip surgery. Interview on 12/20/11 at 4:30 p.m. with the Director of Rehabilitation revealed all residents who had total hip surgeries were to have hip precautions (preventative measures to keep hips aligned to prevent injury which included not crossing legs or bending over) even if the physician did not write it in the orders. The Director stated it was important for cognitively impaired residents to maintain the abductor pillow while in bed to prevent injury. The Director also stated alert and oriented residents might not need the abductor pillow because they could be taught hip precautions. The Occupational Therapy Progress Note, dated 11/10/11, reflected Resident #1 remained cognitively impaired and was to use the hip abductor pillow as a precaution. Interview on 12/20/11 at 4:50 p.m. with CNA A revealed when she came on duty she often found the abductor pillow was not being utilized on Resident #1 when he was in bed. CNA A stated Resident #1 would often kick his legs around and cross one leg over the other leg. CNA A stated she knew Resident #1 should have the abductor pillow on and she would keep it on Resident #1 when she was on duty. CNA A stated she served as a translator for the family and previous DON on one occasion. At that time, the family complained about the abductor pillow not being maintained on the resident. The previous DON told the family there was no physician's order for the abductor pillow. Interview on 12/20/11 at 6:00 p.m. with ADON B and ADON C revealed Resident #1 was very confused and pulled off his abductor pillow and blankets. The Nurses' Notes, dated 11/13/11, reflected the family complained the abductor pillow was not maintained for Resident #1. The family reported Resident #1's hip looked out of place and requested an x-ray be done. The physician was notified and an x-ray was ordered. The x-ray report, dated 11/14/11, reflected Resident #1 had sustained a dislocation of the right hip artificial joint. The Nurses' Notes, dated 11/15/11 reflected Resident #1 was sent to the emergency room . Review of Luckmann and Sorensen's Medical-Surgical Nursing, Fourth Edition, Copyright 1993, pg. 1926 revealed, "...Handle the operated leg gently following hip surgery...Avoid extremes of position following hip surgery. Keep the leg abducted, i.e., out to the side at all times. Never adduct the leg past the body's midline (e.g., over the other leg), or the head of the femur (prosthesis) may dislocate out of the acetabulum. Place a pillow or A-frame between the client's legs to help maintain abduction and to remind the client not to cross the legs...." The computer-generated CMS Form 802 (Roster/Sample Matrix), provided on 12/20/11, reflected there were 43 cognitively impaired residents.

Based on observation, interview and record review, it was determined the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical and mental well-being for two (Residents #1 and #2) of eleven residents reviewed for pain. 1) Resident #1 was not provided with pain medication as ordered by the physician to ensure the resident's pain was controlled. When Resident #2 complained of pain to LVN A on 10/26/10 at 10:30 a.m., Resident #1 rated her pain to LVN A as a 6 out of ten 10 on a 1 to 10 scale. LVN A told the resident the facility had run out of her pain medication. Resident #1's pain medications arrived at the facility at 12:10 p.m. Resident #1 was transported shortly thereafter to the hospital for pain management. 2) Resident #2 was admitted to the facility on [DATE], post-surgery. A nursing assessment at 4:45 p.m. revealed a pain level of 2 out of 10 on a 1 to 10 scale. Pain medication was not administered until 08/18/10 at 3:00 a.m. when the resident rated her pain as a 9 out of 10. This failure could affect the 30 residents, including Residents #1 and #2, who were receiving narcotic pain medications, and placed them at risk for not having pain medication administered as ordered by the physician, not being assessed for pain and having to endure unrelieved pain. Findings included: 1) Resident #1 according to physician orders [REDACTED]. Pain medication orders were as follows: [MEDICATION NAME] (a narcotic pain medication) 5/325 mg every 4 hours as needed for pain and [MEDICATION NAME] Patch 12 mg/hr [MEDICATION NAME], every 72 hours for pain. Resident #1's MDS assessment dated [DATE] reflected the resident was modified independent with cognitive decision-making skills, required extensive to total assistance of 1-2 staff members for all ADLs and normally had moderate pain less than daily. On 10/26/10 at 10:30 a.m., the surveyor observed RN A enter Resident #1's room and tell the resident they were out of her pain medication, but had been attempting to get in touch with her physician for two days. At 10:35 a.m. on 10/26/10, the surveyor entered the resident's room, and the resident, who appeared clearly in distress and pain, was asked about the conversation with RN A. Resident #1 stated tearfully, "They ran out of my meds. How could they let that happen?" The resident stated she was hurting in her right arm, legs and feet. "They have to be on time with my pain medicine," she stated, "Otherwise it's hard to get under control." The resident was asked to rate her pain on a 1 to 10 scale and she quickly responded, "10." As they surveyor began to leave the room to investigate the situation, the resident pleaded, "Can't they please give me some Tylenol or something until my medicine gets here? I am hurting so bad." At 11:00 a.m. on 10/26/10, in an interview the facility's only ADON, she stated she was unaware of issues with Resident #1's pain medications. She then was observed to administer Resident #1 two 325 mg Tylenol via [DEVICE] and stated she would follow up on the resident's pain medications. At 12:00 p.m. on 10/26/10, Resident #1 rated her pain at an 11-12 out of 10 on a 1 to 10 scale. At 12:10 p.m. on 10/26/10, Resident #1's pain medications were observed to have been received from the pharmacy. On 10/26/10 at 12:10 p.m., RN A was interviewed regarding Resident #1's pain medications. She stated she noticed on Friday (10/22/10), the resident was running low on her [MEDICATION NAME]. She contacted the physician and thought the issue would be resolved. She was told by the night nurse that morning (10/26/10), the resident was out of pain medication. She stated she had RN F contact the pharmacy and they were told it would arrive on the 2:00 p.m. delivery. RN A further stated Resident #1 would not have received a dose until 10:00 a.m., and the first time she had been told Resident #1 was in pain was at 10:30 a.m. when the resident rated her pain as a 6 out of 10. Resident #1's [MEDICATION NAME] sign out sheet initiated 10/22/10 reflected the resident had received 30 [MEDICATION NAME] 5/325 mg tablets since 10/22/10, and the resident's MAR dated October 2010 reflected her pain levels had been rated from 8 -10 on a 1 to 10 scale each dose as follows: On 10/23/10 at 12:27 p.m., her pain level prior to medication was 10, at 12:57 p.m., her pain level was 10. On 10/23/10 at 4:42 p.m., her pain level prior to medication was 10, at 5:50 p.m. her pain level was 8. On 10/23/10 at 8:00 p.m., her pain level prior to medication was 10, her pain level documented at 12:00 midnight was 8. On 10/23/10 at 11:00 p.m., her pain level prior to medication 10, her pain level documented at 12:00 midnight was 8. No pain assessments were documented for doses given on 10/24/10. The last documented pain assessment was on 10/25/10 at 3:05 p.m., and her pain level prior to medication was 10, and at 4:00 p.m., her pain level was 8. On 10/26/10 at 12:30 p.m., the ADON stated Resident #1 had asked to go to the hospital to get her pain under control, and she was sent to the hospital. 2) Resident #2, according to her physician orders [REDACTED]. Pain medication orderes were as follows: [MEDICATION NAME] 7.5/325 mg one by mouth every four hours for moderate pain, and two tablets every four hours for severe pain. In a confidential interview, an individual reported Resident #2 had been in a great deal of pain due to her surgery, and the facility failed to receive her pain medication timely resulting in her having to wait until 3:00 a.m. to receive her first dose. A nurses assessment dated [DATE] and timed 4:45 p.m. reflected Resident #2 was alert and oriented and rated her pain as aching, burning and at a level of 2 out of 10 on a 1-10 scale. According to Resident #2's MAR dated August 2010, she received one [MEDICATION NAME] pain pill for pain on 08/19/10 for pain at a level of 9 out of 10. There was no evidence a follow up assessment was conducted. According to the Individual Control Drug Record dated 08/17/10, Resident #2 did not receive her first pain pill until 10 hours after admission, 08/18/10 at 3:00 a.m., when she received two (for severe pain) [MEDICATION NAME] 7.5/325 tablets. No pain assessment or record of administration was documented on the MAR for August 2010. 3) Review of the facility's current policy entitled 4.2 New Orders for Schedule II Controlled Substances dated 12/01/07 and revised 07/22/08 and 05/01/10 revealed the following, "...Facility staff may fax Schedule II prescriptions for long term care residents...2. Physicians/Prescribers should provide Pharmacy with verbal authorization for Schedule II controlled substances in cases of an 'Emergency Situation....' " Review of the current facility policy entitled Pain Management and dated 08/31/09 reflected the following, "...8. The licensed nurse shall administer pain medication as ordered and document on the Medication Administration Record (MAR), the drug, time of administration, dose, pain scale rating pre-medication and the resident's response to medication a minimum of one hour post pain medication, using the pain scale rating. 9. If pain is of new onset, change in nature, not relieved with current medication, etc., the nurse will notify the physician for a review of the medication and pain management plan...12. Train staff that everyone is responsible to screen and report resident's complaint of pain." 4) A document entitled Physician order [REDACTED].