Every finding on record at Fortress Nursing and Rehabilitation

Based on observation, interview, and record review, the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 2 of 4 medication carts (100-hall nurse cart and 400-hall medication cart) reviewed for pharmacy services. 1. The facility failed to ensure the 400-hall medication cart, was locked, medications secured, and not accessible to other staff, residents, or visitors on 08/15/2026. 2. The facility failed to ensure 100-hall nurse cart, was locked, medications secured, and not accessible to other staff, residents, or visitors on 08/15/2026. These failures could place residents at risk of having unauthorized access to medications, decreased effectiveness of medication, or missing medications.Findings include: 1. During an observation on 08/15/2026 at 11:11 AM on the 400-hall, the medication cart was facing toward the hall about halfway down the hall. The lock was protruding outward on the 400-hall medication cart. Observation reflected there was not anyone in the hallway or near the observed unlocked medication cart. MA C entered the hallway near the nurses' station at approximately 11:13 AM and walked toward the unlocked medication cart on the 400-hall. During an interview on 08/15/2026 at 11:14 AM, MA B stated she was responsible for the 400-hall medication cart. She stated she was trained on medication storage. She stated the Nurse or Medication Aide who was working on the cart was responsible for locking the medication cart. She stated if the staff left the medication cart unlocked and unattended, a resident could get into the medication cart and take medication that did not belong to them and possibly have an allergic reaction. She stated she forgot to lock the cart because she had to go to the bathroom. MA B stated the DON monitored by observation during her rounds. 2. During an observation on 08/15/2026 at 03:08 PM at the nurses' station, the 100-hall nurse cart was sitting with the cart facing away from the nurses' station and the lock was protruding. Observation revealed LVN A sitting at the nurses' station looking at the computer, her back was facing the 100-hall nurse cart. There was not anyone observed in the direct vicinity of the unlocked medication cart. During an interview on 08/15/2026 at 03:09 PM, LVN A stated she was responsible for the 100-hall nurse cart. She stated she was trained on medication storage. She stated she stepped away from the cart to look at her computer and forgot to lock it again. She stated the nurses were responsible for ensuring the nurse carts were locked when unattended. She stated if the staff left the nurse cart unlocked and unattended, a resident could get into the nurse cart and take something they were not supposed to, or they could get a hold of a needle and poke themselves. LVN A stated the administration staff monitored for unlocked carts during their rounds. During an interview on 08/15/2026 at 05:17 PM, the DON stated she received training on medication storage. She stated the policy for medication storage was to lock it as soon as staff stepped away from it. She stated the staff passing medication from the cart was responsible for ensuring the cart was locked when unattended. The DON stated if the medication cart was left unlocked and unattended then a resident could take medication out of it and digest it potentially causing death. She stated all staff monitored for the medications carts to be locked during their rounds. During an interview on 08/15/2026 at 05:50 PM, the ADM stated she had received training on medication storage. She stated the policy for medication storage was if the cart was out of sight, then it should be locked. The ADM stated the staff passing medications from the cart were responsible for ensuring the cart was locked when it was unattended. She stated if the cart was left unlocked, then a resident could get into it and take medication that was not theirs and it could be dangerous to them. The ADM stated management monitored to ensure the medication carts were locked during their observation rounds. Record review of the facility's, undated, policy titled, Medication Storage in the Facility, reflected Policy . The medication supply is accessible only to license nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.Procedure.2. Only licensed nurses, the Consultant Pharmacist, and those lawfully authorized to administer medications (e.g. medication aides) are allowed unsupervised access to medications. Medication rooms, carts, and medication supplies are locked or attended to by persons with authorized access.

Based on observation, interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for two of eight residents (Resident # 57 and Resident #59) reviewed for ADL care.The facility failed to ensure Resident #57 and Resident #59's nails were cleaned and did not have any rough edges on 01/20/2026 and 1/21/2026. This failure could place residents at risk of not receiving services or care, diminished quality of life , and decreased self-esteem. Findings included: Record review of Resident #57's face sheet, dated 01/21/2026, reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: anemia ( a blood disorder where there are not enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues. The lack of oxygen can cause fatigue, weakness, and shortness of breath), generalized anxiety disorder (a chronic mental health condition characterized by excessive, uncontrollable, and persistent worry about every day aspects of life such as health, finances, or family), and vitamin d deficiency (your body lacks sufficient vitamin D, crucial absorbing calcium and phosphorus to build strong bones, and supporting immune and muscle function, leading to issues like weak bones, muscle pain, fatigue, and frequent infections). Record review of Resident #57's admission MDS Assessment, dated 12/03/2025, reflected Resident #57 was assessed to have a BIMS score of 15 indicating cognition was intact. Resident #57 did not refuse care. Resident #57 required partial/moderate assistance- helper does less than half the effort with personal hygiene, putting on/taking off footwear, transfers in and out of showers and bathing. Record review of Resident #57'a Comprehensive Care Plan, dated 01/18/2026, reflected Resident #57 had an ADL self-care performance deficit. Intervention: Bathing: check nail length, trim, and clean on bath day and as necessary. Report any changes to the nurse. If diabetic, the nurse will provide toenail care.Observation and interview on 01/21/26 at 09:58 AM revealed Resident #57 was lying in bed in his room. His nails on his right and left hands were not smooth around the edges and there was a blackish/brownish substance underneath his middle and fore fingernails on his right hand. He stated he asked someone over the weekend to file and clean his nails and the person stated they would sometime during the week. Resident #57 stated he did not recall the staff's name. He stated he believed the staff worked in nursing but did not recall if the staff was a CNA or a Nurse. Resident #57 stated he did not recall seeing a name badge on the staff's clothes. Record review of Resident #59's face sheet, dated 01/21/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. Resident #59 had a diagnoses of type 2 diabetes ( your body either does not make enough insulin or does not use insulin properly, causing sugar to build up in the blood instead of entering cells for energy, leading to high blood sugar), hypothyroidism ( does not make enough hormones leading to symptoms like fatigue, weight gain, constipation, muscle/joint pain and/ or depression), and depression ( a low mood or loss of pleasure or interest in activities for long periods of time). Record review of Resident #59's MDS assessment dated [DATE], reflected Resident #59 had a BIMS score of 6 which indicated his cognition was severely impaired. Resident #59 did not refuse care. Resident #59 required supervision or touching assistance with the following: eating, oral hygiene, personal hygiene, showers, upper and lower body dressing, toileting hygiene.Record review of Resident #59's Comprehensive Care Plan, dated 01/08/2026, reflected Resident #59 had an ADL self-care performance deficit. Intervention: Bathing: check nail length, trim, and clean on bath day and as necessary. Report any changes to the nurse. If diabetic, the nurse will provide toenail care.Observation and interview on 01/20/2026 at 9:10 AM revealed Resident #59 was sitting near the nurses' station in his wheelchair. Resident #59's fingernails on his right hand underneath his middle and ring fingernails had a blackish/brownish substance. Resident #59 had rough edges around his fingernails on his right hand and had blackish/brownish substance underneath his middle and fore fingernails on his left hand. Resident #59 stated he did not like his nails to be dirty. He stated he did not remember if he asked someone to help him with his nails. Resident #59 stated his nails had been dirty and rough for the past 4 or 5 days. In an interview on 01/21/2025 at 1:50 PM, LVN Charge Nurse A stated the nurses were responsible for residents with a diagnosis of diabetes with nail care such as trimming, cleaning, and filing. She stated the CNAs were responsible for all other residents' nail care. LVN Charge Nurse A stated if a resident had brownish/blackish substance underneath their nails and if a resident swallowed the substance there was a possibility a resident may become ill, such as stomach problems nausea and vomiting. She stated she would need to ask staff questions for the reason nail care was not completed on Resident #57 and Resident #59. LVN Charge Nurse A stated no one reported to her that Resident #57 or Resident #59 refused nail care. She stated anytime a resident refused care it was documented in the nurses' notes.In an interview on 01/21/2026 at 2:20 PM, Lead CNA B stated the CNAs were responsible for cleaning, trimming, and filing all residents' nails except for the residents with a diagnosis of diabetes (a disease that occurs when blood sugar is too high). She stated the nurses were responsible for all the residents' nails with a diagnosis of diabetes. Lead CNA B stated the residents' nails were usually cleaned on Sundays, their shower days and as needed. She stated if there was a blackish substance on the residents' fingertips or underneath their nails and the resident swallowed the blackish substance there was a possibility a resident may become ill, such as vomiting and diarrhea. She stated if a resident had rough edges around the fingernails there was a potential a resident may scratch another resident or themselves and obtain a skin tear. She stated a resident could get their nail caught on something and pull their nail off their finger. Lead CNA B stated she was in-serviced on cleaning, filing, and trimming residents' nails but she did not recall the date. She stated she had given care to Resident #57 and Resident #59, and they did not refuse nail care. She stated the lead CNA assists with some training with new CNAs. In an interview on 01/21/2025 at 2:40 PM, CNA C stated the CNAs were responsible for cleaning, trimming, and filing all residents' nails except for the residents with a diagnosis of diabetes. She stated the nurses were responsible for all the residents' nails with a diagnosis of diabetes. CNA C stated the residents' nails were usually cleaned on their shower days and as needed. She stated if there was a blackish substance on the residents' fingertips or underneath their nails and the resident swallowed the blackish substance there was a possibility a resident may become ill, such as nausea and diarrhea. CNA C stated she was in-serviced on cleaning, filing, and trimming residents' nails but she did not recall the date. She stated she had given care to Resident # 57 and Resident #59, and they did not refuse nail care. CNA C stated she did not know the last time these residents' nails were trimmed or cleaned she would need to check the medical records. She stated if a Resident's nails were rough around the edges there was a possibility the resident could scratch themselves and cause a skin tear. CNA C stated anytime a resident refused any type of care she reported it to the charge nurse. In an interview on 01/22/26 at 10:20 AM, the DON stated if a resident ingested the blackish substance on their fingers or underneath their fingernails, there was a possibility the substance may be some type of bacteria, however it would be difficult to determine if the blackish/ brownish substance was bacteria. She stated it was a possibility a resident may become ill with stomach issues such as vomiting and nausea if they ingested the blackish/ brownish substance. She stated the CNAs were responsible for all residents' nails such as cleaning, trimming, and filing except for the residents with diabetes. She stated for any resident with a diagnosis of diabetes the nurse was responsible for these residents' fingernails. The DON stated the nurse supervisor was responsible for monitoring CNAs giving ADL care which included nail care, and the ADON and DON were responsible for monitoring the nurse supervisors. Record review of the facilities policy on Nail Care, not dated, reflected Nail management is the regular care of the toenails and fingernails to promote cleanliness, and skin integrity of tissues, to prevent infection, and injury from scratching by fingernails or pressure of shoes on toenails. It includes cleansing, trimming, smoothing, and cuticle are and is usually done during the bath. Nails can become thinner and more brittle in the elderly and thicker if peripheral circulation isimpaired. Nails are also important in assessment, as changes occur with certain medical conditions,such as clubbing with chronic obstructive pulmonary disease or cardiac disease. Color changes withcirculatory or lymphatic impairment and certain drug therapy is common. Ingrown toenails are alsocommon in the elderly. Fungal infections of the toenails, dry, brittle ridges and thickening of the nailsall occur in the elderly with some frequency.Goals1. Nail care will be performed regularly and safely.2. The resident will free from abnormal nail conditions3. The resident will be free from infection. ProcedureShould be performed according to the resident centered plan of care.1. Explain the procedure to the resident.2. Wash hands.3. Immerse hands or feet in a basin of warm soapy water to cleanse and soften the nails for ease incleansing and trimming. Use a soft brush if necessary to cleanse under and around the nails.4. Remove debris from under the nails with an orange stick while soaking.5. Remove the hands or feet from the basin and pat dry.6. Apply lotion and massage into the cuticles and push back with a towel. Avoid cutting anycuticle.7. Trim the nails with a clipper, straight across for the toenails and rounded for the fingernails.8. Smooth the nails with an emery board.9. Apply hose and shoes or slippers as appropriate.10. Discard removed nails, cleanse basin and articles used and store for future use.11. Wash hands.12. Nails that are ingrown, thickened, or infected should be cared for by a podiatrist. Reportconditions immediately to the primary nurse. The nurse will ensure a referral to the podiatrist.13. Cutting should not be any shorter than at the line even with the nail folds on each side.14. When performed at bath time, the nail care can be done following the procedure or as a separateprocedure when needed at the convenience of the resident.

Based on interview and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 6 residents (Resident #1) reviewed for accidents and supervision. The facility failed to provide safe transport for Resident #1 on 05/27/25 which resulted in a fall and Nondisplaced fracture of the proximal fibular metaphysis of the left knee. This failure could result in serious injury such as a left knee fracture and a reduced quality of life . The noncompliance was identified as PNC. The PNC began on 5/27/25 and ended on 5/28/25. The facility had corrected the noncompliance before the survey began. Findings include: Record review of Resident #1's face sheet, dated 06/02/25, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included a left proximal fibular fracture (a break in the fibula bone, located on the outside of the lower leg, near the knee, often caused by twisting or blunt force injuries to the leg or foot), dementia (deterioration of brain and memory loss), diabetes mellitus type 2, rheumatoid arthritis (auto-immune disorder affecting major joints) , major depressive disorder, hypertension, and anxiety . Record review of Resident #1's care plan, revised 05/28/25, reflected, Resident #1 had a skin tear to right shin and right knee, and sustained a left knee fracture (left proximal fibular metaphysis) related to fall with interventions of splint to left knee, and teach the purpose of and the procedure for performing isometric and flexion/extension exercises, and pain treatment as indicated by MD. The care plan further reflected Resident #1 was at risk for trauma that may have a negative impact, related to a van incident. Interventions included a Licensed Mental Health Provider, consult with family regarding her condition, identify situation/event/images that trigger recollections of the traumatic event and limit Resident #1's exposure to these as much as possible, monitor for escalating anxiety, depression, or suicidal thought and report immediately to the nurse, mental health provider, and physician. The care plan further reflected Resident #1 had a potential for uncontrolled pain due to fracture of her left knee. Interventions included administration of analgesia per physician orders, and give ½ hour before treatments or care, anticipate her need for pain relief and respond immediately to any complaint of pain, and evaluate the effectiveness of pain interventions, review for alleviation of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. Record review of Resident #1's Quarterly MDS, dated [DATE] , reflected a BIMS score of 04, which indicated a moderate to severe cognitive impairment. Resident #1 required extensive assistance for bed mobility, transfers, and toilet use. She required the assistance of two people for transfers between surfaces. Record review of Resident #1's Physician Order Summary Report, dated 06/02/25, reflected a 20-inch Universal Basic Knee Splint for stabilization of left fibula fracture, and ensure splint is in right place, patient able to perform weight bearing as tolerated while her knee was immobilized. The Order Summary Report further reflected Tramadol 50mg 1 tablet by mouth three times a day for pain, and every 6 hours for moderate pain, Psychiatry to evaluate and treat, and skin tear to right and left knee - cleanse with normal saline and pat dry, apply Xeroform and cover with gauze island dressing every day shift every Monday, Wednesday, and Friday, and as needed. Record review of Resident #1's incident report, dated 05/27/2025, at approximately 1:30 PM, reflected the following, Resident #1 was being transported to a doctor's appointment. Driver A braked for a red-light resident slid out of wheelchair scraping knees, received a skin tear and a cut toe. Incident happened right by doctor's office parking lot. Doctor's staff cleaned and bandaged cuts and scrapes. Assessment conducted on 05/27/25 at 5:50 PM reflected Resident #1 had bruising to bilateral upper extremities, skin tear left knee, left upper extremity, abrasion right knee, moisture skin damage sacrum, and irritation to great right toe. Resident #1 was sent to the hospital for X-rays. Driver A was suspended immediately, and van was out of service until all drivers had been re-in serviced and safety check was done on all van equipment. Facility notified the responsible party and the nurse practitioner. Record review of hospital records with an admission date/time of 05/27/25 at 09:36 PM and discharge date /time of 05/28/25 at 03:23 AM reflected, Resident #1 was a [AGE] year-old female presenting to the ED for evaluation of a fall that occurred today at approximately 4:00 PM. Resident #1 reported she was riding in a transport van when Driver A forcefully pressed the brakes, launching Resident #1 out of her wheelchair. Resident #1 landed on the vehicle floor and suffered impact to both knees. Associated symptoms included bilateral knee pain and mild neck pain. Denied back pain, chest pain, cough, congestion, rhinorrhea (runny nose), or headaches. There were no other complaints at this time. X-ray Right Knee 3 Views reflected: 1. No acute osseous abnormality. 2. Severe tricompartmental osteoarthritic changes. X-ray Left Knee 3 Views reflected: 1. Nondisplaced fracture of the proximal fibular metaphysis. 2. Moderate tricompartmental osteoarthritic changes. 3. Possible soft tissue wound anterior to the patella. Narrative: This patient is a pleasant non-ambulatory [AGE] year-old female who was in a transport van today and was in her wheelchair and the transport driver stopped abruptly and the patient fell from her wheelchair. Patient reporting bilateral knee pain. Patient with report of lower cervical and upper thoracic discomfort. Imaging showing no acute abnormalities of the head neck chest abdomen or pelvis. Patient with notable proximal fibular fracture on the left. X-ray of the ankle found to be unremarkable. Patient placed in a knee immobilizer. Given referral to orthopedics. Patient discharged home. At time of discharge patient is pain-free. Diagnosis: Closed left fibular fracture . Interview on 06/01/25 at 3:25 PM with the DON, who stated she had not been able to get Driver A to answer the phone since 05/27/25, and Driver A had been a no call/no show for CNA duties since the day of the van incident. The DON stated the facility conducted re-training on transporting residents in the van, and anyone who was not re-trained was not driving. She stated in the van the 4 black straps with hooks were to secure the wheelchair in place, and the red seatbelts were to secure the resident in a wheelchair and were to go across the resident's chest and across the resident's lap. The DON further stated Resident #1 stated Driver A had slammed on the brakes and she slid out of the wheelchair onto her knees. Interview on 06/01/25 at 3:15 PM with Driver B revealed she worked in Housekeeping and was also a van driver. Driver B stated she had received training on 05/28/25 that included inspecting the vehicle inside and out every week, and to check acceptable or document if there are repairs needed on the form and submit to Administration and Corporate. Telephone interview on 6/02/25 at 07:15 AM, Driver A stated she received 30 minutes of training from another van driver before she drove the van herself. Driver A stated she had worked for the facility for 4 months. She stated she thought Resident #1 had been up too long on the day of her appointment. Driver A stated Resident #1 had been to her therapy session that morning, and was up for lunch, and then went to her doctor appointment in the early afternoon. Driver A stated she thought Resident #1 became fatigued and started slipping out of her wheelchair . Driver A stated she had all of the straps and hooks on to secure the wheelchair in the van, and the seat belts were secured on the resident for resident safety. Driver A stated there were no witnesses riding in the van with her, other than Resident #1's RP who had met them at the doctor's appointment. Driver A stated the RP met them at the doctor's appointment and had entered the van to assisted in getting Resident #1 back up and into the wheelchair . Interview on 06/02/25 at 2:14 PM with MAINT revealed on the interior of the van the 4 black straps with hooks were to secure the wheelchair in place, and the red seatbelts were to secure the resident in a wheelchair and were to go across the resident's chest and across the resident's lap. MAINT demonstrated how the seatbelt would secure a resident in a wheelchair once the 4 straps and hooks secured the wheelchair in place. MAINT stated he was up to date on the transport van maintenance, and he had looked at the Vehicle Inspection Reports and the van was in good working condition. He stated he looked at the transport van seatbelts and wheelchair straps after the incident and saw no issues. Interview on 06/02/25 at 4:42 PM with the RP, who stated Driver A had asked her to hold the wheelchair and then Driver A lifted Resident #1, and the RP pushed the wheelchair forward under Resident #1's bottom so Driver A could get her back in the wheelchair . The RP stated Resident #1was seeing the orthopedic surgeon on Wednesday, 06/04/25. The RP believed Resident #1 had not been strapped in the wheelchair since she went forward on her knees and hit her head on the backside of the driver's seat. The RP further stated Resident #1 told her when Driver A turned, she slammed on her brakes, and that was when she fell out of the wheelchair. Interview on 06/02/25 at 5:04 PM with Resident #1 revealed she knew something had happened to her, but she was not able to recall all the events. She stated she was having pain in her left knee and pointed to the left knee with a brace on it. Resident #1 stated Driver A slammed on the brakes and she remembered sliding out of the wheelchair and landed on her knees, and she did not remember too much after that. Resident #1 stated she did not remember if there was a seat belt on her or not. Resident #1 stated she had an appointment with a doctor who would check on her knee tomorrow, and the RP would be going along. Record review of a statement from Resident #1, dated 05/27/25, included in the facility investigation reflected, Resident #1 stated that she slid out of her wheelchair while in the back of the van. She stated that she hit the back of the driver seat, and her knees went under her. Resident #1 stated that Driver A then attempted to help her but was unsuccessful due to how she was positioned. Resident #1 then stated that when she stopped, Driver A asked her RP who met them there to assist her in helping her back into the wheelchair. Resident #1 stated to ADON , during this statement, that at the time she had no pain but that she felt a slight tingling and burn just a tad bit but stated that she was having no pain when asked to rate pain. Resident #1 stated that the nurse at the doctor assessed her knee and cleaned it up and applied bandages. Educated Resident #1 on pain assessments and assessed her knees as well. Resident #1 stated that it was not that bad. Informed resident that we will send for X-ray of knees, and she said OKAY. Record review of In-service conducted on 05/27/25 for staff who transport or assist with transporting residents in the van on the following (with return demonstration): Staff members not in-serviced will not transport residents. 1. How to safely load and unload residents in the van using the lift 2. Properly securing a resident in the van: Ambulatory resident - securing with seat belt. Non-ambulatory resident - securing the wheelchair and the resident. Record review of the Vehicle Inspection Report dated 05/28/25 reflected the following relevant items were checked for the interior of the vehicle: Instruments, gages, horn, and warning lights working properly. Floors, seats, doors, and steps all clean and free of debris/stains Seat Belts clean and in good working condition Wheelchair Tie-Downs inspected and working properly. Summary of the report reflected the van and equipment in good working condition. Record review of In-service, conducted on 05/27/25, reflected, Resident involved in a van incident such as slipping out of the chair, tipping back in the chair, or hitting head, the transported should immediately stop and call 911, notify the Administrator and/or the DON immediately if you are off the property. Do not move the resident. If you're on the property immediately go, get a nurse to assess the resident. Record review of the Employee Auto Training Handbook - Vehicle Inspection Report, dated 05/28/25, reflected the vehicle interior (including the seatbelts clean and in good working condition), vehicle exterior, fluid levels, and emergency equipment were acceptable, and the van and equipment were in good working condition. Record review of the undated Employee Auto Training Handbook reflected, The Driver Training Handbook is a statement of company and expectations as it pertains to transport vehicles, procedures to ensure resident safety and to promote safe driving practices. Employee safety responsibilities 1. Observe all organization safety and health rules and apply the principles of accident prevention in your day-to-day duties. 2. Report any job-related injury, illness, or property damage to your supervisor immediately. 3. Report any hazardous conditions and unsafe acts to your supervisor promptly. 4. Follow proper lifting procedures always. 5. Whenever driving an organization vehicle or personally owned vehicle for organization business seat belts must be used. The noncompliance was identified as PNC. The PNC began on 5/27/25 and ended on 5/28/25. The facility had corrected the noncompliance before the survey began.

Based on observations, interviews, and record review, the facility failed to ensure that residents who needed respiratory care was provided such care, consistent with professional standards of practice, for 3 of 4 residents (Resident #1, Residents #2, and Resident # 3) reviewed for the use of oxygen cannula and nebulizer. The facility failed to ensure: -Resident #1 and Resident #2's nebulizer mask and tubing were in a bag. - Resident #3's oxygen cannula was in a bag This failure could place residents at risk for respiratory infections. The findings included: 1. Record review of Resident #1's face sheet on 04/16/25 revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses were acute respiratory failure with hypoxia (low oxygen level), Dementia, Anxiety, Hypertension, Type 2 diabetes mellitus and Iron deficiency. Record review on 04/16/25 of Resident #1's initial MDS assessment, dated 02/15/25 revealed a BIMS score of 12 indicating his cognition was moderately impaired. Record review on 04/16/25 of Resident #1's care plan dated 04/08/25 reflected he had COPD (Difficulty to Breath), and the relevant intervention was administering bronchodilators (agents that dilates airways) and oxygen therapy as ordered by the physician. Record review on 04/16/25 of Resident #1's physician's order reflected: Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML. 3 milliliter inhales orally every 4 hours as needed for SOB or Wheezing via nebulizer. 2. Record review of Resident #2's face sheet on 04/16/25 revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses were COPD (Difficulty to Breath), Acute respiratory failure with hypoxia, Anxiety disorder, Heart failure, Presence of cardiac pacemaker and Hypertension. Record review on 04/16/25 of Resident #2's quarterly MDS assessment, dated 04/07/25 revealed a BIMS score of 15 indicating his cognition was intact. Record review on 04/16/25 of Resident #2's care plan dated 04/08/25 reflected he had COPD, and the relevant intervention was administering bronchodilators and oxygen therapy as ordered by the physician . Record review on 04/16/25 of Resident #2's physician's order reflected: Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) 1 vial inhale orally every 4 hours as needed for Wheezing/SOB. 3. Record review of Resident #3's face sheet on 04/16/25 revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses were Hypertension, Type 2 diabetes mellitus, Chronic obstructive pulmonary disease, Heart failure, and End stage renal disease. Record review on 10/16/24 of Resident #3's quarterly MDS assessment, dated 03/27/25 revealed a BIMS score of 15 indicating her cognition was intact. Record review on 04/16/25 of Resident #3's care plan dated 03/28/24 revealed there were no care plan for oxygen therapy. Record review on 04/16/25 of Resident #3's physician's order on 04/26/25 reflected:. 1.Check O2 sat Q shift and PRN every shift. 2.Oxygen 2-5L PRN for comfort/keep oxygen saturation >92% as needed for SaO2 < 92%. Record review of Resident #3's April 2025 MAR on 04/16/25 at 11:30am revealed the O2 level was checked on every day in April,2025, every shift. The last check was on 04/16/25 in the day shift. During an observation and interview on 04/16/25 at 10:50 a.m., Resident #1 was lying in his bed . He was using oxygen through a cannula. There was a nebulizer on the bed side table. The mask and tubing of the nebulizers were exposed to the environment as they were not stored in a protective bag. There was a male urinal bottle sitting next to the exposed nebulizer mask of Resident #1. He stated the staff administer medication via nebulizer occasionally. He stated he could not remember when had used it lately. Resident #1 stated he used the urinal bottle regularly as he was not able to get out of bed for toileting. He stated he used the bottle about 30 minutes ago. During an observation and interview on 04/16/25 at 11:10 a.m., Resident #2 was lying in bed in his room. There was a nebulizer on his bedside table that was not secured in a protective bag. Resident #2 stated he had breathing difficulties and used inhalers and oxygen therapy regularly. During an observation and interview on 04/16/25 at 11:25 a.m., Resident #3 was in her room lying in her bed. Her oxygen cannula and tubing were laying on the floor. She stated she was not able to get up from bed and the staff assisted her to administer oxygen via a canula occasionally on request. During an observation and interview with DON on 04/16/25 at 11:35 a.m., it was revealed the nebulizers and oxygen canula were at the same places as the previous observations, exposed to the open air . The DON who observed the masks and canula stated they were supposed to be stored in protective bags whenever not in use. The DON stated all staff were supposed to be compliant with the facility policy for using the oxygen cannula and nebulizers. She stated she noted down this deficiency in infection control practices among the staff and stated they needed more in services and training on oxygen and nebulizer therapies, sooner than later. She stated bagging the masks and cannulas while not in use was necessary to minimize the risk of spreading respiratory diseases among the residents. Record review of the facility's policy, titled Protocol for Oxygen administration revised on 03/21/2023 reflected: change the tubing (including any nasal prongs or mask) that is in use on one patient when it malfunctions or becomes visibly contaminated. Record review of facility's policy titled Infection Control policy and procedure manual 2019 updated in March,2024 reflected: The facility will establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection.

Based on observations, interviews, and record reviews, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. The facility failed to ensure the Director of Rehabilitation/PT and LVN D were wearing effective hair restraints, while in the kitchen. This failure could place residents who received meals and/or snacks from the kitchen at risk of foodborne illness due to physical contamination. Findings included: During an observation of the dining room on 10/22/2024 at 11:55 AM, LVN D walked in and out of the kitchen three different times to get meal trays without wearing a hair restraint. An observation of the kitchen on 10/22/2024 at 12:59 PM, revealed the Director of Rehabilitation/PT was in the kitchen by the steamtable. The Dir Rehab had long hair past her shoulders and was not wearing a hair restraint. During an interview with the Dir Rehab on 10/23/2024 at 7:46 AM, she stated that she was in the kitchen on 10/22/2024 and was not wearing a hair restraint. She stated there was a policy that required hair restraints in the kitchen, but she thought that was not needed for the front area of the kitchen on the front side of the steamtable. She stated that hair restraints were needed to avoid hair getting in the residents' food, which could cause a negative outcome to residents getting sick. During an interview with the DM on 10/23/2024 at 7:50 AM, she stated she received training on proper hair restraints before she started work and was in-serviced with web-based training. She stated that hair restraints were important in the kitchen to avoid hair getting in the residents' food, which could make them sick or vomit. Her expectation was for staff to wear hair nets in the kitchen, but she did not think the front area of the kitchen on the other side of the steamtable was considered the kitchen area and was not concerned that staff did not wear hair nets in that area. She stated that there was a plastic shield/ plexiglass on the steamtable that protected food. She stated that a sign about hair restraints used to be posted on the wall outside the kitchen, but it fell off and had not been replaced. The Director of Food and Nutrition pointed to a yellow sign on the kitchen interior door by the ice machine and steamtable that read, Dietary Employees Only Beyond This Point Thank You. Ring Bell for Assistance. During an interview with dietary aide on 10/23/2024 at 7:53 AM, she stated she received training on proper hair restraints before she started work. During the training, she learned everyone had to wear a hair net while in the kitchen. During an observation of the kitchen and outside the kitchen area on 10/23/2024 at 8:00 AM, there were no signs regarding hair restraints. There was a container of hair restraints available on a table next to the main kitchen door. During an interview on 10/23/2024 at 11:03 AM, the [NAME] stated that she received training in hair restraints before she started work. She stated everyone must wear hair restraints all the time while in the kitchen. The [NAME] stated hair restraints were required to avoid cross-contamination of getting hair into resident food, which could make them sick. During an interview with the ADMIN on 10/23/2024 at 2:08 PM, he stated that he was new and had only been at the facility for three weeks. He did not know what the facility's policy was regarding staff entering the kitchen or wearing hair restraints. He was not sure what his expectation regarding staff entering the kitchen or the use of hair restraints would be. During an interview with the DON on 10/23/2024 at 2:15 PM, she stated that the facility's policy was all staff entering the kitchen must wear a hair net/hair restraint. She stated potential negative outcome for residents was that staff's hair could get into the food and cause contamination. Her expectation was that her staff would not enter the kitchen, but rather stand at the door and ask for assistance. If her staff needed to enter the kitchen, her expectation was that staff would wear a proper hair restraint and wash their hands. During a telephone interview with LVN D on 10/23/2024 at 2:26 PM, she stated it was the facility's policy that all staff entering the kitchen must wear a hair net/hair restraint. LVN D stated on 10/22/2024 during lunch, she helped in the dining room and was asked to enter the kitchen to get meal trays. She did not think about putting on a hair net. She knew that she should have, but she forgot. She stated that hair restraints were important to keep food sanitary. She stated there was a potential for hair or dandruff to get in food without a hair restraint and that could make residents sick and they could vomit. Record review of the 2022 Food Code; Section 2-402 Hair Restraints, from the United Stated Food and Drug Administration, revealed food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that were designed and worn to effectively keep their hair from contacting exposed food. Record review of the facility's Dietary Services Policy and Procedures Manual 2012 HR 00-2.0 titled Dietary Food Service Personnel Policy and Procedures under Sanitation and Food Handling revealed: Hair nets or hats covering the hairline are worn at all times.

Based on observation, interview, and record review the facility failed to ensure storage of medications used in the facility in accordance with currently accepted professional principles and include the appropriate -The medication cart for the 400 halls had four unidentified loose pills. -The facility failed to ensure expired medications were removed from the medication carts and medication room. These failures could place residents at risk of not receiving the intended therapeutic effect of the medications or a contaminated medication. The findings were: Observation of medication cart for the 400 halls on 10/22/2024 at 2:00 pm revealed one green round pill imprinted with the number 40 on it and three white oval pills with the letter F on one side and the number 91 on the other side in the top-left drawer. RN B was not able to identify the four loose pills. Observation on 10/23/2024 at 11:17 AM revealed the facility hall 400 Medication cart with an Advair Diskus Inhalation Aerosol Powder Breath Activated 250mg/50mcg with the expiration date of 05/23. Interview with RN B on 10/22/2024 at 2:10 pm voiced that all four loose pills would be destroyed because she doesn't know who they belong to. The pills were immediately placed in the biohazard bin attached to the nurse cart. RN B voiced she thinks the pills may have gotten to the bottom of the cart and outside the pill packet because sometimes the packets are punctured and that would cause the pills to fall out. RN B verbalized that sometimes she has seen pills on the bottom of the cart. RN B voiced the facility can't really do anything to prevent it from happening. Interview with DON on 10/23/2024 at 11:22 am verbalized loose pills don't need to be on the bottom of the carts. DON voiced if a nurse doesn't find a pill after they notice it missing and can't locate it in the cart, it would eventually lead to an issue. When asked what kind of issue. DON voiced someone could grab it accidentally and give it to another resident. She emphasized that a resident would not be able to get into a cart, that issue would be more of a concern for another employee, giving a pill to another resident. DON verbalized that she thinks the pills that been in there for a long time tend to get loose adhesives on the backings of the pill packets and that is why the pills fell out. DON voiced sometimes it could be a manufacturing issue or they have received the pill packets from pharmacy with loose adhesives in the past and they have sent them back to send sealed packets back to them. DON voiced audits on carts are done weekly and weekly audits are done for medication rooms too. More thorough audits are conducted monthly. DON verbalized that if a nurse found loose pills on the bottom of their carts she would expect them to dispose of it in the bio-hazard or they can come to her office so they can dispose of the pills using the drug buster. Observation on 10/22/2024 at 1:58 PM revealed the facility medication room with a bottle of Aspirin with an expired date of 09/24 and a bottle of Daily Vitamin formula and Iron with an expired date of 08/24. In an interview on 10/23/2024 at 11:19 AM with CMA (K), when asked if the resident that the expired inhaler is still a resident in the facility. CMA(K) acknowledged yes, resident still lives here and still uses the inhaler. CMA (K) verbalized she checks her cart for expired medications periodically. There is not a time period for checking the dates, staff just need to remember to check the dates. When CMA (K) was asked what some potential adverse effects could happen to the resident if they are given an expired inhaler. CMA (K) voiced the medication will not work properly. CMA (K) could not remember the last time she received an in service on checking carts for expired medications. In an interview on 10/24/2024 at 01:43 PM, DON verbalized that the medication room is audited weekly, and all medications should be discarded if expired. The DON verbalized she is responsible for the audits and pharmacy and staff do them too. DON verbalized she would not expect her staff to administer an expired inhaler to a resident. The potential adverse effects if a resident received an expired inhaler would be the resident would not get the maximum benefit of the medication if it is expired. It could lead to respiratory depression or other complications. The DON voiced that the CMAs are supposed to be checking their carts for expired medications on a regular basis and she does spot checks for expired medications. Review of the facility's Policy Medication Administration Procedures Policy does not specify when staff should check for expired dates. The policy does not specify or include anything related to ensuring residents do not get expired medications.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the need of 4 (Resident#55, #54, #56, and#268) of 6 residents reviewed for narcotic pharmacy services. 1.CMA (F) administered narcotics and did not document in the narcotic book after administering to the residents. This failure placed residents at risk for inadequate therapeutic outcomes, ineffective disease management and a decline in health. The findings included: Review of Resident #55's face sheet, dated 10/23/2024 revealed an [AGE] year-old male admitted to the facility with an initial admitted [DATE] and a admitted [DATE] with the following diagnosis: Gerstmann-Straussler-Scheinker Syndrome (GSS) is an extremely rare, always fatal (due to it being caused by prions) neurodegenerative disease that affects patients from 20 to [AGE] years in age, Adjustment disorder with depressed mood, mild cognitive impairment of uncertain or unknown etiology, anxiety disorder (Unspecified), nontraumatic intracerebral hemorrhage in hemisphere (cortical), cerebral amyloid angiopathy (CAA) happens when amyloid (abnormal) proteins build up in blood vessels in your brain. The proteins damage your blood vessels and cause bleeding inside your brain. The condition is the most common cause of cognitive decline in people aged 60 and older, other abnormalities of gait and mobility, primary open-angle glaucoma a progressive eye disease that damages the optic nerve and causes vision loss., bilateral, indeterminate stage, unspecified dementia (Dementia is the loss of cognitive functioning that interferes with daily life and activities). Review of Resident # 55's Quarterly MDS dated [DATE] reflected a BIMS score of 02. Which indicates severe cognitive impairment. Review of Resident #55's Physician order revealed PHENobarbital Oral tablet 32.4 MG give one tablet by mouth two times a day related to other epilepsy. Observation on 10/22/2024 at 11:37 AM, revealed CMA (F) administered PHENobarbital Oral tablet 32.4 MG to Resident #55 at 08:00 AM and the medication at had not been documented in the narcotic book after being administered. Review of Resident #54's face sheet, dated 10/23/2024 revealed an [AGE] year-old female admitted to the facility with an initial admitted [DATE] and a admitted [DATE] with the following diagnosis: Chronic respiratory failure with hypoxia, mild cognitive impairment of uncertain or unknown etiology, noninfective gastroenteritis (is inflammation of the stomach and intestines, often caused by viruses, bacteria or chemicals) and colitis (Unspecified), major depressive disorder, recurrent severe without psychotic features, generalized anxiety disorder, morbid (severe) obesity due to excess calories, hyperlipidemia (abnormally high levels of fats (lipids) in the blood, which include cholesterol and triglycerides), other sleep apnea, essential (primary) hypertension, fibromyalgia (is a disorder characterized by widespread musculoskeletal pain accompanied by fatigue, sleep, memory and mood issues), other malaise (a general feeling of discomfort, illness, or uneasiness whose exact cause is difficult to identify). Review of Resident # 54's Quarterly MDS dated [DATE] reflected a BIMS score of 05. Which indicates severe cognitive impairment. Review of Resident #54's Physician order revealed an order for Lyrica Capsule 150MG (Pregabalin) give one capsule by mouth two times a day for nerve pain. Review of Resident #56's face sheet, dated 10/23/2024 revealed an [AGE] year-old female admitted to the facility with an initial admitted [DATE] and a admitted [DATE] with the following diagnosis: Chronic Diastolic (Congestive) heart failure (a long-term condition that happens when your heart can't pump blood well enough to meet your body's needs), Dysuria (is pain or discomfort when urinating), Atherosclerotic heart disease(Atherosclerosis is a hardening of your arteries from plaque building up gradually inside them) of native coronary artery without angina pectoris (Angina is chest pain or discomfort that happens when your heart isn't receiving enough oxygen-rich blood), major depressive disorder (single episode, moderate), Major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), recurrent severe without psychotic features, Dysphagia (difficulty swallowing), oropharyngeal phase, Other lack of coordination, Cognitive communication deficit, Pain (Unspecified), Unspecified protein caloire malnutrition, hyperlipemia (medical term for abnormally high levels of fats (lipids) in the blood), Essential (primary) hypertension (common condition that can damage your arteries and lead to serious complications), Cerebrovascular disease (term for conditions that affect blood flow to or within the brain), Muscle weakness (generalized), chest pain (unspecified), personal history of transient ischemic attack (brief stroke-like attack wherein symptoms resolve within 24 hours) and cerebral infarction (stroke is a life-threatening condition that happens when part of your brain doesn't have enough blood flow) without residual deficits. Review of Resident # 56's Quarterly MDS dated [DATE] reflected a BIMS score of 06. Which indicates severe cognitive impairment. Review of Resident #56's Physician order revealed an order for APAP/Codeine TAB 300-30MG give one tablet three times daily. Review of Resident #268's face sheet, dated 10/23/2024 revealed an [AGE] year-old male admitted to the facility with an initial admitted [DATE] with the following diagnosis: Hypertensive heart disease with heart failure, Type 2 diabetes mellitus without complications, mixed Hyperlipemia (abnormally high levels of fats in the blood), Depression (Unspecified), Anxiety disorder (Unspecified), Occlusion and stenosis of right middle cerebral artery, Hemiplegia (form of paralysis that affects one side of the body) and hemiparesis (is weakness or paralysis on one side of the body caused by stroke) following cerebral infarction affecting left non-dominant side, Gastro-esophageal reflux disease (a digestive disorder that causes heartburn and acid indigestion) without esophagitis (inflammation of the esophagus), sacroiliitis (inflammation of the sacroiliac joint), radiculopathy (can cause pain, numbness and tingling along a pinched nerve in your back), lumbar region. Review of Resident # 268's Quarterly MDS dated [DATE] reflected a BIMS score that was not given because the MDS was still in process and had not been completed during the survey visit. Review of Resident #268's Physician order revealed Lyrica oral capsule 75MG (Pregabalin) give one capsule by mouth two times a day for nerve pain. Observation on 10/22/2024 at 11:37 AM, revealed CMA (F) administered Lyrica Capsule 150MG (Pregabalin) at 8:00 AM to Resident #54 and the medication had not documented in the narcotic book after being administered. Observation on 10/22/2024 at 11:37 AM, revealed CMA (F) administered one tablet of APAP/Codeine TAB 300-30MG to Resident #56 and the medication had not been documented in the narcotic book after being administered. Observation on 10/22/2024 at 11:37 AM, revealed CMA (F) administered Lyrica oral capsule 75MG (Pregabalin) to Resident #268 and the medication had not been documented in the narcotic book after being administered. During an interview on 10/22/2024 at 11:42 AM, CMA (F) stated that she did not log the narcotics in the book after administering them because she forgot today. CMA (F) voiced this could lead to a med error and acknowledged it could harm the resident. CMA (F) verbalized that another CMA or Nurse can come along after her and think the resident did not get the medication and administer it again to the resident. CMA (F) said she can't recall the last time she was in-serviced on documenting narcotics or medications after they are administered but she feels like they get in-services a lot. During an interview on 10/23/2024 at 11:22 AM, the DON stated that adverse effect of the act of CMA (F) could be the resident receiving too much medication because staff would not know that the resident already received their narcotic medication. This would lead to a med error voiced the DON. DON voiced her expectations are for staff to document in the narcotic count sheet in the narcotic book and acknowledge the medication has been given in the electronic medical record. When the correct steps are completed a progress note is populated in the electronic medical record and staff are to document resident response to the medication at the time of administration. Also, DON stated that an in-service would be performed for narcotic administration. Review of facility policy titled Medication Administration Procedures Pharmacy Policy & Procedure Manual 2003, Policy Statement reflected After the resident has been identified, administered the medication and immediately chart doses administered on the medication administration record. It is recommended that mediations be charted immediately after administration, but if facility policy permits, medication may be charted immediately before administration. Initials are to be used.

Based on observation, interview and record review, the facility failed, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for all residents in the facility. 1. The facility failed to provide activities as scheduled on October 5th- October 6th, October 12th- October 13th , and October 19th to October 20th. These failures placed residents at risk of boredom, depression, increased behaviors, and diminished quality of life. Findings include: Record review of the resident participation record for October 2024 no activities did not occur on the weekends. Record review of the Activity Calendar the times for activities on the weekend was not documented on the activity calendar. The activity participation records for the month of October weekend activities were not provided for the residents on the following dates: a. 5th: Activity of Choice Outside Social Hydration Station b. 6th: Football Social Word Puzzles Dominoes c. 12th: Good News Social College Football Social Crossword Puzzles d. 13th: Football Social Morning News Activity of Choice e. 19th Activity of Choice Name that [NAME] College Football Social f. 20th Football Social Music Memory Word Find Pages In a confidential Resident Group Meeting on 10/23/2024 at 10:00 AM, there were nine residents present for the meeting. All nine residents stated there was not any weekend activities during the month of October 2024. The residents in the group stated they did not understand the weekend activities on the activity calendar. All residents discussed some of them did not enjoy football, puzzles, or dominoes. The residents in the group were voiced their concerns about most of the residents in the facility was not able to come out of their room and was not able to do puzzles or dominoes. The group also stated there were not any times on the calendar and they did not know what time the activity began on weekends. One person stated it has football social in the morning and football does not come on television until the afternoons. The group stated some of the residents' watches football does not prefer to watch the same teams. The group was asked what was name that [NAME] and everyone in the group stated they had never heard of [NAME]. The group stated during the week there is activities and they liked the Activity Director, however, she could not be at the facility seven days a week. The group stated someone needed to work on weekends to only do activities. Five of the seven residents in the meeting stated the CNAs and nurses did not have time to do activities on the weekends they were busy giving care and we do not want them to do activities it would decrease time giving care. One resident stated she became sad and lonely on the weekends because there was not anything to do. Five of the seven residents in attendance stated they became bored. One of the seven residents stated he felt this was when there were more behaviors from the residents on the weekends. The residents in the group stated activities were discussed in group but it was for during the week and not on weekends. In an interview on 10/22/2024 at 9:30 AM, CNA C stated she did work sometimes on the weekends. She stated no one had discussed doing activities with the residents on the weekends with her. CNA C stated the nurses and the CNAs did not have time on the weekends to do activities in the dining room with the residents. She stated they were very busy giving care to the residents. CNA C stated if the staff did activities the residents care would decline. In an interview on 10/24/2024 at 10:15 AM, RN A stated the staff was very busy on the weekends providing ADL care to the residents. She stated she had not observed any activities occurring on the weekends especially during the month of October 2024. RN A stated it would be very helpful if volunteers came in on weekends and did activities with the residents or hire a part time assistant to work weekends. She stated there was an activity assistant and she was no longer there as of few weeks ago. RN A stated there were activities during the week but not on weekends. She stated if residents did not receive activities there was a possibility a resident may become depressed, bored, have a decline in their cognition and/ or isolate themselves in their rooms. In an interview on 10/24/2024 at 10:30 AM, the Administrator stated his expectations of the activity department was to follow the facility policies and CMS regulations. When asked if there was a possibility a resident may become bored or sad if they did not have activities on the weekends, the Administrator did not respond to the question. When asked about the participation records and if he expected the activities be documented when an activity occurred in the facility or outside the facility, the Administrator did not respond. The Administrator did not respond when asked who was responsible to ensure the Activity Director was providing activities for the residents on weekends. In an interview on 10/24/2024 at 10:43 AM, the Corporate Regional Director stated activities were to be provided seven days per week. She stated a participation record was to be kept on all residents attending activity programs. She stated if a resident was not receiving activities on the weekends there was a possibility a resident may become bored and may affect the resident's quality of life. In an interview on 10/24/24 11:10 AM, the Activity Director stated she was not aware of the CMS Federal guidelines for the activity department. She stated she read the activity policy few years ago, however, did not recall what the policy stated about weekend activities or participation records. She stated it was very difficult to find volunteers to come to the facility on weekends. She stated she did have dominoes, puzzle books, cards, etc. available in the dining area for the residents to do on the weekends. The Activity Director stated not all residents was physically able to do puzzles, dominoes or play cards. She stated if a resident was not able to do these type of activities they would not have anything to do on the weekends. She stated she had an assistant and was no longer working at the facility approximately 3 weeks ago. The Activity Director stated she had been an activity director at the facility at least 3 years. Activity Director stated she did not ask the residents about weekend activities. Activity Director stated there was a possibility a resident may become bored, depressed , lonely if they did not have any activities on the weekends. She stated the facility had a new Administrator approximately 3 weeks. She stated since he had been at the facility she did not have the opportunity to discuss her concerns in the activity department and the weekend activities was one of her concerns. She stated it was her responsibility to ensure all residents received activities they enjoyed and met their individual preference. She stated if an activity occurs she was to document it on the participation records. The Activity Director stated she made copies of the monthly calendar and documented each resident on a separate calendar. She stated she highlighted the activity the resident attended on their personal calendar she kept in a binder. The Activity Director stated she did not document participation records anywhere but on the calendar in the binder she gave to the surveyor, and this had been her participation record system for three years. Activity Director stated she did not document participation records in the computer. She stated residents not receiving activities on weekends the resident may have a decline in their mood, cognition, and overall life. The Activity Director stated she did not recall over the past year of doing any in services with the nursing department about doing activities on the weekends. She stated if there were not any times on the calendar the residents would not know what time to attend the activity. The Activity Director stated it would be difficult for some residents to go outside and socialize and she did not provide an alternative activity for the residents unable to go outside. She stated activity of choice was when the residents did what they wanted to do in their rooms. The Activity Director agreed this was not a group activity and she understands how this may be confusing to the residents. In an interview on 10/24/2024 at 11:45 AM, Resident # 5 stated she had someone to visit on the weekends but sometimes she wanted to do an activity to socialize with other people. She stated sometimes it seemed lonely at the facility because there were no activities and nothing for the residents to do. Resident #5 stated they had activities during the week but did not have any on weekends this month. Resident #5 stated she did not want to discuss any-more about activities. In an interview on 10/24/2024 at 12:15 PM, Resident #16 stated she did become sad sometimes on the weekends and lonely but did not have these feelings during the week. She stated there were activities during the week but on the weekends during this month there was not any activities and sometimes she became bored and tired of watching television. Resident #16 stated she did not like to play dominoes or wanted to do puzzles. She stated she did not recall the activity director asking her what she would prefer to do on weekends. Record review of the Activity Director Personnel Record she had been an Activity Director for [AGE] years at this facility and she did have her current Activity Certification. Record review of the Facilities Policy on Activity Programming, dated 2011, reflected The Activity director and staff will provide for ongoing Activity programs. Practice Guidelines: 1. Recreation programs are based on the interest and needs of the residents expressed through the Activity assessment. 2. Resident's or families expressed needs and interests are included in the development of programs. Input from residents may be done on an individual basis or may be discussed at Resident Council/ Group. 3. Activity programs are be designed ( this is exactly how the policy is written) on resident's leisure interests and implemented to meet the needs (physical, cognitive, creative, social, spiritual, independent, and sensory) of the residents. 4. Programs will be geared to maintain functional ADLs, provide social interaction and, at the same time, protect residents from environmental over stimulation. 5. Those who cannot participate in group settings are provided individual programming. Inability to participate could include those who refuse to participate in activities, those who are in isolation, or 'physician ordered' bed rest. 6. Programming includes large groups, small groups, individual and independent opportunities. 7. Programs may take place in mornings, afternoons and/or evenings that span throughout the entire week. 8. Programs use various areas available in and out of the health care center. 9. The resident population is cognitive assessed routinely to determine the number of functional level programs needed. 10. The opportunity is provided for regular community outings/ trips. Programs are developed to include community resources and involvement within, as well as outside the health care center. Record review of the Facility Policy on Activity Participation Records, dated 2019, reflected The Activity Department will maintain accurate records of group and individual program participation for each resident. 1. Resident attendance in programs is recorded on a daily basis to reflect resident attendance and will be used as a source of information for recording the resident's progress or lack of progress in the progress note. 2. Each resident has separate participation record of group activities and/or individual attendance and participation. 3. Active, passive, and refused is noted on the participation records. 4. Individual programs (one on ones) not the response to intervention by either a checklist or a narrative for each program or visit 5. Participation records stored in health care center per state regulation, but no fewer than five years.

Based on record review and interviews, the facility failed to ensure the comprehensive care plan described the services that were to be furnished to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being for 1 (Resident #40) of 25 residents reviewed for care plans, in that: 1. The facility failed to ensure Resident #40's comprehensive care plan addressed a discharge plan. This failure could place the residents at risk of not receiving care and services to meet their needs. Findings included: Record review of Resident #40's Face sheet, 10/22/2024, reflected she was a [AGE] year-old woman, who was admitted to facility on 9/28/24 with a diagnoses of clostridioides difficile (C.Diff [contagious bacteria]) acute osteomyelitis (serious bone infection), right ankle and foot, cellulitis (bacterial infection) right toe, type II diabetes (insulin resistance), major depressive disorder and generalized anxiety. Record review of Resident #40's MDS 10/22/2024, indicated she had a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognitive function. In an observation and interview with Resident #40 on 10/22/2024 at 2:10 PM, resident was observed to be clean and appropriately groomed. She reported that she was doing okay and felt safe at the facility. The resident stated she is on antibiotics due to a bone infection. She stated she is scheduled to return home on November 2, 2024, and had no concerns. Records review on of Resident #40's comprehensive care plan dated 9/28/2024, reflected the resident's diagnosis with a focus on interventions that were actively being completed to support residents' health. Record review on 10/24/2024 at 9:00 AM, Resident #40's comprehensive care plan dated 9/28/2024 and later revised 10/14/2024, revealed there was no discharge plan. Record review of the facility's Discharge Planning Process Policy and Comprehensive Care Planning Policy revealed facility policy stated a comprehensive care plan will be developed within 7 days after completion of the comprehensive assessment. In an interview on 10/24/2024 at 2:10 PM, Minimum Data Set Nurse (MDS) stated a resident's discharge should be documented in their care plan. MDS stated there could be some potential negative effects when discharge information is missing, leading to possible negative outcomes. In an interview on 10/24/2024 at 2:15 PM, Social Worker (SW) stated the discharge plan has not been part of the care plan in the past but believed it should be included. SW was questioned on how staff would be aware of a resident's discharge plan if a discharge was to occur, she stated she hoped they would review the progress notes, though she was unsure if they would. SW stated she has not been trained on the facility's policy and procedures for discharge. In an interview on 10/24/2024 at 2:23 PM, Director of Nursing (DON) stated, the discharge plan is created at the new admission. When asked if the discharge plan was part of the care plan, she stated it probably should be included. She stated the SW initiates the assessment while the team is responsible for the care plan. She stated the admission meeting usually have the MDS, SW, Dietary, Rehab Director, and Activity Coordinator present. DON stated the interventions would be documented on a care plan along with the discharge information. DON stated there is a potential for a bad outcome with no information documented but they usually have a care plan meeting before discharge.

Based on observations, interviews, and record review the facility failed to ensure the residents received services in the facility with reasonable accommodation of each resident's needs for 2 (Resident # 24, and Resident #45) out of 8 residents reviewed for call lights. The facility failed to ensure Resident # 24 and Resident #45's call light was within reach. This failure could affect all residents who needed assistance with activities of daily living and could result in needs not being met. Findings included: 1. Record review of Resident #24's Face Sheet, dated 10/23/2024, reflected a [AGE] year-old male admitted to the facility on [DATE] with a diagnoses of unspecified lack of coordination (uncoordinated movement due to a muscle control problem that causes inability to coordinate movements), unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance , mood disturbance and anxiety ( a group of symptoms that affect the brain, such as memory loss, personality changes, and difficulty thinking can be mild or mixed without any behaviors), and personal history of traumatic brain injury ( an injury to the brain caused by an external force, such as a blow to the head or an object penetrating the skull). Record review of Resident #24's Quarterly MDS Assessment, dated 09/23/2024, reflected Resident #24 had a BIMS score of a 3 indicating his cognition was severely impaired. Resident #24 was assessed to be dependent on staff for the following ADLs: personal hygiene, dressing, showers, toileting hygiene, chair to bed, and bed to chair transfers. Record review of Resident #24's Comprehensive Care Plan revised on 07/21/2024 and target date of 10/22/2024 reflected Resident #24 was at risk for falls related to impaired mobility and dementia. Intervention: be sure Resident #24's call light was within reach and encourage the resident to use it for assistance as needed. Resident #24 had an ADL self-care deficit. Intervention: Encourage Resident #24 to use bell to call for assistance. Observation and interview on 10/22/2024 at 9:15 AM, Resident #24 was lying in bed. His call light was located under his bed. Resident #24 stated no when asked if he knew where his call light was located. He stated yes when asked if he used the call light. Resident #24 did not respond to any further questions such as: is his call light usually within reach and how would he call for help if his call light was on the floor. 2. Record review of Resident # 45's face sheet dated 10/23/2024 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of unspecified dementia, unspecified severity, with other behavioral disturbance ( a group of symptoms that affect the brain, such as memory loss, personality changes, and difficulty thinking can be mild or mixed with behavior problems), unspecified mood (affective) disorder ( a diagnostic category for people who have mood disorder symptoms that do not meet the criteria for another mood disorder diagnosis), and Alzheimer's disease ( a progressive, irreversible brain disorder that destroys memory and thinking skills, and eventually the ability to perform daily tasks). Record review of Resident #45's Quarterly MDS Assessment, dated 09/07/2024, reflected Resident #45 had a BIMS score of 0 indicating her cognition was severely impaired. Resident #45 was assessed to be dependent on staff for the following ADLs: personal hygiene, dressing, showers, toileting hygiene, chair to bed, and bed to chair transfers. Record review of Resident # 45's care plan, dated 09/15/2024, reflected the resident was at risk for falls. Intervention: Ensure the resident's call light was within reach and encourage resident to use it for assistance as needed. Resident #45 had an ADL Self Care Performance Deficit. Intervention: Encourage Resident #45 to use bell to call for assistance. Observation and interview on 10/22/2024 at 9:28 AM, Resident #45 was lying in bed. She had a soft pad call device and it was hanging over the side of her bed. Resident #45 was not capable of reaching the soft pad call device. In an attempted interview on 10/22/2024 at 9:30 AM, Resident #45 was not interview able In an interview on 10/22/2024 at 9:32 AM, CNA C revealed Resident #45 required a soft pad call device related to Resident #45 was not physically or mentally capable of using a call light button. CNA C stated it was easier to pat the soft pad call device. She stated the call light device was hanging over the bed and Resident #45 was not able to reach the call device. CNA C stated if Resident #45 needed assistance she would not be able to yell for help or do anything to alert staff she needed assistance because she spoke with a very soft voice and it would be difficult to hear Resident #45. CNA C stated she had been in-serviced on call lights; however, she did not recall the time or date of the in-service. She stated all call lights needed to be on the bed where the Resident was able to find and use the call light. In an interview on 10/22/24 at 10:00 AM, CNA B stated the residents needed their call lights within reach. She stated if a resident needed assistance with any type of ADL care such as: toileting, transferring, dressing, etc. the Residents needs would not be met if they were unable to call for help. CNA B stated most residents have a regular call light except Resident # 45 who has a soft pad call device. She stated she knew Resident #45 was confused sometimes and it was easier for her to find the soft pad call device. CNA B stated Resident # 45 had a soft voice and it would be difficult to hear her talk loud when she was in her room. She stated it would be impossible for Resident #24 to obtain his call light from under Resident #24's bed. CNA B stated Resident #24 would have difficulty receiving any type of assistance he may need if he did not have his call light in reach. CNA B stated she had been in serviced on call lights. She stated all call lights were expected to be in reach of all residents at all times. She stated the nursing staff or any staff can check call lights. In an interview on 10/24/2024 at 10:15 AM, RN A stated if a resident's call light was not within reach of the resident there was a possibility a resident may fall and break a hip or hit their head on the floor attempting to reach the call light. LVN A stated it would be difficult to hear Resident # 24 and Resident #45 if staff were not near their rooms. She stated it was the responsibility of all staff in the facility to check call lights when they entered a resident room to ensure the call light was attached where the residents had easy access to use the call light. RN A stated she had been in-serviced on call lights and placing the call light within reach of the resident when they were in their room. RN A did not recall the last time he received the in-service. In an interview on 10/24/2024 at 10:30 AM, the Administrator stated the facility did not have a policy on call lights. The administrator did not respond to the following question: What was his expectation of the call lights being within reach of a resident. Was there a possibility if the call light were not in reach and a resident may need emergency nursing assistance and would not be able to call out for help. In an interview on 10/24/2024 at 10:43 AM, the Corporate Regional Director stated a call light under the bed and over the bed was not within reach of a resident. She stated there was a possibility a resident may attempt to assist self out of bed to locate the call light. The Corporate Regional Director stated any staff can check call lights to ensure the resident was capable or reaching the call light. The Corporate Regional Director stated the facility did not have a policy on call lights but her expectations were the call lights be within reach of the residents at all times. In an interview on 10/24/2024 at 11:25 AM, the DON stated it was all the staff's responsibility when they entered a resident room to ensure the call light was within reach of the resident. She stated if the call light were not within reach, it would be difficult for a resident to obtain the help they may need in a timely manner. She stated some residents were able to yell for help and some residents would not be able to yell loud enough. She stated a resident had a potential to fall if the resident attempted to reach for their call light. The DON stated a resident may need medical emergency and would not be able to use the call light for nursing assistance. The DON stated it was safe practice for all staff to ensure call lights were within reach of all residents. She stated an in-service had been given to all staff on call light placement. She stated she did not recall the date when the in-service was given to the staff. Record request on 10/24/2024 at 10:30 AM, of the call light facility's policy from the Administrator. He stated the facility did not have a call light policy.

Based on observations, interviews, and record review, the facility failed to ensure residents unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for three of eight residents (Resident #17, Resident #24, and Resident #35) reviewed quality of life. 1. The facility failed to ensure Resident #17 and Resident #24 nails were cleaned. 2. The facility failed to ensure Resident #35 nails were trimmed and did not have any rough edges. These failures could place residents at risk for poor hygiene, dignity issues, and decreased quality of life. Findings include: 1. Record review of Resident # 17's Face Sheet dated, 10/23/2024, reflected a [AGE] year-old male admitted on [DATE] and readmitted on [DATE] with diagnoses of lack of coordination (uncoordinated movement due to a muscle control problem that causes inability to coordinate movements), neuroleptic induced parkinsonism ( slowed movements, difficulty with fine motor tasks, problems with balance, walking, and resting tremor), tremor unspecified ( a neurological condition that causes involuntary shaking or trembling in one or more parts of the body), and cognitive communication deficit ( difficulty with communication that is caused by an impairment such as memory, attention, or problem-solving). Record review of Resident #17's Annual MDS Assessment, dated 08/20/2024, reflected the resident had a BIMS score of 5 indicating his cognition was severely impaired. Resident #17 required supervision or touching assistance with personal hygiene, lower body dressing, showers, transfers, and toileting hygiene. Record review of Resident #17's Comprehensive Care Plan, revised on 09/10/2024 reflected Resident #17 had an ADL self-care performance deficit. Interventions: Bathing- Check nail length, trim and clean on bath day and as necessary. Report any changes to the nurse. Resident #17 had an alteration in neuroleptic induced Parkinson. Intervention: cueing, reorientation as needed. Monitor/ document/ report to MD as needed signs and symptoms of tremors, rigidity, dizziness changes in level of consciousness, and slurred speech. Observation on 10/22/2024 at 9:37 AM, resident #17 was propelling self in his wheelchair from his room into the hall. Resident #17 had blackish / brownish substance underneath all of his nails on his right hand. In an interview on 10/22/2024 at 9:38 AM, Resident #17 stated he thinks he knows what it is underneath his nails but he was not going to tell anyone. Resident #17 stated he did request for his nails to be cleaned yesterday and the girl that works here told him someone would clean them when he got a shower. Record review of Resident #24's Face Sheet, dated 10/23/2024, reflected a [AGE] year-old male admitted to the facility on [DATE] with a diagnoses unspecified lack of coordination (uncoordinated movement due to a muscle control problem that causes inability to coordinate movements), unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance , mood disturbance and anxiety ( a group of symptoms that affect the brain, such as memory loss, personality changes, and difficulty thinking can be mild or mixed without any behaviors), and personal history of traumatic brain injury ( an injury to the brain caused by an external force, such as a blow to the head or an object penetrating the skull). Record review of Resident #24's Quarterly MDS Assessment, dated 09/23/2024, reflected Resident #24 had a BIMS score of a 3 indicating his cognition was severely impaired. Resident #24 was assessed to be dependent on staff for the following ADLs: personal hygiene, dressing, showers, toileting hygiene, chair to bed, and bed to chair transfers. Record review of Resident #24's Comprehensive Care Plan revised on 07/21/2024 and target date of 10/22/2024 reflected Resident #24 had an ADL self-care deficit. Intervention: Resident #24 required assistance with bathing: check nail length, trim, and clean on bath day and as necessary. Report any changes to the nurse. If diabetic, the nurse will provide toenail care. Resident #24 was dependent on staff for activities, cognitive stimulation, social interaction related to dementia. Interventions: Resident #24 needed assistance with ADLs as required during the activity. Observation on 10/22/2024 at 9:40 AM, Resident #24 was lying in bed. Resident #24 had blackish/brownish hard substance underneath his forefinger and middle fingernails. In an interview on 10/22/2024 at 9:42 AM, Resident #24 was asked if he reported to anyone about his nails having a blackish/brownish substance underneath two of his nails on his right hand. He stated, yes but don't know who. Resident #24 did not respond to any other questions such as: when he reported his nails being dirty and how long they had been dirty. 2. Record review of Resident #35's Face Sheet, dated 10/23/2024, reflected a [AGE] year-old female was admitted on [DATE] and readmitted on [DATE] with a diagnosis of multiple sclerosis (a chronic disease that damages the central nervous system, including the brain and spinal cord- this damage can slow or block messages between the brain and body, leading to a range of symptoms such as muscle weakness, difficulty with coordination and balance, numbness, thinking and memory problems, etc.), muscle wasting and atrophy ( muscle wasting or thinning of your muscle mass). Record review of Resident #35's Quarterly MDS Assessment, dated 10/04/2024, reflected the resident had a BIMS score of 8 indicated her cognition status was moderately impaired. Resident # 35 was dependent on staff for personal hygiene, dressing, showers, toileting hygiene, oral hygiene, and transfers. Record review of Resident 35's Comprehensive Care Plan, revised on 10/17/2024, reflected Resident #35 had an ADL Self Care Performance Deficit. Resident #35 will maintain or improve current level of function in personal hygiene. Resident #35 required assistance with bathing. Resident #35 had multiple sclerosis. Intervention: Pain management as needed. Give medications as ordered. Resident #35 was at risk for falls related to multiple sclerosis and muscle wasting and atrophy. Interventions: anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Resident #35 needed activities that minimize the potential for falls while providing diversion and distraction. Record review of Resident #35's Physician Orders and she did not have a diagnosis of diabetes or being administered any type of diabetic medication. Observation on 10/22/2024 at 10:13 AM, Resident #35 was in her room lying in bed. Resident #35 had approximately 2-inch nails on both hands. Resident #35 had rough edges around her ring and middle fingernails on her right hand. There were no scratch marks on her left or right hands or arms. In an interview on 10/22/2024 at 10:16 AM, Resident #35 stated she asked someone few days ago if they would trim her nails and file them. She stated she explained two of her nails were broken and she was scratching herself and leaving scratch marks on her left arm first of October (2024). She stated she bent one of her nails back and it broke. Resident #35 stated this is when the nails became rough and had a point on the corner of two of her nails(she pointed to the ring and middle finger of her right hand). She stated staff she talked to about her nails stated the aides was not allowed to cut or trim nails that was the nurses job. She stated she was not a diabetic. Resident #35 did not recall the CNA's name or the day this conversation occurred in Resident #35's room. In an interview on 10/22/2024 at 9:32 AM, CNA C stated the CNAs was responsible for cleaning, trimming, and filing all residents' nails except for the residents with diagnosis of diabetes. She stated the nurses was responsible for all residents' nails with diagnosis of diabetes. CNA C stated residents nails were usually cleaned on their shower days and as needed. She stated if there was a blackish substance on the residents' fingertips or underneath their nails and the resident swallowed the blackish substance there was a possibility a resident may become ill such as vomiting and diarrhea. CNA C stated there were also a possibility a resident may become severely dehydrated and may need to be transferred to emergency room to determine what type of bacteria was underneath the residents' fingernails. CNA C stated a resident may scratch their face or their arm. She stated a resident may cause a skin tear on their skin if the nail was not filed. CNA C stated she had been in-serviced on cleaning, filing and trimming residents' nails but she did not recall the date. CNA C stated she was not aware of Resident #17, Resident #24 or Resident #35 refusing nail care. She stated Resident #24 sometimes refused to be shaved. In an interview on 10/22/2024 at 10:00 AM, CNA B stated the nurses completed all diabetic fingernails, and the CNAs were responsible for all other residents' nails. She stated the CNAs were responsible to complete nail care such as trimming, filing, and cleaning the nails during showers. CNA B stated if a resident's nails needed to be cleaned, trimmed, or filed and it was not their shower day, the staff were expected to do any type of nail care as needed. CNA B stated if a resident had blackish substance underneath their nails, it was probably some type of bacteria. CNA B stated if a resident swallowed bacteria it was a potential the resident may develop major stomach problems such as nausea and/or diarrhea. CNA B stated if a resident became severely ill the resident may need to be transferred to emergency room for more care. CNA B stated if a resident had rough edges around their nails it was a possibility the resident may scratch themselves and develop a skin tear or scratch another resident. She stated Resident # 17, Resident #24 and Resident #35 did not refuse nail care. CNA B stated Resident #24 would refuse to be shaved. She stated she had been in-service on nail care but did not remember the date of the in-service. She stated it had been approximately 6 months to a year. In an interview on 10/24/2024 at 9:45 AM, RN A stated the CNAs was responsible for cleaning, trimming, and filing all residents' nails except for the residents with diagnosis of diabetes. RN A stated the nurses was responsible for all residents' nails with diagnosis of diabetes. RN A stated residents' nails were usually cleaned, filed, and trimmed on their shower days. She stated if a resident had a hang nail or their nails were dirty, nail care was expected to be completed as needed. RN A stated if a resident had nails that were rough around the edges, there was a possibility a resident may scratch themselves and develop a skin tear. RN A stated if there was a blackish substance on the residents' fingertips or underneath their nails and the resident swallowed the blackish substance there was a possibility a resident may become ill with stomach issues such as vomiting. RN A stated there was a potential for a resident to develop or a throat infection. RN A stated she had been in-serviced on cleaning, filing and trimming residents' nails. RN A stated she did not remember the date of the in-service. She stated she was not aware of Resident #24, Resident #17 or Resident #35 refusing nail care. She stated sometimes Resident #24 would refuse clothes to be changed and to be shaved. In an interview on 10/24/2024 at 10:30 AM, the Administrator stated he would need to refer to the facilities policy on nail care when he was asked of his expectations of cleaning and trimming residents nails. In an interview on 1024/2024 at 10:43 AM, the Corporate Regional Director stated the nurses was expected to perform nail care including trimming and cleaning on the residents with diagnosis of diabetes (a disease that occurs when your blood glucose, also called blood sugar, was too high). The Corporate Regional Director stated the CNAs was expected to trim and clean all other residents' nails during showers and as needed. She stated if there was a blackish/ brownish substance underneath a resident's nails there was a possibility it may be bacteria. She stated if a resident ingested some bacteria there was a possibility a resident may have stomach issues, however, it was according to what type of bacteria was underneath the residents fingernails. In an interview on 10/24/2024 at 8:45 AM, Director of Nurses stated if a resident ingested blackish substance on their fingers or underneath their fingernails, there was a possibility the substance may be some type of bacteria. She stated a resident may become physically with infection of their stomach. She stated there was a possibility a resident may develop vomiting or diarrhea. She stated all residents was expected to receive nail care during showers and as needed. Director of Nurses stated the CNAs completed nail care on all residents except for the residents with diagnosis of diabetes (a disease when your blood sugar was too high). She stated it was the nurse's supervisor responsibility to monitor residents nail care. The facility Policy on Nail Care, dated 2003, reflected Nail management is the regular care of the toenails and fingernails to promote cleanliness, and skin integrity of tissues, to prevent infection, and injury from scratching by fingernails or pressure of shoes on toenails. It includes cleansing, trimming, smoothing, and cuticle are and is usually done during the bath. Nails can become thinner and more brittle in the elderly and thicker if peripheral circulation is impaired. Nail care will be performed regularly and safely. The resident will be free from abnormal nail conditions and the resident will be free from infection.

Based on observations, interviews, and record review the facility failed to ensure that its medication error rate was not 5 percent or greater. The facility had a medication error rate of 8.57 % based on 3 errors out of 35 opportunities, which involved 1 of 8 residents (Resident #34) and 1 of 2 staff (CMA F) reviewed for medication errors, in that: The facility failed to ensure residents were free from medication errors. These failures could place residents at risk of medication errors that could cause a decline in health. Findings included: Record Review on 10/23/2024 of Resident #34's face sheet dated 10/24/2024 reflected Resident #34 was a [AGE] year-old male with an admitted [DATE]. Resident #34's diagnoses included: Posterior reversible encephalopathy syndrome, Parkinson's disease without dyskinesia (without mention of fluctuations), major depressive disorder (recurrent, moderate), anemia (unspecified), Type 2 diabetes mellitus without complications, bipolar disorder (unspecified), essential (primary) hypertension. Record Review on 10/24/2024 of the most recent MDS assessment dated [DATE] reflected Resident #34 had a BIMS score of 12 indicating Resident #34 was moderately cognitively impaired. Record review on 10/24/2024 of Resident #34's clinical physician orders revealed: Procardia XL Oral Tabled Extended Release 24 Hour 30 MG (Nifedipine) Give 30 mg by mouth two times a day for HTN hold if systolic is less than 120, and Hr less than 60. Record review on 10/24/2024 of Resident #34's clinical physician orders revealed: Chlorthalidone Tablet 25 MG Give 1 tablet by mouth one time a day for edema, hypertension. Record review on 10/24/2024 of Resident #34's clinical physician orders revealed: Toprol XL Oral Tablet Extended Release 24 Hour 100 MG (Metoprolol Succinate) Give 100 mg by mouth one time a day for HTN Hold for SBP less than 110 or DBP less than 60. CMA (F) administered 1 medication which was ordered to be given if blood pressure reading was within the parameters. Orders indicated to hold (don't give to resident) if blood pressure reading is outside of the parameters. The blood pressure was outside of the parameters. CMA (F) should have held the medication. CMA (F) documented that she gave a medication that she did not give, and she documented she did not give a medication that she did give to the resident. During an observation on 10/23/2024 at 07:46 AM, CMA (F) was observed passing medication to Resident # 34 which included 3 medications (Nifedipine tab 30 MG, Chlorthalid tab 25 MG and Toprol XL Oral Tablet Extended release 24-hour 100 MG) that were ordered by the physician to be given if blood pressure reading was within the parameters given. During an observation on 10/23/2024 at 07:46 AM, CMA (F) was observed obtaining Resident #34 blood pressure and it was: 102/71 with a HR of 70. The physician order for medication parameters read: Procardia XL Oral Tabled Extended Release 24 Hour 30 MG (Nifedipine) Give 30 mg by mouth two times a day for HTN hold if systolic is less than 120, and Hr less than 60. Chlorthalidone Tablet 25 MG Give 1 tablet by mouth one time a day for edema, hypertension. Toprol XL Oral Tablet Extended Release 24 Hour 100 MG (Metoprolol Succinate) Give 100 mg by mouth one time a day for HTN Hold for SBP less than 110 or DBP less than 60. Per physician order CMA (F) was not supposed to administer the Nifedipine because it was outside the parameters per the physician's order. CMA (F) verbalized that she did not give the Toprol XL oral Tablet because it was outside of the parameters but upon checking the residents record after the administration, CMA (F) documented she did give the medication. Upon observation on 10/23/2024 CMA (F) administered the Chlorthalidone Tablet 25 MG but documented she did not give it because it was outside of the parameters as indicated in the order. During an interview on 10/24/2024 at 11:22 AM, the DON stated it is her expectation that medications be given to residents as ordered by the doctor. She stated if a medication is ordered to be given within certain blood pressure parameters staff are to follow the instructions and administer accordingly. She stated she would have concerns if a medication as given outside of the parameters it could lead to a medication error. She stated she will provide an in-service to staff on medication administration and the 10 rights of medication administration. Record Review on 10/24/2024 of the Medication Administration Policy (Pharmacy Policy & Procedure Manual 2003) provided by the DON, revealed the following: Comprehensive care plan #13. When ordered or indicated, include specific item(s) to monitor (e.g., blood pressure, pulse, blood sugar, weight) frequency (e.g., weekly, daily) timing (e.g., before or after administering the medication), and parameters for notifying the prescriber. # 15. Medication errors and adverse drug reactions are immediately reported to the resident's Physician. In addition, the Director of nurses and/or designee should be notified of any medication errors. Any medication error will require a medication error report that includes the error and actions to prevent reoccurrence. #20. The 10 rights of medication should always be adhered to: 1. Right patient, 2. Right medication, 3. Right dose, #4. Right route, #5. Right time, #6. Right patient education, #7. Right documentation, #8. Right to refuse, #9. Right assessment, #10. Right evaluation.

Based on interview and record review, the facility failed to ensure residents were free from verbal abuse for 1 of 5 residents (Resident #1) reviewed for abuse. The facility failed to prevent Med Aide A, on 6/23/24, from verbally abusing Resident #1 when she used foul language and threatened to keep him up late. The noncompliance was identified on 6/23/24. The facility had corrected the noncompliance before the investigation began and was corrected 06/24/24. These failures could place resident at risk for emotional distress, fear, decreased quality of life and further abuse. Findings included: Review of the face sheet for Resident #1 reflected he was admitted to the facility on [DATE] with diagnoses of: Metabolic Encephalopathy, Pain, Stiffness of unspecified joints, Cerebral Infarction, Epilepsy, and Aphasia following Cerebral Infarction. Review of the Discharge MDS Assessment for Resident #1 dated 5/11/24 reflected Resident #1 was transferred to the hospital. His physical assessment reflected he could feed himself with set up and needed extensive assistance for all other ADLs. He was assessed as always incontinent of bladder and bowel. Review of the Care Plan for Resident #1 dated 5/14/24 reflected interventions were in place for: Seizure disorder, Fall risk r/t hemiplegia, metabolic encephalopathy/weakness, Heart Failure, Anemia, UTI (6/25/24), and a Stroke on 6/25/24. In an interview on 7/23/24 at 9:30 am the Administrator stated Resident #1 and his roommate Resident #5 confirmed the Med Aide A had threatened them verbally and stated she was punishing Resident #1 by keeping him up late. The Administrator stated the facility investigation confirmed verbal abuse and the Med Aide was terminated. The Administrator stated ongoing interviews had confirmed Resident #1 denied any harm from the incident. In an interview on 7/23/24 at 10:00 am Resident #1 stated he felt fine and safe since the Med Aide was removed from the building. He stated she had demonstrated a bad attitude on different occasions. He stated he didn't think he needed to speak to a Psychologist or Councilor. Resident #1's speech was slow but he answered questions appropriately. Attempts to interview MED AIDE A were unsuccessful, three attempts were made to reach her by telephone on 7/23/24 at 9:30 am 11:18 am and 1:00 PM. No return call was received. Review of the facility investigation reflected the incident was reported on 6/24/24 and occurred on the evening of 6/23/24. Review of the incident report reflected Resident #1 was told by MA A I am punishing you for last night for being on the light. The Resident's room mate Resident #5 gave a statement to the administrator on 6/24/24 the Med Aide A left Resident #1 up in his chair until 10 PM on 6/23/24. On interview by the Administrator Resident #1 corroborated the statement. Resident #1 stated he had back pain . Assessment of Resident #1 showed no signs of physical injury. In a follow-up interview on 08/08/2024 at 11:18 AM Resident #1 up in w/c in room he stated he was ok and voiced no complaints about care or staff at the facility. When asked about MED AIDE A he stated 'who then was able to recall the incident he stated she did put him in bed at 10:00 pm because he was on his light last night and then she said if you do I will not put you to bed until 1:00 PM tomorrow. When asked if he felt abused and how the incident made him feel he stated, I feel like she was in a bad mood. Then stated no to being abused but yes to feeling threatened. He stated he felt safe at the facility and was happy with how the facility handled the situation. He stated did not have pain but did not want any pain medicine. He stated he usually went to bed at 6 or 7 pm. He stated MED AIDE A had taken care of him before and he stated he had not had any problems with her before. Review of facility investigation dated 07/01/2024 revealed the administrator and Social Worker interviewed Resident #1 individually as part of the facility investigation. Psych services conducted a brief interview and no adverse issues were reported. Review of Med Aide A Termination Statement dated 07/01/24 revealed Med Aide was suspended on 06/24/24 and terminated on 07/01/24. Review of a Statement from Resident #1 dated 6/24/24 reflected he had been kept up until 10 PM on 6/23/24 and the med Aide A threatened to keep him up until 1:00 am if he used the call light too much. Review of a Statement from Resident #5 dated 6/24/24 reflected he had overheard Med Aide A tell his roommate Resident #1 I am punishing you for last night for being on the light. Review of the Facility Policy on Abuse Neglect dated 3/29/2018 reflected the resident has a right to be free from abuse, neglect and misappropriation. Examples of verbal abuse in the policy include threats to harm or frighten a resident. Review of Abuse, Neglect and Exploitation Inservice dated 06/24/24 revealed all staff inserviced on abuse, negelct and exploitation. Review of Med Aide A's employee record reflected she was hired 4/15/2022 back ground check completed, her last abuse prevention training was done 5/29/24 no disciplinary actions. An observation on 08/08/2024 at 9:35 AM revealed staff interacting at the facility respectfully with residents. In an interview on 08/08/2024 at 9:55 AM Resident #10 stated he thought the staff were competent and felt safe at the facility. He denied any abuse. In an interview on 08/08/2024 at 9:57 AM Resident #11 stated she felt safe and had no concerns for abuse or neglect. In an interview on 08/08/2024 at 11:00 AM RN G stated she was educated regarding the facility abuse and neglect policy and would notify their abuse coordinator, the administrator. If she did not feel the situation was addressed by the abuse coordinator she would notify HHSC. Review of Satisfaction Rounds by the Social Worker dated 06/27/2024 revealed the social worker completed satisfaction rounds with all residents with no additional concerns revealed. Review of Resident #1's Care plan dated 06/25/2024 revealed Resident #1's care plan was updated for recent trauma related to abuse for incident with MED AIDE A.

Based on observation, interview, and record review, the facility failed to ensure that residents are free from abuse, neglect, misappropriation of resident property, and exploitation for one (Resident #1) of four residents reviewed for abuse. The facility failed to ensure Resident #1 was in a safe environment when LVN A recorded instances of pouring water onto her face, verbally taunting her, and striking her with her knee and sitting on her arm. An immediate jeopardy existed from 03/05/24 - 03/06/24. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the investigation. This failure could affect residents by placing them at risk for abuse that could cause diminished quality of life and increased psychosocial harm as well as physical harm. Findings included: Review of Resident #1's undated face sheet revealed she was an [AGE] year-old female admitted to the facility 07/18/19 with diagnoses including: depression, history of stroke (bleeding in the brain), dementia, and kidney disease requiring dialysis (removal of blood by a machine to clean toxins then replacing cleaned blood). Review of Resident #1's quarterly MDS assessment dated [DATE] revealed she had moderate difficulty with her hearing. It further revealed she usually understood others and usually could be understood. The review also revealed Resident #1 had impaired vision that required corrective lenses. Resident #1's BIMS score was an 8, which correlated with moderately impaired cognition. Further review revealed that Resident #1 did not exhibit physical or verbal behavioral symptoms directed towards others nor behavioral symptoms not directed towards others. Review of Resident #1's latest care plan, dated 12/22/23, revealed Resident #1 was at risk for pressure related injury due to impaired mobility with intervention of administering medications as ordered and repositioning Resident #1 at least every 2 hours. Further review revealed Resident #1 was at risk for fluid deficit (dehydration) due to medications, dialysis and variable intake; the intervention for this concern was administer medication, encourage Resident #1 to drink fluids of choice, ensure fluids were within reach, and notify the nurse if Resident #1 refused to drink fluids. Further review revealed Resident #1 was at risk for discomfort/pain due to impaired mobility and recent hospitalization that led to dialysis; the intervention for Resident #1's potential discomfort/pain was anticipate her need for pain relief and respond immediately to any complaint of pain, evaluate the effectiveness of the pain intervention, and review for compliance. Further review revealed Resident #1 had a focus of being non-compliant with medication due to anxiety and interventions were to notify family and physician and notify supervisor. Review of the facility's self-report dated 03/06/24 revealed that LVN A used her cell phone camera to record herself verbally and physically abusing Resident #1. There was a total of 5 videos, with 2 being repeats, that were sent by LVN A to an undisclosed employee who then sent the videos to the corporate office of the facility. Review of the videos, sent to Corporate 03/05/24, revealed LVN A poured water on Resident #1 who was lying in bed. LVN A was heard taunting Resident #1 when Resident #1 became upset about the water poured on her face. Resident #1 swung her left arm out at LVN A each time LVN A approached her bed. LVN A was seen kneeing Resident #1, who was lying on a scoop mattress, and telling Resident #1 that she was going to take these pills. Resident #1 was heard calling LVN A a Black Bitch as she swung her arm at LVN A when LVN A approached Resident #1's bed. LVN A was heard asking Resident #1 if she is gay and throughout the video LVN A was laughing and taunting Resident #1. The next video revealed LVN A continued to taunt Resident #1 and she sat on Resident #1 while commenting that she was sitting on her. LVN A was seen sitting on Resident #1's left hip area, getting up and motioning to sit again as Resident #1 swung her arm at LVN A. LVN A was then seen grabbing Resident #1's blanket and trying to take it from Resident #1 while laughing and telling Resident #1 she was going to take these pills. The next video showed LVN A tugging at Resident #1's blanket and telling her that she would take the blanket if Resident #1 did not take these pills. Resident #1 stated to LVN A that it was her blanket and called LVN A a bitch. Resident #1 struck out with her right arm toward LVN A and LVN A responded by pouring more water on Resident #1's face, which was turned away from LVN A. Resident #1 called LVN A a bitch and LVN A laughed and held the water above Resident #1's head while Resident #1 lifted her right arm above her face to protect from further water being poured. LVN A slowly pretends to pour the water on Resident #1 while Resident #1's arm was over her face for protection but then withdrew the cup of water and laughed, then slowly moved closer to again threaten to pour water on Resident #1's face, held the cup for a few seconds and then poured the water when Resident #1 had lowered her arm. LVN A stated she was going to pour the water and Resident #1 said go ahead and pour it on me. LVN A poured a small amount on Resident #1 who then stated pour it all on me as she wiped the water away. LVN A was laughing and facing the camera. In the next clip, LVN A was kneeing Resident #1 3 times with Resident #1 swinging her left arm toward LVN A after the first kneeing incident. LVN A then grabbed Resident #1's left arm by the wrist and told her to open her mouth while grabbing Resident #1's mouth, and then poking her several times in the breast/chest area while calling Resident #1's name. LVN A then sat down on Resident #1's left arm and part of her abdomen while holding a cup of medication to Resident #1's mouth and looking back at the camera. LVN A then pulled on Resident #1's chin and Resident #1 opened her mouth and LVN A tilted the cup, so the medication ended up in Resident #1's mouth. LVN A then laughed and said ha ha gotcha; LVN A then grabbed the phone/camera. In all 5 video clips Resident #1 was wearing the same clothing and LVN A was wearing the same clothing in all 5 clips. During an interview on 03/13/24 at 11:00 am with the ADM she stated that LVN A sent the videos to an unknown employee who then sent the videos to the corporate office on 03/05/24; the corporate office immediately contacted the ADM, around 03/05/24 at 3:30 pm, and ADM began suspension and termination paperwork. LVN A was not at work at the time, so ADM stated she contacted LVN A to come to the building to sign the suspension paperwork and that she would be terminated for abuse. Corporate office reported LVN A to the board of nursing and included the video files. ADM contacted the family, the police department , the ombudsman and reported to SA . In addition, she notified the MD. The ADM, with support staff from the Corporate Office, began in-servicing all employees on Abuse/Neglect/Exploitation, use of photography/social media, and HIPAA privacy laws. All in-servicing was started 03/05/24 and completed 03/06/24. In addition, skin sweeps of all residents were started 03/05/24 and completed 03/06/24. Resident #1 was assessed by nursing immediately and Social Work met with the resident and continued meeting with her through 03/13/24 (exit ). Resident #1 was followed by Psychiatry, so a call for an immediate visit was made and a psychologist visited with Resident #1 on 03/11/24 (first available time). The psychologist had seen Resident #1 in the past and stated that she had not declined in her baseline from the last time he had seen her several months before and this visit. All residents were given safe resident surveys with no other issues identified. Staff were all given surveys related to LVN A and whether any staff had observed abusive behavior, but no witnessed or other issues were identified. An Ad Hoc QAPI was held with ADM, DON, and MD on 03/05/24. The dialysis clinic that Resident #1 visited 3 times per week were notified to be on alert. In addition, the facility notified every facility in a 60-mile radius that LVN A was terminated and not eligible for re-hire. ADM stated that the police detective informed the ADM that Resident #1's RP would have to press charges for LVN A to be charged with any criminal act. The ADM also stated that the facility would continue asking 5 alert and oriented residents about any abuse or neglect concerns and if the residents feel safe; these questions would be asked for the next 5 weeks (if no concerns are voiced in the future questioning). Record review of Resident #1's EHR assessments tab revealed a Weekly Skin Assessment was performed on 03/05/24 at 4:09 pm and revealed no bruising or skin tears, but noted bilateral non-pressure wounds to the heals which were not marked as new. Record review of the resident safe surveys revealed no other residents documented concerns about safety, nor did the residents feel abused and nor had they witnessed abuse at the facility. Record review of staff surveys revealed that no staff member documented witnessing abuse or neglect of any resident by LVN A nor by any other staff member. In addition, all staff were able to identify the ADM as the abuse coordinator to contact immediately should staff have any concerns about abuse or neglect. Record review of Resident #1's March 2024 Progress Notes revealed a progress note authored by the Social Worker (SW) on 03/05/24 at 6:02 pm and revealed the SW documented trying to interview Resident #1 about the abuse she endured from LVN A, but Resident #1 did not answer about abuse and asked for her breakfast. The SW documented that Resident #1 did not display signs of fear, distress or behavioral agitation. The next progress note authored by the SW on 03/06/24 at 12:24 revealed she contacted Resident #1's psychiatric provider who stated they would arrange for counseling services to contact the SW to setup an appointment. The SW authored a note on 03/06/24 at 5:01 pm that the counseling services contacted the SW, and a therapist would call the SW to discuss telehealth and in-person options. During an interview and observation on 03/13/24 at 3:00 pm with Resident #1 revealed her room was dark and she said to go away. Resident #1 appeared to be resting comfortably in bed; no concerns were visible. Police officer exited room moments before. During an interview with Police Detective on 03/13/24 at 3:10 pm he stated that he was gathering evidence still, as he had just attempted to interview Resident #1 but was unsuccessful. He further stated he still needed to interview Resident #1's RP and LVN A. He provided his contact information and stated he would provide an update and report when he was able. During an interview on 03/19/24 at 9:10 am with LVN A she stated that nobody liked Resident #1 because Resident #1 was physically abusive, used bad language and refused care. She stated that sometime in January of 2024, LVN A had a cup of water to give Resident #1 and Resident #1 swung her hand and caused a little bit of water to spill on Resident #1. She said Resident #1 would respond to requests from LVN A by calling her a bitch and Resident #1 said fuck you. She stated she was supposed to go to work on 03/06/24, and she picked up her paycheck on 03/05/24 and everything was fine but was contacted by the ADM on 03/05/24 around 5 or 6 pm and the ADM told her she was suspended pending an investigation. She said the ADM was not allowed to tell her the allegations. LVN A stated on 03/06/24 she was called and asked to come to the facility and was notified she would be terminated. She denied any further incidents of water being spilled on Resident #1, she denied raising her voice to Resident #1, putting her hands on Resident #1, or any other incidents that would be viewed as abusive. LVN A did state that she had documented when Resident #1 had aggressive behavior toward LVN A. Record review of Resident #1's January 2024 progress notes revealed that LVN A documented a behavior note on 01/30/24 at 7:22 am that further revealed that Resident #1 refused her medication and used foul language and told LVN A to leave her room. LVN A then offered Resident #1 her medication in the shower room and Resident #1 pulled LVN A's hair and knocked the medication cup out of LVN A's hand. LVN A then documented notifying Resident #1's RP of the encounter. Record review of Resident #1's February 2024 progress notes revealed that LVN A documented on 02/03/24 at 2:51 pm that she had contacted Resident #1's RP about a behavior incident earlier that morning (no description or note found specifying the incident) and that a new order for in-patient psychiatric services was placed and RP would be updated when new information was available. Further review revealed a progress note on 02/09/24 at 8:13 am authored by LVN A that stated LVN A called the Mental health and mental rehabilitation crisis hotline to report that Resident #1 was using explicit language and displaying inappropriate behavior (not described) towards LVN A and another staff; LVN A was waiting for a return phone call. Review of a note dated 02/09/24 at 11:22 am by LVN A that revealed the return call from the crisis hotline personnel recommended LVN A speak with RP and MD to obtain inpatient psychiatric services for Resident #1; LVN A spoke to the ADM who recommended LVN A speak to the SW. During an interview on 03/13/24 at 3:13 pm with LVN B, she stated the facility constantly trained on abuse and abuse prevention. She said, it starts your first day of work on the computer before you can work with residents. She stated at least once a month, but usually more, abuse was covered. LVN B stated the most recent abuse in-service was within the last week, she thought last Tuesday or Wednesday (03/05/24 or 03/06/24). She stated if she was concerned about abuse, she would have reported it to the abuse coordinator, the ADM and she felt the ADM would take it seriously. During an interview on 03/13/24 at 3:20 pm with LVN C, she stated that they were in-serviced at least every month on abuse and the most recent was within the last few days. If she suspected abuse, she would protect the resident and notify the abuse coordinator, the ADM. She stated the ADM was new, but seemed good, she said staff were told there was an incident of abuse and to watch Resident #1 for any signs of change from her baseline. LVN C said Resident #1 seemed to be having more good days this week than the last few weeks. During an interview on 03/13/24 at 3:26 pm with CNA D, she said she was trained on abuse at least every other month, but most recently last week. She said if she had witnessed abuse, she would have stopped it and notified the charge nurse immediately, then the DON, and the ADM who was the abuse coordinator. She gave the types of abuse and examples. During an interview on 03/13/24 at 3:37 pm with HK E she said abuse was mentioned in trainings and meetings at least 3 - 4 times a month, and the latest was within the last week. She stated Resident #1 had good and bad days, but Resident #1 had never been physical with her. She said sometimes Resident #1 would yell at her, but when HK E responded calmly to Resident #1 and told her what she was doing and kept talking to her that Resident #1 would calm down. She stated that usually staff stepped out and gave Resident #1 a moment to calm down and tried again later. Record review of in-services revealed all staff in-serviced on Abuse/neglect/exploitation, photography, social media usage, and HIPAA privacy laws which started on 03/05/24 and completed 03/06/24. Record review revealed an attendance sheet for an Ad Hoc QAPI meeting on 03/05/24 which included the ADM, the DON, and the MD. Record review of HR folder revealed termination paperwork that stated that LVN A was hired 11/17/23 and was suspended by the ADM on 03/05/24 with the ADM's stated intent to move straight to termination due to a substantiated allegation that LVN A abused a resident; the ADM also requested that LVN A be added to a list of people not to be rehired due to the abuse. Further review revealed a form titled Personnel Action Form and was marked Termination with LVN A's name and employee identification number. LVN A's final termination date was marked as 03/06/24, and her last day worked according to the form was 03/04/24. Further review of LVN A's HR folder revealed she was last in-serviced on Abuse/neglect/exploitation on the computer on 01/02/24. Further review revealed the facility documented all required background checks for LVN A, which included verification of her nursing license, criminal background check, check with the employee misconduct registry, and the state and federal office of the inspector general exclusion lists. Record review of March 2024 nursing schedule revealed LVN A was not scheduled after 03/05/24. Record review of facility's policy titled Abuse/Neglect dated 03/29/18 revealed abuse included . willful infliction of injury, intimidation, or punishment .verbal abuse included language that was disparaging or derogatory . Mental abuse included harassment, threats of punishment .physical abuse included . pinching, kicking, and hitting .

Based on observation, interview, and record review the facility failed to provide necessary services to maintain personal hygiene for 3 (Resident #1, Resident #2, and Resident #3) of 5 residents reviewed for ADLs. -The facility did not provide Resident #1 with a shower 8/11/2023 through 8/22/2023, 8/24/2023 through 8/30/2023, and 9/6/2023 through 9/13/2023. -The facility did not provide Resident #2 with a shower 8/1/2023 through 8/4/2023, 8/13/2023 through 8/31/2023. -The facility did not provide Resident #3 with a shower 8/2/2023 through 8/14/2023, 8/16/2023 through 9/12/2023. This failure could place residents who required assistance of 1 or 2 staff or who are dependent on staff for bathing at risk for discomfort, skin breakdown and infection. Findings include: Resident #1 Record Review of Resident #1's Face Sheet dated 9/14/2023 revealed an [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Displaced Intertrochanteric Fracture of Left Femur(Left Broken Hip), Subsequent encounter for Closed Fracture with Routine Healing (Right Hip Fracture, at Facility for Physical Therapy), Urinary Tract Infection, Major Depressive Disorder, Anxiety. Record Review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS Score of 15 out of 15 indicating intact cognitive skills. The resident required one person assist with locomotion on unit, dressing, toilet use and personal hygiene which excluded baths and showers. Resident #1 required physical help in part of bathing activity. Record review of Resident #1's Care Plan dated 9/6/2023 reflected in part .The resident has an ADL Self Care performance Deficit Impaired balance .Bathing .The resident requires 1 staff participation with bathing. Record review of Resident #1's ADL sheets dated 8/2023 and 9/2023 revealed no documentation of shower or baths 8/11/2023 through 8/22/2023, 8/24/2023 through 8/30/2023 and 9/6/2023 through 9/13/2023. In an interview on 9/12/2023 at 8:20 a.m. with Resident #1 she said it would take all day to say what had been going on at the facility with short staffing. She said she had been at the facility for over a month, and she was supposed to have baths on Tuesday's, Thursday's. She said the staff did not come in the room to offer her a shower. She said she was told last Friday 9/8/2023 she would get a bath. She said she had a rash break out on her neck from not getting a shower. In an interview on 9/13/2023 at 12:40pm with Resident #1 she said she had been at the facility for a while. She said she was gone at the hospital for a few days and came back. She said she would be at the facility for another 2 to 3 weeks for physical therapy. She said she would go 5 days without a bath and would have to fight with the staff to get one. She said the CNAs would give her a hard time She said she did get a bath this morning. She said the CNA told her she did not want to give her a shower because she did not want to get wet. She said the CNA came into her room with a book and told her today was not her shower day. She said she has had a total of 2 showers since she had been at the facility. She said when she would ask staff for a shower, they would tell her it was not her day. She said staff would tell her they did not have enough help at the facility and could not give her a shower. Resident #2 Record review of Resident #2's Face Sheet dated 9/14/2023 revealed a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease (Blocked airflow, difficulty breathing), Atrial Fibrillation (Irregular heart rate), Difficulty Walking. Record review of Resident #2's quarterly MDS dated [DATE] revealed a BIMS score of 14 out of 15 indicating the resident was cognitively intact. Resident #2 required supervision with walking in the corridor, dressing and personal hygiene excluding baths and showers. Bathing was coded as an 8 indicating activity did not occur or family and or non-facility staff provided care 100% of the time for that activity over the entire 7-day period. The MDS further reflected for mobility devices the resident used a walker, wheelchair. Residents functional abilities and goals were to shower and bathe self. 5. Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity. Record review of Resident #2's ADL sheets dated 8/2023 revealed no shower or baths 8/1/2023 through 8/4/2023 and 8/13/2023 to 8/31/2023. On 9/12/2023 at 8:30 a.m. the Surveyor observed Resident #2 with oily hair. On 9/12/2023 at 8:30 a.m. with Resident #2, he said he had lived at the facility for 2 years. He said he is happy with his stay at the facility, but he has not been getting his showers. He said the facility has been shorthanded. He said he has been asking to get a bath and facility staff say they are shorthanded. He said the last time he had a bath was last Friday 9/8/2023. In an interview on 9/13/2023 at 12:30 p.m. with Resident #2, he said he has missed getting baths and showers. He said they could not catch up in one day and said the facility staff told him he would get a shower tomorrow. He said he did get a bath in the month of August 2023 a couple of weeks ago by a new girl who had been at the facility for a few weeks. He said he would have to ask for a shower and was told they did not have enough help. He said they do not have to help him, but they must be in the shower with him in case he falls. He said he would like to have his showers on the days they are scheduled. Resident #3 Record review of Resident # 3's Face Sheet dated 9/14/2023 revealed a [AGE] year-old female who was admitted to the facility on [DATE] with an admission diagnosis of Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side (Left Sided Paralysis), Unspecified Lack of Coordination, Major Depressive Disorder (Sadness), Anxiety Disorder (Inability to Set Aside a Worry). Record review of Resident #3's quarterly MDS revealed a BIMS score of 15 out of 15 indicating the resident was cognitively intact. Resident #3 required 1 person assistance with transfers, dressing, eating, toilet use, and personal hygiene not including baths and showers. The resident required physical help with bathing. Record review of Resident #3's Care Plan dated 7/18/2023 reflected in part .The resident has an ADL Self Care Performance Deficit .The resident will maintain current level of function Personal Hygiene through review date .Bathing requires staff x1 for assistance. Record review of Resident #'3's ADL sheets revealed no shower or bath 8/2/2023 through 8/14/2023 and 8/16/2023 through 9/12/2023. On 9/14/2023 at 3:00 p.m. observation revealed Resident #3 in her wheelchair. Resident #3 was not able to move her left side. Resident #3 had oily, unkept hair. In an interview on 9/14/2023 with Resident #3 at 3:00 p.m. she said she occasionally went without a shower. She said she refused to [NAME] people who had to work an entire hall by themselves so she washed herself at the sink with a washcloth. She said she did not like doing it that way because she would get cold. She said she preferred a shower. She said they would have only one aide. She said she was not getting the time she needed to get a shower from the staff. She said it had been over a week since she had a shower. In an interview on 9/13/2023 at 11:33 a.m. with Nurse Aid A, she said she had worked at the facility for 4 months. She said she was in-serviced on bathing when she first came to the facility to work. She said she would be taking her CNA test soon. She said the facility had a shower sheet the CNAs went by and Resident #1's shower days were Monday, Wednesdays, and Friday. She said the number 8 on the ADL sheet meant the shower did not occur. She said Resident #1 never asked her for a bath, but she might have declined once so she told the charge nurse. She said she had been told by residents the facility was too short staffed to provide showers. She said when residents were not bathed it was neglect and it hurt the residents pride. She said if a residents were not bathed, they could get a skin infection. In an interview on 9/13/2023 at 11:35 a.m. with CNA A, she said she had been a CNA for [AGE] years. She said she had worked at the facility since 2018. She said the last in-service on bathing and showering was 2 months ago. She said she worked the 300 hall but worked the 100 hall on Sunday. She said some of the CNAs did not give their baths and showers even when they were fully staffed but she had heard the residents saying the facility was too short staffed to provide showers. She said she stayed over to give Resident #2 a shower on Sunday and Resident #2 said she had only been showered twice in a month. She said if residents were not bathed or showered it was neglect and they could have gotten skin breakdown. In an interview on 9/13/2023 at 1:45 p.m. with LVN B, she said she had been a nurse for 2 years and had worked at the facility for a couple of years. She said the facility had problems with the 2 to 10pm shift because of staffing. She said they did not have enough CNAs to do all the baths. She said she had heard of residents and families complaining and it had been escalated to management. She said there were more aides in the building the last 2 days,9/12/2023 and 9/13/2023. In an interview on 9/14/2023 at 10:45am with the Administrator, she said she had received complaints from residents and staff that the residents were not getting baths and showers. She said they all pitched in, but staff left and they were shorthanded. She said when residents were not bathed or showered, they could have skin issues and it was a dignity issue. She said when residents do not receive good peri care they can get urinary tract infections. In an interview on 9/14/2023 at 1:50 p.m. with LVN C, she said she had worked at the facility for 5 years and had been a nurse for 2 of those years. She said the last time she was in-serviced on ADLs was within the last year. She said residents and staff had been complaining there had been minimal staff all the time. She said sometimes when she had come to work there would only be 1 CNA in the entire building for that day. She said residents did not get baths or showers like they should have. She said they had asked corporate to help them with staffing and they had not done anything to resolve the issue. Record review of Certified Nurse Aide Job Description, no date, reflected in part . Accountable for personal care (i.e., grooming, bathing, catheter care, peri care, and dressing). Record review of facility's policy titled Bath, Tub/Shower dated 2003 reflected in part, Bathing by tub or shower is done to remove soil, dead epithelia cells, microorganisms from the skin and body odor to promote comfort, cleanliness, circulation, and relaxation Goals 1. The resident will experience improved comfort and cleanliness by bathing. 2. The resident will maintain intact skin integrity. Record review of facility's policy titled, Resident Rights, no date, reflected in part . A facility must treat each resident with respect and dignity and care of each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the walk-in refrigerator in that: -The facility stored unlabeled and unsealed foods in the refrigerator. This failure had the potential to place residents at risk of serious complications from foodborne illness as a result of their compromised health status Findings include: Observation and interview on [DATE] at 11:25 AM with Cook A revealed containers labeled green tomatoes and ketchup in the refrigerator were opened and unsealed, open to the air. She said the green tomatoes and ketchup should be closed so that nothing like bugs or bacteria got inside. She closed and sealed the lids on the containers and said she would have to throw it away. A bag of what appeared to be coleslaw mix was observed with no label, in the refrigerator. Cook A identified the food as coleslaw mix and said the food in the fridge should be dated so staff knew if it was good or bad. She said she would throw away the coleslaw mix as well. She said the policy was that food in the refrigerator should be sealed and labeled. She said risk to residents if food was not sealed or labeled was they could get sick and or die. Interview on [DATE] at 1:51 PM with the Dietary Manager, she said she had worked at the facility since February 2023. She said as the dietary manager she managed the dietary department, new staffing, ordered all supplies, charted the dietary side of things, and cooked, and/or washed dishes when needed. She said if food was cooked and placed in the refrigerator, it should be sealed and dated. She said there were two dates on it, an open date, and the delivery date. She said canned fruit was dated from the date it was opened. She said food was dated to ensure food was not expired. She said the risk to residents if food was not labeled or sealed was it could make residents sick, or they could die. Record review of the Dietary Services Policy & Procedure Manual 2012 dated 2012 reflected in part .Open packages of food are stored in closed containers with tight covers and dated as to when opened Record review of U.S. Food and Drug Administration Food Code dated 2022 reflected in part . ,d+[DATE].11 (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination .

Based on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly for 1 of 2 waste receptacles reviewed for garbage disposal. -Waste receptacle #1 had its top lid opened when no one was disposing of trash. These failures could place residents at risk for exposure to germs and diseases carried by vermin and rodents. Findings include: Observation and interview on 09/13/2023 at 11:25 AM with the Dietary Manager, revealed that one of the two waste receptacle's' lid was observed opened. The waste receptacle was located on facility property about 15 yards from the building. The closest entrance to the facility was through an external kitchen door. There was no fence surrounding the waste receptacles. There was trash inside the dumpster and no facility staff was disposing of trash at the time the lid was observed open. The Dietary Manager said the lid to the dumpster should be closed to avoid flies and pest getting into the dumpster which could then possibly get into the facility. She said the lid was open because the staff could not reach the lid to close it and that normally staff used a stick to reach the lid to close it. She said the risk to residents was they could get sick because of the flies and pest that could get inside the facility. The maintenance person went outside, and the Dietary Manager asked him if he could close it. The maintenance person walked towards the dumpster, found the stick, and closed the lid on the dumpster. She said the facility had a policy on food storage and refuse disposal. The Dietary Manager said the policy was the dumpster lid should always be closed unless someone was throwing away trash. Interview on 09/14/2023 at 5 PM with the Administrator who said the outdoor trash receptacle applied to the dumpster. Record review of the Dietary Services Policy & Procedure Manual 2012 dated 2012 reflected in part .Trash cans must be covered at all times, except during use

Based on interview and record review the facility failed to immediately consult and notify the resident's physician in an accident including the resident for one (Resident #1) of 7 Residents reviewed for quality of care. The facility nurses failed to immediately consult and notify the Physician when resident #1 sustained a fall with head injury on 09/04/2023 at 04:00 p.m. and the physician was not notified until 09/05/2023 at midnight, 8 hours later. Per the facility policy nurses should not hesitate to contact the physician at any time when an assessment and their professional judgement deem it necessary for immediate medical attention. An Immediate Jeopardy (IJ) situation was identified on 09/06/2023. While the IJ was removed on 09/07/2023, the facility remained out of compliance at a scope of isolated with actual harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of not receiving the highest practicable interventions, treatments and care through resident assessments by recognizing and addressing the physical, mental, and neurological dysfunctions such as altered state of consciousness, cognitive decline, confusion, memory loss, changes in behavior in an effective and timely manner to prevent residents from further harm, injury, or death. Findings include: Record review of Resident #1's face sheet, dated 09/06/2023, revealed a [AGE] year-old-female who was admitted to the facility on [DATE] with diagnoses which included cerebral infarction (stroke), metabolic encephalopathy (brain disruption), heart failure, obesity, and hypertension. Record review of Resident #1's MDS, dated [DATE], revealed a BIMS of 05, which indicated a severe cognitive impairment. Further review of Resident #1's MDS, Hearing, Speech, and Vision, revealed a Speech Clarity code of 0 revealed clear speech-distinct intelligible words, Makes Self Understood code of 1 revealed Usually understood-difficulty communicating some words or finished thoughts but able if prompted or given time. Further review of Resident #1's MDS, Health Conditions, revealed Fall history code of 0, which indicated Resident #1 did not have a fall in the last month, last 2 to 6 months, or fracture related to fall in the 6 months prior to admission. Further review of Resident #1's MDS, Functional status, revealed bed mobility at total dependence with two plus persons physical assist, transfer at activity did not occur, walk in room at activity did not occur, walk in corridor at activity did not occur, locomotion on unit at activity did not occur, dressing at total dependence with two plus persons physical assist, eating at limited assistance with one person physical assist, toilet use at total dependence with two plus persons physical assist, personal hygiene at total dependence with two plus persons physical assist, bathing at total dependence with two plus persons physical assist, balancing during transition and walking code of 8 which indicated activity did not occur, no impairment in upper and lower extremity, and that Resident #1 believes he or she is capable of increased independence code of 1 which indicated yes. Record review of Resident #1's care plan, undated, revealed a focus that resident (Resident #1) is risk for falls related to weakness, incontinent, a goal of resident (Resident #1) will be free of falls and will not sustain serious injury, and interventions/tasks to anticipate and meet resident (Resident #1) needs, be sure the resident's (Resident #1) call light is within reach and encourage the resident to use it for assistance as needed, educate resident/family/caregiver about safety reminders and what to do if a fall occurred, encourage resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility, keep furniture in locked position, keep needed items in reach, mechanical lift with staff x2 with transfers, physical therapy evaluate and treat as ordered or PRN, review information on past falls and attempt to determine cause of falls possible root causes, removed any potential causes, educate resident/family/caregivers/IDT (Interdisciplinary Team), provide a safe environment, and activities that minimize the potential for falls while providing diversion and distraction. Record review of the facility's incident report, dated 09/06/2023, revealed a fall incident with Resident #1 on 09/04/2023 at 4:00 p.m. Record review of Resident #1's, undated, progress notes in the EHR revealed a medical practitioner note effective date 09/05/2023 at 02:05 (2:00 a.m.), note text: yesterday 9/4/23 resident (Resident #1) was discovered on the floor, she was lying on her left side. Upon assessment on 10-6pm shift, it has been noted that, resident does not respond like she normally does. If someone asked her a question she responds with simple words. Now, if a questioned is asked she just shakes her head or she just stares at you with no response (this is new). Further review of progress notes revealed a transfer notification, 09/05/2023 05:09 (05:09 a.m.), note text: Resident #1 was transferred to a hospital on 09/05/2023 at 04:43 AM related to neuro changes r/t (related) fall 9/4/23. Record review of Resident #1's assessment page in the, undated, EHR revealed the following assessments completed: 09/04/2023 Event Nurses-Note 8hr Fall 09/04/2023 Neuro Assessment 09/04/2023 Neuro Assessment 09/04/2023 Fall-Risk Assessment 09/05/2023 Neuro Assessment 09/05/2023 Fall Nurses Note 8 hr 09/05/2023 SBAR (situation, background, assessment, and recommendation) 09/05/2023 Transfer Form Record review of Resident #1's Event Nurses-Note 8hr Fall, dated 09/04/2023 at 16:00 (4:00 p.m.), LVN A noted a nursing description of event, resident (Resident #1) was found by staff on the floor laying on her side on the side of her bed, in residents' room, un-witnessed fall discovered on floor, resident received a bruise from fall, located in face, redness noted, resident not in pain, NP notified on 09/04/2023 at 00:00 (12:00 a.m.), interventions prior to fall was low bed, interventions in response to fall was floor mat and low bed, cognition/behavior at time of event was oriented/no problem. Record review of Resident #1's Neuro Assessment, dated 09/04/2023 at 21:56 (9:56 p.m.), LVN A noted vitals: blood pressure at 117/58, pulse 58, and respirations 18, GCS (Glasgow Coma Scale): eyes opening spontaneously, oriented to person, place, and time, obeys commands, pupils reactive to light, and hand grips are equal. Record review of Resident #1's Neuro assessment dated [DATE] at 21:57 (9:57 p.m.), LVN A noted vitals: blood pressure at 108/58, pulse 60, and respirations 18, GCS (Glasgow Coma scale): eyes opening spontaneously, oriented to person, place, and time, obeys commands, pupils reactive to light, and hand grips are equal. Record review of Resident #1's Fall-Risk assessment dated [DATE] at 21:58 (9:58 p.m.), LVN A noted Resident #1 was alert and oriented. Record review of Resident #1's Neuro Assessment, dated 09/05/2023 at 02:02 (2:02 a.m.), revealed vitals: blood pressure at 116/73, pulse 56, and respirations n/a (not applicable), GCS (Glasgow Coma Scale): eyes opening spontaneously, words only intelligible single words, cannot have a conversation, considered as a new observation for Resident #1, obeys commands, pupil reactive to light, hand grips unable to assess due to paralysis, hemiplegia, injury, contractures, notification to NP/MD on 09/05/2023 02:10 (2:10 a.m.), physician/NP comments or orders listed as none at this time. Record review of Resident #1's Event Nurses-Note 8hr Fall, dated 09/05/2023 at 02:11 (2:11 a.m.), revealed left side of cheek was red, notification to NP/MD on 09/05/2023 02:10 (2:10 a.m.), physician/NP comments or orders listed as none at this time. Record review of Resident #1's SBAR (situation, background, assessment, and recommendation), 9/5/2023 04:51 (4:51 a.m.), situation neurological change, description of symptoms or signs revealed baseline as single words able to answer questions if asked, although currently no words just stares and difficult to arose, symptoms first appeared 9/5/2023. Record review of Resident #1's Transfer form, date 09/05/2023 05:09 (5:09 a.m.), LVN B's note reason for transfer was neuro changes r/t (related to) fall 09/04/2023. Record review of Resident #1's progress note, dated 09/05/2023 at 02:05 (02:05 a.m.), revealed LVN B's note text, Yesterday 9/4/23 resident was discovered on the floor, she was lying on her left side. Upon assessment on 10-6pmshift, it has been noted that resident does not respond like she normally does. If someone asked her a question she responds with simple words. Now, if a questioned is asked she just shakes her head or she just stares at you with no response (this is a new). Interview on 09/06/2023 at 10:29 a.m., the NP stated she needed to confirm if she was notified of the incident of Resident #1 on 9/4/2023, that would have been the on-call MD/NP. The NP stated she did not see a notification of the incident; The NP checked the call log used to record notifications and stated she could not confirm if the on-call MD/NP was notified. The NP stated after falls, when there was an injury to the head of any resident, the corporation had its own policy on neurological checks and monitoring that was evidenced based, nurses would monitor the set of criteria, and if there were any changes to the resident. When asked what the timeframes were for monitoring a resident with an unwitnessed fall or a injury to head, the NP could not recall the exact policy on time frames for neurological testing as it all depended on the evidence available, the NP stated with Resident #1's unwitnessed fall, she should have met the neurological monitoring criteria. The NP stated it was hard to speculate if the fall led to the Resident #1's change of condition. Interview on 09/06/2023 at 11:20 a.m., the ADM stated she had just received information Resident #1 is being transferred to another hospital. The ADM stated she did not know the detailed reason for a transfer, although she attempted to obtain hospital records where Resident #1 was first sent to and to call the family. Interview and observation on 09/06/2023 at 01:14 p.m., the Interim DON stated when a Resident fell , the facility did a standard check on residents ranging from obtaining vitals, assess resident for injuries, pain, skin assessment, and other recommended checks. The Interim DON stated if a resident could be placed back in his or her bed it was done, although after they contacted the MD or NP, and orders were obtained to send the resident to a hospital then they pursued those orders. The Interim DON stated if staff could place a resident back in his or her bed, they continued routine assessments and reported all changes to the MD or NP. The DON stated assessments were important as the process gave staff objective information on the resident, and to monitor a resident's condition. An observation was completed with the Interim DON to demonstrate how assessments were opened and completed to activate the facility's EHR systems UDA (User Defined Assessment) after resident involved incident. The Interim DON revealed the EHR systems risks management option, that documented related information for the resident, the incident, location, date, and time. The Interim DON revealed the EHR systems action plan for falls and UDA, which included the resident's fall nurses note, all details relevant information such as the location of injury, how the resident was found, pain, all pertinent information related to a resident's fall. The Interim DON demonstrated an option for an unwitnessed fall or head injury in the EHR systems automatically triggered a neurological assessment for the resident involved in an unwitnessed fall or a fall with a head injury. Interview during the demonstration, the Interim DON stated the nurses should call the MD or NP on duty and document any notes or additional interventions, and document what to do notes. The Interim DON stated per the facility policy it did not reveal specific timeframes for the completion of neurological checks, the Interim DON stated the facility EHR system would reveal timeframes for neurological assessments, and it would trigger the EHR's POC (point of care) systems to alert nursing for UDAs. The Interim DON stated and demonstrated, there was a timeframe for neurological checks for nursing practice and the EHR system, a neurological check should have been completed 15 minutes after opening the 8 hours fall note. The Interim DON stated at this time she was unable to provide documentation if LVN A documented the neurological assessments within the timeframes. The Interim DON stated if nursing did not properly open and document assessments it would create an inconsistency with timeframe assessments and accuracy on a resident's condition. The Interim DON stated nursing must do required assessments and document all findings, stating if it is not documented, it did not happen . Interview on 09/06/2023 at 02:13 p.m., the ADM stated she contacted Resident #1's family and obtained limited information on Resident #1, the resident had a suspected brain bleed, on the left side of the brain. The ADM revealed she reported the incident to HHSC after finding out about the serious injury. The ADM revealed the facility policy did not reveal specific timeframes for the completion of neurological checks, and the ADM was not able to confirm the process or timeframes of doing neurological checks for falls with head injuries or unwitnessed falls. The ADM stated staff were supposed to assess the residents for all incidents and call the MD or NP to inform them of the situation. The ADM stated assessments were needed to obtain current and accurate information on a resident's medical condition, such as pain, swelling, head injuries, and resident vitals. Interview on 09/06/2023 at 04:10 p.m., LVN A stated resident assessments were completed for all resident incidents, this included falls, unwitnessed falls, elopement, skin issues, or any new findings for a resident. LVN A stated after fall incidents with head injury or unwitnessed falls, staff used the EHR system to create an incident report, and neurological assessments would be triggered by the EHR system. LVN A stated neurological assessments were completed every 15 minutes for the first hour initially, and was not entirely clear on the next timeframes, LVN A stated she was aware of the first hour, having a quarterly or 15-minute neurological check. LVN A recalled the incident that involved Resident #1, the resident had an unwitnessed fall, on 9/4/2023, she could not recall the exact timeframe but stated it was during her shift which would be the early morning shift. LVN A stated Resident #1 was on the floor, in her room , laying on left side by the wall in room. LVN A stated Resident #1 had a bruise on the left side of face, LVN A proceeded to do a full body assessment, Resident #1 was not found to be in pain, and Resident #1 was able to state she fell . LVN A stated she completed the incident report a little later, LVN A stated she could not recall the exact time frame the resident was found on the floor, although gave an approximate timeframe between 4:00 p.m. and 5:00 p.m., LVN further stated she opened up the incident report but did not complete maybe around 8:00 p.m. or 9:00 p.m., as there were other duties performed that evening. LVN A stated she did not contact the NP on duty. LVN A stated she believes I did a neuro check; I was checking her already. LVN A stated she listed the neurological check information down on paper. When asked to provide that information, LVN A could not confirm the whereabouts of that information. LVN A stated, this was on me, I did not follow the procedure of documenting the neurological checks, there was a lot going on that day. LVN A stated if nurses did not properly perform neurological assessments, and all assessments, it could place the residents at risk as it is used for early detection. Record review of Resident #1's hospital records, dated 09/05/2023, revealed, encounter date 09/05/2023, history of present illness, patient (Resident #1) is not oriented and barely opens eyes to stimulation. On arrival in ER (emergency room ) she (Resident #1) has a CT scan and chest x-ray which did not reveal significant acute abnormality. Hospital exam, general appearance ill appearing, cranial nerve intact, no focal deficits (There are no specific problems with nerve, spinal cord, or brain function). Record review of Resident #1's hospital records, dated 09/05/2023 and signed 05:49 a.m., revealed CAT scan report, preliminary report, Exam was CT head without intravenous contract. Findings: brain no masses, midline shift or intracranial hemorrhage, chronic atrophy, white matter disease, no hydrocephalus, orbits unremarkable, paranasal sinuses and mastoid air cells are clear, no significant facial or scalp tissue swelling evident, no radiopaque foreign body is seen, no acute skull fracture, impression no acute intracranial abnormality. Record review of Resident #1's hospital records, dated 9/6/2023 at 10:02 a.m., revealed CAT scan report, report status is a draft, preliminary report CAT angio head, findings included increased volume of left sylvian fissure subarachnoid hemorrhage. Impression increased left sylvian fissure subarachnoid hemorrhage now measuring up to 2.6 cm (centimeters) in AP dimension, with a width of up to 8 mm (millimeter) and a craniocaudal of 11 mm (millimeter), no high-grade mass effect. Large left frontal parietal scalp contusion and hemorrhage with contrast blush indicating active hemorrhage coronal. Record review of the facility policy for neurological checks, revised May 2016, revealed neurologic checks, they are a combination of objective observation and measurements done to evaluate neurologic status. The results of the checks assist to determine nervous system damage and/or deterioration. Goals are to identify changes indicating progressive improvement or deterioration in neurologic status, and the resident will be free from injury. Record review of the facility policy for notifying the Physician of Change in Status, revised March 11, 2013, revealed the nurse should not hesitate to contact the physician at any time when an assessment an their professional judgement deem it necessary for immediate medical attention. This facility utilizes the INERACT tool, Change in Condition-When to Notify the MD/NP/PA to review resident condition and guide the nurse when to notify the physician. This tool informs the nurse if the resident condition requires immediate notification of the physician or non-immediate/Report on Next Work day notification of the physician. 1. The nurse will notify the physician immediately with significant change in statis. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record. 2. Before the physician is contacted, the nurse will gather and organize resident information. Applicable information will include current medications, vital signs, signs and symptoms initiating call, current laboratory information, and interventions that have currently been implemented. 3. The nurse may collect several non-emergent items and place one telephone call during the shift in order to avoid multiple calls to a physician with non-emergent questions. The nurse is responsible, however, for responding to a change of condition in a timely and effective manner. The nurse will document the time of the call to the physician in the clinical record. 4. If the physician does not return the call within a reasonable amount of time, the nurse will attempt to contact the physician a second time. If the situation is an emergency, and the physician does not call back within a reasonable amount of time, the nurse will contact the Medical Director or the nearest ambulance service for assistance. The nurse will document all attempts to contact the physician in the resident's clinical record. 5. The resident's family member or legal guardian should be notified of significant change in resident's status unless the resident as specified otherwise. 6. The nurse will monitor and reassess the resident's status and response to intervention. Physicians should develop a working diagnosis and guide nursing staff in what to monitor, and when to notify the physician if the resident's condition does not improve. 7. The nurse will document all attempts to contact the physician, all attempts to notify the family and/or legal representative, the physician's response, the physician's orders and the resident's status and respond to interventions. 8. If the resident remains in the facility and a significant change has occurred, update the car plan accordingly. 9. Faxes should be following up by the end of the business day. 10. If a resident is transferred to the hospital, complete a transfer form. Send a copy of the most recent H & P, progress note, advance directives, MAR, diagnosis list, and pertinent lab and x-ray reports to the hospital. Document actions in the resident's clinical records. 11. Abnormal lab, x-ray and other diagnostic reports require physician notification. This was determined to be an Immediate Jeopardy (IJ) on 09/06/2023 at 05:28 p.m. The ADM was notified. The ADM was provided with the IJ template on 09/06/2023 at 05:57 p.m. The following plan of Removal submitted by the facility was accepted on 09/07/2023 at 06:00 p.m.: PLAN OF REMOVAL September,6, 2023 IJ Component: F684 Quality of Care Facility failed to initiate neurological checks on CR#1 after resident sustained a head injury. Seven residents with falls could have been affected by the deficient practice. Immediate Actions: As of 9/5/23 resident CR#1 was transferred to the hospital for evaluation. LVN-A was provided 1 on 1 education by Administrator on 9/6/23 and will be re-in serviced prior to next scheduled shift, regarding Event Notification; Abuse and Neglect; and Change of Condition, neuro checks and how to notify DON/Physician/RP and oncoming nurses. Facility Plan to ensure compliance: Inservices: Abuse & Neglect policy was reviewed by the Compliance Nurse, Administrator, DON, and ADON and in-serviced on 9/06/23. No changes were made to the policy. The Compliance Nurse in-serviced the DON and ADONs. The Compliance Nurse, DON, ADONs inserviced all staff including clinical, administrative, dietary, housekeeping, laundry, therapy, maintenance, and activities. to ensure compliance for this policy and procedure. All staff not present on 9/06/23 will be in-serviced prior to start of their next shift. Newly hired, PRN, and agency staff will be in-serviced by the DON or ADON prior to start of their scheduled shift. Compliance Nurse in-serviced Administrator, DON, and ADON's on Event note completion and Neuro check policy 9/06/23. The Compliance Nurse, DON, and the ADONs in-serviced Charge Nurses on neuro checks (neuro checks are to be initiated if a resident hits their head or had an un-witnessed fall) and Event note completion. Return demonstration with PCC was included in the in-services. In-services will be completed by the DON/Designee monthly for the next 3 months, then as needed thereafter. All staff not present on 9/06/23 will be in-serviced prior to start of their next shift. Newly hired, PRN, and agency staff will be in-serviced by the DON or ADON prior to start of their scheduled shift. Notifying Physician on change in status policy that includes falls with head injury or other serious injury was reviewed & in-serviced on 9/06/23, the Compliance Nurse in-serviced DON and ADONs. The Compliance Nurse, DON, and ADON in-serviced Charge Nurses to ensure compliance for this policy & procedure. Return demonstration with PCC was included in the in-services. In-services will be completed by the DON/Designee monthly for the next 3 months, then as needed thereafter. All staff not present on 9/06/23 will be in-serviced prior to start of their next shift. Newly hired, PRN, and agency staff will be in-serviced by the DON or ADON prior to start of their scheduled shift. The Regional Compliance Nurse visited the facility 9/06/23 to review resident falls in PCC. Inservicing was provided by the Compliance Nurse with the Administrator, DON, and ADON on Abuse & Neglect, Neuro checks, Notifying Physician on change in status, and process of reporting changes to oncoming shift nurses. The Administrator, Compliance Nurse, DON, and ADON provided all facility staff in-servicing on Abuse and Neglect. The Compliance Nurse, DON, and ADON inserviced the Charge Nurses on neuro checks and notifying the MD for a change in condition and reporting changes to the oncoming shifts. Inservicing began on 9/6/23. All staff not present on 9/6/23 will be in-serviced prior to start of their next shift. Newly hired, PRN, and agency staff will be in-serviced by the DON or ADON prior to start of their scheduled shift. Audits completed: Falls for the last 30 days were audited by the Regional Compliance Nurse and DON on 9/6/23. No additional issues were noted. Inservicing: Notifying oncoming Nurse in charge on any resident injury or change in condition that include falls during the change of shift report process. The Compliance Nurse in-serviced DON and ADON on 9/6/23. The DON/ADON in-service Charge Nurses to ensure compliance for this policy & procedure. The DON/Designee will continue in-servicing monthly for the next 3 months, then as needed thereafter. All staff were in-serviced by the compliance nurse, DON, and ADON on notifying the DON for any resident change in condition on 9/6/23. All staff not present on 9/6/23 will in-serviced prior to the start of the next shift. Newly hired, PRN, and agency staff will be in-serviced by the DON or ADON prior to start of their scheduled shift. The Medical Director was notified by the Administrator on 9/06/23 at 6:20pm on the immediate jeopardy citation. An AD HOC QAPI meeting was held on 9/06/23 by the Interdisciplinary Team to discuss the Immediate Jeopardies and review the Plan of Removal. Monitoring: The DON / designee will monitor Real Time clinical software and/or the PCC Dashboard for clinical alerts for any resident change of condition including falls, head injuries, other serious injuries, or changes of condition 7 days per week to ensure physician/NP were notified. All charge nurses will be responsible for notifying the MD on the weekends. DON/ADON/Designee will provide oversight. Monitoring began 9/06/23 and will continue x 4 weeks and weekly thereafter. The DON and/or designee will monitor fall events 7 days a week to ensure neuro checks and assessments were initiated for all falls. Monitoring began 9/06/23 and will continue x 4 weeks or until the administrator determines substantial compliance has been achieved and maintained. This plan will be reviewed monthly at QAPI for the next three months. The State Survey Team monitored the Plan of Removal on 09/07/2023 and included the following: Observation on 09/07/2023 at 10:39 a.m., reflected corporate staff in facility monitoring the POR process initiated by the facility. Interview on 09/07/2023 at 03:03 p.m., LVN A stated she was provided 1-on1 education by Administrator, LVN A stated she was in serviced regarding Event Notification; Abuse and Neglect; and Change of Condition, neuro checks and how to notify DON/Physician/RP and oncoming nurses. Interview on 09/07/2023, the Interim DON and ADON stated they were in-service and reviewed by corporate nurse, on 09/06/2023 on Abuse and Neglect, Event note completion and Neuro check policy, Notifying Physician on change in status policy that included falls with head injury or other serious injury. Interview on 09/07/2023 from 12:33 p.m. to 02:20 p.m., charge nurses from all shifts, stated they were in-serviced by Interim DON and ADON on 09/06/2023 and 09/07/2023 on Abuse and Neglect, Event note completion and Neuro check policy, Notifying Physician on change in status policy that included falls with head injury or other serious injury. Interview on 09/07/2023, the Interim DON stated continued monitoring on Real Time clinical software and fall events 7 days a week to ensure neuro checks and assessments were initiated for all falls. Interview on 09/07/2023 from 12:19 p.m. to 02:20 p.m., AIT (administrator in training), rehabilitation director, and two CNAs stated in-service, knowledge and reporting on Abuse and Neglect. Record review on 09/07/2023, revealed in-service initiated on 09/06/2023 on training of notification of change of conditions to DON, Fall prevention, Abuse & Neglect, Neuro checks, Shift change=nurse provides oncoming shift nurse with information to provide care to residents, and Event note completion. Record review on 09/07/2023, revealed Neuro Checks-Relias course, when a resident hits their head during a fall or the fall is unwitnessed, neuro checks will need to be completed at the time of the fall then according to the schedule below: every 15 minutes x 4, then every 30 minutes x2, then every 1 hour x2, then every 2 hours x 2, then every 8 hours x 8 Record review on 09/07/2023, revealed QAPI meeting held 9/7/23. The ADM was informed the Immediate Jeopardy was removed on 09/07/2023 at 08:00 p.m. The facility remained out of compliance at a severity level of actual harm with potential for more than minimal harm that is not immediate jeopardy with 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 interview and record review the facility failed to ensure based on the comprehensive assessment of a resident, the resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of 7 Residents reviewed for quality of care. The facility nurses failed to ensure nurses conducted neurological exams after Resident #1 sustained a fall with head injury on 09/04/2023 at 4:00 p.m., 10 of 12 neuro checks were not conducted. The first documented neuro exam was not until approximately 6 hours after the incident, 09/04/2023 at 9:56 pm. The next neuro exam was not until 09/05/2023 at 2:05 am at which time a change in condition was identified. The resident was not sent to the hospital until 09/05/2023 at 4:43 am. The 04:00 am Neuro check was not done. Resident #1 was subsequently diagnosed with a left sylvian fissure subarachnoid hemorrhage (bleeding). An Immediate Jeopardy (IJ) situation was identified on 09/06/2023. While the IJ was removed on 09/07/2023, the facility remained out of compliance at a scope of isolated with actual harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of not receiving the highest practicable care through resident assessments by recognizing and addressing the physical, mental, and neurological dysfunctions such as altered state of consciousness, cognitive decline, confusion, memory loss, changes in behavior in an effective and timely manner to prevent residents from further harm, injury, or death. Findings include: Record review of Resident #1's face sheet, dated 09/06/2023, revealed a [AGE] year-old-female who was admitted to the facility on [DATE] with diagnoses which included cerebral infarction (stroke), metabolic encephalopathy (brain disruption), heart failure, obesity, and hypertension. Record review of Resident #1's MDS, dated [DATE], revealed a BIMS of 05, which indicated a severe cognitive impairment. Further review of Resident #1's MDS, Hearing, Speech, and Vision, revealed a Speech Clarity code of 0 revealed clear speech-distinct intelligible words, Makes Self Understood code of 1 revealed Usually understood-difficulty communicating some words or finished thoughts but able if prompted or given time. Further review of Resident #1's MDS, Health Conditions, revealed Fall history code of 0, which indicated Resident #1 did not have a fall in the last month, last 2 to 6 months, or fracture related to fall in the 6 months prior to admission. Further review of Resident #1's MDS, Functional status, revealed bed mobility at total dependence with two plus persons physical assist, transfer at activity did not occur, walk in room at activity did not occur, walk in corridor at activity did not occur, locomotion on unit at activity did not occur, dressing at total dependence with two plus persons physical assist, eating at limited assistance with one person physical assist, toilet use at total dependence with two plus persons physical assist, personal hygiene at total dependence with two plus persons physical assist, bathing at total dependence with two plus persons physical assist, balancing during transition and walking code of 8 which indicated activity did not occur, no impairment in upper and lower extremity, and that Resident #1 believes he or she is capable of increased independence code of 1 which indicated yes. Record review of Resident #1's care plan, undated, revealed a focus that resident (Resident #1) is risk for falls related to weakness, incontinent, a goal of resident (Resident #1) will be free of falls and will not sustain serious injury, and interventions/tasks to anticipate and meet resident (Resident #1) needs, be sure the resident's (Resident #1) call light is within reach and encourage the resident to use it for assistance as needed, educate resident/family/caregiver about safety reminders and what to do if a fall occurred, encourage resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility, keep furniture in locked position, keep needed items in reach, mechanical lift with staff x2 with transfers, physical therapy evaluate and treat as ordered or PRN, review information on past falls and attempt to determine cause of falls possible root causes, removed any potential causes, educate resident/family/caregivers/IDT (Interdisciplinary Team), provide a safe environment, and activities that minimize the potential for falls while providing diversion and distraction. Record review of the facility's incident report, dated 09/06/2023, revealed a fall incident with Resident #1 on 09/04/2023 at 4:00 p.m. Record review of Resident #1's, undated, progress notes in the EHR revealed a medical practitioner note effective date 09/05/2023 at 02:05 (2:00 a.m.), note text: yesterday 9/4/23 resident (Resident #1) was discovered on the floor, she was lying on her left side. Upon assessment on 10-6pm shift, it has been noted that, resident does not respond like she normally does. If someone asked her a question she responds with simple words. Now, if a questioned is asked she just shakes her head or she just stares at you with no response (this is new). Further review of progress notes revealed a transfer notification, 09/05/2023 05:09 (05:09 a.m.), note text: Resident #1 was transferred to a hospital on 09/05/2023 at 04:43 AM related to neuro changes r/t (related) fall 9/4/23. Record review of Resident #1's assessment page in the, undated, EHR revealed the following assessments completed: 09/04/2023 Event Nurses-Note 8hr Fall 09/04/2023 Neuro Assessment 09/04/2023 Neuro Assessment 09/04/2023 Fall-Risk Assessment 09/05/2023 Neuro Assessment 09/05/2023 Fall Nurses Note 8 hr 09/05/2023 SBAR (situation, background, assessment, and recommendation) 09/05/2023 Transfer Form Record review of Resident #1's Event Nurses-Note 8hr Fall, dated 09/04/2023 at 16:00 (4:00 p.m.), LVN A noted a nursing description of event, resident (Resident #1) was found by staff on the floor laying on her side on the side of her bed, in residents' room, un-witnessed fall discovered on floor, resident received a bruise from fall, located in face, redness noted, resident not in pain, NP notified on 09/04/2023 at 00:00 (12:00 a.m.), interventions prior to fall was low bed, interventions in response to fall was floor mat and low bed, cognition/behavior at time of event was oriented/no problem. Record review of Resident #1's Neuro Assessment, dated 09/04/2023 at 21:56 (9:56 p.m.), LVN A noted vitals: blood pressure at 117/58, pulse 58, and respirations 18, GCS (Glasgow Coma Scale): eyes opening spontaneously, oriented to person, place, and time, obeys commands, pupils reactive to light, and hand grips are equal. Record review of Resident #1's Neuro assessment dated [DATE] at 21:57 (9:57 p.m.), LVN A noted vitals: blood pressure at 108/58, pulse 60, and respirations 18, GCS (Glasgow Coma scale): eyes opening spontaneously, oriented to person, place, and time, obeys commands, pupils reactive to light, and hand grips are equal. Record review of Resident #1's Fall-Risk assessment dated [DATE] at 21:58 (9:58 p.m.), LVN A noted Resident #1 was alert and oriented. Record review of Resident #1's Neuro Assessment, dated 09/05/2023 at 02:02 (2:02 a.m.), revealed vitals: blood pressure at 116/73, pulse 56, and respirations n/a (not applicable), GCS (Glasgow Coma Scale): eyes opening spontaneously, words only intelligible single words, cannot have a conversation, considered as a new observation for Resident #1, obeys commands, pupil reactive to light, hand grips unable to assess due to paralysis, hemiplegia, injury, contractures, notification to NP/MD on 09/05/2023 02:10 (2:10 a.m.), physician/NP comments or orders listed as none at this time. Record review of Resident #1's Event Nurses-Note 8hr Fall, dated 09/05/2023 at 02:11 (2:11 a.m.), revealed left side of cheek was red, notification to NP/MD on 09/05/2023 02:10 (2:10 a.m.), physician/NP comments or orders listed as none at this time. Record review of Resident #1's SBAR (situation, background, assessment, and recommendation), 9/5/2023 04:51 (4:51 a.m.), situation neurological change, description of symptoms or signs revealed baseline as single words able to answer questions if asked, although currently no words just stares and difficult to arose, symptoms first appeared 9/5/2023. Record review of Resident #1's Transfer form, date 09/05/2023 05:09 (5:09 a.m.), LVN B's note reason for transfer was neuro changes r/t (related to) fall 09/04/2023. Record review of Resident #1's progress note, dated 09/05/2023 at 02:05 (02:05 a.m.), revealed LVN B's note text, Yesterday 9/4/23 resident was discovered on the floor, she was lying on her left side. Upon assessment on 10-6pmshift, it has been noted that resident does not respond like she normally does. If someone asked her a question she responds with simple words. Now, if a questioned is asked she just shakes her head or she just stares at you with no response (this is a new). Interview on 09/06/2023 at 10:29 a.m., the NP stated she needed to confirm if she was notified of the incident of Resident #1 on 9/4/2023, that would have been the on-call MD/NP. The NP stated she did not see a notification of the incident; The NP checked the call log used to record notifications and stated she could not confirm if the on-call MD/NP was notified. The NP stated after falls, when there was an injury to the head of any resident, the corporation had its own policy on neurological checks and monitoring that was evidenced based, nurses would monitor the set of criteria, and if there were any changes to the resident. When asked what the timeframes were for monitoring a resident with an unwitnessed fall or a injury to head, the NP could not recall the exact policy on time frames for neurological testing as it all depended on the evidence available, the NP stated with Resident #1's unwitnessed fall, she should have met the neurological monitoring criteria. The NP stated it was hard to speculate if the fall led to the Resident #1's change of condition. Interview on 09/06/2023 at 11:20 a.m., the ADM stated she had just received information Resident #1 is being transferred to another hospital. The ADM stated she did not know the detailed reason for a transfer, although she attempted to obtain hospital records where Resident #1 was first sent to and to call the family. Interview and observation on 09/06/2023 at 01:14 p.m., the Interim DON stated when a Resident fell , the facility did a standard check on residents ranging from obtaining vitals, assess resident for injuries, pain, skin assessment, and other recommended checks. The Interim DON stated if a resident could be placed back in his or her bed it was done, although after they contacted the MD or NP, and orders were obtained to send the resident to a hospital then they pursued those orders. The Interim DON stated if staff could place a resident back in his or her bed, they continued routine assessments and reported all changes to the MD or NP. The DON stated assessments were important as the process gave staff objective information on the resident, and to monitor a resident's condition. An observation was completed with the Interim DON to demonstrate how assessments were opened and completed to activate the facility's EHR systems UDA (User Defined Assessment) after resident involved incident. The Interim DON revealed the EHR systems risks management option, that documented related information for the resident, the incident, location, date, and time. The Interim DON revealed the EHR systems action plan for falls and UDA, which included the resident's fall nurses note, all details relevant information such as the location of injury, how the resident was found, pain, all pertinent information related to a resident's fall. The Interim DON demonstrated an option for an unwitnessed fall or head injury in the EHR systems automatically triggered a neurological assessment for the resident involved in an unwitnessed fall or a fall with a head injury. Interview during the demonstration, the Interim DON stated the nurses should call the MD or NP on duty and document any notes or additional interventions, and document what to do notes. The Interim DON stated per the facility policy it did not reveal specific timeframes for the completion of neurological checks, the Interim DON stated the facility EHR system would reveal timeframes for neurological assessments, and it would trigger the EHR's POC (point of care) systems to alert nursing for UDAs. The Interim DON stated and demonstrated, there was a timeframe for neurological checks for nursing practice and the EHR system, a neurological check should have been completed 15 minutes after opening the 8 hours fall note. The Interim DON stated at this time she was unable to provide documentation if LVN A documented the neurological assessments within the timeframes. The Interim DON stated if nursing did not properly open and document assessments it would create an inconsistency with timeframe assessments and accuracy on a resident's condition. The Interim DON stated nursing must do required assessments and document all findings, stating if it is not documented, it did not happen . Interview on 09/06/2023 at 02:13 p.m., the ADM stated she contacted Resident #1's family and obtained limited information on Resident #1, the resident had a suspected brain bleed, on the left side of the brain. The ADM revealed she reported the incident to HHSC after finding out about the serious injury. The ADM revealed the facility policy did not reveal specific timeframes for the completion of neurological checks, and the ADM was not able to confirm the process or timeframes of doing neurological checks for falls with head injuries or unwitnessed falls. The ADM stated staff were supposed to assess the residents for all incidents and call the MD or NP to inform them of the situation. The ADM stated assessments were needed to obtain current and accurate information on a resident's medical condition, such as pain, swelling, head injuries, and resident vitals. Interview on 09/06/2023 at 04:10 p.m., LVN A stated resident assessments were completed for all resident incidents, this included falls, unwitnessed falls, elopement, skin issues, or any new findings for a resident. LVN A stated after fall incidents with head injury or unwitnessed falls, staff used the EHR system to create an incident report, and neurological assessments would be triggered by the EHR system. LVN A stated neurological assessments were completed every 15 minutes for the first hour initially, and was not entirely clear on the next timeframes, LVN A stated she was aware of the first hour, having a quarterly or 15-minute neurological check. LVN A recalled the incident that involved Resident #1, the resident had an unwitnessed fall, on 9/4/2023, she could not recall the exact timeframe but stated it was during her shift which would be the early morning shift. LVN A stated Resident #1 was on the floor, in her room , laying on left side by the wall in room. LVN A stated Resident #1 had a bruise on the left side of face, LVN A proceeded to do a full body assessment, Resident #1 was not found to be in pain, and Resident #1 was able to state she fell . LVN A stated she completed the incident report a little later, LVN A stated she could not recall the exact time frame the resident was found on the floor, although gave an approximate timeframe between 4:00 p.m. and 5:00 p.m., LVN further stated she opened up the incident report but did not complete maybe around 8:00 p.m. or 9:00 p.m., as there were other duties performed that evening. LVN A stated she did not contact the NP on duty. LVN A stated she believes I did a neuro check; I was checking her already. LVN A stated she listed the neurological check information down on paper. When asked to provide that information, LVN A could not confirm the whereabouts of that information. LVN A stated, this was on me, I did not follow the procedure of documenting the neurological checks, there was a lot going on that day. LVN A stated if nurses did not properly perform neurological assessments, and all assessments, it could place the residents at risk as it is used for early detection. Record review of Resident #1's hospital records, dated 09/05/2023, revealed, encounter date 09/05/2023, history of present illness, patient (Resident #1) is not oriented and barely opens eyes to stimulation. On arrival in ER (emergency room ) she (Resident #1) has a CT scan and chest x-ray which did not reveal significant acute abnormality. Hospital exam, general appearance ill appearing, cranial nerve intact, no focal deficits (There are no specific problems with nerve, spinal cord, or brain function). Record review of Resident #1's hospital records, dated 09/05/2023 and signed 05:49 a.m., revealed CAT scan report, preliminary report, Exam was CT head without intravenous contract. Findings: brain no masses, midline shift or intracranial hemorrhage, chronic atrophy, white matter disease, no hydrocephalus, orbits unremarkable, paranasal sinuses and mastoid air cells are clear, no significant facial or scalp tissue swelling evident, no radiopaque foreign body is seen, no acute skull fracture, impression no acute intracranial abnormality. Record review of Resident #1's hospital records, dated 9/6/2023 at 10:02 a.m., revealed CAT scan report, report status is a draft, preliminary report CAT angio head, findings included increased volume of left sylvian fissure subarachnoid hemorrhage. Impression increased left sylvian fissure subarachnoid hemorrhage now measuring up to 2.6 cm (centimeters) in AP dimension, with a width of up to 8 mm (millimeter) and a craniocaudal of 11 mm (millimeter), no high-grade mass effect. Large left frontal parietal scalp contusion and hemorrhage with contrast blush indicating active hemorrhage coronal. Record review of the facility policy for neurological checks, revised May 2016, revealed neurologic checks, they are a combination of objective observation and measurements done to evaluate neurologic status. The results of the checks assist to determine nervous system damage and/or deterioration. Goals are to identify changes indicating progressive improvement or deterioration in neurologic status, and the resident will be free from injury. Record review of the facility policy for notifying the Physician of Change in Status, revised March 11, 2013, revealed the nurse should not hesitate to contact the physician at any time when an assessment and their professional judgement deem it necessary for immediate medical attention. This facility utilizes the INERACT tool, Change in Condition-When to Notify the MD/NP/PA to review resident condition and guide the nurse when to notify the physician. This tool informs the nurse if the resident condition requires immediate notification of the physician or non-immediate/Report on Next Work day notification of the physician. 1. The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record. 2. Before the physician is contacted, the nurse will gather and organize resident information. Applicable information will include current medications, vital signs, signs and symptoms initiating call, current laboratory information, and interventions that have currently been implemented. 3. The nurse may collect several non-emergent items and place one telephone call during the shift in order to avoid multiple calls to a physician with non-emergent questions. The nurse is responsible, however, for responding to a change of condition in a timely and effective manner. The nurse will document the time of the call to the physician in the clinical record. 4. If the physician does not return the call within a reasonable amount of time, the nurse will attempt to contact the physician a second time. If the situation is an emergency, and the physician does not call back within a reasonable amount of time, the nurse will contact the Medical Director or the nearest ambulance service for assistance. The nurse will document all attempts to contact the physician in the resident's clinical record. 5. The resident's family member or legal guardian should be notified of significant change in resident's status unless the resident as specified otherwise. 6. The nurse will monitor and reassess the resident's status and response to intervention. Physicians should develop a working diagnosis and guide nursing staff in what to monitor, and when to notify the physician if the resident's condition does not improve. 7. The nurse will document all attempts to contact the physician, all attempts to notify the family and/or legal representative, the physician's response, the physician's orders and the resident's status and respond to interventions. 8. If the resident remains in the facility and a significant change has occurred, update the car plan accordingly. 9. Faxes should be following up by the end of the business day. 10. If a resident is transferred to the hospital, complete a transfer form. Send a copy of the most recent H & P, progress note, advance directives, MAR, diagnosis list, and pertinent lab and x-ray reports to the hospital. Document actions in the resident's clinical records. 11. Abnormal lab, x-ray and other diagnostic reports require physician notification. This was determined to be an Immediate Jeopardy (IJ) on 09/06/2023 at 05:28 p.m. The ADM was notified. The ADM was provided with the IJ template on 09/06/2023 at 05:57 p.m. The following plan of Removal submitted by the facility was accepted on 09/07/2023 at 06:00 p.m.: PLAN OF REMOVAL September,6, 2023 IJ Component: F684 Quality of Care Facility failed to initiate neurological checks on CR#1 after resident sustained a head injury. Seven residents with falls could have been affected by the deficient practice. Immediate Actions: As of 9/5/23 resident CR#1 was transferred to the hospital for evaluation. LVN-A was provided 1 on 1 education by Administrator on 9/6/23 and will be re-in serviced prior to next scheduled shift, regarding Event Notification; Abuse and Neglect; and Change of Condition, neuro checks and how to notify DON/Physician/RP and oncoming nurses. Facility Plan to ensure compliance: Inservices: Abuse & Neglect policy was reviewed by the Compliance Nurse, Administrator, DON, and ADON and in-serviced on 9/06/23. No changes were made to the policy. The Compliance Nurse in-serviced the DON and ADONs. The Compliance Nurse, DON, ADONs inserviced all staff including clinical, administrative, dietary, housekeeping, laundry, therapy, maintenance, and activities. to ensure compliance for this policy and procedure. All staff not present on 9/06/23 will be in-serviced prior to start of their next shift. Newly hired, PRN, and agency staff will be in-serviced by the DON or ADON prior to start of their scheduled shift. Compliance Nurse in-serviced Administrator, DON, and ADON's on Event note completion and Neuro check policy 9/06/23. The Compliance Nurse, DON, and the ADONs in-serviced Charge Nurses on neuro checks (neuro checks are to be initiated if a resident hits their head or had an un-witnessed fall) and Event note completion. Return demonstration with PCC was included in the in-services. In-services will be completed by the DON/Designee monthly for the next 3 months, then as needed thereafter. All staff not present on 9/06/23 will be in-serviced prior to start of their next shift. Newly hired, PRN, and agency staff will be in-serviced by the DON or ADON prior to start of their scheduled shift. Notifying Physician on change in status policy that includes falls with head injury or other serious injury was reviewed & in-serviced on 9/06/23, the Compliance Nurse in-serviced DON and ADONs. The Compliance Nurse, DON, and ADON in-serviced Charge Nurses to ensure compliance for this policy & procedure. Return demonstration with PCC was included in the in-services. In-services will be completed by the DON/Designee monthly for the next 3 months, then as needed thereafter. All staff not present on 9/06/23 will be in-serviced prior to start of their next shift. Newly hired, PRN, and agency staff will be in-serviced by the DON or ADON prior to start of their scheduled shift. The Regional Compliance Nurse visited the facility 9/06/23 to review resident falls in PCC. Inservicing was provided by the Compliance Nurse with the Administrator, DON, and ADON on Abuse & Neglect, Neuro checks, Notifying Physician on change in status, and process of reporting changes to oncoming shift nurses. The Administrator, Compliance Nurse, DON, and ADON provided all facility staff in-servicing on Abuse and Neglect. The Compliance Nurse, DON, and ADON inserviced the Charge Nurses on neuro checks and notifying the MD for a change in condition and reporting changes to the oncoming shifts. Inservicing began on 9/6/23. All staff not present on 9/6/23 will be in-serviced prior to start of their next shift. Newly hired, PRN, and agency staff will be in-serviced by the DON or ADON prior to start of their scheduled shift. Audits completed: Falls for the last 30 days were audited by the Regional Compliance Nurse and DON on 9/6/23. No additional issues were noted. Inservicing: Notifying oncoming Nurse in charge on any resident injury or change in condition that include falls during the change of shift report process. The Compliance Nurse in-serviced DON and ADON on 9/6/23. The DON/ADON in-service Charge Nurses to ensure compliance for this policy & procedure. The DON/Designee will continue in-servicing monthly for the next 3 months, then as needed thereafter. All staff were in-serviced by the compliance nurse, DON, and ADON on notifying the DON for any resident change in condition on 9/6/23. All staff not present on 9/6/23 will in-serviced prior to the start of the next shift. Newly hired, PRN, and agency staff will be in-serviced by the DON or ADON prior to start of their scheduled shift. The Medical Director was notified by the Administrator on 9/06/23 at 6:20pm on the immediate jeopardy citation. An AD HOC QAPI meeting was held on 9/06/23 by the Interdisciplinary Team to discuss the Immediate Jeopardies and review the Plan of Removal. Monitoring: The DON / designee will monitor Real Time clinical software and/or the PCC Dashboard for clinical alerts for any resident change of condition including falls, head injuries, other serious injuries, or changes of condition 7 days per week to ensure physician/NP were notified. All charge nurses will be responsible for notifying the MD on the weekends. DON/ADON/Designee will provide oversight. Monitoring began 9/06/23 and will continue x 4 weeks and weekly thereafter. The DON and/or designee will monitor fall events 7 days a week to ensure neuro checks and assessments were initiated for all falls. Monitoring began 9/06/23 and will continue x 4 weeks or until the administrator determines substantial compliance has been achieved and maintained. This plan will be reviewed monthly at QAPI for the next three months. The State Survey Team monitored the Plan of Removal on 09/07/2023 and included the following: Observation on 09/07/2023 at 10:39 a.m., reflected corporate staff in facility monitoring the POR process initiated by the facility. Interview on 09/07/2023 at 03:03 p.m., LVN A stated she was provided 1-on1 education by Administrator, LVN A stated she was in serviced regarding Event Notification; Abuse and Neglect; and Change of Condition, neuro checks and how to notify DON/Physician/RP and oncoming nurses. Interview on 09/07/2023, the Interim DON and ADON stated they were in-service and reviewed by corporate nurse, on 09/06/2023 on Abuse and Neglect, Event note completion and Neuro check policy, Notifying Physician on change in status policy that included falls with head injury or other serious injury. Interview on 09/07/2023 from 12:33 p.m. to 02:20 p.m., charge nurses from all shifts, stated they were in-serviced by Interim DON and ADON on 09/06/2023 and 09/07/2023 on Abuse and Neglect, Event note completion and Neuro check policy, Notifying Physician on change in status policy that included falls with head injury or other serious injury. Interview on 09/07/2023, the Interim DON stated continued monitoring on Real Time clinical software and fall events 7 days a week to ensure neuro checks and assessments were initiated for all falls. Interview on 09/07/2023 from 12:19 p.m. to 02:20 p.m., AIT (administrator in training), rehabilitation director, and two CNAs stated in-service, knowledge and reporting on Abuse and Neglect. Record review on 09/07/2023, revealed in-service initiated on 09/06/2023 on training of notification of change of conditions to DON, Fall prevention, Abuse & Neglect, Neuro checks, Shift change=nurse provides oncoming shift nurse with information to provide care to residents, and Event note completion. Record review on 09/07/2023, revealed Neuro Checks-Relias course, when a resident hits their head during a fall or the fall is unwitnessed, neuro checks will need to be completed at the time of the fall then according to the schedule below: every 15 minutes x 4, then every 30 minutes x2, then every 1 hour x2, then every 2 hours x 2, then every 8 hours x 8 Record review on 09/07/2023, revealed QAPI meeting held 9/7/23. The ADM was informed the Immediate Jeopardy was removed on 09/07/2023 at 08:00 p.m. The facility remained out of compliance at a severity level of actual harm with potential for more than minimal harm that is not immediate jeopardy with 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 interview and record review, the facility failed to ensure the resident was free from abuse for 4 (Residents #1, #2, #3, and #4) of 8 residents reviewed for abuse. The facility failed to ensure Resident #1, #2, #3, and #4 were protected from verbal abuse including yelling when communicated to when cared for. This failure could place residents at risk for fear, anguish, depression, intimidation, and a diminished quality of life resulting in psychosocial harm. Findings included: Resident #1 Record review of Resident #1's undated face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including, blindness in the right eye(no vision), major depressive disorder (sad), anxiety (feeling of worry), and type 2 diabetes (resist insulin). Record review of Resident #1's quarterly MDS, dated [DATE] revealed: Section C for Brief Interview for Mental Status score revealed a score of 14, which indicated the resident's cognition was intact. Record review of Resident #1's care plan dated 07/06/23 revealed Resident #1 has depression with anxiety. Resident #1 will remain free of distress, symptoms of depression, anxiety, or sad mood. An interview on 07/21/23 at 3:30 PM revealed Resident #1 stated she was outside smoking when she asked housekeeping A had she seen her red dress. Resident #1 stated housekeeping A yelled at her saying she didn't know where her dress was. Resident # 1 stated, she felt very disrespected and very low when housekeeping A yelled at her. Resident #2 Record review of Resident #2's undated face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including, Schizophrenia (affecting the ability to think) and major depressive disorder(sad). Record review of Resident #2's quarterly MDS dated [DATE] revealed: Section C for Brief Interview for Mental Status score revealed a score of 07, which indicated the resident's cognition was severely cognitivety impaired. Record review of Resident #2's care plan dated 05/18/23 revealed Resident #2 requires antipsychotic medications for depression. An attempted interview on 07/21/23 at 3:45 PM with Resident # 2 was unable to be conducted due to Resident # 2 being asleep. Resident # 2 was observed appearing well groomed and sleeping peacefully. An attempted interview on 07/22/23 at 3:06 PM with Resident # 2 family member was unsuccessful and not able to leave a voice mail. Resident #3 Record review of Resident #3's undated face sheet revealed that she was a [AGE] year-old female admitted [DATE] with diagnoses including dementia(memory loss), Alzheimer's Disease(loss of memory), and anxiety disorder(feeling of worry) Record review of Resident #3's quarterly MDS dated [DATE] revealed: Section C for Brief Interview for Mental Status score revealed a score of 10, which indicated the resident's cognition was moderately impaired. Record review of Resident #3's care plan dated 05/27/23 revealed Resident #3 uses anti-anxiety medications and Resident #3 will be free of adverse reactions related to anti-anxiety. Resident #4 Record review of Resident #4's undated face sheet revealed that she was a [AGE] year-old female admitted [DATE] with diagnoses of major depressive disorder (sad) and anxiety (feeling of worry). Record review of Resident 4's quarterly MDS dated [DATE] revealed: Section C for Brief Interview for Mental Status score revealed a score of 12, which indicated the resident's cognition was moderately impaired. Record review of Resident 4s care plan dated 06/20/23 revealed Resident #4 used anti-anxiety medications and Resident #4 will show decreased episodes of anxiety. An interview on 07/21/23 at 3:00 PM revealed Resident #3 and Resident #4 stated Hospitality Aide A came in the room yelling and screaming calling them liars. Hospitality Aide A had told them she would come back to their room to change Resident #4. Resident #4 stated she needed to be changed again because she was wet and Hospitality Aide A stated that Resident # 4 had already been changed and Resident # 3 was just telling Hospitality Aide A that Resident #4 needed to be changed again and Hospitality Aide A stated they were liars. Resident # 3 and Resident #4 stated they felt like trash and the Hospitality Aide A was very disrespectful to both of them. An interview on 07/21/23 at 4:00 PM with the Administrator stated for Resident #1, Resident #2, Resident #3, and Resident #4 the investigations with Hospitality Aide A, Housekeeping A, and Housekeeping B were substantiated and confirmed. The Administrator stated, she took as if it was her family member, and the yelling was very wrong'. The Administrator stated those actions were disrespectful and Hospitality Aide A, Housekeeping A, and Housekeeping B could have been more professional in communicating with Resident # 1, Resident #2, Resident #3, and Resident #4. The administrator stated that type of behavior was unacceptable, and Hospitality Aide A, Housekeeping A, and Housekeeping B were terminated. The incident with Resident #2 was witnessed by the Housekeeping Supervisor and Housekeeping C; both witnessed Housekeeping B yelling at Resident # 2 to stop playing in the water. An attempted interview on 07/22/23 at 2:00 PM with the Hospitality Aide A was unsuccessful as the phone number disconnected and was no longer in service. An attempted interview on 7/22/23 at 2:23 PM with Housekeeping B was unsuccessful as no one answered and was unable to leave a voice message. An interview on 07/22/23 at 2:30 at 2:30 PM with Housekeeping A stated she was outside monitoring smoke breaks when Resident #1 asked her where her red dress was. Housekeeping A stated Resident #1 was blind, and she spoke a little louder to her when she responded she did not have her dress. Housekeeping A stated they were outside the facility, and she did not yell at Resident #1. Housekeeping A stated Resident # 1 was her friend, and she would never yell at her. An attempted interview on 07/22/23 at 3:21 PM with the Housekeeping Supervisor was unsuccessful and not able to leave a voice mail. An attempted interview on 07/22/2023 at 3:23 with Housekeeping C was unsuccessful and not able to leave a voice message. An interview on 07/22/23 at 3:30 PM with the RN she stated she was not in the building when the incidents occurred with Resident #1, Resident #2, Resident #3, and Resident #4. RN stated the behavior was very unacceptable and that the Hospitality Aide A, Housekeeping A, and Housekeeping B should have been more professional. The RN stated they should have handled with appropriate approaches to communicate effectively with residents and talk where residents can understand clearly. RN stated yelling at residents could make residents in fear of what staff would eventually do and this make it very scary for residents. In an interview on 08/10/2023 at 1:11PM the Administrator was asked about incidents regarding time frames for reporting, she stated she knows she has 2 hours to report and does report as soon as she is made aware of incidents. In an interview on 08/10/2023 at 2:07 PM, ADON B stated he did recall a night when an aide did not provide care for a resident, and she had disappeared, and he could not find her. He then stated the resident later told him the Hospitality Aide A was yelling at her and calling her a liar. He stated he called the Administrator and DON that night and stated the investigation was started the next day. In an interview on 08/10/2023 at 3:10 PM, the Administrator stated she did not recall ADON B telling her on 06/09/2023 (Friday) regarding the incident with the residents. She stated if ADON B had told her she would have reported it to HHSC as required. She stated she recalled being told of potential abuse on 6/12/23 (Monday) and she reported it. Record review of Provider Investigation report dated 06/23/2023 revealed Housekeeping A was immediately suspended on 06/24/2023 when the Adminisrator was notified of incident. Housekeeping A was teminated 06/28/2023 when the allegaton of verbal abuse investigaton was confirmed. Record review of Provider Investigation report dated 06/12/2023 revealed Hospitality Aide A was immediately suspended on 06/12/2023 when the Adminisrator was notified of incident. Housekeeping A was teminated 06/16/2023 when the allegaton of verbal abuse facility investigaton was confirmed. Record review of Provider Investigation report dated 06/23/2023 revealed Housekeeping B was immediately suspended on 06/24/2023 when the Adminisrator was notified of incident. Housekeeping B was teminated 06/28/2023 when the allegaton of verbal abuse facility investigaton was confirmed. Record review of the Abuse policy dated 03/29/18 revealed the resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. Verbal Abuse: Any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Review of Inservice Record Abuse/Neglect/Exploitation - Allegation of Yelling/Intimidation at/of Residents dated 06/12/2023 revealed all required staff were educated on abuse, neglect and exploitation to include verbal abuse and yelling at residents.

Based on observations, interviews and record reviews, the facility failed to ensure each resident received adequate supervisions and assistance devices to prevent accidents for 1 of 5 residents (Resident #1) reviewed for accidents and hazards, in that:supervision. The facility failed to conduct two-hour checks and Resident #1 eloped from the facility without facility knowledge and Resident #1 was found on a busy roadway a mile from the facility by a passer-by. An IJ was identified on 06/28/2023. The IJ began on 06/18/2023 and was removed on 06/20/2023. The facility took action to remove the IJ before the survey began. While the IJ was removed on 06/20/2023, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with a potential for more than minimal harm that is not immediate due to the facility's need to monitor interventions. This failure could place residents at risk of elopement, accidents and, heat exhaustion due to lack of supervision. Findings included: Record review of Resident #1's face sheet, dated 06/28/2023, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had with diagnoses which included Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), cognitive communication deficit (difficulty with thinking and how someone uses language), muscle weakness (a lack of strength in the muscles), unspecified osteoarthritis (a progressive, degenerative joint disease, the most common form of arthritis, especially in older persons), and essential hypertension (when you have abnormally high blood pressure that is not the result of a medical condition). Record review of Resident #1's Quarterly MDS, dated [DATE], reflected a BIMS score of a 3, indicating which indicated the resident's cognition was severely impaired. Resident #1 did not wander or have any type of behavioral symptoms. Resident #1 required supervision with bed mobility, transfers, walk in room/corridor, eating, and toileting. Resident #1 required limited one person assistance with dressing and personal hygiene. He was total dependent on staff for bathing. Resident #1 did not require and any devices when ambulating. Record review of Resident #1's Comprehensive Care Plan, revised on 06/18/2023 , reflected the resident was confused and wandered outside the facility unattended. Interventions: supervise closely and make regular compliance rounds whenever resident is was in room. Frequent monitoring of resident. Apply alarm system, such as wander-guard, to reduce risk of elopement. If resident is was exit seeking, stay with the resident, and notify the charge nurse by calling out, sending another staff member, call system etc . Record review of Resident #1's Elopement Risk Assessment, dated 06/18/2023, reflected Resident #1 was not a risk for elopement. Resident did not have a history of attempts to leave the facility. He understood and verbalized acceptance of need for nursing home care. Resident #1 recognized stop lights and signs. He knew precautions when crossing streets. He could state name and knew location of current residence. He recognized physical needs and there were not any changes in his status such as: medication, illness, pain, infection, frustration, or personal tragedy. Signed by LVN C. Record review of Resident #1's event nurses' note, dated 06/18/2023 at 12:20 PM, reflected LVN B was notified at 12:00 PM by a Policeman, Resident #1 was found on a busy roadway and had been taken to the ER for observation and evaluation of physical condition. LVN B last saw Resident #1 approximately 7:00 AM in the dining room after obtaining his blood sugar. LVN B notified the Administrator, DON, ADON and family. LVN B called the hospital and checked on Resident #1's condition. The ED Nurse stated the resident was fine and routine labs were being completed and the ER nurse would call and if they needed anything. It was unknown the door exited and, how long resident was missing. There were not any injuries related to the elopement. Resident #1 was unable to give statement (Resident was at the hospital). Record review of Resident #1's Elopement Nurses Note, dated 6/18/2023 at 08:20 PM, reflected Resident #1 had not attempted to leave the facility. Resident #1 was on one-on-one monitoring. Resident #1 did not have any changes that required physician notification. Resident #1 was calm. Signed by the DON. Record review of Resident #1's Skin Assessment, dated 06/18/2023 , reflected the resident's skin color was normal. Resident #1 did not have any bruises, skin tears, abrasions, or lacerations. Resident #1 had a rash to the upper chest area. There was not any moisture associated skin damage. He did not have any pressure, venous, arterial, or diabetic ulcer. He had some redness to face. The assessment also reflected there was not any new areas that had not been communicated to the physician/NP or family. Signed by RN B. Record review of Resident #1's Emergency Record, dated 06/18/2023, reflected the following: Cardiovascular- Heart sounds normal- no murmur rubs of [NAME], normal sinus rhythm Respiratory chest- lungs clear to auscultation Abdomen: abdomen soft, non-tender, no guarding, rebound or rigidity Upper and lower extremities: Pulses equal in all extremities and moves all extremities Neuro: alert and oriented x 1, cranial nerves intact, no visual field deficits. Skin: no rash, warm, dry, and normal color Head: no hemotympanum, no battle sign, no raccoon eyes Back: no midline spinal tenderness Labs and imaging reviewed. All results normal. CT head was negative. Resident #1's vital signs were the following: B/P- 113/75, Pulse- 75, Pain -0, and O2 96. Reviewed studies with nursing home and plan for Resident #1 to be discharge to the facility. Record review of Resident #1's Physician Orders, dated 6/19/2023, there was a verbal order for the resident to wear wander guard . Record review of Resident #1's Elopement Nurses Note, dated 06/19/2023 at 8:20 PM, reflected Resident #1 was calm and there were no elopement attempts. Resident #1 received one - one monitoring and was wearing wander alarm bracelet. Signed by RN E. Record review of Psychiatric Services note, dated 06/19/2023, reflected Resident #1 reported he was good. The Medical Doctor had a meeting with nursing staff. The nursing staff reported to the Medical Doctor, Resident #1 had normal appetite. Resident #1 did not exhibit any anxiety or hostility toward other residents or staff. Resident #1 did not have any depression and no sleep complaints. His energy level was normal. Resident #1 did not have any paranoid ideations and he was not resisting assistance with ADLs. Resident #1 was not isolating himself and did not have any emotional behaviors such as crying. During the Medical Doctor assessment of Resident #1 it was determined he did not have any acute distress. Resident #1 was smiling and interactive. No suicide ideations or mood disturbance. Resident was screened for future fall risk: no documentation of two or more falls in the past year and no documentation of any fall with injury in past year. Signed by Medical Doctor Record review of the Social Workers documentation dated 06/19/2023, in the electronic medical records reflected Resident #1's Responsible Party was contacted concerning Resident #1 being transferred to a facility with a secure unit. Resident #1's Responsible Party was pleased with the decision for resident's safety . Record review of plan to monitor dated 06/19/2023 the front door reflected the nursing supervisor would sit at the nurse's desk facing the front door. When the nurse supervisor needed to visit residents for wound care she would have another staff sit at the nurse's desk facing the front door to ensure residents does not leave the facility when families exited the facility. The facility had increased changing their door codes from monthly to weekly. Observation on 6/28/2023 between 9:30 AM - 5:30 PM revealed a nurse was sitting at the nurses station facing the front door. Observation on 6/28/2023 at 8:30 AM - 10:15 AM revealed the front door was locked and all the exit doors on all the halls were locked. The alarm did sound when the doors were opened. There was a sign on the doors which reflected Visitors: Please check with nurses' station before allowing residents outside. This sign was posted on the front door when entering and exiting the facility. In an interview with the Administrator on 06/28/2023 at 8:55 AM, the Administrator stated Resident #1 was last seen by Med-Aide A at 9:45 AM. She stated Resident #1 never wandered or exit seek prior to 6/18/2023. She stated he was usually in his room or sitting in the common area watching TV . She also stated an elopement risk assessment was completed on the resident on 06/16/2023 and reflected he was not at risk for elopement. She also stated the facility had more than usual number of visitors all day on 06/18/2023 due to being Father's Day. She also stated there were no reports of the doors or alarms not working in the facility on 06/18/2023. She stated there were some family members who knew the code to exit from the front door. She stated these were the families frequently visited their loved ones visit during the week and on weekends . She stated during the investigation of Resident #1's elopement no one in the facility heard sounds of any door alarms. She stated on 6/18/2023 the police officer arrived at the facility approximately 12:00 PM. Nurse Supervisor B informed the police officer Resident #1 did reside at the facility. She stated the police officer explained to Nurse Supervisor B a lady was in her car was driving on [NAME] the street on a busy roadway and observed Resident #1 on the sidewalk (approximately 1 mile from the facility). The lady contacted the police. The police arrived where Resident #1 was located and transported him to the ER. Once at the ER the police saw Resident #1's name in his shoes and determined Resident #1 was probably a resident at a nearby nursing home. She stated Resident #1 was evaluated at the ER and was later transferred to the facility at approximately 4:15 PM on 06/18/2023. She stated Resident #1 did not have any injuries or any health concerns when discharged from the ER. She stated a skin assessment was completed on the resident when he returned from the hospital, and he had a small area of a rash on his chest and this area was not exposed to the sun. She stated the shirt he was wearing was a button-down shirt and it covered the chest area. The Administrator also stated his vital signs were normal and there were not any changes in his mood or behavior. She stated a wander guard was placed on the resident. She stated he was placed on 1:1 monitoring until he was discharged to a secured unit at a sister facility with agreement of the resident and the resident's R/P. He was discharged on [DATE]. She also stated she had spoken with the Administrator at the sister facility and was informed Resident #1 was adjusting satisfactory to his new environment and had developed a friendship with his roommate and was more social . She stated the facility was informed by the Police Officer of Resident #1 was missing from the facility. She also stated resident was out of snuff on 06/18/2023. She stated in conclusion of the facilities investigation it was determined he exited the facility behind the families and probably was going to get snuff. She stated it was very seldom he was without snuff and the facility had called the family to remind the R/P to bring resident snuff , mail check to facility for his patient trust fund or to bring money to facility for the facility staff to purchase him some snuff. Record review of Resident #1's Monitoring Records reflected Resident #1 was monitored one-on-one upon returned fromER on [DATE] until he was discharged to sister facility on 06/20/2023. Record review of Elopement Drill records reflected the facility had elopement drills on 04/05/2023, 05/02/2023, 05/08/2023, and 6/20/2023. Record review of Elopement Inservice was conducted on 06/19/2023. Record review of Abuse/Neglect and elopement Inservice was conducted on 06/18/2023. Record review of Doors, Locks and Alarms tests reflected all doors, and all alarms were tested and checked on 05/30/2023, 06/06/2023, 06/13/2023,06/18/2023, 06/20/2023 and 06/27/2023. Record review of nursing staff record for 06/18/2023 on the day shift reflected 6- CNAs, 2- Med-Aides, 1- Restorative Aide, and 4- Nurses. In an interview with the Administrator on 06/28/2023 at 8:55 AM, The Administrator stated Resident #1 was last seen by Med-Aide A at 9:45 AM. She stated Resident #1 never wandered or exit seek prior to 6/18/2023. She stated he was usually in his room or sitting in the common area watching tv. She also stated an elopement risk assessment was completed on resident 06/16/2023 and reflected he was not at risk for elopement. She also stated the facility had more than usual number of visitors all day on 06/18/2023 due to being Father's Day. She also stated there were no reports of the doors or alarms not working in the facility on 06/18/2023. She stated there were some family members knew the code to exit from the front door. She stated these were the families frequently visited their loved ones visit during the week and on weekends. She stated during the investigation of Resident #1's elopement no one in the facility heard sounds of any door alarms. She stated on 6/18/2023 the police officer arrived at the facility approximately 12:00 PM. Nurse Supervisor B informed the police officer Resident #1 did reside at the facility. She stated the police officers explained to Nurse Supervisor B a lady was in her car was driving on [NAME] Street and observed Resident #1 on the sidewalk (approximately 1 mile from the facility). The lady contacted the police. The police arrived where Resident #1 was located and transported him to the ER. Once at the ER the police saw Resident #1's name in his shoes and determined Resident #1 was probably a resident at a nearby nursing home. She stated Resident #1 was evaluated at the ER and was later transferred to the facility approximately 4:15 PM on 06/18/2023. She stated Resident #1 did not have any injuries or any health concerns when discharged from the ER. She stated a skin assessment was completed on the resident when he returned from the hospital, and he had a small area of a rash on his chest and this area was not exposed to the sun. She stated the shirt he was wearing was a button-down shirt and it covered the chest area. The Administrator also stated his vital signs were normal and there were not any changes in his mood or behavior. She stated a wander guard was placed on resident. She stated he was placed on 1:1 monitoring until he was discharged to a secured unit at a sister facility with agreement of Resident and Resident's R/P. He was discharged on [DATE]. She also stated she had spoken with the Administrator at the sister facility and was informed Resident #1 was adjusting satisfactory to his new environment and had developed a friendship with his roommate and was more social. The staff did not ask the Police officer name or receive a card from the police officer or inquire of the name of the lady saw Resident #1 on the sidewalk. In an interview on 06/28/2023 at 10:50 AM, LVN Charge Nurse F stated on 06/18/2023 she was in the dining room at approximately 7:30 AM until 9:00 AM and assisted with delivering meal trays to residents and making observations of residents during meals. She stated she was sat at the same table with Resident #1. She stated she was feedingfed another resident. She stated Resident #1 was exited the dining room at approximately 9:00 AM. She also stated she was not assigned to the hall where Resident #1 resided. She stated she did not see Resident #1 after 9:00 AM on 06/28/2023. She also stated Resident #1 did not have a history of attempting to exit seek or elope from the facility. She stated she had beenwas assigned to the hall where he resided. She stated she was walking from 300 hall toward the nurses' desk and saw a police officer at the desk. She stated she stopped at the nurses' desk and heard the Policeman speaking with RN B. She stated she heard the police officer ask if the facility had a resident named - [stated Resident #1 last name]. RN B stated the facility did have a resident with the same last name. She stated the police officer stated he identified the resident by the name in his shoes. She stated she called the DON and was instructed to check every resident to ensure all residents were in the facility. She stated the staff was divided and they verified all residents was in the facility except for Resident #1. She also stated she checked the doors, and all the doors were locked. She stated she opened the doors, and the alarms were soundingsounded, and she assisted all residents to the doors with wander guards and the system was working when the residents with wander guards was were near all the doors. She stated this was very unusual for Resident #1 to elope or even attempt to elope from the facility. She also stated he had the same routine every day. He would go to the dining room for meals, go to his room after eating and he would sit in the common area and watch tv. She stated she did not hear any alarms sound on 06/18/2023 and no one reported to her any of the exit doors was not locking. LVN Charge Nurse stated she did visited with Resident #1 on 06/19/2023 during breakfast and he did not have any signs or symptoms of being in any physical or mental distress. She stated he was calm, smiling and was acting normal. She stated the resident was on one-one monitoring as soon as he returned from the hospital and a wander guard was placed on Resident #1. She also stated there were a lot of visitors in the morning and afternoon on 06/18/2023. She stated the frequent visitors knows knew the code to exit the facility, however, the visitors did not visit very often will and would ask staff to assist them with the code. In an interview on 06/28/2023 at 11:25 AM, CNA G stated she was assigned to Resident #1 on 06/18/2023. She stated before 7:20 AM on 6/18/2023 she assisted Resident #1 with dressing for breakfast. She stated he exited his room and was ambulating toward the dining room. She stated the next time she observed Resident #1 he was in dining room for breakfast at approximately 7:20 AM -8:00 AM. She stated she did not see Resident #1 after 8:00 AM on 06/18/2023. She also stated Resident #1 had his own schedule he liked to do things such as: after he ate he would go to his room and then go to the tv area and watch tv. She stated when she finished in the dining room she exited and assisted another resident with a shower. She stated after the shower it was time for her break at 8:30 AM and she returned from her break at approximately 8:45 AM. She stated she did not make her rounds on Resident #1 . She stated she was busy with shower and checking residents remains in bed she didn't think about the time. She stated she was required to do every 2-hour rounds on all the residents she was assigned to, and she did not make rounds on Resident #1 . She stated he had his daily routine where he went to his room after breakfast and then to the common area. She stated she mostly did rounds on bedfast residents she was assigned to, but she was required to make rounds on every resident on her assignment sheet. She also stated she did not know why she did not check on Resident #1 during her rounds at 10:00 AM. She stated she expected him to be in the common area where he usually was around that time every day. She also stated she took her lunch break at 11:00 AM and returned from her lunch break at 11:30 AM. She stated when she returned from her lunch break, she entered the dining room to assist with the lunch meal service. She stated CNA H entered the dining room and asked her if there were any residents missing on the 400 hall. She stated she explained to CNA H she was not aware of any resident missing. She stated Resident #1 had not returned from the hospital when she clocked out for the day. She stated she had been in serviced on making rounds every 2 hours, and she participated in elopement drills several times. She also stated she was in serviced on elopement. She also stated she had been assigned to Resident #1 several times per week. She stated Resident #1 never attempted to ambulate to the doors and attempt to leave the facility. She stated He did not wander into other resident's room. She also stated The resident did not always interact with other residents. She stated when she heard Resident #1 eloped from the facility, she was shocked due to Resident #1 did not have a history of trying to leave the facility or wander. She stated she did not hear any door alarm sounds on 06/18/2023. She stated No one reported to her of any ofthat the alarms were not working or any of the doors having had problems of not locking. She stated there were more than usual visitors in the morning and the afternoon on 06/18/2023 for Father's Day. She stated she did not know when staff observed Resident #1 during the morning of 06/18/2023 and if she did know other staff observed Resident #1, she was expected to make rounds every 2 hours. She stated she was in serviced on abuse/ neglect, elopement, and making rounds on residents every two hours in June and few months ago. In an interview on 06/28/2023 at 11:50 AM, LVN D stated she was workingworked on 06/18/2023 when Resident #1 eloped from the facility. She stated at approximately 7:00 AM she checked Resident #1's blood sugar, and this was the first time she observed Resident #1. She also stated she did not observe the resident after 7:00 AM on 06/18/2023. She stated the CNAs and nurses were expected to make rounds on the residents they were assigned to every 2 hours. She stated Resident #1 did not have a history of exit seeking or attempting to leave the facility. She stated He did not wander inside the facility. He usually had a routine of going to his room after breakfast and would go to the common area and watch TV. She stated he did not interact very often with other residents. She stated There were a lot of visitors in the facility all day on 06/18/2023 due to it being Father's Day. She also stated The nurses or med-aides did not report to the CNAs if they have observed a resident unless there was unusual behavior or circumstances with the resident. She stated the only time a med-aide would report to a CNA they observed a resident was if the med-aide gave a resident a certain medication such as a laxative. She stated the families visited numerous times per week knew the code to enter and exit the front door of the facility. She stated only the families very seldom visited did not know the code to exit the front door of the facility. She stated she had been in serviced on making rounds every 2 hours on 06/18/2023 and few months ago. She stated this was expected of nurses and CNAs to make rounds every 2 hours by the administration. In an interview on 06/28/2023 at 2:45 PM, RN E stated she was workingworked the 2-10 PM shift on 06/18/2023. She stated she observed Resident #1 when he returned from the hospital at approximately 5:30 PM. She stated she did not observe any changes in his cognition or his mood . She stated he did eat supper in the dining room. She stated she completed a skin assessment on resident, and she did see a small rash on his chest area. She stated resident was always calm unless he had an urinary tract infection and he would sometimes become agitated. She also stated he would a quiet person and he very seldom interacted with other residents. She also stated he would usually go to his room after meals and go to watch tv in the area where all the residents could watch tv together. She stated he had is daily routine. She stated she did not observe him every wandering into other resident's room. She stated this was a surprise to her that he left the facility it was not his usual behavior. She stated Resident #1 did not require any type of treatment. She stated he was calm and relaxed during her interaction with him. She also stated he was immediately placed on one-on-one monitoring when he returned from hospital. She stated A staff was sitting outside his door and when he exited his room the staff would walk with him to wherever he wanted to go, and it was usually the common area. She stated Resident #1 did not have any sunburn or blisters on his skin. She stated his cognition or mood had not changed. She also stated there were not changes in his physical, mood, or mental condition. She stated Resident #1 did not exhibit any signs or symptoms of pain such as moaning, grimacing, furrowed brow, flinching, yelling, crying, complain of headache, and or rapid or unusual breathing. She also stated nurses and CNAs were expected to make rounds every 2 hours of their assigned residents. She stated she had beenwas in serviced on elopement, abuse/neglect and making rounds every 2 hours in June 2023 and within the last 2 or 3 months. In an interview on 06/28/2023 at 3:45 PM, CNA I stated he worked on 06/18/2023 from 6:00 AM - 6:00 PM. He stated he observed the Resident #1 in the common area at approximately 8:30 AM. He stated Resident #1 was calm and he did not observe any changes in his mood or behavior. He stated he did not observe him after 8:30 AM until he returned from the hospital later that day. CNA I stated he did observed the resident in the dining room at approximately 5:45 PM on 06/18/2023 and Resident #1 was calm and did not appear to have any changes in his mood or mental status. He stated resident went to his room and then he went to watch tv with other residents. He stated this what he usually did every day. He stated he had not observed Resident #1 wander in the facility or even attempt to leave the facility for any reason. He stated CNA I stated there were more visitors in the morning and afternoon than usual for a weekend. He stated Resident #1 was out of snuff. He stated he usually does did the smoke breaks and noticed Resident #1 did not have any snuff over the weekend and he was informed by Nurse Supervisor that the family had been contacted. He stated this did not occur very often to his knowledge. He also stated the families who visits visited the facility frequently throughout the week knows knew the code to the door to exit the facility and the families who only visited very few times usually did not know the code to the front door and would require assistance to exit the facility. CNA I stated all the staff in the facility was were in serviced on elopement and participated in elopement drills the week of 06/18/2023. She also stated the staff was were in serviced at the same time of on abuse/ neglect and making rounds every two hours. She stated the staff was were in serviced approximately 2 months ago about making rounds every 2 hours and abuse /neglect. The staff also participated in elopement drills in April and May of 2023. In an interview on 06/28/2023 at 4:30 PM, the Maintenance Supervisor stated he received a form generated by the corporate office of the steps he is was to complete when checking all exit doors, and alarms on the doors. He stated the doors, and door alarms are were checked monthly. Since the elopement, he stated the doors and alary alarm systems on the doors were being checked daily. He stated he was not at work on 06/18/2023, however, he received a phone call about the elopement and immediately came in the facility to check the exit doors and the alarms. He stated he checked all the doors and door alarms in the facility. He stated all were in working order. He also stated he did not find any alarm or door not working properly. He also stated the wander guards were also checked and all were working properly. He stated if there was anything not working properly in the facility the staff filled out a maintenance request and there was not any request filled out concerning which concerned the doors but he stated if the doors or door alarms was were not working the staff would notify him immediately. He stated the codes are were not given to the families, however, when there are were families visits who visited numerous times a week they will would watch staff enter the code and will would know the code and use it when they visited their family families in the facility. He stated a company came to the facility on [DATE] and checked all the doors and alarms and they did not find any alarm or doors not in working order. In an interview on 06/28/2023 at 5:45 PM, the Administrator stated upon her investigation of Resident #1's elopement there were more than the usual number of visitors in the facility on 06/18/2023. She stated the families visits who visited frequently throughout the week knows knew the code to exit the facility. She stated she interviewed the employees who worked on 06/18/2023 and no one observed Resident #1 exit seeking or any changes in his mood /behavior. She stated Resident #1 did not have a history of exit seeking or wandering. She stated the staff did not hear any door alarms sounding. She also stated it was determined the only door the resident may have exited when he eloped was the front door and may have followed visitors out the front door. The Administrator stated Resident #1 was out of snuff over the weekend and it was a possibility he may have been trying to leave the facility to get snuff. She stated the activity director or social worker usually will would go shopping for residents. She also stated Resident #1's family had been contacted to bring money for his snuff and they had not visited the resident to bring snuff or bring money for staff to purchase the snuff. She stated it was determined all the exit doors and alarms were in working order and no one heard any door alarms in the AM morning, on 06/18/202. She stated in the area where the front door is was located there is was approximately 100 feet from the only nurses' desk to the front door. She stated during the week she was in her office and the business office manager was in her office. She stated our office doors was were within 5-10 feet of the front door. She stated there were staff entering and exiting their offices throughout the day and more people could make more observations of the front door than on the weekends. She stated they had begun a stricter monitoring system for weekends and holidays . She stated the nurse supervisor was always at the nurse's desk except when she was doing wound care. She stated the nurse supervisor was to sit at the nurse's desk facing the front door. When she left the nurses desk for any reason she was to assign another staff to sit at the nurse's desk facing the front door . She also stated she placed a sign on the outside and inside of the front door which stated and there is was staff by the front door continuously during the week entering and exiting the offices. The nursing staff and administrative staff had increased making rounds on the residents and observing the front door. She stated the systems breakdown was the nursing staff was were not making rounds every two hours to ensure residents were not going outside without assistance from staff. The Administrator stated she also expected the nurses to make rounds every 2 hours and monitor to ensure the CNAs were completing their tasks. She stated if a resident eloped the resident had a potential of a heat stroke or acquire any type of injury and possibly need to be hospitalized . She stated it was the DON and ADON's responsibility to in-service and train nursing staff. She stated the nurses speaking who spoke with the police officer did not ask for his name and they did not know the policeman's name. She stated the interdisciplinary team had a meeting and discussed the elopement and [TRUNCATED]

Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for two (Resident #1 and Resident #2) of eight residents (Resident #1 and Resident #2) reviewed for accidents and hazards. 1. The facility failed to ensure staff properly transferred Resident #1 from her wheelchair to bed and suffered a laceration to her right calf. 2. The facility failed to ensure staff properly transferred Resident #2 from his bed to his wheelchair and from his wheelchair on 5/25/2023 resulting in bruises under both arms. This These failures could result in residents experiencing accidents, injuries, unrelieved pain, and diminished quality of life. Findings included: 1.Record review of Resident #1's face sheet, dated 06/06/2023, revealed Resident #1 was a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses which included muscle wasting and atrophy (the wasting or thinning of muscle mass), muscle weakness ( a lack of strength in muscles), abnormality of gait and mobility ( when a person is unable to walk in the usual way), repeated falls ( risk factors for falls weak muscles especially in legs, poor balance, causing unsteadiness on your feet), hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side (paralysis of partial or total body function on one side of the body, whereas hemiparesis is characterized by one-sided weakness, but without complete paralysis), and morbid obesity ( if weight is more than 80 to 100 pounds above their ideal body weight). Record review of Resident #1's Annual MDS assessment, dated 03/17/2023, reflected Resident #1 had a BIMS score of seven, which indicated the residents' cognition was seven indicated residents' cognition was severely impaired. She did not have any behavior problems such as interfering with care. Resident #1 was assessed to require extensive assistance by two staff members for bed mobility, dressing, toileting, and bathing. She was assessed to be totally dependent by two staff members for transfers and bathing. Record review of Resident #1's comprehensive care plan, dated 03/25/2023, reflected the resident had an ADL self-care performance deficit related to hemiplegia and limited mobility. Interventions: transfers required 2 staff for assistance with Hoyer lift. Resident #1 used a wheelchair for mobility. Resident #1 had skin tears. Resident #1 was at risk for falls related to gait/balance problems, incontinence, and poor communication/comprehension. Resident had hemiplegia/ hemiparesis. Record review of Resident #1's nursing progress notes reflected an entry, dated 06/04/2023 at 11:35 PM, CNA A called LVN B to Resident #1's room where LVN B observed CNA A holding napkins over Resident #1's right calf. Resident #1 was bleeding from a laceration to the right calf. The laceration was sustained while Resident #1 was transferred from her wheelchair to her bed after dinner. LVN B called 911 and EMS transported Resident #1 to hospital. LVN B notified the on-call physician, The DON, and Resident #1's daughter family member of the incident. Resident #1 was transported to the facility from the hospital via ambulance. Resident #1 had sutures intact to the right calf. Resident#1 was given PRN pain medication upon return to the facility. Documented by LVN B. Record review of Resident #1's event nurses' assessment, dated 06/04/2023, reflected the resident sustained a laceration to the right lower leg (calf) after improper transfer by staff from wheelchair to bed in Resident #1's room. The resident was transferred to the ER to close laceration. The resident was unable to provide a statement related to the incident of her right calf. Resident #1 required a mechanical lift for transfers. Signed by LVN B. Record review of the providers investigation report, on 06/06/2023, reflected the report was incomplete. The facility had five days to complete their investigation . The incident occurred on 06/04/2023 and the investigation was to be completed on 06/10/2023. Record review of in-service records, dated 05/25/2023, reflected staff were to check electronic medical records for proper transfer technique on each resident, hydraulic lift, and moving a resident bed to chair/ chair to bed . Observation on 06/06/2023 at 9:30 AM reflected Resident #1 was in bed. She was not interviewable. Resident #1 stated she hurt her leg when she was walking in the woods. Resident #1's sutures was were intact. The resident denied being in pain. She was smiling and did not have any signs or symptoms of being in pain. In an interview on 06/06/2023 at 2:13 PM, CNA A stated Resident #1 was in her wheelchair, and she began to slide from her wheelchair. CNA A stated she did not want her to fall to the floor and the Hoyer lift pad was underneath Resident #1 while she was sitting in her wheelchair. She stated she transferred Resident #1 with her gait belt from the wheelchair to the bed. When Resident #1 was in her bed, it was at this that time she realized Resident #1 had cut her leg on the bed rail. CNA A stated she obtained a napkin and/ a cloth from Resident #1's room and held it on the laceration. She stated she yelled for help and the nurse came into Resident #1's room and began to assess the resident. CNA A stated she knew when she entered Resident #1's room she was going to transfer her to bed. She stated she made the mistake of not getting another staff and the Hoyer lift prior to entering Resident #1's room. She also stated Resident #1 was a 2 person assist with the use of Hoyer lift. She stated she has been trained on how to transfer residents via Hoyer lift and gait belt. She stated she had beenwas in serviced where the information on each individual resident's ADL care including which included what type of transfers each resident required is was in the electronic medical record. She also stated Resident #1 was a two person assist and required Hoyer lift. She also stated if any resident is was sliding out of the chair, she had beenwas in serviced to assist the resident to sit on the floor. This was safe to do instead of attempting to transfer a resident by yourself when the resident required two people to assist with the transfer. She stated it happened so fast she was not thinking clearly. She stated the wheelchair was approximately 4 feet from the bed and the wheelchair was not facing the bed. In an interview on 06/06/2023 at 3:36 PM, LVN B stated she was near the nurses' desk standing beside her medication cart when she heard CNA A yelled my her name in a panic tone. She stated she entered Resident #1's room and CNA A was holding a cloth over a laceration on Resident #1's right calf. LVN B stated she assessed Resident #1 and immediately called the ambulance service, the physician, the DON, and the family. She sated after Resident #1 was transferred out of the facility she spoke with CNA A to gather information on how the laceration occurred on Resident #1. LVN B stated CNA A explained she was transferring Resident #1 from her wheelchair to the bed when she saw Resident #1 slipping from her wheelchair. CNA A stated this was when Resident #1 cut her leg on the bed frame. LVN B stated she in serviced CNA A immediately on how to properly transfer a resident. LVN B stated she explained to CNA A to lower a resident to the floor if they are were sliding out of their wheelchair especially if the resident is was a 2-person Hoyer lift transfer. She also stated she explained to CNA A to always ask for assistance and get the Hoyer lift if the resident was required to be transferred by 2 staff member and a Hoyer lift. LVN B also stated the Hoyer lift pad was in Resident #1's wheelchair. She stated CNA A did not transfer Resident #1 properly, it was an improper transfer. She stated Resident #1 is was overweight and is was very heavy. She stated the wheelchair was approximately 3 feet from the bed. She also stated Resident #1 was not able to assist with the transfer she was totally dependent on staff for transfers. 2. Record review of Resident #2's face sheet, dated 06/06/2023, revealed Resident #2 was a [AGE] year-old male who was admitted to the facility on [DATE] with the following diagnoses which included myelodysplastic syndrome ( a group of cancers in which immature blood cells in the bone marrow do not mature or become healthy blood cells), chronic obstructive pulmonary disease, unspecified ( a group of diseases that cause airflow blockage and breathing-related problems), and essential hypertension (high blood pressure can lead to blood vessel damage). Record review of Resident #2's Quarterly MDS assessment, dated 04/24/2023, reflected Resident #2 had a BIMS score of five which indicated the residents' cognition was severely impaired. Resident #2 was assessed to require extensive assistance by two staff members for transfers, bed mobility, dressing, toileting, and personal hygiene. Resident was assessed for total dependence for bathing with two staff member assistance. Resident #2 was assessed to ambulate in a wheelchair. Record review of Resident #2's comprehensive care plan reflected the resident had an ADL self-care performance deficit (date initiated 04/25/2023) Intervention: revised on 04/25/2023, transfer: the resident required 2 staff participation with transfers and required mechanical lift. Record review of Resident #2's event nurses note, dated 05/25/2023, reflected CNA (did not specify name of CNA) noticed and reported to charge nurse Resident #2 had discoloration under both arms during brief change. Location of injury RUE and LUE. The discoloration was blue/purple. Resident #2 required mechanical lift for transfers. He did not walk, had unsteady gait, balance problems, and lack of mobility strength. Signed by LVN E. Record review of the facility investigation report reflected upon investigation, it was found that the discoloration under both right and left arms of Resident #2 were consistent with being transferred improperly. CNA D was observed transferring Resident #2 by lifting him under his arms versus using the Hoyer lift as indicated. As a result, CNA D was pending termination, but opted to self-terminate instead. Staff continued to receive education/training over use of Hoyer lift, abuse, neglect as well as proper transferring of residents. Record review of Resident #2's electronic medical record indicated no documentation of bruises under residents' arms on 5/23/2023. Observation and /interview of Resident #2 on 06/06/2023 at 10:05 AM reflected the resident was in his room lying in bed. He was not interviewable. He moved his eyes and mouth during visit. He did not respond to any questions. Did not observe any No bruises were observed on his left and right arms. He refused to allow the State Surveyor to look under his arms, his feet and bottom portion of his legs. Observation of the Hoyer lift transfers on 06/06/2023 reflected an attempt to observe Hoyer lift transfers in the afternoon. There was only one female who required to use Hoyer lift and she refused to allow the State Surveyor to observe the transfer. in In an interview on 06/06/2023 at 11:20 AM, NA F stated she was in facility training for non-certified assistants on 05/24/2023 . She stated her assignment for that day was to observe CNA D. NA F stated CNA D was assigned to 400 hall the same hall Resident #2 resided. NA F stated she walked into Resident #2 room before breakfast approximately 7:30 AM and CNA D began to transfer Resident #2 from bed to his wheelchair by placing her hands and portion of her arms under Resident #2's upper arms . She stated CNA D was the only person who transferred Resident #2. NA F also stated she went with CNA D to Resident #2's room after lunch to observe CNA D transfer Resident #2 from the wheelchair to the bed. She stated CNA D placed her hands and portion of her arms under Resident #2's arms and transferred him from the wheelchair to the bed. She stated she did not remember if CNA D used a gait belt when she transferred the resident. NA F stated approximately 2 hours after assisting Resident #2 to bed she went with CNA D in Resident #2's room to change his brief and clothes. NA F stated the front of the wheelchair was not facing the resident's bed. She also stated the wheelchair was approximately 3 feet away from the bed. She stated the side of She stated this is was when she observed bruises underneath Resident #2's arms. She stated when CNA D dressed Resident #2 on 5/25/2023 in AM prior to transferring him, she did not observe any bruising underneath his arms. She stated the bruising was where CNA D placed her hands to transfer the resident before breakfast and after lunch. She stated she was in training and was not allowed to perform any type of ADL tasks. She also stated she did not have access to the electronic computer system on 5/24/2023. She stated she did not have any reason to believe CNA D was doing anything wrong due tobecause this was her the first time to she worked 400 hall and she was in training. She did not know the residents and was relyingrelied on CNA D to train her. She stated she reported the bruises on Resident #2 to the DON either 5/24/2023 or 5/25/2023 . NA F stated when she returned to work on 5/25/2023 the bruising underneath the residents' arms were was the color of the bruises were darker and the bruises were larger. She also stated she had beenwas in serviced on using electronic medical records and currently had access to the electronic computer system when she needs needed information on any of the resident's care. She stated she had beenwas in serviced on transfers, abuse, and neglect. In an interview on 06/06/2023 at 12:30 PM, CNA G stated she had beenwas assigned to work 400 hall and 200 hall numerous times over the past 2 months. CNA G stated in the past 2 months she had assisted with Resident #1 and Resident #2. She also stated other staff would ask her to assist them with transfers when a resident was a 2 person transfer and/or required a Hoyer lift. She stated in the past 2 months she had assisted other staff or asked other staff to help assist her when transfers were needed with either Resident #1 or Resident #2. She stated the staff used a Hoyer lift with two staff members. She stated the electronic computer system for the CNAs were was updated whenever there was a change in a resident's condition. CNA G stated she would view the electronic computer system every morning, of the residents she was assigned to for that day. She stated she had beenwas in serviced on how to use the electronic computer system, how to transfer residents with Hoyer lift or with a gait belt, and on abuse and neglect. She stated the staff had these in services/ training in May 2023. She stated if there was a change in a resident's care during the day the nurse supervisor would report the change to the CNA and ask them to check the electronic medical records. She stated all CNAs had their own password to log into the electronic records. In an interview on 06/06/2023 at 12:45 PM, CNA H stated she had beenwas assigned to give care to Resident #1 and Resident #2 numerous times. She stated if a CNA was not 100 percent certain of what type of transfer a resident wasrequired, the CNA was expected to view the electronic medical records designed for the CNAs to check the status of what type of transfer the resident required. She stated Resident #2 had beenwas a 2-person Hoyer lift transfer for an exceptionally long time. She could not recall how long. CNA H stated Resident #1 had recently became a 2-person Hoyer lift transfer approximately 3 months ago. She stated she recalled Resident #2 needing a 2-person Hoyer lift transfer was in his electronic medical record . She stated she had training and in serviced on how to use a Hoyer lift, transfers from one surface to another surface, and abuse/ neglect. She stated Resident #1 was overweight and was very heavy. She stated it would be difficult to attempt to transfer her alone. She stated Resident #1 was not capable of assisting with transfers. She stated Resident #2 also needed 2 people to transfer him because he would lean and did not always try to help when transferring. In an interview on 06/06/2023 at 1:20 PM, LVN I stated the CNAs has their own password to log into the electronic medical records designed especially for the CNAs to access for information on each resident and what type of ADL care including transfers, their diet, and any other pertinent information the CNAs may need to know about a particular resident. She stated if there were any changes with residents ADL care during the day, the nurse supervisor or any nurse would verbally report it to the CNAs and ensure it was updated in the electronic medical system. She stated the MDS nurses, DON, and ADON was were very prompt with reporting any changes in resident's care. LVN I stated the facility had a training with every staff on how the proper use of a Hoyer lift and transfers using a gait belt. She stated the facility administration in May completed abuse and neglect in-service with the staff. She stated Resident #1's transfers was were changed approximately in April to Hoyer lift with 2 person assist. She stated she recalled it being changed in the electronic medical records. In an interview on 06/06/2023 at 4:30 PM, MDS Coordinator J and MDS Coordinator K both stated the information in the electronic medical records section for the CNAs had all the information the CNAs needed to care for the residents. MDS Coordinator K stated when the care plans were written, and the information needed to be shared with the CNAs to provide care to a resident the MDS Coordinator and select K on the care plan and it automatically transfers transferred to the CNAs electronic medical records. MDS Coordinator J agreed with the explanation given by MDS coordinator K. MDS Coordinator J stated she would need to check with the DON and Administrator to verify whose responsibility it was to monitor the electronic medical records. In an interview on 06/606/2023 at 5:05 PM, the DON stated the CNAs was were expected to check the electronic medical records every morning to verify what type of care the residents needed. She stated this electronic system used by the CNAs had everything they needed to know to care for each resident such as: transfers, feeding, bathing, hygiene, bed mobility, etc . She stated she was notified of Resident #2's bruises on 05/25/2023. She stated she assessed Resident #2 and observed bruising underneath his arms. She stated an investigation began immediately. The DON also stated Resident #1 and Resident #2 was were not transferred properly. She stated Resident #1 and Resident #2 required 2 person assist with Hoyer lift on the dates of the incidents with both residents. She stated if a resident was sliding out of the wheelchair her expectation was for the staff to lower the resident to the floor. The staff was to yell for assistance or use the call light for assistance. The staff was expected to wait for another staff to enter the room and assist with the transfer by the facilities protocol and/ or by the resident's care plan. She stated all ADLs documented on the care plan was transferred to the CNAs electronic medical record. The DON stated if a resident was not transferred according to their plan of care, the resident may fall, develop a skin tear, fracture a bone, and had a potential for hospitalization due to injury. She stated the staff had been trained on how to transfer a resident using a Hoyer lift and/or a gait belt. She also stated the staff was required to take competency tests on transfers in December 2022, March 2023, and June 2023. She stated the staff was expected to complete transfers while being tested on the efficiency of the transfers. The DON stated it was the MDS, DON's and ADON's responsibility to monitor the CNAs electronic medical records to ensure of accuracy. She stated it was the administrator's responsibility to ensure each department was monitoring their employees and the systems in place to ensure the residents received the appropriate care. She also stated the correct transfer information was in the CNAs electronic portion of the medical record on the days of the transfer incidents with Resident #1 and Resident #2. In an interview on 06/06/2023 at 5:35 PM, the Administrator stated it was her responsibility to ensure each department were was completing their job duties. She stated the MDS coordinators were responsible to ensure what is was documented on each resident's care plan is was filtered to the electronic medical records designed for the CNAs. She stated the CNAs had been in serviced on how to use the electronic medical records. She also stated it was part of their orientation and the administration staff had recently completed an in-service on how to use the section of the electronic medical records where the CNAs viewed to know what type of care each resident needed. The Administrator stated the staff was were recently trained in May 2023 on how to use Hoyer lifts and gait belts. She stated if the staff was were not using the correct transfers for a particular resident, the staff may drop a resident, the resident may fall, the resident had a possibility of receiving a concussion, a laceration, a fracture bone, etc. She stated it was a possibility a resident may require medical care in the hospital if they received an injury from an improper transfer. The Administrator stated Resident #1 did not receive a proper transfer on 06/04/2023 and Resident #2 did not receive a proper transfer on 05/24/2023. She also stated the investigation on Resident #1 was not completed . She stated she began the investigation on 06/04/2023 and she had until 6/10/2023 to complete the investigation. Record review of Facilities the facility's Policy on Moving a Resident, Bed to Chair/ Chair to Bed, dated 2003, reflected. This procedure may require two persons. 1. Moving a resident from bed to chair: place the chair so that it touches the side of the bed and faces the foot of the bed (Note: have the chair on the resident's strong side). Loosen covers, as necessary. Avoid unnecessary exposure of the resident's body. Assist the resident to a sitting position. Swing the resident's legs over the side of the bed. (Note: the bed should be low enough for the resident's feet to touch the floor.) Allow the resident a moment to get used to the sitting position. If the person required, two persons (one on each side) should grasp the gait belt and gently stand and turn the resident and sit him or her in the chair. 2. Moving a resident from chair to bed: place the chair so that it touches the side of the bed and faces the foot of the bed. (Note: have the chair on the resident's strong side). If the resident required, two persons (one on each side) should grasp the gait belt and gently stand and turn the resident and sit him or her on the edge of the bed. Support the resident by placing a gait belt around the resident's waist for you to hold and steady the resident. Instruct the resident to place his or her hands on the arms of the chair for support. Instruct the resident to place his or her hands on the arms of the chair for support. Instruct the resident to stand and turn with is or her back to the bed and sit on the edge of the bed. Move the resident. Instruct the resident to raise his or her legs on the bed. Assist, as necessary. Make the resident as comfortable as possible. Place call light within reach of resident. Report any abnormalities to charge nurse. Record review of Facilities the facility's, undated, policy on Hydraulic Lift , not dated, reflected it is reserved for those who are paralyzed, obese, or too weak for transfer without complete assistance. The number of staff to provide assistance with transfer should be determined by the manufacturer recommendations.

Based on observation, interview, and record review, the facility failed to ensure the medical care of each resident was supervised by a physician for one (Resident #15) of five residents reviewed for supervision of medical care by a physician. The facility did not ensure Resident #15's physician examined and assessed Resident #15 upon a significant change in condition following Resident #15 having intermittent high blood pressures, shortness of breath, chest pain, and a 41.9-pound weight gain in 36 days. These failures resulted in an Immediate Jeopardy (IJ) situation on 06/22/2022. While the IJ was removed on 06/24/2022, the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could affect residents who had a change in condition by not ensuring that residents' care was provided by a physician who was knowledgeable of their current health status changes. Findings included: Review of Resident #15 face sheet revealed Resident #15 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #15 quarterly MDS dated [DATE] revealed Resident #15 had a BIMS score of 14 to indicate he had intact cognition. Resident #15 required extensive assistance by two or more staff members for bed mobility, transfers and toilet use. Review of Resident #15 Care plan dated 03/24/2022 revealed Resident #15 was on diuretic therapy ([MEDICATION(S)]) with interventions including administer medication as ordered, monitor vital signs as ordered and report to physician if abnormal for this resident, report any increased swelling of legs, arms or face to the charge nurse, report ordered labs to the physician, and resident could experience dizziness, postural hypertension, fatigue and increased risk for falls. Observed for possible side effects. Review of Resident #15 Physician or Non-Physician Provider (Nurse Practitioner or Physician Assistant) Visits dated from 03/22/2022 through 06/20/2022 revealed Resident #15 was seen these following dates: -03/29/2022 by PHYS ASST upon admission -05/05/2022 by nurse practitioner via tele-health Review of physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #15 noted to have prior diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . His weight was noted at 310.6 pounds and he was noted to have mild peripheral [CONDITION(S)] and right lower extremity [CONDITION(S)]. There was no note that the right upper extremity had [CONDITION(S)]. Review of Resident #15 Blood Pressures from 05/25/2022-06/22/2022, that were out of range in the EMR or greater than 145/90 were as follows : -05/25/2022 - 9:26 AM - 176/84 mmHg -05/25/2022 - 8:38 PM - 157/99 mmHg -05/26/2022 - 9:53 AM - 158/72 mmHG **no other BP readings document for this day.** -05/28/2022 - 10:04 AM - 164/79 mmHG -05/28/2022 - 7:50 PM - 157/70 mmHG -05/29/2022 - 6:28 PM - 167/94 mmHG -05/30/2022 - 10:12 AM - 178/90 mmHG -05/30/2022 - 8:41 PM - 155/80 mmHG -05/31/2022 - 10:29 AM - 165/100 mmHG -05/31/2022 - 7:57 PM - 151/99 mmHG -06/01/2022 - 10:05 AM - 166/99 mmHG -06/01/2022 - 7:43 PM - 170/83 mmHG -06/02/2022 - 4:47 AM - 153/100 mmHG -06/02/2022 - 9:51 AM - 159/95 mmHG -06/02/2022 - 7:02 PM - 150/98 mmHG -06/03/2022 - 2:32 AM - 155/80 mmHG -06/03/2022 - 10:38 AM - 164/86 mmHG -06/04/2022 - 10:28 AM - 166/82 mmHG -06/04/2022 - 8:44 PM - 176/84 mmHG -06/05/2022 - 1:09 AM - 163/96 mmHG -06/05/2022 - 10:33 AM - 175/97 mmHG -06/05/2022 - 5:43 PM - 186/94 mmHG -06/05/2022 - 6:02 PM - 190/100 mmHG -06/06/2022 - 9:45 AM - 158/78 mmHG -06/06/2022 - 7:44 PM - 176/73 mmHG -06/07/2022 - 2:09 AM - 174/80 mmHG -06/08/2022 - 1:25 AM - 174/88 mmHG -06/08/2022 - 11:28 AM - 179/91 mmHG -06/08/2022 - 8:22 PM - 183/84 mmHG -06/09/2022 - 2:02 AM - 149/80 mmHG -06/09/2022 - 1:38 PM - 189/100 mmHG -06/09/2022 - 6:50 PM - 167/87 mmHG -06/10/2022 - 9:45 AM - 169/84 mmHG -06/10/2022 - 7:11 PM - 186/53 mmHG -06/11/2022 - 6:29 AM - 156/76 mmHG -06/11/2022 - 10:23 AM - 193/91 mmHG -06/11/2022 - 7:45 PM - 145/76 mmHG -06/12/2022 - 8:57 AM - 160/100 mmHG -06/13/2022 - 7:38 PM - 153/96 mmHG -06/14/2022 - 10:30 AM - 154/68 mmHG -06/14/2022 - 6:50 PM - 150/74 mmHG -06/15/2022 - 9:44 AM - 181/89 mmHG -06/15/2022 - 6:49 PM - 190/94 mmHG -06/16/2022 - 9:49 AM - 163/71 mmHG -06/16/2022 - 6:51 PM - 189/85 mmHG -06/17/2022 - 10:21 AM - 160/81 mmHG -06/18/2022 - 10:08 AM - 175/91 mmHG -06/18/2022 - 6:20 PM - 165/86 mmHG -06/19/2022 - 10:09 AM - 155/86 mmHG -06/19/2022 - 7:36 PM - 152/88 mmHG -06/22/2022 - 10:21 AM - 160/101 mmHG Review of Resident #15 Nursing Progress Notes dated 05/25/2022 to 06/20/2022 revealed no progress notes regarding Resident #15's elevated blood pressures or any interventions regarding resolution of the elevated blood pressures. Review of Resident #15 Imaging Report dated 05/31/2022 revealed Resident #15 had a chest x-ray (single frontal projection of the chest) related to chest pain. The impression was a slight right basilar infiltrate in the right lung. A note written by LVN D on 05/31/2022 on the x-ray report revealed verbal order from PHYS K start [MEDICATION(S)] 100 MG BID (twice per day) for seven days. Review of Resident #15 Nursing Progress note dated 05/30/2022 at 11:55 PM written by LVN J revealed Resident #15 is alert and oriented. Skin is warm and dry to touch. At 2325[11:35pm] , resident had complained of wheezing, SOB and chest pain rated 4/10., not radiating to the shoulders or other areas. Lung's sound cleared on both sides; no apparent wheezing noticed at this time. V/S Temp 98.2 Pulse 90, Resp 26, BP 169/96 LT arm lying, 02 sat between 88% to 96% on room air. Doctor on call informed to the situation, nurse practitioner ordered for duo nebulizer treatment (aerosol breathing treatment), chest x-ray, 02 therapy. Staff to call back if resident condition is not improving. Please see TAR/orders. Duo nebulizer and 02 therapy initiated. Resident denies chest pains before treatment initiated. Call light put within reach. Will continue to monitor. Review of Resident #15 Nursing progress note dated 05/31/2022 at 5:32 AM written by LVN J revealed At 1150 V/S Temp 97.5, Pulse 90, Resp 22 02 95% N/C, BP 157/94 At 0108 [1:08 AM]V/S Temp 96.3, Pulse 85, 02 99% N/C At 0135 [1:35 AM]Pulse 87, 02 97% At 0210 [2:10 AM] V/S Temp 96.4, Pulse 84, Resp 22, 02 97% N/C At 0255 [2:55 AM] V/S Temp 96.3, Pulse 82, Resp 24, 02 99% N/C, At 0320 [3:20 AM] V/S Temp 96.2, Pulse 81, Resp 22, 02 96% N/C At 0455 [4:55 AM]V/S Temp 96.3, Pulse 78, 02 99% N/C At 0545 [5:45 AM] V/S Temp 97.5, Pulse 82, 02 97% N/C, BP 155/100. [family member] called this morning about the change in condition and the treatment initiated. Would like update from of us. Review of Resident #15 Respiratory Infection Nurses Note dated 06/01/2022 at 8:00 AM, written by LVN H revealed Resident #15 was being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #15 blood pressure noted at 170/83 taken 06/01/2022 at 7:43 PM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. Review of Resident #15 Respiratory Infection Nurses Note dated 06/01/2022 at 4:00 PM, written by LVN H revealed Resident #15 was being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #15 blood pressure noted at 170/83 taken 06/01/2022 at 7:43 PM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. Review of Resident #15 Respiratory Infection Nurses Note dated 06/02/2022 at 12:00 AM, written by LVN J revealed Resident #15 was being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #15 blood pressure noted at 153/100 taken 06/02/2022 at 4:47 AM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. Review of Resident #15 Respiratory Infection Nurses Note dated 06/03/2022 at 12:00 AM, written by LVN H revealed Resident #15 was being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #15 blood pressure noted at 155/80 taken 06/03/2022 at 2:32 AM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. Resident #15 was noted to have an additional symptom of fatigue. Review of Resident #15 Respiratory Infection Nurses Note dated 06/03/2022 at 8:00 AM, written by LVN Drevealed Resident #15 was being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #15 blood pressure noted at 164/86 taken 06/03/2022 at 10:38 AM and to nasal congestion with fatigue. Under question #16 Notification were there any negative changes that required physician notification the answer was no. Review of Resident #15 Respiratory Infection Nurses Note dated 06/04/2022 at 7:00 PM, written by LVN D revealed Resident #15 was being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #15 blood pressure noted at 166/82 taken 06/04/2022 at 10:28 AM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. Review of Resident #15 Respiratory Infection Nurses Note dated 06/04/2022 at 11:00 PM, written by LVN J revealed Resident #15 was being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #15 blood pressure noted at 163/96 taken 06/05/2022 at 1:09 AM and had fatigue. Under question #16 Notification were there any negative changes that required physician notification the answer was no. Review of Resident #15 Respiratory Infection Nurses Note dated 06/05/2022 at 10:00 AM, written by LVN H revealed Resident #15 was being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #15 blood pressure noted at 175/97 taken 06/05/2022 at 10:33 AM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. Review of Resident #15 Respiratory Infection Nurses Note dated 06/05/2022 at 5:00 PM, written by LVN Q revealed Resident #15 was being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #15 blood pressure noted at 183/94 taken 06/05/2022 at 5:43 PM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. Review of Resident #15 Respiratory Infection Nurses Note dated 06/06/2022 at 1:00 AM, written LVN J revealed Resident #15 was being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #15 blood pressure noted at 130/97 taken 06/05/2022 at 1:09 AM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. Review of Nursing Progress Note dated 06/16/2022 at 10:27 AM written by ADON revealed Significant weight gain noted. Resident receives large portions at mealtimes and request a to go plate as well of lunch and dinner meals. Resident is non-compliant with diet orders and frequents the vending machine often and eats outside food that friends bring into him. 2+ [CONDITION(S)] noted to right lower leg. Provider and dietitian notified. Review of Nursing Progress Note dated 06/16/2022 at 10:27 AM written by ADON revealed Significant weight gain noted. Resident receives large portions at mealtimes and request a to go plate as well of lunch and dinner meals. Resident is non-compliant with diet orders and frequents the vending machine often and eats outside food that friends bring into him. 2+ [CONDITION(S)] noted to right lower leg. Provider and dietitian notified. There were no follow-up notes completed or additional interventions provided to Resident #15 after 06/16/2022. In an observation on 06/21/2022 at 9:28 AM, Resident #15 was observed to have swelling in his right arm, right lower leg, in his neck and back of head. In an interview on 06/21/2022 at 9:30 AM, Resident #15 stated he felt like he had a lot of fluid on him, and his right arm and leg were swollen. He stated he had pneumonia recently and was not seen by a doctor and he wanted to see a doctor. He said the lady down the hall had pneumonia too and was seen by a doctor. He said the facility told him the swelling was normal for him and not to worry about it. He said his family member had recently been hospitalized for fluid in her lungs and he was worried he had the same problem. He said at the end of May (2022) he felt like he could not breathe, and his chest was hurting and when he reported it to the first nurse , she told him he was fine and did nothing. He said he was on the phone with his family members, who told him to go to the hospital. He said the nurse told him if he wanted to go to the hospital, he would have to call 911 himself. He said his family member called up to the facility and the nurse coming on shift assessed him and started him on oxygen and breathing treatments which made him feel better. He said he had a chest x-ray the next day and was started on antibiotics for pneumonia. He did not see a doctor since that happened and requested to the nurses multiple times to see a doctor. He said the facility told him last week he gained a lot of weight and needed to stop eating so many snacks from the vending machine. In an interview on 06/21/2022 at 3:25 PM, the ADMIN stated the medical director, or his physician assistant saw all their residents weekly. She stated Resident #15 was followed by an attending physician from Resident #15's previous facility that was evacuated in March 2022 due to tornado damage. She stated PHYS K was Resident #15 attending physician and he rounded on his own patients. She was not sure of when the doctor rounded on Resident #15 since Resident #15 was admitted to the facility. When asked for physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 06/21/2022 at 3:31 PM, the medical records assistant stated she uploaded all physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated Resident #15's EMR should be current with no missing physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . She said she typically received the notes within two days of the doctor or physician assistant rounding and uploaded them to the EMR within a day. In an interview on 06/21/2022 at 4:00 PM, the DON said Resident #15 was seen by PHYS K's nurse practitioner via tele-health on 05/05/2022. When asked if anyone had performed a physical exam on Resident #15 since 03/29/2022, she said no. In an interview on 06/21/2022 at 5:29 PM, LVN D said Resident #15 had been having issues with intermittent high blood pressures and [CONDITION(S)]. She tried to contact Resident #15's attending physician, PHYS K, about two weeks ago regarding the issues but had not received a response. She stated the CMAs would notify the nurse of high blood pressure if it was over 145/90. She stated she will notify a resident's doctor depending on the parameters set by the doctor. She stated she did not know the parameters for Resident #15 but did call and leave a message for PHYS K when Resident #15's blood pressure was 190/94 and received no response. She stated Resident #15 had a chest x-ray at the end of May (2022) and was diagnosed with pneumonia. She stated she notified PHYS K at that time and received a verbal order for antibiotics for the pneumonia. She stated she was not aware of a physician examining Resident #15 following the pneumonia diagnosis. She stated she was not aware of Resident #15's increase weight from May to June 2022 . When asked where the documentation of the notification of the high blood pressures and [CONDITION(S)] to PHYS K was, she said she was not sure she documented it and then stated it was not in the EMR. In an interview on 06/21/2022 at 5:52 PM, PHYS K stated he was notified by the facility about the excessive weight gain from May to June 2022. He stated he was told by the facility that Resident #15 ate a lot and was likely to blame for the 41.9-pound weight gain. He stated he was told Resident #15 had increased swelling on his right arm and leg but attributed that to the stroke causing a change in blood flow. He stated he did not remember being contacted about intermittent high blood pressures but did not consider them a hypertensive emergency since they resolved when his BP medications were administered. He did not remember being contacted about increased [CONDITION(S)] overall. Without seeing Resident #15, he stated could not say whether Resident #15 needed an intervention for the [CONDITION(S)], weight gain, and elevated blood pressures. He could not say whether the shortness of breath and decreased O2 saturation levels Resident #15 experienced at the end of May were caused by congestive heart failure or a complication of Resident #15 having [CONDITION(S)]. He stated he had not physically examined Resident #15 since he was admitted to the facility. In a follow-up interview on 06/24/2022 at 4:00 PM, the DON stated Resident #15 was not seen by a physician due to PHYS K wanting to continue to follow Resident #15. She stated staff contacted PHYS K multiple times regarding Resident #15's elevated blood pressures and received no response. When asked why they did not follow their facility policy regarding a lack of response from an attending physician, she said she they did when Resident #15 experienced respiratory distress at the end of May. She said they should have had the MED DIR or the PHYS ASST follow-up with Resident #15 after the respiratory issues and the discovery of the large weight gain. She said they did not have anyone follow-up with Resident #15 after the discovery of the large weight gain because she and the ADON felt the weight gain was from excess calories because Resident #15 eats a lot of food . She said a physician should have examined and assessed Resident #15 sooner. In an interview on 06/24/2022 at 4:15 PM, the ADMIN said they did not follow their facility policy to have the medical director see the resident if they did not receive a response from an attending physician. The ADMIN could not say why Resident #15 was not seen sooner by a doctor. In an interview on 06/25/2022 at 11:30 AM, RNC B stated, it would have been ideal to have Resident #15 seen by a physician following his respiratory distress, elevated blood pressures and excessive weight gain. He said he was not sure why the facility did not follow the policy to have the medical director see Resident #15 when they facility was not receiving a response from the attending physician. Facility did not have a policy for physician services or supervision of a resident by a physician. Review of the facility's policy, Notifying the Physician of Change in Status dated 03/11/2013 revealed the nurse should notify the physician immediately with significant change in status. If the physician does not return the call and if the nurse does not receive a response after trying twice, the nurse will contact the medical director for assistance. The nurse will document all attempts to contact the physician in the resident's clinical record. The Administrator, DON and the Regional Compliance Nurse were notified of on 06/22/2022 at 2:35 PM an IJ situation was identified due to the above failures and the IJ template was provided. The Plan of Removal was accepted on 06/24/2022 at 3:38 PM and included the following: Problem: Physician Visits All residents have the potential to be affected by this deficient practice. Interventions: o Physician was notified by the Compliance Nurse and DON of identified resident's weight gain, increased [CONDITION(S)], elevated B/P and blood sugar readings on 6/22/2022 and completed an evaluation of identified resident on 6/22/2022. o The DON, ADON and/or compliance nurse obtained blood pressure notification parameters from the Physician / NP which have been entered as an order in PCC. As ordered by the Physician, treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . This was completed in PCC on 6/22/22. o The DON/ADON will ensure all new admissions are followed by a Physician. This was completed on 6/22/22 and will be ongoing. o All charge nurses were in-serviced beginning 6/22/2022 by the Compliance Nurse / DON and/or ADON regarding the following and all nurses not in-serviced by 6/22/2022 will not be allowed to work their assigned position until completion of these in-services: This will be ongoing. DON and ADON were in-serviced by Compliance Nurse. o Immediate reporting changes of condition to the physician including Elevated B/P, Blood sugar (according to parameters as determined by the Physician), increased [CONDITION(S)] and significant weight gain. o Ensuring appropriate size blood pressure cuffs are utilized to ensure accurate readings. o Assessing for increased [CONDITION(S)] and/or swelling. o Signs and symptoms of [CONDITION(S)] and notification of Physician. o The DON, ADON, and or compliance nurse reviewed last weeks documented blood pressures to ensure physician/NP were notified for blood pressures out of parameters. This was completed on 6/22/22 for all residents. DON/ADON/Compliance Nurse will review EMR clinical alert reports/Real Time Clinical software at least 5 times per week indefinitely. o The DON, ADON, and or compliance nurse reviewed the last weeks documented blood sugars for applicable residents to ensure physician/NP were notified for blood sugars out of parameters. This was completed on 6/22/22. There were no additional finding that required physician notification. DON/ADON/Compliance Nurse will review EMR clinical alert reports/Real Time Clinical software at least 5 times per week indefinitely for any abnormal blood sugars. o The DON, ADON, compliance nurse, and/or designated licensed nurses assessed all residents to determine if the resident has new or increased [CONDITION(S)], and there were no additional findings requiring physician notification. This was completed on 6/22/22. Weekly skin assessments on all residents will be performed ongoing by the Treatment Nurse/designee for any skin changes including [CONDITION(S)]. This will be monitored by DON/ADON weekly, ongoing. o The medical director was notified by the administrator of this plan on 6/22/2022. An Ad Hoc QAPI meeting was held 6/23/2022. Monitoring: o Monitoring of this plan began on 6/22/2022 and will continue weekly x 4. o The DON and/or designee will monitor the vitals summary report from EMR at least 5 times per week to determine if blood pressures or blood sugars were out of parameters and/or significant weight gains and if so, the physician/NP will be notified. Monitoring began 6/22/2022 and will continue x 4 weeks. o The DON and/or designee will monitor Real Time clinical software and the PCC dashboard at least 5 times per week, indefinitely to ensure any new or worsened [CONDITION(S)] is communicated to the physician/NP and follow up as needed. o The DON and/or designee will ensure that the proper blood pressure cuffs are available for use at least 5 times per week x 4 weeks. DON/ADON provided in-servicing on the use of manual blood pressure cuffs on 6/22/22. Training is ongoing. Staff will not report to their assigned shifts prior to in-servicing. New hires will be trained during orientation. The Survey team monitored the plan of removal as follows: Monitoring done from 06/23/2022 - 06/25/2022. Observation on 06/25/2022 at 11:40 AM Resident #15 was weighed using the mechanical lift and his weight was 346.6 which was a 6.5 pound decreased since Resident #15 received three doses of [MEDICATION(S)] on 06/23/2022, 06/24/2022 and 06/25/2022. Resident #15 was noted to have decreased swelling in his leg, arm and area behind his head and neck. In an interview on 06/25/2022 at 11:35 AM, Resident #15 stated he had been using the bathroom a lot and could tell his arm and leg was less swollen. He stated he felt better now that someone was monitoring his swelling and having fluid on. Review of Resident #15 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 06/24/2022 at 3:07 PM CMA R stated she was educated regarding the use of the appropriate blood pressure cuff and that Resident #15's blood pressure should be taken using the arm cuff and not the wrist cuff. She was educated regarding the parameters of what to report to a nurse for follow-up when Resident #15's blood pressure was high. She said they were also in serviced regarding high blood sugars for Resident #15. In an interview on 06/24/2022 at 3:15 PM, LVN P stated she was educated regarding blood pressure parameters, notifying a doctor regarding a change in condition and using the right sized blood pressure cuff. Review of facility Inservice education completed as part of Plan of Removal: 06/22/2022 Reporting Change in Condition to include high BP, increased [CONDITION(S)] and significant weight gain. All nurses completed the education. 06/22/2022 Notifying Charge Nurse of Abnormal Vital Signs. Medication Aides and nurses were educated. 06/22/2022 Bariatric BP cuff can be found on the crash cart as well as in the med room. These are to be cleaned and returned after each use. The appropriate sized cuff has to be used for accurate readings. All nurses and medication aides were educated. 06/22/2022 Signs and Symptoms of [CONDITION(S)] and physician notification. All nurses completed the education. 06/22/2022 [CONDITION(S)] Causes and signs. All nurses completed the education. While the IJ was removed on 06/24/2022, the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review the facility failed to, ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the resident's choices for one (Resident #15) of five residents reviewed for quality of care. -The facility failed to provide treatment and care to Resident #15 who had a 41.9-pound weight gain with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . -The facility failed to notify Resident #15's physician when he experienced high blood pressures up to 190/110 and increased [CONDITION(S)]. -The facility failed to have parameters in place for notification to physician for nursing staff regarding high blood pressure and failed to have standing orders for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] -The facility failed to ensure they had the proper size blood pressure cuff to ensure accurate blood pressure readings in Resident #15 following a high result from a wrist cuff. -The facility failed to properly address Resident #15's health complications from 05/30/2022 to 06/20/2022 and subsequently retaliated against Resident #15 by having him sign a Negotiated Risk Agreement effectively blaming him for his health problems related to his non-compliance with his diet. These failures resulted in an Immediate Jeopardy (IJ) situation on 06/22/2022. While the IJ was removed on 06/24/2022, the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures placed residents at risk for heart failure, kidney disease, increased disease complications, hospitalization , and death. Findings included: Review of Resident #15 face sheet revealed Resident #15 was a [AGE] year-old male admitted to the facility on [DATE] with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #15 quarterly MDS assessment dated [DATE] revealed Resident #15 had a BIMS score of 14 to indicate intact cognition. Resident #15 required extensive assistance by two or more staff members for bed mobility, transfers and toilet use. Resident #15 was not noted to have gained or lost weight in the last month or six months. Review of Resident #15 Care plan dated 03/24/2022 revealed Resident #15 was on diuretic therapy ([MEDICATION(S)]) with interventions including administer medication as ordered, monitor vital signs as ordered and report to physician if abnormal for this resident, report any increased swelling of legs, arms or face to the charge nurse, report ordered labs to the physician, and resident could experience dizziness, postural hypertension, fatigue and increased risk for falls. Observed for possible side effects. Review of Resident #15 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #15 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] 25 MG - Give 1 tablet by mouth times per day related to high blood pressure. Hold for SBP less than 90, DBP less than 50, pulse less than 50 and notify charge nurse. -[MEDICATION(S)] Capsule 12.5 MG - Give one capsule by mouth one time a day as related to high blood pressure. -[MEDICATION(S)] Tablet 20 MG - Give one table by mouth one time a day as related to high blood pressure. Hold for SBP less than 90, DBP less than 50, pulse less than 50 and notify charge nurse. -[MEDICATION(S)] ER Tablet 60 MG - Give one table by mouth one time a day related to high blood pressure. Hold for SBP less than 90, DBP less than 50, pulse less than 50 and notify charge nurse. There were no high blood pressure parameters defined in the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #15 EMR for physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no other physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .Review of physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #15 noted to have prior diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . His weight was noted at 310.6 pounds and he was noted to have mild peripheral [CONDITION(S)] and right lower extremity [CONDITION(S)]. There was no note that the right upper extremity had [CONDITION(S)]. In an interview on 06/21/2022 at 3:31 PM, the medical records assistant stated she uploaded all physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated Resident #15's EMR should be current with no missing physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . She said she typically received the notes within two days of the doctor or physician assistant rounding and uploaded them to the EMR within a day. Review of Resident #15 Weight Records dated 03/22/2022 -06/21/2022 revealed: 03/24/2022 - 310.6 pounds on the wheelchair scale 04/01/2022 - 314.6 pounds (scale unknown) 05/10/2022 - 314.8 pounds (scale unknown) 06/16/2022 - 356.7 pounds (scale unknown) Review of Resident #15 Nursing Progress note dated 06/16/2022 at 10:27 AM, written by ADON revealed Significant weight gain noted. Resident receives large portions at mealtimes and request a to go plate as well of lunch and dinner meals. Resident is non-compliant with diet orders and frequents the vending machine often and eats outside food that friends bring into him. 2+ [CONDITION(S)] noted to right lower leg. Provider and dietitian notified. In an observation on 06/21/2022 at 9:28 AM, Resident #15 was observed to have swelling in his right arm, right lower leg and in his neck and back of head. In an interview on 06/21/2022 at 9:30 AM, Resident #15 stated he felt like he had a lot of fluid on him, and his right arm and leg were swollen. He stated he had pneumonia recently and was not seen by a doctor and he wanted to see a doctor. He said the lady down the hall had pneumonia too and was seen by a doctor. He said the facility told him the swelling was normal for him and not to worry about it. He said his auntie had recently been hospitalized for fluid in her lungs and he was worried he had the same problem. He said at the end of May (2022) he felt like he could not breathe, and his chest was hurting and when he reported it to the first nurse, she told him he was fine and did nothing. He said he was on the phone with family members, who were telling him to go to the hospital. He said the nurse told him if he wanted to go to the hospital, he would have to call 911 himself. He said his family member called up to the facility and the nurse coming on shift assessed him and started him on oxygen and breathing treatments which made him feel better. He said he had a chest x-ray the next day and was started on antibiotics for pneumonia. He did not see a doctor since that happened and requested multiple times to see a doctor. He said the facility told him last week he gained a lot of weight and needed to stop eating so many snacks from the vending machine. In an interview on 06/23/2022 at 2:45 PM, RP T stated she was the family member of Resident #15 and was on the phone with him when he was short of breath, coughing and having chest pain at the end of May (2022). She said Resident #15 said he had fluid on and did not feel good and felt like he could not breathe. She said she called to the nurse's station because no one was answering his call light. The nurse said she would go check on Resident #15. She said she was back on the phone with Resident #15 when the nurse checked on him and heard Resident #15 tell her the same symptoms. She said Resident #15 asked to see a doctor or go to the hospital and the nurse responded that if if he wanted to go to the hospital he would have to call 911 himself. She said the nurse then left the room. She said it was shift change and she called back to speak with new nurse, and she checked on Resident #15 and found his oxygen levels to be low and started him on oxygen. She said she was grateful the nurse did something for the resident and the other nurse refused to help. She said she could not remember that nurse's name. She said she checked on Resident #15 the next day and was told he had pneumonia. She said they called yesterday and told her Resident #15 had a large weight gain in one month and said it was because of large meals and too many snacks from the vending machine. She said they told her the PHYS ASST started him on fluid pills. She said she asked, if the weight gain was from snacks why would fluid pills help? and they had no answer. In an interview on 06/21/2022 at 04:25 PM, CMA G stated she weighed Resident #15 on 06/16/2022 using the wheelchair scale in the therapy room. She stated she did not re-weigh him to confirm the weight. She stated she gave the ADON the weights for the residents and she manually entered them into the EMR. She stated she did not realize there was a significant difference in the previous weight because she did not have his record in front of her when weighing him and the other residents. She stated he did tell her about the increase swelling his right arm, but she thought that was his baseline due to his stroke that affected his right arm. An observation 06/21/2022 at 4:28 PM, Resident #15 was weighed using the mechanical lift scale. His weight was 353.0 pounds, an increase of 38.2 pounds since 05/10/2022. In an interview on 06/21/2022 at 3:25 PM, the ADMIN stated the medical director, or his physician assistant sees all of their residents weekly. She stated Resident #15 was followed by an attending physician from Resident #15's previous facility that was evacuated in March 2022 due to tornado damage. She stated PHYS K was Resident #15 attending physician and he rounded on his own patients. She stated she was not sure of when he rounded on Resident #15 since admission. When asked for physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated she was aware of the large weight gain in Resident #15 from May to June, but he was non-compliant with his diet and ate snacks from the vending machines, larger portions at meals and his family brought food from the outside in large portions. She stated his diet was the cause of the weight gain and the dietitian was notified to conduct an assessment. In an interview on 06/21/2022 at 4:00 PM, the DON stated the weight for Resident #15 may have been an error because his weight in April and May were done using the mechanical lift scale and the weight on 06/16/2022 was done using the wheelchair scale. She said she would have him re-weighed using the mechanical lift scale. She said Resident #15 was non-compliant with his diet and ate all meals with larger portions and snacks from the vending machine all day. She said she had not spoken to him regarding the [CONDITION(S)] in his arm and leg. She said the swelling was normal for him on his right side because he had a stroke on his right side that caused paralysis and affected blood flow which resulted in the swelling. She said the swelling was normal for him and there had not been a change that she knew of in his right arm and leg from baseline. She said Resident #15 was seen by PHYS K's nurse practitioner via tele-health. When asked if anyone had performed a physical exam on Resident #15 since 03/29/2022, she said no. In an interview on 06/21/2022 at 4:35 PM, the DON stated Resident #15 decided to switch to the medical director as his physician and the PHYS ASST would see him the next morning to assess and evaluate the weight gain. In a follow-up interview on 06/23/2022 at 2:16 PM, Resident #15 said the DON made him sign a document that he would not eat so much. He said he told them he had fluid on his body, and they told him that maybe if you did not eat so many snacks you wouldn't have so much fluid. He said he did not understand why they kept blaming snacks for his swelling when the PHYS ASST told him the swelling was due to fluid related to him either having congestive heart failure or decreased kidney function. He said he did not understand why they did not want to help him see a doctor when he first began complaining about the fluid when he was short of breath and told him he would have to call 911 himself. Review of Resident #15 Negotiated Risk Agreement signed 06/22/2022 at 3:20 PM by Resident #15 and the facility. The summary of Resident's Current Health and Potential Risk were 36 pound weight gain in one month, [CONDITION(S)], hypertensive crisis, diabetic crisis, repeated stroke death. The resident's desire or preference was noted as to eat, drink and smoke cigarettes as he desires without diet restrictions - resident eats double portions, seconds, and take away trays from kitchen as well as outside foods and vending machine. The final agreement with Resident #15 was he agreed to to try eating only double portions but not seconds or take away trays. Agrees to try to smoke less. Agrees to try to stay away from junk foods. In an interview on 06/23/2022 at 2:03 PM, RNC A stated they had Resident #15 sign the NRA because he was not following his diet and subsequently gained 36 pounds. She said they asked him to limit his portions to stop the weight gain. When asked if the weight could be due to [CONDITION(S)] from complications of his health conditions, she responded the resident needed to control his portions to reduce his weight gain. When asked if his diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] #15 having [CONDITION(S)] as it was not on his diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 06/23/2022 at 2:10 PM, the ADMIN stated she wanted the doctor to stop the larger portions for Resident #15 because he was eating too much and that caused the weight gain. She said he ate two snacks at activities and would have two ice creams at ice cream socials which likely caused the weight gain. When asked if she thought he was eating greater than 14,000 calories per day consistently to be able to gain that much weight so fast, she said she did not know and was not a doctor, nurse or dietitian. In an interview on 06/23/2022 at 1:36 PM, the RD stated she was notified of Resident #15's weight gain and planned to complete an assessment when she returned to the facility next week. She stated the ADON said he gained 40 pounds. She asked the ADON if Resident #15 had fluid on legs and arms and the ADON said he ate a lot at meals, ate snacks from the vending machine, and had food brought in from the outside that caused the weight gain. She said she saw Resident #15 was on a mild diuretic. She said had she known about the [CONDITION(S)] she would have recommended they re-weigh Resident #15 and assess for [CONDITION(S)]. She said the doctor would have been consulted for further orders regarding [CONDITION(S)] and the need for a stronger diuretic. She said she did not know why Resident #15 was not assessed for [CONDITION(S)] and his doctor notified of his weight gain and [CONDITION(S)]. She said it was not likely that Resident #15 gained 40 pounds in a month and all of it be related to excess calories causing increased fat stores. She said it was more likely he had fluid on and needed a diuretic. She stated she was not aware that Resident #15 had chronic kidney as it was not on his list of diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #15 Nursing Progress note dated 05/30/2022 at 11:55 PM written by LVN J revealed Resident #15 is alert and oriented. Skin is warm and dry to touch. At 2325, resident had complained of wheezing, SOB and chest pain rated 4/10., not radiating to the shoulders or other areas. Lung's sound cleared on both sides; no apparent wheezing noticed at this time. V/S Temp 98.2 Pulse 90, Resp 26, BP 169/96 LT arm lying, 02 sat between 88% to 96% on room air. Doctor on call informed to the situation, nurse practitioner ordered for duo nebulizer treatment (aerosol breathing treatment), chest x-ray, 02 therapy. Staff to call back if resident condition is not improving. Please see TAR/orders. Duo nebulizer and 02 therapy initiated. Resident denies chest pains before treatment initiated. Call light put within reach. Will continue to monitor. In an interview on 06/24/2022 at 3:14 PM, LVN J stated in late May she was called by Resident #15's responsible party and they reported Resident #15 was having respiratory problems. She said she assessed Resident #15 and found him to be breathing heavy and his oxygen levels were low. She said started oxygen on him and paged the on-call doctor. She said she received orders for Resident #14 for nebulizer treatments and with the oxygen and nebulizer treatment his symptoms improved. She said he required oxygen for several days all day and then only at night. She said she was not sure if any physician or anyone followed up on his symptoms or resolution of pneumonia. She said Resident #15 did report increased swelling or [CONDITION(S)] but was not sure if anyone was addressing it with his attending physician. She stated she was unaware of Resident #15 having a large weight gain from May to June. She said that would likely fit with his elevated blood pressures, respiratory issues and [CONDITION(S)]. Review of Resident #15 Imaging Report dated 05/31/2022 revealed Resident #15 had a chest x-ray (single frontal projection of the chest) related to chest pain. The impression was a slight right basilar infiltrate in the right lung. A note written by LVN D on 05/31/2022 on the x-ray report revealed verbal order from PHYS K start [MEDICATION(S)] 100 MG BID (twice per day) for seven days. Review of Resident #15 Nursing progress note dated 05/31/2022 at 5:32 AM written by LVN J revealed At 1150 V/S Temp 97.5, Pulse 90, Resp 22 02 95% N/C, BP 157/94 At 0108 [1:08 AM]V/S Temp 96.3, Pulse 85, 02 99% N/C At 0135 [1:35 AM]Pulse 87, 02 97% At 0210 [2:10 AM] V/S Temp 96.4, Pulse 84, Resp 22, 02 97% N/C At 0255 [2:55 AM] V/S Temp 96.3, Pulse 82, Resp 24, 02 99% N/C, At 0320 [3:20 AM] V/S Temp 96.2, Pulse 81, Resp 22, 02 96% N/C At 0455 [4:55 AM]V/S Temp 96.3, Pulse 78, 02 99% N/C At 0545 [5:45 AM] V/S Temp 97.5, Pulse 82, 02 97% N/C, BP 155/100. [family member] called this morning about the change in condition and the treatment initiated. Would like update from of us. Review of Resident #15 Respiratory Infection Nurses Note dated 06/01/2022 at 8:00 AM, written by LVN H revealed Resident #15 was being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #15 blood pressure noted at 170/83 taken 06/01/2022 at 7:43 PM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. Review of Resident #15 Respiratory Infection Nurses Note dated 06/01/2022 at 4:00 PM, written by LVN H revealed Resident #15 was being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #15 blood pressure noted at 170/83 taken 06/01/2022 at 7:43 PM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. Review of Resident #15 Respiratory Infection Nurses Note dated 06/02/2022 at 12:00 AM, written by LVN J revealed Resident #15 was being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #15 blood pressure noted at 153/100 taken 06/02/2022 at 4:47 AM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. Review of Resident #15 Respiratory Infection Nurses Note dated 06/03/2022 at 12:00 AM, written by LVN H revealed Resident #15 was being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #15 blood pressure noted at 155/80 taken 06/03/2022 at 2:32 AM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. Resident #15 was noted to have an additional symptom of fatigue. Review of Resident #15 Respiratory Infection Nurses Note dated 06/03/2022 at 8:00 AM, written by LVN D revealed Resident #15 was being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #15 blood pressure noted at 164/86 taken 06/03/2022 at 10:38 AM and to nasal congestion with fatigue. Under question #16 Notification were there any negative changes that required physician notification the answer was no. Review of Resident #15 Respiratory Infection Nurses Note dated 06/04/2022 at 7:00 PM, written by LVN D revealed Resident #15 was being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #15 blood pressure noted at 166/82 taken 06/04/2022 at 10:28 AM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. Review of Resident #15 Respiratory Infection Nurses Note dated 06/04/2022 at 11:00 PM, written by LVN J revealed Resident #15 was being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #15 blood pressure noted at 163/96 taken 06/05/2022 at 1:09 AM and had fatigue. Under question #16 Notification were there any negative changes that required physician notification the answer was no. Review of Resident #15 Respiratory Infection Nurses Note dated 06/05/2022 at 10:00 AM, written by LVN H revealed Resident #15 was being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #15 blood pressure noted at 175/97 taken 06/05/2022 at 10:33 AM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. Review of Resident #15 Respiratory Infection Nurses Note dated 06/05/2022 at 5:00 PM, written by LVN Q revealed Resident #15 was being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #15 blood pressure noted at 183/94 taken 06/05/2022 at 5:43 PM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. Review of Resident #15 Respiratory Infection Nurses Note dated 06/06/2022 at 1:00 AM, written LVN J revealed Resident #15 was being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #15 blood pressure noted at 130/97 taken 06/05/2022 at 1:09 AM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. There were no follow-up notes completed or additional interventions provided to Resident #15 after 06/16/2022. In an interview on 06/21/2022 at 5:52 PM, PHYS K stated he was notified by the facility about the excessive weight gain from May to June 2022. He stated he was told by the facility that Resident #15 ate a lot and was likely to blame for the 41.9-pound weight gain. He stated he was told Resident #15 had increased swelling on his right arm and leg but attributed that to the stroke causing a change in blood flow. He stated he did not remember being contacted about intermittent high blood pressures but did not consider them a hypertensive emergency since they resolved when his BP medications were administered . He did not remember being contacted about increased [CONDITION(S)] overall. Without seeing Resident #15, he stated could not say whether Resident #15 needed an intervention for the [CONDITION(S)], weight gain and elevated blood pressures. He could not say whether the shortness of breath and decreased O2 saturation levels Resident #15 experienced at the end of May were caused by congestive heart failure or a complication of Resident #15 having [CONDITION(S)]. He stated he had not physically examined Resident #15 since he was admitted to the facility. Review of Resident #15 physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The note referred to labs drawn 10 days prior to the date of the note. There wereno labs drawn in the previous 10 days for Resident #15. It noted Resident #15 to have [CONDITION(S)] on his right arm and right leg likely due to lack of movement as Resident #15 was partially paralyzed due to a stroke two years prior. This is a stable, chronic issue. Resident #15's high blood pressure was noted as stable, continue present prescriptions and monitor. In an interview on 06/23/2022 at 3:10 PM, RNC B was asked to provide a copy of the labs MED DIR referred to in his note on 06/21/2022. RNC B stated those labs did not exist as Resident #15 had not had labs since 03/25/2022. He said he did not know what MED DIR was referring to in his note. When asked why MED DIR wrote the progress note and did not address the 36 pound weight gain, he did not know. In an interview on 06/23/2022 at 3:21 PM, MED DIR stated he saw Resident #15 briefly on 06/21/2022 because Resident #15 had a question regarding the swelling in his right arm and leg. He said the swelling was likely due to Resident #15 not being able to move his right arm and leg because of a stroke that caused [CONDITION(S)]. When asked if the swelling in Resident #15's arm and leg accounted for a 36 pound weight gain in one month, he responded that is the same resident that has the swollen arm and leg? I thought they were two different residents. He said the 36 pound weight was fluid retention related to an underlying health condition either decreased kidney function or congestive heart failure. He said Resident #15 needed to be seen by a cardiologist to rule out congestive heart failure. He said 10 pounds of the weight gain may be due to excessive calories, but not 36 pounds. He said the respiratory distress Resident #15 experienced at the end of May was possibly related diastolic heart failure and Resident #15 should have been evaluated by a physician. He stated an echocardiogram was needed to look at Resident #15's heart. He stated he and his physician assistant would be following Resident #15 moving forward and refer him to a cardiologist. In an interview on 06/24/2022 at 4:00 PM, the DON stated Resident #15 was not seen by a physician due to PHYS K wanting to continue to follow Resident #15. She stated staff contacted PHYS K multiple times regarding Resident #15's elevated blood pressures and received no response. When asked why they did not follow their facility policy regarding a lack of response from an attending physician, she said she they did when Resident #15 experienced respiratory distress at the end of May. She said they should have had the MED DIR or PHYS ASST follow-up with Resident #15 after the respiratory issues and the discovery of the large weight gain. She said they did not have anyone follow-up with Resident #15 after the discovery of the large weight gain because she and the ADON felt the weight gain was from excess calories because Resident #15 eats a lot of food. She said she was not aware that when Resident #15 first complained of respiratory distress in May that he was told he would have to call 911 himself. She said a physician should have examined and assessed Resident #15 sooner. When asked why the facility had Resident #15 sign the negotiated risk agreement within an hour of the IJ being called, she said yeah she could see now that the timing could have been better and could be seen as punitive towards Resident #15. When asked why they did not have him sign it when they saw him eating all the snacks, she said she did not realize until the weight gain and the complications that they were a problem. When asked why another non-compliant resident with CHF who was sent out to the hospital for high fluid gains was not asked to sign an NRA, she said she did not know, and they should probably have her sign an NRA as well. She said she knew the facility had the extra-large cuffs in the past and was not sure when or how they went missing. She said they had one in the crash cart and should have used it until the new cuff was bought to take Resident #15's blood pressure. She stated she did not know why Resident #15 did not have upper parameters for his blood pressure except it was chaotic when they evacuated the sister facility that was damaged by a tornado and some areas were dropped. She said they have since added parameters and PRN medications for high blood pressures for Resident #15. She said the nurses should have been documenting for blood pressures > 160/110 an intervention or a re-check. She said they likely re-took the blood pressure with a manual cuff and it wasn't as high, or they administered his morning medications and re-checked his blood pressure, and it was normal. She said they should have been documenting any out of parameter blood pressure and noted the intervention. In an interview on 06/24/2022 at 4:15 PM, the ADMIN stated she was not a nurse and did not know much about Resident #15's disease process, [CONDITION(S)] and weight gains. She said they attributed to high meal and snack intake. She said they signed the NRA with him so he would know his daily choices have an effect on his health. She said she was not aware of him experiencing swelling and fluid gains. She said she was not aware of his CKD diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She said she did not think the NRA was punitive, it was done to educate the resident. She said they had not previously had him sign it because RNC A recommended after the IJ was called. She said a physician should have seen Resident #15 following the respiratory issues and excessive weight gain. She said they did not follow their facility policy to have the medical director see the resident if they did not receive a response from an attending physician. In an observation and interview on 06/22/2022 at 10:19 AM, the PHYS ASST completed a physical exam and assessment of Resident #15. Resident #15 stated to the PHYS ASST he had not seen a PHYS K since admitted to the facility. The PHYS ASST said she saw the swelling in Resident #15's right arm and right leg. Resident #15 stated he felt like he had swelling in his abdomen. He reported the shortness of breath in late May of 2022 to the PHYS ASST and she stated she ordered the chest x-ray which showed pneumonia. She stated she was not told Resident #15 was also complaining of having fluid on and swelling. Resident #15 reported to the PHYS ASST he needed oxygen at night and in the past at his previous facility he did not need oxygen routinely. He said he has not been able to wear a shoe on his right foot because of the swelling in at least 2 months. He stated he had a family history of having fluid on their heart and lungs. The PHYS ASST asked Resident #15 was on fluid pills in the past, and he said yes at his previous facility but not since being admitted here. He said he was told his kidneys were not working all the way, but they

Based on interview and record review, the facility failed to immediately inform a resident's physician when there was a significant change in a resident's physical, mental, or psychosocial status for 1 of 5 residents (Resident #15) reviewed for notification of changes in that: The facility failed to fully notify Resident #15's primary care physician of all of Resident #15's status including ongoing elevated blood pressures and increased [CONDITION(S)]. These failures resulted in an Immediate Jeopardy (IJ) situation on 06/22/2022. While the IJ was removed on 06/24/2022, the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This deficient practice could place residents at risk of not having their primary care physician notified of changes, resulting in a delay in medical intervention and decline in health. Findings included: Review of Resident #15 face sheet revealed Resident #15 was a [AGE] year-old male admitted to the facility on [DATE] with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #15 quarterly MDS assessment dated [DATE] revealed Resident #15 had a BIMS score of 14 to indicate intact cognition. Resident #15 required extensive assistance by two or more staff members for bed mobility, transfers and toilet use. Review of Resident #15 Care plan dated 03/24/2022 revealed Resident #15 was on diuretic therapy ([MEDICATION(S)]) with interventions including administer medication as ordered, monitor vital signs as ordered and report to physician if abnormal for this resident, report any increased swelling of legs, arms or face to the charge nurse, report ordered labs to the physician, and resident could experience dizziness, postural hypertension, fatigue and increased risk for falls. Observed for possible side effects. In an observation on 06/21/2022 at 9:28 AM, Resident #15 was observed to have swelling in his right arm, right lower leg and in his neck and back of head. In an interview on 06/21/2022 at 9:30 AM, Resident #15 stated he felt like he had a lot of fluid on him, and his right arm and leg were swollen. He stated he had pneumonia recently and was not seen by a doctor and he wanted to see a doctor. He said the lady down the hall had pneumonia too and was seen by a doctor. He said the facility told him the swelling was normal for him and not to worry about it. He said his auntie had recently been hospitalized for fluid in her lungs and he was worried he had the same problem. He said at the end of May (2022) he felt like he could not breathe, and his chest was hurting and when he reported it to the first nurse, she told him he was fine and did nothing. He said he was on the phone with his brother and sister, who were telling him to go to the hospital. He said the nurse told him if he wanted to go to the hospital, he would have to call 911 himself. He said his sister called up to the facility and the nurse coming on shift assessed him and started him on oxygen and breathing treatments which made him feel better. He said he had a chest x-ray the next day and was started on antibiotics for pneumonia. He did not see a doctor since that happened and requested multiple times to see a doctor. He said the facility told him last week he gained a lot of weight and needed to stop eating so many snacks from the vending machine. Review of Resident #15 EMR for physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no other physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #15 Weight Records dated 03/22/2022 -06/21/2022 revealed: 03/24/2022 - 310.6 pounds on the wheelchair scale 04/01/2022 - 314.6 pounds (scale unknown) 05/10/2022 - 314.8 pounds (scale unknown) 06/16/2022 - 356.7 pounds (scale unknown) In an interview on 06/21/2022 at 4:00 PM, the DON said PHYS K was notified of Resident #15's weight gain but was not sure if he was notified regarding Resident #15's elevated blood pressures. In an interview on 06/21/2022 at 5:29 PM, LVN D said Resident #15 had issues with intermittent high blood pressures and [CONDITION(S)] since May 2022. She tried to contact Resident #15's attending physician, PHYS K, about two weeks ago regarding the issues but had not received a response. When asked where the documentation of the notification of the high blood pressures and [CONDITION(S)] to PHYS K was, she said she was not sure she documented it and then confirmed it was not in the EMR. She stated she will notify a resident's doctor depending on the parameters set by the doctor. She stated she did not know the parameters for Resident #15 but did call and leave a message for PHYS K when Resident #15's blood pressure was 190/94 and received no response. She stated Resident #15 had a chest x-ray at the end of May (2022) and was diagnosed with pneumonia. She stated she notified PHYS K at that time (05/31/2022) and received a verbal order for antibiotics for the pneumonia. She stated she did not report increased [CONDITION(S)] and elevated blood pressures to PHYS K at that time. She stated she was not aware of a physician examining Resident #15 following the pneumonia diagnosis. She stated she was not aware of Resident #15's increased weight from May to June 2022. In an interview on 06/21/2022 at 5:52 PM, PHYS K stated he was notified by the facility about the excessive weight gain from May to June 2022. He stated he was told by the facility that Resident #15 ate a lot and was likely to blame for the 41.9-pound weight gain because diet non-compliance. He stated he was told Resident #15 had increased swelling on his right arm and leg, but the facility attributed that to the stroke causing a change in blood flow. He stated he did not remember being contacted about intermittent high blood pressures. He did not remember being contacted about increased [CONDITION(S)] overall. Review of Resident #15 Blood Pressures 05/25/2022-06/22/2022 out of range in the EMR or greater than 145/90: 05/25/2022 - 9:26 AM - 176/84 mmHg 05/25/2022 - 8:38 PM - 157/99 mmHg 05/26/2022 - 9:53 AM - 158/72 mmHG **no other BP readings documented for this day.** 05/28/2022 - 10:04 AM - 164/79 mmHG 05/28/2022 - 7:50 PM - 157/70 mmHG 05/29/2022 - 6:28 PM - 167/94 mmHG 05/30/2022 - 10:12 AM - 178/90 mmHG 05/30/2022 - 8:41 PM - 155/80 mmHG 05/31/2022 - 10:29 AM - 165/100 mmHG 05/31/2022 - 7:57 PM - 151/99 mmHG 06/01/2022 - 10:05 AM - 166/99 mmHG 06/01/2022 - 7:43 PM - 170/83 mmHG 06/02/2022 - 4:47 AM - 153/100 mmHG 06/02/2022 - 9:51 AM - 159/95 mmHG 06/02/2022 - 7:02 PM - 150/98 mmHG 06/03/2022 - 2:32 AM - 155/80 mmHG 06/03/2022 - 10:38 AM - 164/86 mmHG 06/04/2022 - 10:28 AM - 166/82 mmHG 06/04/2022 - 8:44 PM - 176/84 mmHG 06/05/2022 - 1:09 AM - 163/96 mmHG 06/05/2022 - 10:33 AM - 175/97 mmHG 06/05/2022 - 5:43 PM - 186/94 mmHG 06/05/2022 - 6:02 PM - 190/100 mmHG 06/06/2022 - 9:45 AM - 158/78 mmHG 06/06/2022 - 7:44 PM - 176/73 mmHG 06/07/2022 - 2:09 AM - 174/80 mmHG 06/08/2022 - 1:25 AM - 174/88 mmHG 06/08/2022 - 11:28 AM - 179/91 mmHG 06/08/2022 - 8:22 PM - 183/84 mmHG 06/09/2022 - 2:02 AM - 149/80 mmHG 06/09/2022 - 1:38 PM - 189/100 mmHG 06/09/2022 - 6:50 PM - 167/87 mmHG 06/10/2022 - 9:45 AM - 169/84 mmHG 06/10/2022 - 7:11 PM - 186/53 mmHG 06/11/2022 - 6:29 AM - 156/76 mmHG 06/11/2022 - 10:23 AM - 193/91 mmHG 06/11/2022 - 7:45 PM - 145/76 mmHG 06/12/2022 - 8:57 AM - 160/100 mmHG 06/13/2022 - 7:38 PM - 153/96 mmHG 06/14/2022 - 10:30 AM - 154/68 mmHG 06/14/2022 - 6:50 PM - 150/74 mmHG 06/15/2022 - 9:44 AM - 181/89 mmHG 06/15/2022 - 6:49 PM - 190/94 mmHG 06/16/2022 - 9:49 AM - 163/71 mmHG 06/16/2022 - 6:51 PM - 189/85 mmHG 06/17/2022 - 10:21 AM - 160/81 mmHG 06/18/2022 - 10:08 AM - 175/91 mmHG 06/18/2022 - 6:20 PM - 165/86 mmHG 06/19/2022 - 10:09 AM - 155/86 mmHG 06/19/2022 - 7:36 PM - 152/88 mmHG 06/22/2022 - 10:21 AM - 160/101 mmHG Review of Resident #15 Nursing Progress Notes dated 05/25/2022 - 06/20/2022 revealed no progress notes regarding Resident #15's elevated blood pressures or any interventions regarding resolution of the elevated blood pressures. Review of Resident #15 Nursing Progress note dated 05/30/2022 at 11:55 PM written by LVN J revealed Resident #15 is alert and oriented. Skin is warm and dry to touch. At 2325, resident had complained of wheezing, SOB and chest pain rated 4/10., not radiating to the shoulders or other areas. Lung's sound cleared on both sides; no apparent wheezing noticed at this time. V/S Temp 98.2 Pulse 90, Resp 26, BP 169/96 LT arm lying, 02 sat between 88% to 96% on room air. Doctor on call informed to the situation, nurse practitioner ordered for duo nebulizer treatment (aerosol breathing treatment), chest x-ray, 02 therapy. Staff to call back if resident condition is not improving. Please see TAR/orders. Duo nebulizer and 02 therapy initiated. Resident denies chest pains before treatment initiated. Call light put within reach. Will continue to monitor. Review of Resident #15 Nursing progress note dated 05/31/2022 at 5:32 AM written by LVN J revealed At 1150 V/S Temp 97.5, Pulse 90, Resp 22 02 95% N/C, BP 157/94 At 0108 V/S Temp 96.3, Pulse 85, 02 99% N/C At 0135 Pulse 87, 02 97% At 0210 V/S Temp 96.4, Pulse 84, Resp 22, 02 97% with O2 via nasal cannula At 0255 V/S Temp 96.3, Pulse 82, Resp 24, 02 99% with O2 via nasal cannula At O320 V/S Temp 96.2, Pulse 81, Resp 22, 02 96% with O2 via nasal cannula At 0455 V/S Temp 96.3, Pulse 78, 02 99% with O2 via nasal cannula At 0545 V/S Temp 97.5, Pulse 82, 02 97% with O2 via nasal cannula, BP 155/100 [FAMILY MEMBER] called this morning about the change in condition and the treatment initiated. Would like update from of us. Review of Resident #15 Respiratory Infection Nurses Note dated 06/01/2022 at 8:00 AM, revealed Resident #15 was being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #15 blood pressure noted at 170/83 taken 06/01/2022 at 7:43 PM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. Review of Resident #15 Respiratory Infection Nurses Note dated 06/01/2022 at 4:00 PM, revealed Resident #15 was being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #15 blood pressure noted at 170/83 taken 06/01/2022 at 7:43 PM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. Review of Resident #15 Respiratory Infection Nurses Note dated 06/02/2022 at 12:00 AM, revealed Resident #15 was being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #15 blood pressure noted at 153/100 taken 06/02/2022 at 4:47 AM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. Review of Resident #15 Respiratory Infection Nurses Note dated 06/03/2022 at 12:00 AM, revealed Resident #15 was being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #15 blood pressure noted at 155/80 taken 06/03/2022 at 2:32 AM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. Resident #15 was noted to have an additional symptom of fatigue. Review of Resident #15 Respiratory Infection Nurses Note dated 06/03/2022 at 8:00 AM, revealed Resident #15 was being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #15 blood pressure noted at 164/86 taken 06/03/2022 at 10:38 AM and to nasal congestion with fatigue. Under question #16 Notification were there any negative changes that required physician notification the answer was no. Review of Resident #15 Respiratory Infection Nurses Note dated 06/04/2022 at 7:00 PM, revealed Resident #15 was being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #15 blood pressure noted at 166/82 taken 06/04/2022 at 10:28 AM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. Review of Resident #15 Respiratory Infection Nurses Note dated 06/04/2022 at 11:00 PM, revealed Resident #15 was being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #15 blood pressure noted at 163/96 taken 06/05/2022 at 1:09 AM and had fatigue. Under question #16 Notification were there any negative changes that required physician notification the answer was no. Review of Resident #15 Respiratory Infection Nurses Note dated 06/05/2022 at 10:00 AM, revealed Resident #15 was being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #15 blood pressure noted at 175/97 taken 06/05/2022 at 10:33 AM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. Review of Resident #15 Respiratory Infection Nurses Note dated 06/05/2022 at 5:00 PM, revealed Resident #15 was being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #15 blood pressure noted at 183/94 taken 06/05/2022 at 5:43 PM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. Review of Resident #15 Respiratory Infection Nurses Note dated 06/06/2022 at 1:00 AM, revealed Resident #15 was being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #15 blood pressure noted at 130/97 taken 06/05/2022 at 1:09 AM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. Review of Nursing Progress Note dated 06/16/2022 at 10:27 AM written by ADON revealed Significant weight gain noted. Resident receives large portions at mealtimes and request a to go plate as well of lunch and dinner meals. Resident is non-compliant with diet orders and frequents the vending machine often and eats outside food that friends bring into him. 2+ [CONDITION(S)] noted to right lower leg. Provider and dietitian notified. There were no follow-up notes completed or additional interventions provided to Resident #15 after 06/16/2022. Review of Notifying the Physician of Change in Status dated 03/11/2013 revealed the nurse should notify the physician immediately with significant change in status. If the physician does not return the call and if the nurse does not receive a response after trying twice, the nurse will contact the medical director for assistance. The nurse will document all attempts to contact the physician in the resident's clinical record. The Administrator, DON and the Regional Compliance Nurse were notified of on 06/22/2022 at 2:35 PM an IJ situation was identified due to the above failures and the IJ template was provided. The Plan of Removal was accepted on 06/24/2022 at 3:38 PM and included the following: Problem: Notify of Changes All residents have the potential to be affected by this deficient practice. Interventions: o Physician was notified by the Compliance Nurse and DON of identified resident's weight gain, increased [CONDITION(S)], elevated B/P and blood sugar readings on 6/22/2022 and completed an evaluation of identified resident on 6/22/2022. o The DON, ADON and/or compliance nurse obtained blood pressure notification parameters from the Physician / NP which have been entered as an order in PCC. As ordered by the Physician, treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . This was completed in PCC on 6/22/22. o The DON/ADON will ensure all new admissions are followed by a Physician. This was completed on 6/22/22 and will be ongoing. o All charge nurses were in-serviced beginning 6/22/2022 by the Compliance Nurse / DON and/or ADON regarding the following and all nurses not in-serviced by 6/22/2022 will not be allowed to work their assigned position until completion of these in-services: This will be ongoing. DON and ADON were in-serviced by Compliance Nurse. o Immediate reporting changes of condition to the physician including Elevated B/P, Blood sugar (according to parameters as determined by the Physician), increased [CONDITION(S)] and significant weight gain. o Ensuring appropriate size blood pressure cuffs are utilized to ensure accurate readings. o Assessing for increased [CONDITION(S)] and/or swelling. o Signs and symptoms of [CONDITION(S)] and notification of Physician. o The DON, ADON, and or compliance nurse reviewed last weeks documented blood pressures to ensure physician/NP were notified for blood pressures out of parameters. This was completed on 6/22/22 for all residents. DON/ADON/Compliance Nurse will review EMR clinical alert reports/Real Time Clinical software at least 5 times per week indefinitely. o The DON, ADON, and or compliance nurse reviewed the last weeks documented blood sugars for applicable residents to ensure physician/NP were notified for blood sugars out of parameters. This was completed on 6/22/22. There were no additional finding that required physician notification. DON/ADON/Compliance Nurse will review EMR clinical alert reports/Real Time Clinical software at least 5 times per week indefinitely for any abnormal blood sugars. o The DON, ADON, compliance nurse, and/or designated licensed nurses assessed all residents to determine if the resident has new or increased [CONDITION(S)], and there were no additional findings requiring physician notification. This was completed on 6/22/22. Weekly skin assessments on all residents will be performed ongoing by the Treatment Nurse/designee for any skin changes including [CONDITION(S)]. This will be monitored by DON/ADON weekly, ongoing. o The medical director was notified by the administrator of this plan on 6/22/2022. An Ad Hoc QAPI meeting was held 6/23/2022. Monitoring: o Monitoring of this plan began on 6/22/2022 and will continue weekly x 4. o The DON and/or designee will monitor the vitals summary report from EMR at least 5 times per week to determine if blood pressures or blood sugars were out of parameters and/or significant weight gains and if so, the physician/NP will be notified. Monitoring began 6/22/2022 and will continue x 4 weeks. o The DON and/or designee will monitor Real Time clinical software and the PCC dashboard at least 5 times per week, indefinitely to ensure any new or worsened [CONDITION(S)] is communicated to the physician/NP and follow up as needed. o The DON and/or designee will ensure that the proper blood pressure cuffs are available for use at least 5 times per week x 4 weeks. DON/ADON provided in-servicing on the use of manual blood pressure cuffs on 6/22/22. Training is ongoing. Staff will not report to their assigned shifts prior to in-servicing. New hires will be trained during orientation. The Survey team monitored the plan of removal as follows: Monitoring done from 06/23/2022 - 06/25/2022. Observation on 06/25/2022 at 11:40 AM Resident #15 was weighed using the mechanical lift and his weight was 346.6 which was a 6.5 pound decreased since Resident #15 received three doses of [MEDICATION(S)] on 06/23/2022, 06/24/2022 and 06/25/2022. Resident #15 was noted to have decreased swelling in his leg, arm and area behind his head and neck. In an interview on 06/25/2022 at 11:35 AM, Resident #15 stated he had been using the bathroom a lot and could tell his arm and leg was less swollen. He stated he felt better now that someone was monitoring his swelling and having fluid on. Review of Resident #15 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 06/24/2022 at 3:07 PM CMA R stated she was educated regarding the use of the appropriate blood pressure cuff and that Resident #15's blood pressure should be taken using the arm cuff and not the wrist cuff. She was educated regarding the parameters of what to report to a nurse for follow-up when Resident #15's blood pressure was high. She said they were also in serviced regarding high blood sugars for Resident #15. In an interview on 06/24/2022 at 3:15 PM, LVN P stated she was educated regarding blood pressure parameters, notifying a doctor regarding a change in condition and using the right sized blood pressure cuff. Review of facility Inservice education completed as part of Plan of Removal: 06/22/2022 Reporting Change in Condition to include high BP, increased [CONDITION(S)] and significant weight gain. All nurses completed the education. 06/22/2022 Notifying Charge Nurse of Abnormal Vital Signs. Medication Aides and nurses were educated. 06/22/2022 Bariatric BP cuff can be found on the crash cart as well as in the med room. These are to be cleaned and returned after each use. The appropriate sized cuff has to be used for accurate readings. All nurses and medication aides were educated. 06/22/2022 Signs and Symptoms of [CONDITION(S)] and physician notification. All nurses completed the education. 06/22/2022 [CONDITION(S)] Causes and signs. All nurses completed the education. While the IJ was removed on 06/24/2022, the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the resident's choices based on the resident's comprehensive assessment for one (Resident #1) of three residents reviewed for quality of care. -The facility failed to provide sufficient and competent care in accordance with professional standards to prevent an acute spiral fracture of the femur (thighbone) in Resident #1. -The facility failed to identify the cause of the fractured femur and did not provide treatment and care post-identification of the fractured femur to manage Resident #1's pain and ensure the highest level of comfort for Resident #1. An Immediate Jeopardy (IJ) situation was identified on 12/10/2021. While the IJ was removed on 12/14/2021, the facility remained out of compliance at a severity level of actual harm that is not immediate and a scope of isolation due to the facility needing more time to monitor the plan of removal for effectiveness of the corrective systems. These failures put residents at risk for injuries of unknown origin, serious injury, untreated fractures and unmanaged pain. Findings included: Record review of face sheet for Resident #1 revealed Resident #1 to be a [AGE] year-old female admitted to the facility on [DATE] and diagnosed with [CONDITION(S)] (stroke) with post-hemorrhagic brain damage, dysphagia (difficulty swallowing), muscle wasting and atrophy (muscle function break down), high blood pressure, contractures of all four limbs, [CONDITION(S)], muscle spasms, lack of coordination, and non-verbal. Record review of Resident #1 MDS quarterly assessment dated [DATE] revealed Resident #1 to have a BIMS (Baseline Interview for Mental Status) score of 0 to indicate Resident #1's cognitive status was severely impaired. The MDS assessment revealed Resident #1 to be non-verbal, immobile and totally dependent on staff for ADL care. The MDS assessment revealed Resident #1 to require tube feeding via a PEG tube in her abdomen as she was unable to safely eat food. Record review of Resident #1 care plan dated 10/26/2021 revealed Resident #1 to have a communication problem and speech was unclear and never understood. Interventions included monitor/document for physical/ nonverbal indicators of discomfort or distress, and follow-up as needed and watch for any changes in facial expressions, any crying, moaning. The care plan also noted Resident #1 to have bowel and bladder incontinence and intervention included checking Resident #1 every two hours and provide incontinent care after every incontinent episode. The care plan revealed the focus of alteration in musculoskeletal status related to fracture of the right arm and right femur. With interventions to include anticipate and meet needs. Be sure call light is within reach and respond promptly to all requests for assistance, give analgesics as ordered by the physician, monitor and document for side effects and effectiveness, monitor for any side effects to non-steroidal anti-[CONDITION(S)] drugs such as gastrointestinal bleeding or renal impairment and right immobilizer secured with 2 ace wraps. Check for skin break down every shift and as needed. The care plan noted Resident #1 to have an ADL self-care deficit with interventions to include: o Bathing: requires staff x1 for assistance, dependent on staff for bathing needs and shower bed o Bed Mobility: dependent on staff for bed mobility, may require 2 staff members to reposition in bed, pull up to head of bed. o The resident requires a lift for all transfers, 2 staff members o Toilet use: requires staff x2 for assistance o Dressing: The resident requires 1 - 2 staff assisted o Contractures, upper, lower extremities - needs assistance with all aspects of daily care, report to unit nurse any changes extremities for example: increase tightness, moaning, crying when providing care. Record review of Resident #1 emergency room Discharge Paperwork dated 11/29/2021 revealed Resident #1 to have an acute displaced spiral fracture of the right femur. Record review of nursing progress note dated 10/11/2021 revealed Resident #1 has a positive fracture to left upper arm. In an interview on 12/07/2021 at 10:05 AM, ADMIN stated the facility conducted a full investigation of the injury to Resident #1 and was unable to discover the cause of the injury. He stated the facility interviewed all staff who had contact with Resident #1 from Friday 11/26/2021 and Monday 11/29/2021 and they were unable to determine there was any type of accident or incident that caused the fractured femur in Resident #1. He stated they believe Resident #1's fracture may be a result of her health conditions and the severe contracture in her right limb. He said he, the DON, the Regional Compliance Nurse and RP A for Resident #1 viewed the video footage from the camera in Resident #1's room. He stated RP A had the camera placed in Resident #1's room a couple of years ago and views the footage over an app on her phone. He stated they viewed multiple instances of resident care with RP A and did not see any incident or accident that would have resulted in Resident #1 having a fractured femur. He stated there were no reports from staff of Resident #1 showing any changes through the course of the weekend to indicate an injury. In an interview on 12/07/2021 at 10:10 AM, DON stated she interviewed all facility staff and no one knew how Resident #1 suffered a fractured femur. She stated she was notified of the injury to Resident #1 when she arrived at work on 11/29/2021 and saw Resident #1's right leg was swollen. She said Resident #1's leg was not as contracted which was a big change from its normal state. She stated they have been unable to pinpoint when the injury happened or how it happened. When asked how the facility would prevent future injuries to Resident #1 if they do not know how this injury happened, DON replied she did not know. In an interview on 12/07/2021 at 10:55 AM, RP A stated she was concerned about Resident #1, because Resident #1 had a broken leg and the physician told RP A something had to cause the broken leg. RP A stated she was notified by the facility after Thanksgiving that Resident #1 had a break in her upper leg on her right side and the facility told her they did not know how Resident #1 broke her leg. She stated when she first spoke with them on 11/29/2021, they requested that she check video footage from the camera she had in Resident #1's room to discover the cause of the fractured leg. RP A stated after reviewing video footage with the facility they did not see any video from 11/27/2021 to 11/29/2021 to explain the fractured femur. RP A stated there were times the privacy curtain around Resident #1 was closed and the resident could not be seen on the video but could be heard crying out in pain on 11/27/2021 and 11/28/2021. She said in the days preceding the finding of the fractured leg, Resident #1 was in her bed the entire time and did not leave the room. She stated she spoke with Resident #1's orthopedic physician on 11/30/2021, regarding the broken arm and leg and he expressed concern over the broken leg and that there was no explanation for how it happened. She stated the physician told her the fractured femur was a fresh break and had happened within the 2-3 days prior to the finding of the injury on 11/29/2021. She stated the physician told her the fracture had to be caused by a force exerted by something on Resident #1's leg and would not have happened due to Resident #1's contractures or other health conditions. She stated she expressed these concerns to the facility administration, and they continued to report to her they did not know how the injury happened. She stated Resident #1 also suffered a broken right arm in October 2021 when Resident #1 fell out of her bed and hit the floor. She stated they called her and she watched the incident on video and was able to determine Resident #1's broken arm was an accident in October 2021. She stated she could see on the video footage that the CNA caring for Resident #1 did not reposition her correctly after providing care and Resident #1 slipped out of the bed and broke her right humerus (long bone in the arm that runs from the shoulder to the elbow) during the fall. She stated she spoke with the facility administrator and DON at the time and they corrected the issue. She stated she spoke with the aide as well and the aide stated to her, she should have gotten another staff member to assist her in repositioning Resident #1 because Resident #1's immobility makes it difficult to reposition her with only one staff member. She stated the facility administrator told her the leg could have been broken during that fall, but the orthopedic physician said the fracture in the leg was new and could not have happened in October 2021. She stated she was meeting Resident #1 at the orthopedic surgeon today (12/07/2021) for follow-up on the fractured femur. An observation on 12/07/2021 at 11:31 AM reflected Resident #1 in low bed with low air alarm beeping on her air mattress and fall mat observed in place beside the bed. In an interview on 12/07/2021 at 11:35 Resident #2 (Resident #1 roommate) stated she did not know what happened to Resident #1 and did not see or hear anything. When asked what Resident #2 was referring to, Resident #2 stated Resident #1 was hurt somehow and she did not know anything about it. When asked if there was an accident or incident with Resident #1 and staff, Resident #2 said nothing she knew about. In an interview on 12/07/2021 at 12:21 PM, PA A stated she was the physician assistant for Resident #1 and saw her weekly. She stated the broken arm and broken leg were separate incidents and the fall that caused the broken arm would not have caused the broken leg. She stated she was in the facility on the morning the restorative aide found Resident #1's leg to be injured. She stated staff asked her to look at it and she immediately noticed the significant swelling to the leg and that her leg was moving differently, as in not as a tightly contracted. She stated the type of fracture was a spiral fracture to indicate some type of force was needed to cause it and the two ends of the bone were completely displaced and no longer touching at all. She said she previously saw and examined Resident #1 on 11/24/2021 and her leg was normal. She said the restorative aide puts the brace on daily during the week and Resident #1 does not wear the brace on the weekends. She stated Resident #1 cried out when touched and moved while they examined her leg to indicate she was in pain. She stated she ordered x-rays and the fractured femur was confirmed. She stated the facility sent Resident #1 to the emergency room for further evaluation, but Resident #1 was returned to the facility as she was not a candidate for surgical repair of the fracture. She stated Resident #1 was to be treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated she has not been advised by the DON or facility administrator as to the cause of the injury. She stated the injury to Resident #1 was concerning because Resident #1 was immobile, nonverbal and unable to cause the injury on her own. She stated no one at the facility seems to know what happened to Resident #1. In an interview on 12/08/2021 at 10:37 AM, CNA F stated she worked with Resident #1 overnight Friday 11/26/2021 and Saturday 11/27/2021. She stated Resident #1 would scream in pain when she provided routine resident care or peri-care. She stated on Saturday night around 12:30 AM on 11/27/2021 she was providing peri-care to Resident #1 when she felt a pop in Resident #1's leg and Resident #1 screamed out in pain. She stated she continued to provide care to Resident #1 and the LVN C came in to find out what was wrong with Resident #1. She said the charge nurse heard Resident #1 cry out from the nurses' station which is down the hallway with approximately four resident rooms away. She said the charge nurse brought back acetaminophen for Resident #1 because they both thought Resident #1 had increased pain from her arm fracture. She said Resident #1 did not have any swelling or other indication her leg was injured following her providing peri-care. She said later she thought Resident #1's leg was swollen but there was no change in Resident #1's leg. She said she did not provide any peri-care again on that shift and left at 6:00 AM on 11/27/2021. She said she was the only aide on duty from 2:00 AM until 6:00 AM. She said there were two charge nurses also on duty during that time. She said she would normally ask another aide to help with peri-care for Resident #1, but due to there only being her and the two charge nurses she did not have anyone to ask for assistance. She said when she returned for her shift on 11/27/2021 at 10:00 PM she provided peri-care to Resident #1 and Resident #1 cried out when turned or repositioned. She said she thought it was due to Resident #1's broken arm. She said she did not notice anything unusual about Resident #1's leg during the shift. She said she did not know Resident #1 was injured until she returned to work on Tuesday 11/30/2021 at 10:00 PM. She said she was told Resident #1 had a femur fracture. She said she and another aide went to provide peri-care to Resident #1 and both felt the bone move around in Resident #1's leg and it was shocking. She said they were not told any special instructions or trained on how to care for Resident #1 with the fractured femur. She said Resident #1 did cry out in pain during the peri-care at that time. An observation of video footage on 12/08/2021 at 11:43 AM reflected CNA F preparing to provide resident care to Resident #1 at 12:54:00 AM on 11/27/2021. At 12:55:38 AM CNA F moved Resident #1 and Resident #1 was heard to scream. CNA F then observed to roll Resident #1 from her right side to left side and a pop sound was heard followed by Resident #1 screaming very loudly. At 12:59:11 AM a person is seen to enter the screen on the right and have a conversation with CNA F. In an interview on 12/08/2021 at 10:59 AM LVN C stated she was the charge nurse on 11/26/2021 on the 10:00 PM to 6:00 AM shift and provided care to Resident #1. She stated she heard Resident #1 cry out and she went to the Resident #1's room to find out what happened. She stated CNA F was providing peri-care to Resident #1. She stated CNA F did not report any noise or other concern to her regarding Resident #1's leg. She stated they both believed Resident #1 cried out related to her arm fracture. She stated she did not notice Resident #1 to have facial changes to indicate pain. She said she administered the additional acetaminophen since the resident did cry out in pain loudly. She stated she administered additional ordered medications and assessed Resident PEG tube. She said she did not see anything wrong with Resident #1's right leg throughout the course of her shift. An observation of video on 12/08/2021 at 11:40 AM reflected LVN C administering medication to Resident #1 at 1:44:00 AM on 11/27/2021. Record review of Resident #1 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 12/07/2021 at 12:35 PM RA A stated she went to put the brace for Resident #1's contractures on about 6:16 AM on 11/29/2021 and she noticed immediately that Resident #1's right leg was different. She stated Resident #1's leg was dangling and looser than usual and was very swollen compared to Resident #1's left leg. She stated she immediately left the room and notified LVN A. She stated she and LVN A returned to Resident #1 and LVN A agreed there was something wrong with Resident #1's right leg. She stated LVN A asked PA A to look at Resident #1's leg and then PA A ordered X-rays and confirmed the fractured femur. She stated she put the brace on Resident #1's right leg on Friday 11/26/2021 at 6:16 AM and removed it at approximately 1:30 PM on Friday 11/26/2021. She said when she removed the brace on Friday 11/26/2021 at 1:30 PM Resident #1's right leg was normal with no signs of injury. She stated no one would have put the brace on Resident #1's leg over the course of the weekend because Resident #1 only wore the brace on weekdays. She stated she was not told by anyone that Resident #1 had been injured over the course of the weekend. She stated Resident #1 only had routine resident care over the course of the weekend 11/26/2021 to 11/28/2021. She said Resident #1 did not seem to be in pain when she arrived on Monday 11/29/2021. She said Resident #1 did not cry out in pain when she started to move her leg that morning . She said she had not been told by anyone how Resident #1 was injured. She said she would have thought other staff would have noticed the injury prior to her arrival on Monday 11/29/2021. In an interview on 12/07/2021 at 1:01 PM, LVN A she stated RA A reported to her that something was wrong with Resident #1's leg on the morning of 11/29/2021. She stated she examined Resident #1's leg and found it to be swollen and not as contracted as normal. She stated Resident #1's leg was dangled when it was normally contracted, and she could feel the bone cracking as she moved Resident #1's leg. She stated as she examined Resident #1's leg, Resident #1 grimaced in pain. She stated she then asked PA A to examine Resident #1's leg and then PA A ordered x-rays. She stated no one reported an injury or accident to her that would have caused Resident #1's fractured femur. She stated she has not heard whether a reason has been discovered for Resident #1's fractured femur. She said she worked Friday 11/26/2021, Saturday 11/27/2021 and Sunday 11/28/2021 but was not Resident #1's charge nurse and therefore did not provide any care specific to Resident #1. She said while at work over the three days she did not hear of an accident or anything with Resident #1 that would have caused the injury. She said the injury was apparent to her and should have been noticeable to other staff members. In an interview on 12/07/2021 at 1:15 PM, CNA B stated he worked with Resident #1 on 11/28/2021 (Sunday) and provided routine resident care to her. He stated he did not see anything wrong with her leg and it was normal when he finished his shift at 10:00 PM. He said he did not notice Resident #1 being in pain or yelling out during peri-care. In an interview on 12/07/2021 at 1:21 PM, RP A stated Resident #1 was seen by the orthopedic surgeon today for her right leg fracture and he admitted her to the hospital for surgery. She stated he said Resident #1 was in too much pain with the leg's current condition and they would put a rod in to stabilize the bone tomorrow 12/08/2021. In an interview on 12/07/2021 at 1:46 PM, CNA C stated she worked with Resident #1 overnight from 10:00 AM to 6:00 PM shift on 11/28/2021. She stated she and CNA D made their last rounds between 3:30 AM and 4:00 AM on the morning of 11/29/2021 (Monday) and provided peri-care for Resident #1. She stated she did not notice anything wrong with Resident #1's leg at that time. She said Resident #1's leg was not swollen and did not seem different from its normal contracted state. She said she and CNA D always try to help each other with Resident #1's care because it is easier to position and roll her with two people due to Resident #1's contracted extremities and broken arm. She stated she did not know if all staff had help when providing routine care for Resident #1 or if they completed care with Resident #1 alone. She stated Resident #1 did yell out when they turned her to change her . She said sometimes Resident #1 does yell or scream during care because she was startled, or protesting being bothered. She said she thought if Resident #1 experienced pain during peri-care repositioning, it may have been from Resident #1's broken arm. She stated she and CNA D were the only aides on duty during that time frame and there were two charge nurses. She said normally there were four aides overnight from 10:00 PM to 6:00 AM but due to the holiday and short staffing, there were only two aides. She said she did not feel there were adverse outcomes as a result of having less aides on the overnight shift. She said she knew the administrators tried to find out what happened to Resident #1 but no one was able to figure out what caused the injury to Resident #1. She said she heard through other staff that Resident #1's roommate heard a loud noise and then Resident #1 scream on the Saturday night before the injury was found. She said she has not heard of anything else happening to Resident #1 that would have caused the injury. In an interview on 12/07/2021 at 2:30 PM, CNA D stated she and CNA C worked together to provide peri-care for Resident #1 towards the end of their shift on the morning of 11/29/2021. She stated it is easier and safer to have two people for peri-care for positioning and rolling Resident #1 than by herself. She stated she did not observe any swelling, bruising or other signs of injury to Resident #1 during the last time they provided care to Resident #1. She said she did not see any signs of distress or pain in Resident #1 while providing care the morning of 11/29/2021. She said Resident #1 did not cry out in pain or make a loud sound during peri-care. She stated she has not heard from anyone what happened to Resident #1 to cause the fractured leg. She said she left at 6:00 AM on 11/29/2021 and was not aware of an injury being reported for Resident #1. An observation of video footage on 12/07/2021 at 2:45 PM reflected CNA C and CNA D providing peri-care to Resident #1 on 11/29/2021 at 4:42 AM. As CNA C and CNA D turned Resident #1 at 4:45:38 Resident #1 observed to cry out loudly and at 4:47:35 Resident #1's observed to grimace in pain. An observation of video footage on 12/07/2021 at 2:50 PM reflected RA A to enter Resident #1's room on 11/29/2021 at 6:12 AM and pull back the bedding and set the brace on the end of Resident #1's bed. RA A then looked at Resident #1's leg and touched Resident #1's leg. RA A observed to leave the room and return with LVN A. An observation of video footage on 12/07/2021 at 2:55 PM reflected CNA D providing peri-care for Resident #1 on 11/28/2021 at 4:50 AM (alone). CNA D observed to move Resident #1's leg and Resident #1 cried out in pain. CNA D then turned Resident #1 from her right side to left side quickly and Resident #1 observed to cry out louder. CNA D then completed Resident #1's care and repositioned Resident #1 and then covered Resident #1 with her blanket. An observation of video footage on 12/07/2021 at 3:00 PM reflected CNA E to provide peri-care to Resident #1 on 11/28/2021 at 9:39 AM. CNA E enters the room and then closed Resident #1's privacy curtain and the camera were no longer able to video Resident #1. At 9:40:50 AM Resident #1 was heard to cry out loudly from behind the curtain and CNA E was overheard to say sorry mama, I am just changing you. At 9:42:22 AM, 9:45:51 AM, 9:47:22, Resident #1 was heard to cry out additional times. At 9:47:41 AM CNA E left from behind the curtain and then returned to behind the curtain at 9:48:10 AM. At 9:48:12 AM Resident #1 heard to cry out and CNA D heard to say, I'm sorry. At 9:49:05 AM, the sound of the bed being lowered is heard and at 9:49:39 AM Resident #1 was heard to cry out. At 9:51:07 AM CNA E opened the curtain and left the room. In an interview on 12/08/2021 at 9:50 AM, LVN B arrived to work on 11/29/2021 and was told something was wrong with Resident #1's leg. She stated she saw Resident #1's leg and it was increasingly swollen and by 9:00 AM it was very swollen. She stated Resident #1's leg was dangling as in it was not as contracted and tight as it had been. She said she heard there had been an incident with the mechanical lift and Resident #1. She stated she heard from other staff that Resident #1's roommate told other staff that something happened and Resident #1 screamed. She said she heard Resident #2 said it happened on Saturday. In an interview on 12/08/2021 at 10:25 AM CNA E stated she worked over the weekend 11/27/2021 to 11/28/2021 and cared for Resident #1. She stated she did not see any injury or difference in Resident #1's leg when she provided care to Resident #1. She said she did not see any swelling or other indication on Resident #1's leg to indicate Resident #1 had a broken bone. She stated when she left her shift on 11/28/2021 at 2:00 PM, Resident #1's leg was normal. She stated she closed the curtain every time she provided peri-care to a resident. She stated if someone enters the room without knocking, they would be able to see Resident #1 unclothed. She stated Resident #1 was known to cry out during peri-care or care in general related to being disturbed or confused possibly. An observation on 12/08/2021 at 12:12 PM reflected DON watching video recorded of Resident #1 being provided care on 11/27/2021 at 12:55:38 AM by CNA F. DON observed to visibly react to video with distress and tears in her eyes. In an interview on 12/08/2021 at 12:14 PM DON stated she heard the noise and Resident #1 scream in pain. DON stated the noise was likely Resident #1's right leg breaking. DON stated the video was very upsetting and she had not seen that portion of the video before when RP A showed them video. DON stated that when CNA F was in the process of rolling Resident #1 from her right side to her left side while providing peri-care, CNA F must have pressed on the leg wrong and then when pushing with her body to roll the resident over, it must have broken Resident #1's femur. In an interview on 12/08/2021 at 2:34 PM MED DIR who was also the primary care physician for Resident #1 stated he was concerned about the fractured femur that Resident #1 suffered as it had to be caused by an external force. He stated the resident's health condition and contractures could not cause the extent of the fracture. He stated he did not think Resident #1 suffered the fracture when she broke her arm when she fell out of bed at the beginning of October 2021. He stated the x-rays showed the fracture to be recent and within 2-3 days prior to the finding of the injury. He stated it would take quite a bit of torque (rotation) on the resident's leg to cause the fracture. In an interview on 12/08/2021 at 3:00 PM ADMIN stated he did not know about the video in which CNA F was observed to be providing peri-care to Resident #1 and subsequently the pop was heard and Resident #1 screamed in pain. He stated he, the DON and the regional compliance nurse all viewed video with RP A and they did not see this part of the video. He stated based on what the DON saw in the video this was the incident that likely caused Resident #1's broken leg. In an interview on 12/08/2021 at 3:18 PM LVN D stated she worked overnight and provided care to Resident #1 on Saturday 11/27/2021 and Sunday 11/28/2021 from 10:00 PM to 6:00 AM. She stated she did not observe any injuries or signs of an injury on Resident #1. She stated there were no incidents or accidents she was aware of that would have caused the fractured femur in Resident #1. She stated she administered multiple medications via PEG tube and assessed Resident #1 during her shifts and had no concerns of Resident #1 having a fractured femur. In an interview on 12/08/2021 at 3:26 PM CNA E stated she worked with Resident #1 on the 2:00 PM - 10:00 PM shift on Friday 11/26/2021, Saturday 11/27/2021 and Monday 11/29/2021. She stated she did not observe any indications of an injury to Resident #1's leg or any increased signs of pain in Resident #1 when providing care to her. She stated she had another aide assist her when providing care to Resident #1 because it was easier and safer when turning and repositioning Resident #1. She stated when she arrived at work on Monday 11/29/2021 at 2:00 PM she observed Resident #1's leg to be looser and swollen. She stated she was not given any special instructions for caring for Resident #1 with the fractured leg. She said Resident #1's leg was significantly different on Monday 11/29/2021 from when she saw Resident #1's leg on Saturday 11/27/2021. In an interview on 12/08/2021 at 4:14 PM PHYS B stated he inserted a rod in Resident #1's leg to stabilize the femur and reduce pain for Resident #1 today at 3:00 PM. He stated Resident #1 had a spiral fracture of her right femur that would require some type of force or twisting on her leg to cause the break and displacement of the bone. He stated the break would not be caused by her health conditions or contractures. In an interview on 12/09/2021 at 9:45 AM PHYS A stated he has been treating Resident #1 for the fractured humerus caused from a fall out of bed on 10/09/2021. He stated he has previously examined Resident #1 and there was not a fractured femur, or any indication Resident #1 fractured her femur at the same time she fractured her humerus. He stated he referred Resident #1 the orthopedic surgeon (PHYS B) due to Resident #1 remaining in pain from the break and the femur was displaced. He stated the femur fracture would not have happened due to Resident #1's health conditions and contractures. He stated there had to be an accident or external force on Resident #1's leg to cause the fracture. He stated Resident #1 may have osteopenia (low bone density) as she was non-weight bearing and due to her age. He stated her bone could have snapped with moderate pressure or torque applied. In an interview on 12/09/2021 at 9:59 AM, RP A stated an additional concern she had regarding Resident #1's safety and well-being at the facility was that both injuries, the fractured right humerus and the fractured right femur, happened over the weekend and were not detected until Resident #1's routine staff returned on Monday morning. She stated she does not know how the staff did not realize Resident #1 had a broken arm and leg for two days. She stated she viewed video footage after Resident #1's fall on 10/09/2021 and observed Resident #1 not be positioned correctly which made it possible for Resident #1 to slide out of the bed and it caused Resident #1's fractured humerus. She stated she spoke with the aide that provided care and the aide admitted to her it was difficult to position Resident #1 with only one staff member. She stated the aide no longer worked at the facility but told RP A Resident #1 really needed two staff members to provide safe care. Record review of Staffing Assignment sheet dated 11/26/2021 revealed four aides and two nurses were scheduled for the 10:00 PM to 6:00 AM shift. It revealed there were two aides from 11:00 PM to 2:00 AM and one aide from 2:00 AM to 6:00 AM on the morning of 11/27/2021. There were two nurses from 10:00 PM to 6:00 AM for a total of three staff members in the building from 2:00 AM to 6:00 AM. Record review of Staffing Assignment sheet dated 11/27/2021 revealed four aides and two nurses were scheduled for the 10:00 PM to 6:00 AM shift. It revealed there were two aides and two nurses from 2:00 AM to 6:00 AM. Record review of Staffing Assignment sheet dated 11/28/2021 revealed four aides and two nurses were scheduled for the 10:00 PM to 6:00 AM shift. It revealed there three aides from 10:00 PM to 2:00 AM and two aides from 2:00 AM to 6:00 AM. There were two nurses from 10:00 PM to 6:00 AM shift. In an interview on 12/09/2021 at 11:20 AM DON stated the cause of Resident #1's fractured humerus in her arm was from a fall out of bed . She said this was serious bodily injury to Resident #1, but they confirmed with RP A Resident #1 was injured as a result of the fall and it was not r [TRUNCATED]

Based on interview and record review the facility failed to ensure each resident received adequate supervision to prevent accidents for one of three residents (Resident #1) reviewed for accidents. The facility failed to ensure Resident #1 was free from injury when provided routine care and assistance with ADL's which resulted in Resident #1 suffering a spiral fracture of her femur (thigh bone). This failure placed residents at risk of accidents, injuries, and a diminished quality of life. Findings included: Record review of face sheet for Resident #1 revealed Resident #1 to be a [AGE] year-old female admitted to the facility on [DATE] and has been diagnosed with [CONDITION(S)] (Stroke) with post-hemorrhagic brain damage, dysphagia (difficulty swallowing), muscle wasting and atrophy (muscle function break down), high blood pressure, contractures of all four limbs, [CONDITION(S)], muscle spasms, lack of coordination, and non-verbal. Record review of Resident #1 MDS quarterly assessment dated [DATE] revealed Resident #1 to have a BIMS (Baseline Interview for Mental Status) score of 0 to indicate Resident #1's cognitive status was severely impaired. The MDS assessment revealed Resident #1 to be non-verbal, immobile and totally dependent on staff for ADL care. The MDS assessment revealed Resident #1 to require tube feeding via a PEG tube in her abdomen as she was unable to safely eat food. Record review of Resident #1 care plan dated 10/26/21 revealed Resident #1 to have a communication problem and speech was unclear and never understood. Interventions included monitor/document for physical/ nonverbal indicators of discomfort or distress, and follow-up as needed and watch for any changes in facial expressions, any crying, moaning. The care plan also noted Resident #1 to have bowel and bladder incontinence and intervention included checking Resident #1 every two hours and provide incontinent care after every incontinent episode. The care plan revealed the focus of alteration in musculoskeletal status related to fracture of the right arm and right femur. With interventions to include anticipate and meet needs. Be sure call light is within reach and respond promptly to all requests for assistance, give analgesics as ordered by the physician, monitor and document for side effects and effectiveness, monitor for any side effects to NSAIDS such as GI bleeding or renal impairment and right immobilizer secured with 2 ace wraps. Check for skin break down Q shift and as needed. The care plan noted Resident #1 to have an ADL self-care deficit with interventions to include: o Bathing: requires staff x1 for assistance, dependent on staff for bathing needs and shower bed o Bed Mobility: dependent on staff for bed mobility, may require 2 staff members to reposition in bed, pull up to head of bed. o The resident requires a lift for all transfers, 2 staff members o Toilet use: requires staff x2 for assistance o DRESSING: The resident requires 1 - 2 staff assisted o Contractures, upper, lower extremities - needs asst with all aspects of daily care report to unit nurse any changes extremities for example: increase tightness, moaning, crying when providing care. Record review of Resident #1 emergency room Discharge Paperwork dated 11/29/2021 revealed Resident #1 to have an acute displaced spiral fracture of the right femur . Record review Resident #1 emergency room Discharge Paperwork dated 10/22/2021 revealed Resident #1 to have an acute humerus fracture of the right arm. In an interview on 12/07/2021 at 10:05 AM, ADMIN stated the facility conducted a full investigation of the injury to Resident #1 and was unable to discover the cause of the injury. He stated the facility interviewed all staff who had contact with Resident #1 from Friday 11/26/2021 and Monday 11/29/2021 and they were unable to determine there was any type of accident or incident that caused the fractured femur in Resident #1. He stated they believe Resident #1's fracture may be a result of her health conditions and the severe contracture in her right limb. He said the DON, the Regional Compliance Nurse, RP A and him viewed the video footage from the camera in Resident #1's room. He stated RP A had the camera placed in Resident #1's room a couple of years ago and viewed the footage over an app on her phone. He stated they viewed multiple instances of resident care with RP A and did not see any incident or accident that would have resulted in Resident #1 having a fractured femur. He stated there were no reports from staff of Resident #1 showing any changes through the course of the weekend to indicate an injury. In an interview on 12/07/2021 at 10:10 AM, DON stated she interviewed all facility staff, and no one knew how Resident #1 suffered a fractured femur. She stated she was notified of the injury to Resident #1 when she arrived at work on 11/29/2021 and saw Resident #1's right leg was swollen. She said Resident #1's leg was not as contracted which was a big change from its normal state. She stated they have not been unable to pinpoint when the injury happened or how it happened. When asked how the facility would prevent future injuries to Resident #1 if they do not know how this injury happened, DON replied she did not know. In an interview on 12/07/2021 at 10:55 AM, RP A stated she was concerned about Resident #1, , because Resident #1 had a broken leg and the physician told RP A something had to cause the broken leg. RP A stated she was notified by the facility after Thanksgiving that Resident #1 had a break in her upper leg on her right side and the facility told her they did not know how Resident #1 broke her leg. She stated when she first spoke with them on 11/29/2021, they requested that she check video footage from the camera she has in Resident #1's room to discover the cause of the fractured leg. RP A stated after reviewing video footage with the facility they did not see any video from 11/27/2021 to 11/29/2021 to explain the fractured femur. RP A stated there were times the privacy curtain around Resident #1 was closed and the resident could not be seen on the video but could be heard crying out in pain. She said in the days preceding the finding of the fractured leg, Resident #1 was in her bed the entire time and did not leave the room. She stated she spoke with Resident #1's orthopedic physician on 11/30/2021, regarding the broken arm and leg . She stated the physician expressed concern over the broken leg and that there was no explanation for how it happened. She stated the physician told her the fractured femur was a fresh break and had happened within the 2-3 days prior to the finding of the injury on 11/292/2021. She stated the physician told her the fracture had to be caused by a force exerted by something on Resident #1's leg and would not have happened due to Resident #1's contractures or other health conditions. She stated she expressed these concerns to the facility administration, and they continued to report to her they did not know how the injury happened. In an interview on 12/07/2021 at 10:55 AM, RP A she stated Resident #1 also suffered a broken right arm in October 2021 when Resident #1 fell out of her bed and hit the floor. She stated they called her and she watched the incident on video and was able to determine Resident #1's broken arm was an accident in October 2021. She stated she could see on the video footage that the CNA caring for Resident #1 did not reposition her correctly after providing care and Resident #1 slipped out of the bed and broke her right humerus (long bone in the arm that runs from the shoulder to the elbow) during the fall. She stated she spoke with the facility administrator and DON at the time and they corrected the issue. She stated she spoke with the aide as well and the aide stated to her, she should have gotten another staff member to assist her in repositioning Resident #1 because Resident #1's immobility makes it difficult to reposition her with only one staff member. An observation on 12/07/2021 at 11:31 AM reflected Resident #1 in bed with low air alarm beeping on her air mattress. In an interview on 12/07/2021 at 12:21 PM, PA A stated she was the physician assistant for Resident #1 and sees her weekly. She stated the broken arm and broken leg were separate incidents and the fall that caused the broken arm would not have caused the broken leg. She stated she was in the facility on the morning the restorative aide found Resident #1's leg to be injured. She stated staff asked her to look at it and she immediately noticed the significant swelling to the leg and that her leg was moving differently, as in not as a tightly contracted. She stated the type of fracture was a spiral fracture to indicate some type of force was needed to cause the fracture. She stated the two ends of the bone were completely displaced and no longer touching at all. She stated she had not been advised by the DON or facility administrator as to the cause of the injury. She stated the injury to Resident #1 was concerning because Resident #1 was immobile, nonverbal and unable to cause the injury on her own. She stated no one at the facility seems to know what happened to Resident #1. In an interview on 12/07/2021 at 1:01 PM, LVN A stated RA A reported to her that something was wrong with Resident #1's leg on the morning of 11/29/2021. She stated she examined Resident #1's leg and found it to be swollen and not as contracted as normal. She stated no one reported an injury or accident to her that would have caused Resident #1's fractured femur. She stated she has not heard whether a reason has been discovered for Resident #1's fractured femur. She said she worked Friday 11/26/2021, Saturday 11/27/2021 and Sunday 11/28/2021 but was not Resident #1's charge nurse and therefore did not provide any care specific to Resident #1. She said while at work over the three days she did not hear of an accident or anything with Resident #1 that would have caused the injury. She said the injury was apparent to her and should have been noticeable to other staff members. In an interview on 12/08/2021 at 10:37 AM, CNA F stated she worked with Resident #1 overnight Friday 11/26/2021 and Saturday 11/27/2021. She stated Resident #1 would scream in pain when she provided routine resident care or peri-care. She stated on Saturday night around 12:30 AM on 11/27/2021 she was providing peri-care to Resident #1 when she felt a pop in Resident #1's leg and Resident #1 screamed out in pain. She stated she continued to provide care to Resident #1 and the charge nurse came in to find out what was wrong with Resident #1. She said the charge nurse heard Resident #1 cry out from the nurses' station which is down the hallway with approximately four resident rooms away. She said the charge nurse brought back acetaminophen for Resident #1 because they both thought Resident #1 had increased pain from her arm fracture. She said Resident #1 did not have any swelling or other indication her leg was injured following her providing peri-care. She said later she thought Resident #1's leg was swollen but there was no change in Resident #1's leg. She said she did not provide any peri-care again on that shift and left at 6:00 AM on 11/27/2021. She said she was the only aide on duty from 2:00 AM until 6:00 AM. She said there were two charge nurses also on duty during that time. She said she would normally ask another aide to help with peri-care for Resident #1, because it was only her and the two charge nurses on duty she did not have anyone to ask for assistance. She said when she returned for her shift on 11/27/2021 at 10:00 PM she provided peri-care to Resident #1 and Resident #1 cried out when turned or repositioned her. She said she thought it was due to Resident #1's broken arm. She said she did not notice anything unusual about Resident #1's leg during the shift. She said she did not know Resident #1 was injured until she returned to work on Tuesday 11/30/2021 at 10:00 PM. She said she was told Resident #1 had a femur fracture. She said she and another aide went to provide peri-care to Resident #1 and both felt the bone move around in Resident #1's leg and it was shocking. She said they were not told any special instructions or trained on how to care for Resident #1 with the fractured femur. She said Resident #1 did cry out in pain during the peri-care at that time. An observation of video footage on 12/08/2021 at 11:43 AM reflected CNA F preparing to provide resident care to Resident #1 at 12:54:00 AM on 11/27/2021. At 12:55:38 CNA F moved Resident #1 and Resident #1 was heard to scream. CNA F then observed to roll Resident #1 from her right side to left side and a pop sound was heard followed by Resident #1 screaming very loudly. At 12:59:11 AM LVN C was seen to enter the screen on the right and have a conversation with CNA F. An observation of video on 12/08/2021 at 11:40 AM reflected LVN C administering medication to Resident #1 at 1:44:00 AM on 11/27/2021. An observation on 12/08/2021 at 12:12 PM reflected DON watching video recorded of Resident #1 on 11/27/2021 at 12:55:38 by CNA F. DON observed to visibly react to video with distress and tears in her eyes. In an interview on 12/08/2021 at 12:14 PM DON stated she heard the noise and Resident #1 scream in pain. DON stated the noise was likely Resident #1's right leg breaking. DON stated the video was very upsetting and she had not seen that portion of the video before when RP A showed them video. DON stated that when CNA F was in the process of rolling Resident #1 from her right side to her left side while providing peri-care, CNA F must have pressed on the leg wrong and then when pushing with her body to roll the resident over, it must have broken Resident #1's femur. In an interview on 12/08/2021 at 2:34 PM MED DIR and primary care physician for Resident #1 stated he was concerned about the fractured femur that Resident #1 suffered as it had to be caused by an external force. He stated the Resident #1's health condition and contractures could not cause the extent of the fracture. He stated he did not think Resident #1 suffered the fracture when she broke her arm when she fell out of bed at the beginning of October 2021. He stated the x-rays showed the fracture to be recent and within 2-3 days prior to the finding of the injury. He stated it would take quite a bit of torque on the resident's leg to cause the fracture. In an interview on 12/08/2021 at 3:00 PM ADMIN stated he did not know about the video in which CNA F was observed to be providing peri-care to Resident #1 and subsequently the pop is heard and Resident #1 screams in pain. He stated he, the DON and the regional compliance nurse all viewed video with RP A and they did not see this part of the video. He stated based on what the DON saw in the video this was the incident that likely caused Resident #1's broken leg. In an interview on 12/08/2021 at 3:26 PM CNA E stated she worked with Resident #1 on the 2:00 PM - 10:00 PM shift on Friday 11/26/2021, Saturday 11/27/2021 and Monday 11/29/2021. She stated she had another aide assist her when providing care to Resident #1 because it was easier and safer when turning and repositioning Resident #1. She stated she was not given any special instructions for caring for Resident #1 with the fractured leg. She said Resident #1's leg was significantly different on Monday 11/29/2021 from when she saw Resident #1's leg on Saturday 11/27/2021. In an interview on 12/07/2021 at 1:46 PM, CNA C stated she worked with Resident #1 overnight from 10:00 AM to 6:00 PM shift on 11/28/2021. She stated she and CNA D made their last rounds between 3:30 AM and 4:00 AM on the morning of 11/29/2021 and provided peri-care for Resident #1. She stated she did not notice anything wrong with Resident #1's leg at that time. She said Resident #1's leg was not swollen and did not seem different from its normal contracted state. She said she and CNA D always try to help each other with Resident #1's care because it is easier to position and roll her with two people due to Resident #1's contracted extremities and broken arm. She stated she did not know if all staff had help when providing routine care for Resident #1 or if they completed care with Resident #1 alone. She said she knew the administrators tried to find out what happened to Resident #1 but no one was able to figure out what caused the injury to Resident #1. She said she heard through other staff that Resident #1's roommate heard a loud noise and then Resident #1 scream on the Saturday night before the injury was found. She said she has not heard of anything else happening to Resident #1 that would have caused the injury. In an interview on 12/07/2021 at 2:30 PM, CNA D stated she and CNA C worked together to provide peri-care for Resident #1 towards the end of their shift on the morning of 11/29/2021. She stated it is easier and safer to have two people for peri-care for positioning and rolling Resident #1 than by herself. In an interview on 12/08/2021 at 4:14 PM PHYS B stated he inserted a rod in Resident #1's leg to stabilize the femur and reduce pain for Resident #1 today at 3:00 PM. He stated Resident #1 had a spiral fracture of her right femur that would require some type of force or twisting on her leg to cause the break and displacement of the bone. He stated the break would not be caused by her health conditions or contractures. In an interview on 12/09/2021 at 9:45 AM PHYS A stated he has been treating Resident #1 for the fractured humerus caused from a fall out of bed on 10/09/2021. He stated he has previously examined Resident #1 and there was not a fractured femur or any indication Resident #1 fractured her femur at the same time she fractured her humerus. He stated he referred Resident #1 the orthopedic surgeon PHYS B due to Resident #1 remaining in pain from the break and the femur was displaced. He stated the femur fracture would not have happened due to Resident #1's health conditions and contractures. He stated there had to be an accident or external force on Resident #1's leg to cause the fracture. He stated Resident #1 may have osteopenia (low bone density) as she was non-weight bearing and due to her age. He stated her bone could have snapped with moderate pressure or torque applied. In an interview on 12/09/2021 at 9:59 AM, RP A stated an additional concern she had regarding Resident #1's safety and well-being at the facility was that both injuries, the fractured right humerus and the fractured right femur, happened over the weekend and were not detected until Resident #1's routine staff returned on Monday morning. She stated she does not know how the staff did not realize Resident #1 had a broken arm and leg for two days. She stated she viewed video footage after Resident #1's fall on 10/09/2021 and observed Resident #1 not be positioned correctly which made it possible for Resident #1 to slide out of the bed and it caused Resident #1's fractured humerus. She stated she spoke with the aide that provided care and the aide admitted to her it was difficult to position Resident #1 with only one staff member. She stated the aide no longer worked at the facility but told RP A Resident #1 really needed two staff members to provide safe care. Record review of Staffing Assignment sheet dated 11/26/2021 revealed four aides and two nurses were scheduled for the 10:00 PM to 6:00 AM shift. It revealed there were two aides from 11:00 PM to 2:00 AM and one aide from 2:00 AM to 6:00 AM on the morning of 11/27/2021. There were two nurses from 10:00 PM to 6:00 AM for a total of three staff members in the building from 2:00 AM to 6:00 AM. Record review of Staffing Assignment sheet dated 11/27/2021 revealed four aides and two nurses were scheduled for the 10:00 PM to 6:00 AM shift. It revealed there were two aides and two nurses from 2:00 AM to 6:00 AM. Record review of Staffing Assignment sheet dated 11/28/2021 revealed four aides and two nurses were scheduled for the 10:00 PM to 6:00 AM shift. It revealed there three aides from 10:00 PM to 2:00 AM and two aides from 2:00 AM to 6:00 AM. There were two nurses from 10:00 PM to 6:00 AM shift. In an interview on 12/09/2021 at 11:20 AM DON stated the fractured femur from routine peri-care for Resident #1 was not a result of abuse and was not an intentional injury. She stated the injury seems to have happened when CNA F was turning Resident #1. She stated the cause of Resident #1's fractured humerus in her arm was from a fall out of bed. She said she did not know how Resident #1 was able to fall out of bed as she is immobile and unable to reposition herself. She said they did not investigate if there were any factors that contributed to Resident #1 falling out of bed. She said there were no changes made regarding Resident #1's routine care like always having two aides to provide peri-care and repositioning. She said she had not heard that Resident #1 was not being positioned correctly contributed to Resident #1's fall out of bed. DON stated CNAs were trained on working with residents with contractures and repositioning residents. She stated she would try to find the training materials or policy regarding what was best practice for Resident #1. In an interview on 12/09/2021 at 3:25 PM CNA A stated she and another aide completed peri-care with Resident #1 prior to her leaving. She stated she always has another aide assist her when providing care to Resident #1 because it is difficult to turn and re-position Resident #1 with only one person. She stated she has been working with Resident #1 for over a year and knows her well. She stated it would be difficult for someone to know how to care for Resident #1 safely if you did not know Resident #1 very well due Resident #1's contractures. She stated she does not believe the facility did any specific training for caring for Resident #1 after the arm fracture or the leg fracture. She said there were no changes made in the way they care for Resident #1 or a change that would ensure two caregivers provide peri-care to Resident #1. She stated her CNA training provided her with what she needed to know to care for a resident with contractures. Record review of policy Abuse/Neglect dated March 2018 revealed an Injury of Unknown Source is any injury to a resident where the source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and the injury is suspicious because of the extend of the injury or the location of the injury or the number of injuries observed at one particular point in time or the incidence of injuries over time. The facility will identify and investigate events that my constitute abuse/neglect. The policy further revealed comprehensive investigations will include injuries of unknown source. Record review of CNA Proficiency Audit undated revealed a check-off list to include transfers that require 1-person, 2-person and Hoyer lift assistance. The training check-off list also included range of motion, perineal care for men and women, turns/reposition residents timely/correctly and reports changes in condition promptly. There was not a training checkoff for caring for residents with contractures.

Based on observation, interview and record review the facility failed to provide the required structures and processes in order to meet the needs of one or more residents to prevent neglect for one (1) of four (4) residents (Resident # 1) reviewed for neglect. The facility failed to ensure interventions were in place for Resident #1 who refused his showers and skin assessments consistently for six months. On 10/10/2018 Resident #1 was found to have an untreated and previously unidentified gangrenous infection with osteo[DIAGNOSES REDACTED] of his left great toe. Resident #1's left great toe was noted to be at the point of falling off when admitted to the hospital on [DATE]. These failures resulted in an Immediate Jeopardy situation on 10/12/2018. While the IJ was removed on 10/12/2018, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy with a scope of isolated due to the facility's need for monitoring the implementation of their corrective actions. These failures could cause pain, and lead to systemic infections causing harm for residents that have refusal behavior. Findings include: Review of Resident #1's Face Sheet reflected an [AGE] year-old male admitted to the facility on [DATE] with the following Diagnosis: [REDACTED]. Review of Resident #1's Quarterly Minimum Date Set ((MDS) dated [DATE] reflected Resident #1 was assessed to have a Brief Interview of Mental Status (BIMS) score of 14 indicating Resident #1 was cognitively intact. Resident #1 was assessed to not have behaviors and to reject care one (1) to three (3) days a week. Resident #1 was assessed to require extensive assistance with bed mobility and transfer. Resident #1 was further assessed to require total assistance with toilet use. Resident #1 was assessed to require physical help with one (1) staff for bathing. Resident #1 was assessed to not have any skin conditions. Review of Resident #1's Comprehensive Care Plan Reflected Resident #1 had a problem with the start date 12/05/2017 for ADL (activities of daily living) functional, listed was Resident #1 required staff assist times one (1) for bathing, dressing and personal hygiene. Listed under approaches Bathing with staff assist x 1; Do not force care upon me. Notify MD (Medical Doctor) and RP (Responsible Party) if problems arise; Dressing with staff assist x 1; Encourage independence, praise with attempts are made; if I am resistive to care please leave me alone and try later or have a different care giver try . Hand written at the bottom of the ADL care plan 6/1/2018 Resident refuses care, refuses baths and refuses skin assessments. Will refuse assistance with care from CNA's. No approaches were listed for this behavior. No behavioral care plan was noted. Review of Resident #1's ADL Flow Sheet dated (MONTH) (YEAR) reflected Resident #1 was to have a bath on Tuesdays, Thursdays and Saturdays. Resident #1's ADL Flow Sheet reflected Resident #1 had a bath on (MONTH) 3rd, 5th, 12th and 14th. Resident #1 was coded to have refused the rest of (MONTH) (YEAR). Review of Resident #1's Nursing Assistant Daily Body Observation Forms reflected Resident #1 had been refusing his baths back to 04/19/18. The facility was unable to produce any further documentation. In an interview on 10/12/2018 the DON stated she could not find any Daily Body Observation sheets for Resident #1 dated after 04/19/18. Review of Resident #1's ADL Flow Sheet for (MONTH) (YEAR) could not be located by facility. Review of Resident #1's Weekly Skin Assessments dated 06/15/2018 through 10/02/2018 reflected Resident #1 refused all weekly skin assessments. Review of Resident #1's ADL Flow Sheet dated (MONTH) (YEAR) reflected Resident #1 refused all baths. Review of Resident #1's ADL Flow Sheet dated (MONTH) (YEAR) reflected Resident #1 accepted a bath on the 24th. No other baths were documented. Review of Resident #1's ADL Flow Sheets for August, (MONTH) and (MONTH) (YEAR) reflected Resident #1 refused all baths. Review of Resident #1's Weekly Skin assessment dated [DATE] reflected Resident #1 was assessed to have redness to back and a necrotic left big toe. Review of Resident #1's Nursing Progress Noted dated 10/10/2018 (no time) reflected Called to shower room via wound care nurse to view left great toe. Resident sitting in w/c (wheelchair) in shower room alert and oriented to self and place. Resident Left great toe noted to be dark black with skin cracking and slight redress to 2nd and 3rd base, noted to have scant amount of purulent drainage. Interviewed staff about condition of left great toe and staff reported that resident refuses showers, and care when attempted to provide. Resident denied having any pain or discomfort to left great toe, stated that his toe has been like that. Note signed by the ADON. Review of Resident #1 Hospital Transfer Form dated 10/10/2018 (no time) reflected Left great toe infection, falling off. Review of Resident #1's Emergency Department (ED) Physician Documentation dated 10/10/2018 reflected Resident #1 arrived at the hospital at 12:56 PM. The patient presents with pain, that is acute, necrosis .Patient states that he has pain to both feet, but the pain is worse on the left .Diagnosis: [REDACTED].Necrotic left great toe with osteo[DIAGNOSES REDACTED] revealed by x-ray. Review of Resident #1's Hospital History and Physical exam dated 10/10/2018 reflected Resident #1 is a very pleasant [AGE] year-old Caucasian gentleman with past medical history of [REDACTED].sent to ED for evaluation of left toe severe infection and gangrenous changes and almost falling off. As per nursing home the patient was refusing to be checked out or to take a bath for the last couple days and today he allowed them to wash him and this is when they found out about the toe. As per the patient, he has been having pain and discomfort in that foot for a few months .Assessment and Plan: 1. Gangrenous infection with osteo[DIAGNOSES REDACTED] of the left great toe with area of [MEDICAL CONDITION]. No signs [MEDICAL CONDITION]. Ortho static surgery consulted .Arterial Doppler both lower extremities was done which revealed severe peripheral artery disease . In an Observation/ interview on 10/12/2018 at 2:00 PM Resident #1 was in the hospital in bed. Resident #1's room had the distinctive odor of gangrene in the room. Resident #1 stated they had not taken his toe off yet. Resident #1 stated he told the nurses at the nursing home about his toe. Resident #1 was asked if the nurses at the nursing home checked his skin and he stated yes. Resident #1 was asked when the last time his skin was checked. Resident #1 stated he did not know. Resident #1 stated his foot had been hurting for a while. Resident #1 stated he was worried about his toe. (Resident #1 appeared drowsy and somewhat confused.) In an interview on 10/12/2018 at 2:05 PM Resident #1's Family Member (FM) was at bedside. Resident #1's FM stated Resident #1 had been refusing his baths. Resident #1's FM stated she went to facility once a week and Resident #1 did not tell her anything about his foot. Resident #1's FM stated she did not know how long Resident #1 had been refusing to take a bath. Resident #1's FM stated the first she had heard Resident #1 had a problem with his toe was when he was sent to the hospital. In an interview on 10/12/2018 at 3:35 PM Resident #1 Physician stated he did not know anything about Resident #1's toe till his (NP) Nurse practitioner told him the facility found the toe and sent him to the ER. Resident #1's Physician stated the facility should have seen it or known about it. Resident #1's Physician stated wet gangrene smells, dry gangrene does not, someone should have smelled it. Resident #1's Physician stated the facility had not told him Resident #1 was refusing his baths for so long. Resident #1's Physician stated the condition of Resident #1's toe did not happen in 24 hours it had been going on for a while. In an interview on 10/12/2018 at 4:20 PM CNA D stated prior to Wednesday's (10/10/2018) bath when Resident #1's wound was found on his toe she could not remember the last time Resident #1 had a bath. CNA D stated on Wednesday Resident #1's roommate complained about the smell in the room, stating he could not take it anymore. CNA D stated she noted blood on Resident #1's bottom sheet and asked him where it had come from. CNA D stated Resident #1 didn't know. CNA D stated she notified the nurse. CNA D stated RN A the wound care nurse was in the building, so they asked if he would request Resident #1 to take a bath. CNA D stated they thought maybe he would agree for a male. CNA D stated Resident #1 agreed, and they discovered the condition of his toe. In an interview on 10/12/2018 at 5:00 PM MA C stated she noticed the smell of Resident #1. MA C stated she did not provide any direct care, but she gave him medication. MA C stated she did smell an odor for about a month. MA C stated she thought it was because he did not bath. In an interview on 10/12/2018 at 5:18 PM the DON stated she did not realize Resident #1 had not had a bath since (MONTH) until she looked into the situation after Resident #1 was sent to the hospital. The DON stated she did not know his behaviors were not care planned. The DON stated she did not know why the situation was allowed to gone on as long as it did. When the DON was asked why the doctor was not brought in to assess Resident #1 when he continued to refuse care the DON did not answer. The DON stated the facility should have done more about his refusal behavior. In an interview on 10/12/2018 CNA E stated when asked if she noticed a foul odor in Resident #1's room she stated she did from time to time but because she suffered a car accident it affected her sense of smell. CNA E stated she was aware Resident #1 refused to take showers but denied knowing how long since his last shower. CNA E associated his odor with the lack of showers. In an interview on 10/12/2018 at 5:36 PM RN A stated he was the facility's wound care nurse. RN A stated Resident #1 had been refusing his skin checks for a while. RN A stated Resident #1 got a rash last (MONTH) and allowed him to check his skin for several months. RN A stated when the rash was better, and he was no longer itching Resident #1 refused to let him look at his skin anymore. When asked, RN A stated he did notice a smell when he attempted to check Resident #1's skin, but he associated smell with the fact that Resident #1 was refusing to take a shower. In an interview on 10/12/2018 at 5:50 PM the Administrator stated it was the resident's right to refuse care. The Administrator stated she did not know Resident #1 had not had a bath since April. The Administrator stated she tried to set up a care plan conference with daughter and she did not come. When the Administrator was asked why interventions were not put into place regarding Resident #1's behavior or why she did not investigate the cause of Resident #1's continual refusals for care the Administrator stated it was the resident's right to refuse. When the Administrator was asked if she thought Resident #1's behavior had reached a point where it was unhealthy the Administrator stated what are we supposed to do. You will just write me up for dragging the resident to the shower. When asked if Resident #1's physician had been notified regarding his behavior she stated no. Review of the website: https://www.webmd.com/skin-problems-and-treatments/guide/gangrene-causes-symptoms-treatments#1: reflected Gangrene is a condition that occurs when body tissue dies. It is caused by a loss of blood supply due to an underlying illness, injury, and/or infection. Fingers, toes, and limbs are most often affected, but gangrene can also occur inside the body, damaging organs and muscles. There are different types of gangrene and all require immediate medical attention. Further review of the website reflected [DIAGNOSES REDACTED] is an infection of the bone, a rare but serious condition. Bones can become infected in a number of ways: Infection in one part of the body may spread through the bloodstream into the bone, or an open fracture or surgery may expose the bone to infection. Review of the facility's policy Abuse- Reportable Events dated 01/2008 reflected It is the responsibility of all facility staff to prohibit resident abuse or neglect in any form, an to report in accordance with the law any incident/event in which there is cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person .Neglect as defined in 42 CFR (483.5)- The failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. The Facility's Administrator and DON were notified on 10/12/2018 at 5:50 PM that an IJ (Immediate Jeopardy) situation had been identified due to the above failures in quality of care. The facility's first Plan of Removal (POR) was submitted by the Administrator on 10/12/2018 at 7:14 PM. The final Plan of Removal was accepted the survey team on 10/12/2018 at 8:15 PM. Review of the facility's POR reflected Action Plan for Resident Refusal: All licensed nursing staff will be in-serviced on the following Action Plan for Refusal of shower/ skin assessments. 1. If a resident refuses a shower: *The individual attempting the shower will notify charge nurse of refusal. *Charge Nurse will meet with resident to determine if an alternative intervention will work for the resident. *If resident continues to refuse document in Red on 24-hour report and document on shower sheet. *The 24-hour report will be reviewed at each morning stand-up meeting for refusal. *If resident refuses three (3) consecutive scheduled showers the RP will be notified, and NP will be notified via communication book. *Care plan meeting with family will be scheduled to determine/ explore interventions and behavior modification which include psychiatric services and appropriate necessary intervention. *The Administrator or DON will review the shower sheets each week to ensure the policy is being followed and the appropriate levels of interventions are being recommended. 2. If a resident refuses a skin assessment: *The individual attempting the skin assessment will notify ADON/ DON of refusal. *ADON/ DON will meet with resident to determine if an alternative intervention will work for the resident. *If resident continues to refuse document in Red on 24-hour report and document on skin assessment form. *The 24-hour report will be reviewed at each morning stand-up meeting for refusal. *If resident refuses three (3) consecutive skin assessments the RP will be notified, and NP will be notified via communication book. *Care plan meeting with family will be scheduled to determine/ explore interventions and behavior modification which include psychiatric services and appropriate necessary intervention. *The Administrator or DON will review the skin assessments sheets each week to ensure the policy is being followed and the appropriate levels of interventions are being recommended. Monitoring for the Plan of Removal began on 10/12/2018 at 8:15 PM. Staff were interviewed for understanding regarding the new procedure regarding resident's refusal of showers or skin assessments. All staff interviewed had a good understanding of the training. Approximately 80 % of the staff had received their training. On 10/12/2018 at 8:49 PM the IJ was removed. However, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy with a scope of isolated due to the facility requiring time to train all staff and monitor their plan of removal.

Based on observation, interview and record review, the facility failed to ensure that based on the comprehensive assessment of a resident, the facility ensured residents received treatment and care in accordance with professional standards of practice, and the comprehensive person-centered plan of care for one (1) of four (4) residents reviewed for quality of care. (Resident #1) The facility failed to ensure appropriate assessments had been conducted and treatments were in place for Resident #1 who refused his showers and skin assessments consistently for six months. On 10/10/2018 Resident #1 was found to have an untreated and previously unidentified gangrenous infection with osteo[DIAGNOSES REDACTED] of his left great toe. Resident #1's left great toe was noted to be at the point of falling off when admitted to the hospital on [DATE]. These failures resulted in an Immediate Jeopardy situation on 10/12/2018. While the IJ was removed on 10/12/2018, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy with a scope of isolated due to the facility's need for monitoring the implementation of their corrective actions. These failures could cause pain, and lead to systemic infections causing harm for residents that have refusal behavior. Findings include: Review of Resident #1's Face Sheet reflected an [AGE] year-old male admitted to the facility on [DATE] with the following Diagnosis: [REDACTED]. Review of Resident #1's Quarterly Minimum Date Set ((MDS) dated [DATE] reflected Resident #1 was assessed to have a Brief Interview of Mental Status (BIMS) score of 14 indicating Resident #1 was cognitively intact. Resident #1 was assessed to not have behaviors and to reject care one (1) to three (3) days a week. Resident #1 was assessed to require extensive assistance with bed mobility and transfer. Resident #1 was further assessed to require total assistance with toilet use. Resident #1 was assessed to require physical help with one (1) staff for bathing. Resident #1 was assessed to not have any skin conditions. Review of Resident #1's Comprehensive Care Plan Reflected Resident #1 had a problem with the start date 12/05/2017 for ADL (activities of daily living) functional, listed was Resident #1 required staff assist times one (1) for bathing, dressing and personal hygiene. Listed under approaches Bathing with staff assist x 1; Do not force care upon me. Notify MD (Medical Doctor) and RP (Responsible Party) if problems arise; Dressing with staff assist x 1; Encourage independence, praise with attempts are made; if I am resistive to care please leave me alone and try later or have a different care giver try . Hand written at the bottom of the ADL care plan 6/1/2018 Resident refuses care, refuses baths and refuses skin assessments. Will refuse assistance with care from CNA's. No approaches were listed for this behavior. No behavioral care plan was noted. Review of Resident #1's ADL Flow Sheet dated (MONTH) (YEAR) reflected Resident #1 was to have a bath on Tuesdays, Thursdays and Saturdays. Resident #1's ADL Flow Sheet reflected Resident #1 had a bath on (MONTH) 3rd, 5th, 12th and 14th. Resident #1 was coded to have refused the rest of (MONTH) (YEAR). Review of Resident #1's Nursing Assistant Daily Body Observation Forms reflected Resident #1 had been refusing his baths back to 04/19/18. The facility was unable to produce any further documentation. In an interview on 10/12/2018 the DON stated she could not find any Daily Body Observation sheets for Resident #1 dated after 04/19/18. Review of Resident #1's ADL Flow Sheet for (MONTH) (YEAR) could not be located by facility. Review of Resident #1's Weekly Skin Assessments dated 06/15/2018 through 10/02/2018 reflected Resident #1 refused all weekly skin assessments. Review of Resident #1's ADL Flow Sheet dated (MONTH) (YEAR) reflected Resident #1 refused all baths. Review of Resident #1's ADL Flow Sheet dated (MONTH) (YEAR) reflected Resident #1 accepted a bath on the 24th. No other baths were documented. Review of Resident #1's ADL Flow Sheets for August, (MONTH) and (MONTH) (YEAR) reflected Resident #1 refused all baths. Review of Resident #1's Weekly Skin assessment dated [DATE] reflected Resident #1 was assessed to have redness to back and a necrotic left big toe. Review of Resident #1's Nursing Progress Noted dated 10/10/2018 (no time) reflected Called to shower room via wound care nurse to view left great toe. Resident sitting in w/c (wheelchair) in shower room alert and oriented to self and place. Resident Left great toe noted to be dark black with skin cracking and slight redress to 2nd and 3rd base, noted to have scant amount of purulent drainage. Interviewed staff about condition of left great toe and staff reported that resident refuses showers, and care when attempted to provide. Resident denied having any pain or discomfort to left great toe, stated that his toe has been like that. Note signed by the ADON. Review of Resident #1 Hospital Transfer Form dated 10/10/2018 (no time) reflected Left great toe infection, falling off. Review of Resident #1's Emergency Department (ED) Physician Documentation dated 10/10/2018 reflected Resident #1 arrived at the hospital at 12:56 PM. The patient presents with pain, that is acute, necrosis .Patient states that he has pain to both feet, but the pain is worse on the left .Diagnosis: [REDACTED].Necrotic left great toe with osteo[DIAGNOSES REDACTED] revealed by x-ray. Review of Resident #1's Hospital History and Physical exam dated 10/10/2018 reflected Resident #1 is a very pleasant [AGE] year-old Caucasian gentleman with past medical history of [REDACTED].sent to ED for evaluation of left toe severe infection and gangrenous changes and almost falling off. As per nursing home the patient was refusing to be checked out or to take a bath for the last couple days and today he allowed them to wash him and this is when they found out about the toe. As per the patient, he has been having pain and discomfort in that foot for a few months .Assessment and Plan: 1. Gangrenous infection with osteo[DIAGNOSES REDACTED] of the left great toe with area of [MEDICAL CONDITION]. No signs [MEDICAL CONDITION]. Ortho static surgery consulted .Arterial Doppler both lower extremities was done which revealed severe peripheral artery disease . In an Observation/ interview on 10/12/2018 at 2:00 PM Resident #1 was in the hospital in bed. Resident #1's room had the distinctive odor of gangrene in the room. Resident #1 stated they had not taken his toe off yet. Resident #1 stated he told the nurses at the nursing home about his toe. Resident #1 was asked if the nurses at the nursing home checked his skin and he stated yes. Resident #1 was asked when the last time his skin was checked. Resident #1 stated he did not know. Resident #1 stated his foot had been hurting for a while. Resident #1 stated he was worried about his toe. (Resident #1 appeared drowsy and somewhat confused.) In an interview on 10/12/2018 at 2:05 PM Resident #1's Family Member (FM) was at bedside. Resident #1's FM stated Resident #1 had been refusing his baths. Resident #1's FM stated she went to facility once a week and Resident #1 did not tell her anything about his foot. Resident #1's FM stated she did not know how long Resident #1 had been refusing to take a bath. Resident #1's FM stated the first she had heard Resident #1 had a problem with his toe was when he was sent to the hospital. In an interview on 10/12/2018 at 3:35 PM Resident #1 Physician stated he did not know anything about Resident #1's toe till his (NP) Nurse practitioner told him the facility found the toe and sent him to the ER. Resident #1's Physician stated the facility should have seen it or known about it. Resident #1's Physician stated wet gangrene smells, dry gangrene does not, someone should have smelled it. Resident #1's Physician stated the facility had not told him Resident #1 was refusing his baths for so long. Resident #1's Physician stated the condition of Resident #1's toe did not happen in 24 hours it had been going on for a while. In an interview on 10/12/2018 at 4:20 PM CNA D stated prior to Wednesday's (10/10/2018) bath when Resident #1's wound was found on his toe she could not remember the last time Resident #1 had a bath. CNA D stated on Wednesday Resident #1's roommate complained about the smell in the room, stating he could not take it anymore. CNA D stated she noted blood on Resident #1's bottom sheet and asked him where it had come from. CNA D stated Resident #1 didn't know. CNA D stated she notified the nurse. CNA D stated RN A the wound care nurse was in the building, so they asked if he would request Resident #1 to take a bath. CNA D stated they thought maybe he would agree for a male. CNA D stated Resident #1 agreed, and they discovered the condition of his toe. In an interview on 10/12/2018 at 5:00 PM MA C stated she noticed the smell of Resident #1. MA C stated she did not provide any direct care, but she gave him medication. MA C stated she did smell an odor for about a month. MA C stated she thought it was because he did not bath. In an interview on 10/12/2018 at 5:18 PM the DON stated she did not realize Resident #1 had not had a bath since (MONTH) until she looked into the situation after Resident #1 was sent to the hospital. The DON stated she did not know his behaviors were not care planned. The DON stated she did not know why the situation was allowed to gone on as long as it did. When the DON was asked why the doctor was not brought in to assess Resident #1 when he continued to refuse care the DON did not answer. The DON stated the facility should have done more about his refusal behavior. In an interview on 10/12/2018 CNA E stated when asked if she noticed a foul odor in Resident #1's room she stated she did from time to time but because she suffered a car accident it affected her sense of smell. CNA E stated she was aware Resident #1 refused to take showers but denied knowing how long since his last shower. CNA E associated his odor with the lack of showers. In an interview on 10/12/2018 at 5:36 PM RN A stated he was the facility's wound care nurse. RN A stated Resident #1 had been refusing his skin checks for a while. RN A stated Resident #1 got a rash last (MONTH) and allowed him to check his skin for several months. RN A stated when the rash was better, and he was no longer itching Resident #1 refused to let him look at his skin anymore. When asked, RN A stated he did notice a smell when he attempted to check Resident #1's skin, but he associated smell with the fact that Resident #1 was refusing to take a shower. In an interview on 10/12/2018 at 5:50 PM the Administrator stated it was the resident's right to refuse care. The Administrator stated she did not know Resident #1 had not had a bath since April. The Administrator stated she tried to set up a care plan conference with daughter and she did not come. When the Administrator was asked why interventions were not put into place regarding Resident #1's behavior or why she did not investigate the cause of Resident #1's continual refusals for care the Administrator stated it was the resident's right to refuse. When the Administrator was asked if she thought Resident #1's behavior had reached a point where it was unhealthy the Administrator stated what are we supposed to do. You will just write me up for dragging the resident to the shower. When asked if Resident #1's physician had been notified regarding his behavior she stated no. Review of the website: https://www.webmd.com/skin-problems-and-treatments/guide/gangrene-causes-symptoms-treatments#1: reflected Gangrene is a condition that occurs when body tissue dies. It is caused by a loss of blood supply due to an underlying illness, injury, and/or infection. Fingers, toes, and limbs are most often affected, but gangrene can also occur inside the body, damaging organs and muscles. There are different types of gangrene and all require immediate medical attention. Further review of the website reflected [DIAGNOSES REDACTED] is an infection of the bone, a rare but serious condition. Bones can become infected in a number of ways: Infection in one part of the body may spread through the bloodstream into the bone, or an open fracture or surgery may expose the bone to infection. Review of the facility's policy Abuse- Reportable Events dated 01/2008 reflected It is the responsibility of all facility staff to prohibit resident abuse or neglect in any form, an to report in accordance with the law any incident/event in which there is cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person .Neglect as defined in 42 CFR (483.5)- The failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. The Facility's Administrator and DON were notified on 10/12/2018 at 5:50 PM that an IJ (Immediate Jeopardy) situation had been identified due to the above failures in quality of care. The facility's first Plan of Removal (POR) was submitted by the Administrator on 10/12/2018 at 7:14 PM. The final Plan of Removal was accepted the survey team on 10/12/2018 at 8:15 PM. Review of the facility's POR reflected Action Plan for Resident Refusal: All licensed nursing staff will be in-serviced on the following Action Plan for Refusal of shower/ skin assessments. 1. If a resident refuses a shower: *The individual attempting the shower will notify charge nurse of refusal. *Charge Nurse will meet with resident to determine if an alternative intervention will work for the resident. *If resident continues to refuse document in Red on 24-hour report and document on shower sheet. *The 24-hour report will be reviewed at each morning stand-up meeting for refusal. *If resident refuses three (3) consecutive scheduled showers the RP will be notified, and NP will be notified via communication book. *Care plan meeting with family will be scheduled to determine/ explore interventions and behavior modification which include psychiatric services and appropriate necessary intervention. *The Administrator or DON will review the shower sheets each week to ensure the policy is being followed and the appropriate levels of interventions are being recommended. 2. If a resident refuses a skin assessment: *The individual attempting the skin assessment will notify ADON/ DON of refusal. *ADON/ DON will meet with resident to determine if an alternative intervention will work for the resident. *If resident continues to refuse document in Red on 24-hour report and document on skin assessment form. *The 24-hour report will be reviewed at each morning stand-up meeting for refusal. *If resident refuses three (3) consecutive skin assessments the RP will be notified, and NP will be notified via communication book. *Care plan meeting with family will be scheduled to determine/ explore interventions and behavior modification which include psychiatric services and appropriate necessary intervention. *The Administrator or DON will review the skin assessments sheets each week to ensure the policy is being followed and the appropriate levels of interventions are being recommended. Monitoring for the Plan of Removal began on 10/12/2018 at 8:15 PM. Staff were interviewed for understanding regarding the new procedure regarding resident's refusal of showers or skin assessments. All staff interviewed had a good understanding of the training. Approximately 80 % of the staff had received their training. On 10/12/2018 at 8:49 PM the IJ was removed. However, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy with a scope of isolated due to the facility requiring time to train all staff and monitor their plan of removal.

Based on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living (ADL) received the necessary services to maintain good personal hygiene for one (1) of four (4) residents reviewed for ADLs (Residents #1). The facility failed to ensure interventions were in place for Resident #1 who refused his showers consistently for six months. On 10/10/2018 Resident #1 was found to have an untreated and previously unidentified gangrenous infection with osteo[DIAGNOSES REDACTED] of his left great toe. Resident #1's left great toe was noted to be at the point of falling off when admitted to the hospital on [DATE]. These failures resulted in an Immediate Jeopardy situation on 10/12/2018. While the IJ was removed on 10/12/2018, the facility remained out of compliance at a severity level of actual harm that is not immediate Jeopardy at a scope of isolated due to the facility's need for monitoring the implementation of their corrective actions. This failure to provide routine showers could lead to systemic infections causing harm and a decreased sense of self-esteem for residents that have refusal behavior. Findings include: Review of Resident #1's Face Sheet reflected an [AGE] year-old male admitted to the facility on [DATE] with the following Diagnosis: [REDACTED]. Review of Resident #1's Quarterly Minimum Date Set ((MDS) dated [DATE] reflected Resident #1 was assessed to have a Brief Interview of Mental Status (BIMS) score of 14 indicating Resident #1 was cognitively intact. Resident #1 was assessed to not have behaviors and to reject care one (1) to three (3) days a week. Resident #1 was assessed to require extensive assistance with bed mobility and transfer. Resident #1 was further assessed to require total assistance with toilet use. Resident #1 was assessed to require physical help with one (1) staff for bathing. Resident #1 was assessed to not have any skin conditions. Review of Resident #1's Comprehensive Care Plan Reflected Resident #1 had a problem with the start date 12/05/2017 for ADL (activities of daily living) functional, listed was Resident #1 required staff assist times one (1) for bathing, dressing and personal hygiene. Listed under approaches Bathing with staff assist x 1; Do not force care upon me. Notify MD (Medical Doctor) and RP (Responsible Party) if problems arise; Dressing with staff assist x 1; Encourage independence, praise with attempts are made; if I am resistive to care please leave me alone and try later or have a different care giver try . Hand written at the bottom of the ADL care plan 6/1/2018 Resident refuses care, refuses baths and refuses skin assessments. Will refuse assistance with care from CNA's. No approaches were listed for this behavior. No behavioral care plan was noted. Review of Resident #1's ADL Flow Sheet dated (MONTH) (YEAR) reflected Resident #1 was to have a bath on Tuesdays, Thursdays and Saturdays. Resident #1's ADL Flow Sheet reflected Resident #1 had a bath on (MONTH) 3rd, 5th, 12th and 14th. Resident #1 was coded to have refused the rest of (MONTH) (YEAR). Review of Resident #1's Nursing Assistant Daily Body Observation Forms reflected Resident #1 had been refusing his baths back to 04/19/18. The facility was unable to produce any further documentation. In an interview on 10/12/2018 the DON stated she could not find any Daily Body Observation sheets for Resident #1 dated after 04/19/18. Review of Resident #1's ADL Flow Sheet for (MONTH) (YEAR) could not be located by facility. Review of Resident #1's Weekly Skin Assessments dated 06/15/2018 through 10/02/2018 reflected Resident #1 refused all weekly skin assessments. Review of Resident #1's ADL Flow Sheet dated (MONTH) (YEAR) reflected Resident #1 refused all baths. Review of Resident #1's ADL Flow Sheet dated (MONTH) (YEAR) reflected Resident #1 accepted a bath on the 24th. No other baths were documented. Review of Resident #1's ADL Flow Sheets for August, (MONTH) and (MONTH) (YEAR) reflected Resident #1 refused all baths. Review of Resident #1's Weekly Skin assessment dated [DATE] reflected Resident #1 was assessed to have redness to back and a necrotic left big toe. Review of Resident #1's Nursing Progress Noted dated 10/10/2018 (no time) reflected Called to shower room via wound care nurse to view left great toe. Resident sitting in w/c (wheelchair) in shower room alert and oriented to self and place. Resident Left great toe noted to be dark black with skin cracking and slight redress to 2nd and 3rd base, noted to have scant amount of purulent drainage. Interviewed staff about condition of left great toe and staff reported that resident refuses showers, and care when attempted to provide. Resident denied having any pain or discomfort to left great toe, stated that his toe has been like that. Note signed by the ADON. Review of Resident #1 Hospital Transfer Form dated 10/10/2018 (no time) reflected Left great toe infection, falling off. Review of Resident #1's Emergency Department (ED) Physician Documentation dated 10/10/2018 reflected Resident #1 arrived at the hospital at 12:56 PM. The patient presents with pain, that is acute, necrosis .Patient states that he has pain to both feet, but the pain is worse on the left .Diagnosis: [REDACTED].Necrotic left great toe with osteo[DIAGNOSES REDACTED] revealed by x-ray. Review of Resident #1's Hospital History and Physical exam dated 10/10/2018 reflected Resident #1 is a very pleasant [AGE] year-old Caucasian gentleman with past medical history of [REDACTED].sent to ED for evaluation of left toe severe infection and gangrenous changes and almost falling off. As per nursing home the patient was refusing to be checked out or to take a bath for the last couple days and today he allowed them to wash him and this is when they found out about the toe. As per the patient, he has been having pain and discomfort in that foot for a few months .Assessment and Plan: 1. Gangrenous infection with osteo[DIAGNOSES REDACTED] of the left great toe with area of [MEDICAL CONDITION]. No signs [MEDICAL CONDITION]. Ortho static surgery consulted .Arterial Doppler both lower extremities was done which revealed severe peripheral artery disease . In an Observation/ interview on 10/12/2018 at 2:00 PM Resident #1 was in the hospital in bed. Resident #1's room had the distinctive odor of gangrene in the room. Resident #1 stated they had not taken his toe off yet. Resident #1 stated he told the nurses at the nursing home about his toe. Resident #1 was asked if the nurses at the nursing home checked his skin and he stated yes. Resident #1 was asked when the last time his skin was checked. Resident #1 stated he did not know. Resident #1 stated his foot had been hurting for a while. Resident #1 stated he was worried about his toe. (Resident #1 appeared drowsy and somewhat confused.) In an interview on 10/12/2018 at 2:05 PM Resident #1's Family Member (FM) was at bedside. Resident #1's FM stated Resident #1 had been refusing his baths. Resident #1's FM stated she went to facility once a week and Resident #1 did not tell her anything about his foot. Resident #1's FM stated she did not know how long Resident #1 had been refusing to take a bath. Resident #1's FM stated the first she had heard Resident #1 had a problem with his toe was when he was sent to the hospital. In an interview on 10/12/2018 at 3:35 PM Resident #1 Physician stated he did not know anything about Resident #1's toe till his (NP) Nurse practitioner told him the facility found the toe and sent him to the ER. Resident #1's Physician stated the facility should have seen it or known about it. Resident #1's Physician stated wet gangrene smells, dry gangrene does not, someone should have smelled it. Resident #1's Physician stated the facility had not told him Resident #1 was refusing his baths for so long. Resident #1's Physician stated the condition of Resident #1's toe did not happen in 24 hours it had been going on for a while. In an interview on 10/12/2018 at 4:20 PM CNA D stated prior to Wednesday's (10/10/2018) bath when Resident #1's wound was found on his toe she could not remember the last time Resident #1 had a bath. CNA D stated on Wednesday Resident #1's roommate complained about the smell in the room, stating he could not take it anymore. CNA D stated she noted blood on Resident #1's bottom sheet and asked him where it had come from. CNA D stated Resident #1 didn't know. CNA D stated she notified the nurse. CNA D stated RN A the wound care nurse was in the building, so they asked if he would request Resident #1 to take a bath. CNA D stated they thought maybe he would agree for a male. CNA D stated Resident #1 agreed, and they discovered the condition of his toe. In an interview on 10/12/2018 at 5:00 PM MA C stated she noticed the smell of Resident #1. MA C stated she did not provide any direct care, but she gave him medication. MA C stated she did smell an odor for about a month. MA C stated she thought it was because he did not bath. In an interview on 10/12/2018 at 5:18 PM the DON stated she did not realize Resident #1 had not had a bath since (MONTH) until she looked into the situation after Resident #1 was sent to the hospital. The DON stated she did not know his behaviors were not care planned. The DON stated she did not know why the situation was allowed to gone on as long as it did. When the DON was asked why the doctor was not brought in to assess Resident #1 when he continued to refuse care the DON did not answer. The DON stated the facility should have done more about his refusal behavior. In an interview on 10/12/2018 CNA E stated when asked if she noticed a foul odor in Resident #1's room she stated she did from time to time but because she suffered a car accident it affected her sense of smell. CNA E stated she was aware Resident #1 refused to take showers but denied knowing how long since his last shower. CNA E associated his odor with the lack of showers. In an interview on 10/12/2018 at 5:36 PM RN A stated he was the facility's wound care nurse. RN A stated Resident #1 had been refusing his skin checks for a while. RN A stated Resident #1 got a rash last (MONTH) and allowed him to check his skin for several months. RN A stated when the rash was better, and he was no longer itching Resident #1 refused to let him look at his skin anymore. When asked, RN A stated he did notice a smell when he attempted to check Resident #1's skin, but he associated smell with the fact that Resident #1 was refusing to take a shower. In an interview on 10/12/2018 at 5:50 PM the Administrator stated it was the resident's right to refuse care. The Administrator stated she did not know Resident #1 had not had a bath since April. The Administrator stated she tried to set up a care plan conference with daughter and she did not come. When the Administrator was asked why interventions were not put into place regarding Resident #1's behavior or why she did not investigate the cause of Resident #1's continual refusals for care the Administrator stated it was the resident's right to refuse. When the Administrator was asked if she thought Resident #1's behavior had reached a point where it was unhealthy the Administrator stated what are we supposed to do. You will just write me up for dragging the resident to the shower. When asked if Resident #1's physician had been notified regarding his behavior she stated no. Review of the website: https://www.webmd.com/skin-problems-and-treatments/guide/gangrene-causes-symptoms-treatments#1: reflected Gangrene is a condition that occurs when body tissue dies. It is caused by a loss of blood supply due to an underlying illness, injury, and/or infection. Fingers, toes, and limbs are most often affected, but gangrene can also occur inside the body, damaging organs and muscles. There are different types of gangrene and all require immediate medical attention. Further review of the website reflected [DIAGNOSES REDACTED] is an infection of the bone, a rare but serious condition. Bones can become infected in a number of ways: Infection in one part of the body may spread through the bloodstream into the bone, or an open fracture or surgery may expose the bone to infection. Review of the facility's policy Abuse- Reportable Events dated 01/2008 reflected It is the responsibility of all facility staff to prohibit resident abuse or neglect in any form, an to report in accordance with the law any incident/event in which there is cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person .Neglect as defined in 42 CFR (483.5)- The failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. The Facility's Administrator and DON were notified on 10/12/2018 at 5:50 PM that an IJ (Immediate Jeopardy) situation had been identified due to the above failures in quality of care. The facility's first Plan of Removal (POR) was submitted by the Administrator on 10/12/2018 at 7:14 PM. The final Plan of Removal was accepted the survey team on 10/12/2018 at 8:15 PM. Review of the facility's POR reflected Action Plan for Resident Refusal: All licensed nursing staff will be in-serviced on the following Action Plan for Refusal of shower/ skin assessments. 1. If a resident refuses a shower: *The individual attempting the shower will notify charge nurse of refusal. *Charge Nurse will meet with resident to determine if an alternative intervention will work for the resident. *If resident continues to refuse document in Red on 24-hour report and document on shower sheet. *The 24-hour report will be reviewed at each morning stand-up meeting for refusal. *If resident refuses three (3) consecutive scheduled showers the RP will be notified, and NP will be notified via communication book. *Care plan meeting with family will be scheduled to determine/ explore interventions and behavior modification which include psychiatric services and appropriate necessary intervention. *The Administrator or DON will review the shower sheets each week to ensure the policy is being followed and the appropriate levels of interventions are being recommended. 2. If a resident refuses a skin assessment: *The individual attempting the skin assessment will notify ADON/ DON of refusal. *ADON/ DON will meet with resident to determine if an alternative intervention will work for the resident. *If resident continues to refuse document in Red on 24-hour report and document on skin assessment form. *The 24-hour report will be reviewed at each morning stand-up meeting for refusal. *If resident refuses three (3) consecutive skin assessments the RP will be notified, and NP will be notified via communication book. *Care plan meeting with family will be scheduled to determine/ explore interventions and behavior modification which include psychiatric services and appropriate necessary intervention. *The Administrator or DON will review the skin assessments sheets each week to ensure the policy is being followed and the appropriate levels of interventions are being recommended. Monitoring for the Plan of Removal began on 10/12/2018 at 8:15 PM. Staff were interviewed for understanding regarding the new procedure regarding resident's refusal of showers or skin assessments. All staff interviewed had a good understanding of the training. Approximately 80 % of the staff had received their training. On 10/12/2018 at 8:49 PM the IJ was removed. However, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy with a scope of isolated due to the facility requiring time to train all staff and monitor their plan of removal.

Based on interview and record review the facility failed to implement written policies and procedures that prohibit neglect for one (1) of six (6) residents reviewed for neglect (Resident # 5) when: 1. The facility nursing staff failed to accurately assess Resident # 5 for pain and when pain was evident failed to administer ordered PRN (as needed) pain medication. 2. The facility nursing staff failed to ensure Resident # 5's ordered pain medication was available in the facility after Resident # 5 returned from the emergency room with a new [DIAGNOSES REDACTED]. realigned)of the distal femur (lower end of the thigh bone where the femur attaches to the knee). 3. The facility failed to coordinate with Resident # 5's Hospice Agency after Resident # 5 returned from the emergency room with a new [DIAGNOSES REDACTED]. This deficient practice resulted in Resident # 5 experiencing unnecessary pain and placed an additional 45 residents who require routine and PRN pain medication at risk for experiencing pain. Findings include: Review of the facility policy entitled Abuse-Reportable Events last revised ,[DATE] reflected the following: .Neglect: The failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Review of the facility contract with the hospice agency dated [DATE] reflected the following: .Obligations of Provider .The Provider shall immediately notify the Hospice designated Patient Care Coordinator, Medical Director or other designated representative in the event of any of the following: Changes in the Patient's physical, mental, social or emotional status or condition(s); if clinical complications occur that suggest a need to alter the Hospice Plan of Care; if a need to transfer the Patient arises . Review of Resident # 5's Face Sheet reflected a [AGE] year old female admitted to the facility on [DATE] with the following Diagnosis: [REDACTED]. Review of Resident # 5's Significant Change of Condition Minimum Data Set (MDS) Assessment, dated [DATE], reflected Resident # 5 had a severely impaired cognitive status, required total assistance of two (2) staff for transfers and bathing, and total assistance of one (1) staff for all other Activities of Daily Living (ADL's). Resident # 5 was assessed as receiving no routine or PRN (as needed) pain medication or experiencing pain during the assessment period. Review of Resident # 5's Comprehensive Care Plan, last updated on [DATE] reflected an identified problem with alteration in mobility secondary to a fracture (not specific as to location) with the following interventions: requires two (2) staff to be transferred with the assistance of a mechanical lift, and to log roll when in bed. A second problem identified in the Comprehensive Care Plan was Resident # 5 receiving services from a hospice agency with the following interventions: Coordinate care with the hospice agency, and administer pain medication if needed. Review of Resident # 5's telephone order dated [DATE] at 7:10 AM reflected a telephone order for an x-ray of the right hip & (and) right femur. A second telephone order written on [DATE] (no time) reflected the x-rays were to be discontinued since Resident # 5 was not experiencing pain. Review of Resident # 5's Nurses Notes dated [DATE] at 6:45 AM reflected that CNA's (no names given) reported Resident # 5 was complaining of pain to the left leg when attempting to perform incontinent care. The Nurses Notes also reflected that Resident # 5's physician was notified, an order was received for an x-ray of Resident # 5's left hip and femur, and LVN D (,[DATE] shift) was notified of the new order. In an interview on [DATE] at 4:50 AM, LVN C stated on [DATE] she was working later into the 6:00 AM-2:00 PM shift until the day charge arrived. LVN C stated two (2) day shift CNA's (could not remember who) told LVN C Resident # 5 had complained of pain when they had attempted to reposition Resident # 5 during incontinent care. LVN C stated when she initially assessed Resident # 5 the resident did not appear in pain, but when LVN C assisted the CNA's in repositioning Resident # 5 she hollered out in pain. LVN C stated she informed ADON A of her assessment. LVN C stated after ADON A assessed Resident # 5 ADON A told LVN C she could not see any bruising or swelling to Resident # 5's legs or thighs, but told LVN C to call Resident # 5's physician since Resident # 5 appeared to be in pain earlier. LVN C stated she called Resident # 5's physician, and obtained an order for [REDACTED].# 5's hollering out when repositioned and the order for an x-ray to the left hip and femur. LVN C stated LVN D had called her at home to clarify the x-ray was to be of the left hip and femur. Review of Resident # 5's Nurses Notes dated [DATE] at 8:30 AM reflected LVN D notified Hospice of the order for an x-ray, Resident # 5's physician that Resident # 5 had no swelling, bruising or complaint of pain/discomfort, and obtained an order from Resident # 5's physician to discontinue the order for x-rays. In an interview on [DATE] at 10:15 AM LVN D stated when she arrived at work she was told by LVN C that someone had reported Resident # 5 was in pain and LVN C had obtained an order for [REDACTED].# 5, the resident had no swelling, bruising or indication she was in pain. LVN D stated she reported her findings to Resident # 5's physician, who instructed her to discontinue the order for an x-ray. LVN D stated she never asked the CNA's working the 6:00 AM-2:00 PM shift if Resident # 5 was experiencing any pain, since she expected the CNA's to notify her if Resident # 5 had any pain. LVN D stated she did not reassess Resident # 5 again during her shift for any signs or symptoms of pain. In an interview on [DATE] at 7:50 AM ADON A stated on [DATE] she had been at the facility and had assessed Resident # 5 at the request of LVN C. ADON A stated she understood from LVN C that the 10:00 PM-6:00 AM aides had reported Resident # 5 in pain. ADON A stated she went to assess Resident # 5 and observed no sign of bruising or swelling and no indication of pain. ADON A stated she did not ask the 6:00 AM-2:00 PM CNA's caring for Resident # 5 if they had observed Resident # 5 in pain. ADON A stated she did not work on [DATE]. In an interview on [DATE] at 8:05 AM, ADON B stated she did see Resident # 5 on [DATE] at the request of LVN D. ADON B stated she does not remember the exact time, but it was early on [DATE]. ADON B stated when she observed Resident # 5's left thigh was swollen, she did no other assessment and told LVN D to call Resident # 5's physician and have the CNA's return Resident # 5 to bed with LVN D being present. ADON B stated she left the facility between 10:,[DATE]:00 AM and expected LVN D would have informed her of any problems or concerns. In an interview on [DATE] at 9:00 AM, CNA K stated at the beginning of her shift on [DATE], she and CNA L had attempted to perform incontinent care when Resident # 5 hollered out as if she was in pain. CNA K stated it looked like Resident # 5's left thigh was swollen. CNA K stated they informed LVN C, who came to assess Resident # 5. CNA K stated LVN C told her to leave Resident # 5 in bed, and LVN C would contact Resident # 5's physician. In an interview on [DATE] at 9:15 AM, CNA L stated on [DATE] at approximately 6:30 AM Resident # 5 hollered out in pain when she and CNA K attempted to perform incontinent care. CNA L stated she was standing on Resident # 5's left side and when she touched her thigh it felt like something was moving under Resident # 5's skin. CNA L stated Resident # 5's left thigh appeared swollen to her. CNA L stated she and CNA K had notified LVN C of Resident # 5's pain. CNA L stated LVN C told her Resident # 5's thigh did not look swollen to her, but she would contact Resident # 5's physician regarding the pain. CNA L stated she did not report Resident # 5 being in pain to LVN D since she had already reported the problem to LVN C, who stated she would notify Resident # 5's physician of the pain. Review of Resident # 5's Nurses Notes dated [DATE] at 7:00 AM by LVN D reflected Resident # 5's left knee was shaking, and her thigh appeared swollen and warm to touch. LVN D's Nurses Notes reflected the following, Res (Resident) in obvious pain & (and) facial grimacing, medicated with Tylenol & order for x-ray to L (Left) thigh, hip & knee. Review of Resident # 5's Nurses Notes dated [DATE] at 12:30 PM ( five hours and thirty minutes after Resident # 5 was assess by LVN D to be experiencing pain) reflected the mobile x-ray employee arrived at the facility. The mobile x-ray employee was unable to perform the ordered x-rays secondary to Resident # 5 having contractures and experiencing pain with movement. The Nurses Notes also reflected an order was obtained to send Resident # 5 to the hospital emergency room for the x-rays. Review of the Medication Administration Record [REDACTED]. In an interview on [DATE], LVN D stated at the beginning of her shift on [DATE], the 6:00 AM-2:00 PM CNA's came to her and stated Resident # 5 was in pain. LVN D stated Resident # 5 was sitting up in a Geri-chair in her room. LVN D stated Resident # 5's upper thigh was hot and swollen, Resident # 5 had a look on her face as if in pain and was hitting at LVN D when she attempted to touch Resident # 5's thigh. LVN D stated she assisted the CNA's (could not remember who the aides were) to transfer Resident # 5 back to bed using a hoyer lift (mechanical lift). LVN D stated when Resident # 5 was returned to bed her left thigh did not appear as swollen as it had been while up in the G-chair. LVN D stated the left thigh looked simular to the appearance on [DATE] when she had assessed Resident # 5. LVN D stated when the mobile x-ray employee arrived at the facility at 12:30 PM, she had assisted the mobile x-ray employee in attempting to obtain the ordered x-rays. LVN D stated when she and the mobile x-ray employee attempted to position Resident # 5's left leg for an x-ray Resident # 5 made a fist with her hands and yelled out Don't do that. LVN D stated she called Resident # 5's physician and obtained an order to transfer Resident # 5 to the hospital emergency room to obtain the ordered x-rays. LVN D stated she did not administer Resident # 5 any other medication for pain since approximately 7:30 AM that morning (five hours later) since she was sending Resident # 5 to the emergency room . In an interview on [DATE] at 9:00 AM, CNA K stated on [DATE] she and CNA L notified LVN D of Resident # 5 experiencing pain and having a swollen left thigh. CNA K stated LVN D and ADON-B assessed Resident # 5 and then she, another CNA (can't remember who) and LVN D returned Resident # 5 to bed. CNA K stated Resident # 5's thigh looked the same to her on [DATE] when she first reported Resident # 5 was experiencing pain to LVN C. In an interview on [DATE] at 9:15 AM CNA L stated on [DATE] Resident # 5 she thought Resident # 5 had the same amount of swelling to her thigh on [DATE] as she had on [DATE]. CNA L stated she and CNA K notified LVN D of Resident # 5 being in pain and the swelling on [DATE] at the beginning of the day shift. CNA L stated Resident # 5 would appear to tense her body when providing care on [DATE] and [DATE]. CNA L stated she never saw Resident # 5 do this prior to [DATE]. In an interview on [DATE] at 1:20 PM, CMA J stated CNA K and CNA L had asked her to look at Resident # 5's leg on [DATE] at approximately 6:45 AM. CMA J stated Resident # 5's left thigh was huge and looked like, the elephant man. CMA J stated when she lightly touched Resident # 5's left thigh Resident # 5 screamed out in pain. CMA J told CNA K and CNA L to notify LVN D. CMA J stated the charge nurses administer PRN medications, so LVN D would make the determination regarding Resident # 5's need for PRN pain medication. Review of ambulance transfer records dated [DATE] at 1:19 PM for Resident # 5 reflected a facility nurse informed the ambulance employees that on [DATE] Resident # 5 seemed in pain and had a noticeable deformity to her left leg from an unknown cause. The assessment completed by the ambulance paramedic reflected the following: swelling to the left outer thigh with slight deformity compared to the right leg. The assessment was difficult to complete secondary to Resident # 5 having her legs locked at 90 degree angle and contractures in both knees. Review of the hospital emergency room record revealed Resident # 5 was admitted to the emergency roiagnom on [DATE] at 1:25 PM (55 minutes after LVN D had assessed Resident # 5 to be experiencing pain. Review of the emergency room physician notes reflected the following: Extremities: noted in the left upper left distal aspect: pain, swelling, ROM (Range of Motion): Pain with any passive ROM of the left leg. Review of the two (2) views of the left femur x-rays report reflected Resident # 5 had an acute traumatic, closed, comminuted, and significantly displaced [MEDICAL CONDITION] femoral and severe osteopenia. Review of the hospital emergency room physician notes reflected the following emergency room course of treatment: .In this non-ambulatory, contracted patient, it is concerning as to how she sustained this fracture . Further review of the hospital emergency room record for Resident # 5 reflected Resident # 5 was medicated with [MEDICATION NAME] 10 mg IM (Intramuscular) and the emergency room physician placed a splint to stabilize Resident # 5's leg. Resident # 5 was discharged from the emergency room and transported back to the nursing home on [DATE] at 4:04 PM, with a prescription for Tylenol # 3 ,[DATE] mg tablet, take one (1) tablet PO every six (6) hours as needed for pain. In an interview on [DATE] at 7:30 AM, the emergency room Physician stated she was concerned regarding the severity of Resident # 5's fracture to the left femur. The emergency room Physician stated with the way the femur bone had fractured and the number of bone fragments observed on the x-ray it could have only occurred with a traumatic event. She stated she applied a splint to Resident # 5's leg in an attempt to assist with pain control, but felt Resident # 3 would need pain medication related to the severity of the fracture. The emergency room Physician stated she notified Resident # 5's personal physician of her concerns regarding the severity and type of fracture. Review of the Texas Department of Aging and Disability Services Incident Investigation Worksheet reflected the DON of the facility reported Resident # 5 had a fracture of unknown origin on [DATE]. Review of Resident # 5's Nurses Notes dated [DATE] at 1:30 am Resident # 5 was described as awake, and had a grimace on her face. When LVN E asked if she was in pain, Resident # 5 nodded her head yes. Resident # 5 was documented to have received Tylenol 500 mg one (1) tablet instead of the ordered Tylenol # 3 one (1) tablet due to the Tylenol # 3 had not been delivered to the facility yet (over 9 hours after being readmitted to the facility). Review of Resident # 5's Nurses Notes dated [DATE] at 7:50 AM and 1:15 PM reflected Resident # 5 stated she was in pain when asked by LVN F. LVN F documented on both occasions she administered Tylenol 500 mg one (1) tablet instead of the Tylenol # 3 one (1) tablet. Review of Resident # 5's Nurses Notes reflected no other pain medication was given until [DATE] at 7:20 AM when LVN F administered Resident # 5 [MEDICATION NAME] 15 mg orally was administered. Further review of Resident # 5's Nurses Notes and Resident # 5's [DATE] Medication Administration Record [REDACTED]. In an interview on [DATE] LVN F stated she could not administer Resident # 5's Tylenol # 3 ordered on [DATE] from the hospital emergency room physician since it still was not in the facility on [DATE]. She stated since Resident # 5 had an order for [REDACTED].# 5 was in pain and realized no one had administered any pain medication to Resident # 5 since her shift had ended at 2:00 PM the previous day. LVN F stated she was going to administer Resident # 5 [MEDICATION NAME] 15 mg PO again for pain at 1:15 PM, but Resident # 5's daughter had refused to let her administer the [MEDICATION NAME] since the daughter wanted Resident # 5 awake for Resident # 5's 100th birthday party. LVN F stated when she discovered the pharmacy had not delivered the Tylenol # 3 on [DATE] she faxed the prescription to the facility pharmacy. LVN F stated she did not call the pharmacy to see why the Tylenol # 3 had not been delivered, or notified any nursing administrative staff of the problem. LVN F stated she did not notify hospice Resident # 5 had a new fracture with a new order for Tylenol # 3 since the pain medication was not related to her hospice [DIAGNOSES REDACTED]. In an interview on [DATE] at 9:36 AM, a representative of the contracted pharmacy stated the pharmacy received the order from the facility on [DATE] at 9:27 PM (over five (5) hours after Resident # 5 returned to the facility). The representative stated the pharmacy did not fill the Tylenol # 3 prescription since Resident # 5 was receiving hospice services. The representative stated the pharmacy would not have notified the facility since the facility was aware of this policy. In an interview on [DATE] at 11:07 AM the Hospice DON stated after reviewing Resident # 5's hospice record and all telephone correspondence with the facility that there was no documentation that the hospice agency was notified of Resident # 5's fracture or having a new prescription for pain (Tylenol # 3) until the Hospice Nurse made a routine scheduled visit on [DATE]. The Hospice DON stated if the facility had notified the hospice agency they would have obtained and provided the Tylenol # 3 for Resident # 5 and made a visit to assess Resident # 5's level of pain. In an interview on [DATE] at 3:08 PM the Hospice Nurse stated she was unaware Resident # 5 had a new fracture or a new order for Tylenol # 3 until she reviewed Resident # 5's nursing home clinical record on [DATE] at approximately 2:30 PM. The Hospice Nurse stated when she assessed Resident # 5 she had a grimace on her face and was clinching her hands into a fist, both indicators of pain. The Hospice Nurse stated she notified a facility staff member (did not have the employee name) who was standing at the medication cart that Resident # 5 needed medication for pain. The Hospice Nurse stated she did not see the facility staff member administer the pain medication. The Hospice Nurse stated she did write an order for [REDACTED]. In an interview on [DATE] at 2:15 PM, LVN G stated she worked the evenings of ,[DATE], ,[DATE] and [DATE]. She stated Resident # 5 did not appear in pain to her during her shift on any of the three (3) evening shifts she worked. LVN G stated Resident # 5 did not require any PRN pain medication for her after she was diagnosed with [REDACTED]. LVN G stated LVN's give all the PRN pain medications to residents so she would be aware if Resident # 5 needed or received any pain medication. LVN G stated on [DATE] she only administered the routine [MEDICATION NAME] 15 mg at 9:00 PM. Review of Resident # 5's Nurses Notes reflected she expired in the facility on [DATE] at 8:05 AM when she was found to not have a heart beat, blood pressure or respirations. In an interview on [DATE] at 1:10 PM, the DON stated she expected the nurses to obtain a mobile x-ray within three (3) to four (4) hours from when ordered by the physician if a resident is in pain. The DON stated the charge nurses are to notify hospice when a resident has a change in condition, which would include a new fracture or a new prescription for pain medication. The DON also stated if residents do not receive medication from the facility pharmacy the charge nurse should call the pharmacy and notify one of the ADON's or the DON. In an interview on [DATE] at 1:10 PM Resident # 5's physician stated he became aware of Resident # 5's fracture on [DATE] when he received a telephone call from the emergency room Physician. Resident # 5's physician stated he notified the facility in order to determine how the fracture had occurred. Resident # 5's physician stated he was informed the facility was unable to determine the cause of the fracture. Resident # 5's physician stated normally the type of fracture Resident # 5 sustained is caused by some sort of trauma. He stated even though he was informed Resident # 5 had no problems with pain control, he would have expected the facility to have had the Tylenol # 3 ordered by the emergency room Physician in the facility as soon as possible in case Resident # 5 experienced pain. Resident # 5's physician stated Resident # 5's death was related to her advanced age and not related to the recent fracture. Review of the facility policy entitled Abuse-Reportable Events last revised ,[DATE] reflected the following: .Neglect: The failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Review of the facility contract with the hospice agency dated [DATE] reflected the following: .Obligations of Provider .The Provider shall immediately notify the Hospice designated Patient Care Coordinator, Medical Director or other designated representative in the event of any of the following: Changes in the Patient's physical, mental, social or emotional status or condition(s); if clinical complications occur that suggest a need to alter the Hospice Plan of Care; if a need to transfer the Patient arises . The facility provided a list of 45 residents who receive routine and/or PRN pain medications. .

Based on interview and record review the facility failed to implement written policies and procedures that prohibit neglect for one (1) of six (6) residents reviewed for neglect (Resident # 5) when: 1. The facility nursing staff failed to accurately assess Resident # 5 for pain and when pain was evident failed to administer ordered PRN (as needed) pain medication. 2. The facility nursing staff failed to ensure Resident # 5's ordered pain medication was available in the facility after Resident # 5 returned from the emergency room with a new [DIAGNOSES REDACTED]. realigned) of the distal femur (lower end of the thigh bone where the femur attaches to the knee). 3. The facility failed to coordinate with Resident # 5's Hospice Agency after Resident # 5 returned from the emergency room with a new [DIAGNOSES REDACTED]. This deficient practice resulted in Resident # 5 experiencing unnecessary pain and placed an additional 45 residents who require routine and/or PRN pain medication at risk for experiencing pain. Findings include: Review of Resident # 5's Closed Record Face Sheet reflected a [AGE] year old female admitted to the facility on [DATE] with the following Diagnosis: [REDACTED]. Review of Resident # 5's Significant Change of Condition Minimum Data Set (MDS) Assessment, dated [DATE], reflected Resident # 5 had a severely impaired cognitive status, required total assistance of two (2) staff for transfers and bathing, and total assistance of one (1) staff for all other Activities of Daily Living (ADL's). Resident # 5 was assessed as receiving no routine or PRN (as needed) pain medication or experiencing pain during the assessment period. Review of Resident # 5's Comprehensive Care Plan, last updated on [DATE] reflected an identified problem with alteration in mobility secondary to a fracture (not specific as to location) with the following interventions: requires two (2) staff to be transferred with the assistance of a mechanical lift, and to log roll when in bed. A second problem identified in the Comprehensive Care Plan was Resident # 5 receiving services from a hospice agency with the following interventions: Coordinate care with the hospice agency, and administer pain medication if needed. Review of Resident # 5's telephone order dated [DATE] at 7:10 AM reflected a telephone order for an x-ray of the right hip & (and) right femur. A second telephone order written on [DATE] (no time) reflected the x-rays were to be discontinued since Resident # 5 was not experiencing pain. Review of Resident # 5's Nurses Notes dated [DATE] at 6:45 AM reflected that CNA's (no names given) reported Resident # 5 was complaining of pain to the left leg when attempting to perform incontinent care. The Nurses Notes also reflected that Resident # 5's physician was notified, an order was received for an x-ray of Resident # 5's left hip and femur, and LVN D (,[DATE] shift) was notified of the new order. In an interview on [DATE] at 4:50 AM, LVN C stated on [DATE] she was working later into the 6:00 AM-2:00 PM shift until the day charge arrived. LVN C stated two (2) day shift CNA's (could not remember who) told LVN C Resident # 5 had complained of pain when they had attempted to reposition Resident # 5 during incontinent care. LVN C stated when she initially assessed Resident # 5 the resident did not appear in pain, but when LVN C assisted the CNA's in repositioning Resident # 5 she hollered out in pain. LVN C stated she informed ADON A of her assessment. LVN C stated after ADON A assessed Resident # 5 ADON A told LVN C she could not see any bruising or swelling to Resident # 5's legs or thighs, but told LVN C to call Resident # 5's physician since Resident # 5 appeared to be in pain earlier. LVN C stated she called Resident # 5's physician, and obtained an order for [REDACTED].# 5's hollering out when repositioned and the order for an x-ray to the left hip and femur. LVN C stated LVN D had called her at home to clarify the x-ray was to be of the left hip and femur. Review of Resident # 5's Nurses Notes dated [DATE] at 8:30 AM reflected LVN D notified Hospice of the order for an x-ray, Resident # 5's physician that Resident # 5 had no swelling, bruising or complaint of pain/discomfort, and obtained an order from Resident # 5's physician to discontinue the order for x-rays. In an interview on [DATE] at 10:15 AM LVN D stated when she arrived at work she was told by LVN C that someone had reported Resident # 5 was in pain and LVN C had obtained an order for [REDACTED].# 5, the resident had no swelling, bruising or indication she was in pain. LVN D stated she reported her findings to Resident # 5's physician, who instructed her to discontinue the order for an x-ray. LVN D stated she never asked the CNA's working the 6:00 AM-2:00 PM shift if Resident # 5 was experiencing any pain, since she expected the CNA's to notify her if Resident # 5 had any pain. LVN D stated she did not reassess Resident # 5 again during her shift for any signs or symptoms of pain. In an interview on [DATE] at 7:50 AM ADON A stated on [DATE] she had been at the facility and had assessed Resident # 5 at the request of LVN C. ADON A stated she understood from LVN C that the 10:00 PM-6:00 AM aides had reported Resident # 5 in pain. ADON A stated she went to assess Resident # 5 and observed no sign of bruising or swelling and no indication of pain. ADON A stated she did not ask the 6:00 AM-2:00 PM CNA's caring for Resident # 5 if they had observed Resident # 5 in pain. ADON A stated she did not work on [DATE]. In an interview on [DATE] at 8:05 AM, ADON B stated she did see Resident # 5 on [DATE] at the request of LVN D. ADON B stated she does not remember the exact time, but it was early on [DATE]. ADON B stated when she observed Resident # 5's left thigh was swollen, she did no other assessment and told LVN D to call Resident # 5's physician and have the CNA's return Resident # 5 to bed with LVN D being present. ADON B stated she left the facility between 10:,[DATE]:00 AM and expected LVN D would have informed her of any problems or concerns. In an interview on [DATE] at 9:00 AM, CNA K stated at the beginning of her shift on [DATE], she and CNA L had attempted to perform incontinent care when Resident # 5 hollered out as if she was in pain. CNA K stated it looked like Resident # 5's left thigh was swollen. CNA K stated they informed LVN C, who came to assess Resident # 5. CNA K stated LVN C told her to leave Resident # 5 in bed, and LVN C would contact Resident # 5's physician. In an interview on [DATE] at 9:15 AM, CNA L stated on [DATE] at approximately 6:30 AM Resident # 5 hollered out in pain when she and CNA K attempted to perform incontinent care. CNA L stated she was standing on Resident # 5's left side and when she touched her thigh it felt like something was moving under Resident # 5's skin. CNA L stated Resident # 5's left thigh appeared swollen to her. CNA L stated she and CNA K had notified LVN C of Resident # 5's pain. CNA L stated LVN C told her Resident # 5's thigh did not look swollen to her, but she would contact Resident # 5's physician regarding the pain. CNA L stated she did not report Resident # 5 being in pain to LVN D since she had already reported the problem to LVN C, who stated she would notify Resident # 5's physician of the pain. Review of Resident # 5's Nurses Notes dated [DATE] at 7:00 AM by LVN D reflected Resident # 5's left knee was shaking, and her thigh appeared swollen and warm to touch. LVN D's Nurses Notes reflected the following, Res (Resident) in obvious pain & (and) facial grimacing, medicated with Tylenol & order for x-ray to L (Left) thigh, hip & knee. Review of Resident # 5's Nurses Notes dated [DATE] at 12:30 PM ( five hours and thirty minutes after Resident # 5 was assess by LVN D to be experiencing pain) reflected the mobile x-ray employee arrived at the facility. The mobile x-ray employee was unable to perform the ordered x-rays secondary to Resident # 5 having contractures and experiencing pain with movement. The Nurses Notes also reflected an order was obtained to send Resident # 5 to the hospital emergency room for the x-rays. Review of the Medication Administration Record [REDACTED]. In an interview on [DATE], LVN D stated at the beginning of her shift on [DATE], the 6:00 AM-2:00 PM CNA's came to her and stated Resident # 5 was in pain. LVN D stated Resident # 5 was sitting up in a Geri-chair in her room. LVN D stated Resident # 5's upper thigh was hot and swollen, Resident # 5 had a look on her face as if in pain and was hitting at LVN D when she attempted to touch Resident # 5's thigh. LVN D stated she assisted the CNA's (could not remember who the aides were) to transfer Resident # 5 back to bed using a hoyer lift (mechanical lift). LVN D stated when Resident # 5 was returned to bed her left thigh did not appear as swollen as it had been while up in the G-chair. LVN D stated the left thigh looked simular to the appearance on [DATE] when she had assessed Resident # 5. LVN D stated when the mobile x-ray employee arrived at the facility at 12:30 PM, she had assisted the mobile x-ray employee in attempting to obtain the ordered x-rays. LVN D stated when she and the mobile x-ray employee attempted to position Resident # 5's left leg for an x-ray Resident # 5 made a fist with her hands and yelled out Don't do that. LVN D stated she called Resident # 5's physician and obtained an order to transfer Resident # 5 to the hospital emergency room to obtain the ordered x-rays. LVN D stated she did not administer Resident # 5 any other medication for pain since approximately 7:30 AM that morning (five hours later) since she was sending Resident # 5 to the emergency room . In an interview on [DATE] at 9:00 AM, CNA K stated on [DATE] she and CNA L notified LVN D of Resident # 5 experiencing pain and having a swollen left thigh. CNA K stated LVN D and ADON-B assessed Resident # 5 and then she, another CNA (can't remember who) and LVN D returned Resident # 5 to bed. CNA K stated Resident # 5's thigh looked the same to her on [DATE] when she first reported Resident # 5 was experiencing pain to LVN C. In an interview on [DATE] at 9:15 AM CNA L stated on [DATE] Resident # 5 she thought Resident # 5 had the same amount of swelling to her thigh on [DATE] as she had on [DATE]. CNA L stated she and CNA K notified LVN D of Resident # 5 being in pain and the swelling on [DATE] at the beginning of the day shift. CNA L stated Resident # 5 would appear to tense her body when providing care on [DATE] and [DATE]. CNA L stated she never saw Resident # 5 do this prior to [DATE]. In an interview on [DATE] at 1:20 PM, CMA J stated CNA K and CNA L had asked her to look at Resident # 5's leg on [DATE] at approximately 6:45 AM. CMA J stated Resident # 5's left thigh was huge and looked like, the elephant man. CMA J stated when she lightly touched Resident # 5's left thigh Resident # 5 screamed out in pain. CMA J told CNA K and CNA L to notify LVN D. CMA J stated the charge nurses administer PRN medications, so LVN D would make the determination regarding Resident # 5's need for PRN pain medication. Review of ambulance transfer records dated [DATE] at 1:19 PM for Resident # 5 reflected a facility nurse informed the ambulance employees that on [DATE] Resident # 5 seemed in pain and had a noticeable deformity to her left leg from an unknown cause. The assessment completed by the ambulance paramedic reflected the following: swelling to the left outer thigh with slight deformity compared to the right leg. The assessment was difficult to complete secondary to Resident # 5 having her legs locked at 90 degree angle and contractures in both knees. Review of the hospital emergency room record revealed Resident # 5 was admitted to the emergency roiagnom on [DATE] at 1:25 PM (55 minutes after LVN D had assessed Resident # 5 to be experiencing pain. Review of the emergency room physician notes reflected the following: Extremities: noted in the left upper left distal aspect: pain, swelling, ROM (Range of Motion): Pain with any passive ROM of the left leg. Review of the two (2) views of the left femur x-rays report reflected Resident # 5 had an acute traumatic, closed, comminuted, and significantly displaced [MEDICAL CONDITION] femoral and severe osteopenia. Review of the hospital emergency room physician notes reflected the following emergency room course of treatment: .In this non-ambulatory, contracted patient, it is concerning as to how she sustained this fracture . Further review of the hospital emergency room record for Resident # 5 reflected Resident # 5 was medicated with [MEDICATION NAME] 10 mg IM (Intramuscular) and the emergency room physician placed a splint to stabilize Resident # 5's leg. Resident # 5 was discharged from the emergency room and transported back to the nursing home on [DATE] at 4:04 PM, with a prescription for Tylenol # 3 ,[DATE] mg tablet, take one (1) tablet PO every six (6) hours as needed for pain. In an interview on [DATE] at 7:30 AM, the emergency room Physician stated she was concerned regarding the severity of Resident # 5's fracture to the left femur. The emergency room Physician stated with the way the femur bone had fractured and the number of bone fragments observed on the x-ray it could have only occurred with a traumatic event. She stated she applied a splint to Resident # 5's leg in an attempt to assist with pain control, but felt Resident # 3 would need pain medication related to the severity of the fracture. The emergency room Physician stated she notified Resident # 5's personal physician of her concerns regarding the severity and type of fracture. Review of the Texas Department of Aging and Disability Services Incident Investigation Worksheet reflected the DON of the facility reported Resident # 5 had a fracture of unknown origin on [DATE]. Review of Resident # 5's Nurses Notes dated [DATE] at 1:30 am Resident # 5 was described as awake, and had a grimace on her face. When LVN E asked if she was in pain, Resident # 5 nodded her head yes. Resident # 5 was documented to have received Tylenol 500 mg one (1) tablet instead of the ordered Tylenol # 3 one (1) tablet due to the Tylenol # 3 had not been delivered to the facility yet (over 9 hours after being readmitted to the facility). Review of Resident # 5's Nurses Notes dated [DATE] at 7:50 AM and 1:15 PM reflected Resident # 5 stated she was in pain when asked by LVN F. LVN F documented on both occasions she administered Tylenol 500 mg one (1) tablet instead of the Tylenol # 3 one (1) tablet. Review of Resident # 5's Nurses Notes reflected no other pain medication was given until [DATE] at 7:20 AM when LVN F administered Resident # 5 [MEDICATION NAME] 15 mg orally was administered. Further review of Resident # 5's Nurses Notes and Resident # 5's [DATE] Medication Administration Record [REDACTED]. In an interview on [DATE] LVN F stated she could not administer Resident # 5's Tylenol # 3 ordered on [DATE] from the hospital emergency room physician since it still was not in the facility on [DATE]. She stated since Resident # 5 had an order for [REDACTED].# 5 was in pain and realized no one had administered any pain medication to Resident # 5 since her shift had ended at 2:00 PM the previous day. LVN F stated she was going to administer Resident # 5 [MEDICATION NAME] 15 mg PO again for pain at 1:15 PM, but Resident # 5's daughter had refused to let her administer the [MEDICATION NAME] since the daughter wanted Resident # 5 awake for Resident # 5's 100th birthday party. LVN F stated when she discovered the pharmacy had not delivered the Tylenol # 3 on [DATE] she faxed the prescription to the facility pharmacy. LVN F stated she did not call the pharmacy to see why the Tylenol # 3 had not been delivered, or notified any nursing administrative staff of the problem. LVN F stated she did not notify hospice Resident # 5 had a new fracture with a new order for Tylenol # 3 since the pain medication was not related to her hospice [DIAGNOSES REDACTED]. In an interview on [DATE] at 9:36 AM, a representative of the contracted pharmacy stated the pharmacy received the order from the facility on [DATE] at 9:27 PM (over five (5) hours after Resident # 5 returned to the facility). The representative stated the pharmacy did not fill the Tylenol # 3 prescription since Resident # 5 was receiving hospice services. The representative stated the pharmacy would not have notified the facility since the facility was aware of this policy. In an interview on [DATE] at 11:07 AM the Hospice DON stated after reviewing Resident # 5's hospice record and all telephone correspondence with the facility that there was no documentation that the hospice agency was notified of Resident # 5's fracture or having a new prescription for pain (Tylenol # 3) until the Hospice Nurse made a routine scheduled visit on [DATE]. The Hospice DON stated if the facility had notified the hospice agency they would have obtained and provided the Tylenol # 3 for Resident # 5 and made a visit to assess Resident # 5's level of pain. In an interview on [DATE] at 3:08 PM the Hospice Nurse stated she was unaware Resident # 5 had a new fracture or a new order for Tylenol # 3 until she reviewed Resident # 5's nursing home clinical record on [DATE] at approximately 2:30 PM. The Hospice Nurse stated when she assessed Resident # 5 she had a grimace on her face and was clinching her hands into a fist, both indicators of pain. The Hospice Nurse stated she notified a facility staff member (did not have the employee name) who was standing at the medication cart that Resident # 5 needed medication for pain. The Hospice Nurse stated she did not see the facility staff member administer the pain medication. The Hospice Nurse stated she did write an order for [REDACTED]. In an interview on [DATE] at 2:15 PM, LVN G stated she worked the evenings of ,[DATE], ,[DATE] and [DATE]. She stated Resident # 5 did not appear in pain to her during her shift on any of the three (3) evening shifts she worked. LVN G stated Resident # 5 did not require any PRN pain medication for her after she was diagnosed with [REDACTED]. LVN G stated LVN's give all the PRN pain medications to residents so she would be aware if Resident # 5 needed or received any pain medication. LVN G stated on [DATE] she only administered the routine [MEDICATION NAME] 15 mg at 9:00 PM. Review of Resident # 5's Nurses Notes reflected she expired in the facility on [DATE] at 8:05 AM when she was found to not have a heart beat, blood pressure or respirations. In an interview on [DATE] at 1:10 PM, the DON stated she expected the nurses to obtain a mobile x-ray within three (3) to four (4) hours from when ordered by the physician if a resident is in pain. The DON stated the charge nurses are to notify hospice when a resident has a change in condition, which would include a new fracture or a new prescription for pain medication. The DON also stated if residents do not receive medication from the facility pharmacy the charge nurse should call the pharmacy and notify one of the ADON's or the DON. In an interview on [DATE] at 1:10 PM Resident # 5's physician stated he became aware of Resident # 5's fracture on [DATE] when he received a telephone call from the emergency room Physician. Resident # 5's physician stated he notified the facility in order to determine how the fracture had occurred. Resident # 5's physician stated he was informed the facility was unable to determine the cause of the fracture. Resident # 5's physician stated normally the type of fracture Resident # 5 sustained is caused by some sort of trauma. He stated even though he was informed Resident # 5 had no problems with pain control, he would have expected the facility to have had the Tylenol # 3 ordered by the emergency room Physician in the facility as soon as possible in case Resident # 5 experienced pain. Resident # 5's physician stated Resident # 5's death was related to her advanced age and not related to the recent fracture. Review of the facility policy entitled Abuse-Reportable Events last revised ,[DATE] reflected the following: .Neglect: The failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Review of the facility contract with the hospice agency dated [DATE] reflected the following: .Obligations of Provider .The Provider shall immediately notify the Hospice designated Patient Care Coordinator, Medical Director or other designated representative in the event of any of the following: Changes in the Patient's physical, mental, social or emotional status or condition(s); if clinical complications occur that suggest a need to alter the Hospice Plan of Care; if a need to transfer the Patient arises . The facility provided a list of 45 residents who receive routine and/or PRN pain medications. .

Based on interview and record review the facility failed to provide necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care when: 1. The facility nursing staff failed to accurately assess Resident # 5 for pain and when pain was evident failed to administer ordered PRN (as needed) pain medication. 2. The facility nursing staff failed to ensure Resident # 5's ordered pain medication was available in the facility after Resident # 5 returned from the emergency room with a new [DIAGNOSES REDACTED]. realigned) of the distal femur (lower end of the thigh bone where the femur attaches to the knee). 3. The facility failed to coordinate with Resident # 5's Hospice Agency after Resident # 5 returned from the emergency room with a new [DIAGNOSES REDACTED]. This deficient practice resulted in Resident # 5 experiencing unnecessary pain and placed an additional 45 residents who require routine and/or PRN pain medication at risk for experiencing pain. Findings include: Review of Resident # 5's Closed Record Face Sheet reflected a [AGE] year old female admitted to the facility on [DATE] with the following Diagnosis: [REDACTED]. Review of Resident # 5's Significant Change of Condition Minimum Data Set (MDS) Assessment, dated [DATE], reflected Resident # 5 had a severely impaired cognitive status, required total assistance of two (2) staff for transfers and bathing, and total assistance of one (1) staff for all other Activities of Daily Living (ADL's). Resident # 5 was assessed as receiving no routine or PRN (as needed) pain medication or experiencing pain during the assessment period. Review of Resident # 5's Comprehensive Care Plan, last updated on [DATE] reflected an identified problem with alteration in mobility secondary to a fracture (not specific as to location) with the following interventions: requires two (2) staff to be transferred with the assistance of a mechanical lift, and to log roll when in bed. A second problem identified in the Comprehensive Care Plan was Resident # 5 receiving services from a hospice agency with the following interventions: Coordinate care with the hospice agency, and administer pain medication if needed. Review of Resident # 5's telephone order dated [DATE] at 7:10 AM reflected a telephone order for an x-ray of the right hip & (and) right femur. A second telephone order written on [DATE] (no time) reflected the x-rays were to be discontinued since Resident # 5 was not experiencing pain. Review of Resident # 5's Nurses Notes dated [DATE] at 6:45 AM reflected that CNA's (no names given) reported Resident # 5 was complaining of pain to the left leg when attempting to perform incontinent care. The Nurses Notes also reflected that Resident # 5's physician was notified, an order was received for an x-ray of Resident # 5's left hip and femur, and LVN D (,[DATE] shift) was notified of the new order. In an interview on [DATE] at 4:50 AM, LVN C stated on [DATE] she was working later into the 6:00 AM-2:00 PM shift until the day charge arrived. LVN C stated two (2) day shift CNA's (could not remember who) told LVN C Resident # 5 had complained of pain when they had attempted to reposition Resident # 5 during incontinent care. LVN C stated when she initially assessed Resident # 5 the resident did not appear in pain, but when LVN C assisted the CNA's in repositioning Resident # 5 she hollered out in pain. LVN C stated she informed ADON A of her assessment. LVN C stated after ADON A assessed Resident # 5 ADON A told LVN C she could not see any bruising or swelling to Resident # 5's legs or thighs, but told LVN C to call Resident # 5's physician since Resident # 5 appeared to be in pain earlier. LVN C stated she called Resident # 5's physician, and obtained an order for [REDACTED].# 5's hollering out when repositioned and the order for an x-ray to the left hip and femur. LVN C stated LVN D had called her at home to clarify the x-ray was to be of the left hip and femur. Review of Resident # 5's Nurses Notes dated [DATE] at 8:30 AM reflected LVN D notified Hospice of the order for an x-ray, Resident # 5's physician that Resident # 5 had no swelling, bruising or complaint of pain/discomfort, and obtained an order from Resident # 5's physician to discontinue the order for x-rays. In an interview on [DATE] at 10:15 AM LVN D stated when she arrived at work she was told by LVN C that someone had reported Resident # 5 was in pain and LVN C had obtained an order for [REDACTED].# 5, the resident had no swelling, bruising or indication she was in pain. LVN D stated she reported her findings to Resident # 5's physician, who instructed her to discontinue the order for an x-ray. LVN D stated she never asked the CNA's working the 6:00 AM-2:00 PM shift if Resident # 5 was experiencing any pain, since she expected the CNA's to notify her if Resident # 5 had any pain. LVN D stated she did not reassess Resident # 5 again during her shift for any signs or symptoms of pain. In an interview on [DATE] at 7:50 AM ADON A stated on [DATE] she had been at the facility and had assessed Resident # 5 at the request of LVN C. ADON A stated she understood from LVN C that the 10:00 PM-6:00 AM aides had reported Resident # 5 in pain. ADON A stated she went to assess Resident # 5 and observed no sign of bruising or swelling and no indication of pain. ADON A stated she did not ask the 6:00 AM-2:00 PM CNA's caring for Resident # 5 if they had observed Resident # 5 in pain. ADON A stated she did not work on [DATE]. In an interview on [DATE] at 8:05 AM, ADON B stated she did see Resident # 5 on [DATE] at the request of LVN D. ADON B stated she does not remember the exact time, but it was early on [DATE]. ADON B stated when she observed Resident # 5's left thigh was swollen, she did no other assessment and told LVN D to call Resident # 5's physician and have the CNA's return Resident # 5 to bed with LVN D being present. ADON B stated she left the facility between 10:,[DATE]:00 AM and expected LVN D would have informed her of any problems or concerns. In an interview on [DATE] at 9:00 AM, CNA K stated at the beginning of her shift on [DATE], she and CNA L had attempted to perform incontinent care when Resident # 5 hollered out as if she was in pain. CNA K stated it looked like Resident # 5's left thigh was swollen. CNA K stated they informed LVN C, who came to assess Resident # 5. CNA K stated LVN C told her to leave Resident # 5 in bed, and LVN C would contact Resident # 5's physician. In an interview on [DATE] at 9:15 AM, CNA L stated on [DATE] at approximately 6:30 AM Resident # 5 hollered out in pain when she and CNA K attempted to perform incontinent care. CNA L stated she was standing on Resident # 5's left side and when she touched her thigh it felt like something was moving under Resident # 5's skin. CNA L stated Resident # 5's left thigh appeared swollen to her. CNA L stated she and CNA K had notified LVN C of Resident # 5's pain. CNA L stated LVN C told her Resident # 5's thigh did not look swollen to her, but she would contact Resident # 5's physician regarding the pain. CNA L stated she did not report Resident # 5 being in pain to LVN D since she had already reported the problem to LVN C, who stated she would notify Resident # 5's physician of the pain. Review of Resident # 5's Nurses Notes dated [DATE] at 7:00 AM by LVN D reflected Resident # 5's left knee was shaking, and her thigh appeared swollen and warm to touch. LVN D's Nurses Notes reflected the following, Res (Resident) in obvious pain & (and) facial grimacing, medicated with Tylenol & order for x-ray to L (Left) thigh, hip & knee. Review of Resident # 5's Nurses Notes dated [DATE] at 12:30 PM ( five hours and thirty minutes after Resident # 5 was assess by LVN D to be experiencing pain) reflected the mobile x-ray employee arrived at the facility. The mobile x-ray employee was unable to perform the ordered x-rays secondary to Resident # 5 having contractures and experiencing pain with movement. The Nurses Notes also reflected an order was obtained to send Resident # 5 to the hospital emergency room for the x-rays. Review of the Medication Administration Record [REDACTED]. In an interview on [DATE], LVN D stated at the beginning of her shift on [DATE], the 6:00 AM-2:00 PM CNA's came to her and stated Resident # 5 was in pain. LVN D stated Resident # 5 was sitting up in a Geri-chair in her room. LVN D stated Resident # 5's upper thigh was hot and swollen, Resident # 5 had a look on her face as if in pain and was hitting at LVN D when she attempted to touch Resident # 5's thigh. LVN D stated she assisted the CNA's (could not remember who the aides were) to transfer Resident # 5 back to bed using a hoyer lift (mechanical lift). LVN D stated when Resident # 5 was returned to bed her left thigh did not appear as swollen as it had been while up in the G-chair. LVN D stated the left thigh looked simular to the appearance on [DATE] when she had assessed Resident # 5. LVN D stated when the mobile x-ray employee arrived at the facility at 12:30 PM, she had assisted the mobile x-ray employee in attempting to obtain the ordered x-rays. LVN D stated when she and the mobile x-ray employee attempted to position Resident # 5's left leg for an x-ray Resident # 5 made a fist with her hands and yelled out Don't do that. LVN D stated she called Resident # 5's physician and obtained an order to transfer Resident # 5 to the hospital emergency room to obtain the ordered x-rays. LVN D stated she did not administer Resident # 5 any other medication for pain since approximately 7:30 AM that morning (five hours later) since she was sending Resident # 5 to the emergency room . In an interview on [DATE] at 9:00 AM, CNA K stated on [DATE] she and CNA L notified LVN D of Resident # 5 experiencing pain and having a swollen left thigh. CNA K stated LVN D and ADON-B assessed Resident # 5 and then she, another CNA (can't remember who) and LVN D returned Resident # 5 to bed. CNA K stated Resident # 5's thigh looked the same to her on [DATE] when she first reported Resident # 5 was experiencing pain to LVN C. In an interview on [DATE] at 9:15 AM CNA L stated on [DATE] Resident # 5 she thought Resident # 5 had the same amount of swelling to her thigh on [DATE] as she had on [DATE]. CNA L stated she and CNA K notified LVN D of Resident # 5 being in pain and the swelling on [DATE] at the beginning of the day shift. CNA L stated Resident # 5 would appear to tense her body when providing care on [DATE] and [DATE]. CNA L stated she never saw Resident # 5 do this prior to [DATE]. In an interview on [DATE] at 1:20 PM, CMA J stated CNA K and CNA L had asked her to look at Resident # 5's leg on [DATE] at approximately 6:45 AM. CMA J stated Resident # 5's left thigh was huge and looked like, the elephant man. CMA J stated when she lightly touched Resident # 5's left thigh Resident # 5 screamed out in pain. CMA J told CNA K and CNA L to notify LVN D. CMA J stated the charge nurses administer PRN medications, so LVN D would make the determination regarding Resident # 5's need for PRN pain medication. Review of ambulance transfer records dated [DATE] at 1:19 PM for Resident # 5 reflected a facility nurse informed the ambulance employees that on [DATE] Resident # 5 seemed in pain and had a noticeable deformity to her left leg from an unknown cause. The assessment completed by the ambulance paramedic reflected the following: swelling to the left outer thigh with slight deformity compared to the right leg. The assessment was difficult to complete secondary to Resident # 5 having her legs locked at 90 degree angle and contractures in both knees. Review of the hospital emergency room record revealed Resident # 5 was admitted to the emergency roiagnom on [DATE] at 1:25 PM (55 minutes after LVN D had assessed Resident # 5 to be experiencing pain. Review of the emergency room physician notes reflected the following: Extremities: noted in the left upper left distal aspect: pain, swelling, ROM (Range of Motion): Pain with any passive ROM of the left leg. Review of the two (2) views of the left femur x-rays report reflected Resident # 5 had an acute traumatic, closed, comminuted, and significantly displaced [MEDICAL CONDITION] femoral and severe osteopenia. Review of the hospital emergency room physician notes reflected the following emergency room course of treatment: .In this non-ambulatory, contracted patient, it is concerning as to how she sustained this fracture . Further review of the hospital emergency room record for Resident # 5 reflected Resident # 5 was medicated with [MEDICATION NAME] 10 mg IM (Intramuscular) and the emergency room physician placed a splint to stabilize Resident # 5's leg. Resident # 5 was discharged from the emergency room and transported back to the nursing home on [DATE] at 4:04 PM, with a prescription for Tylenol # 3 ,[DATE] mg tablet, take one (1) tablet PO every six (6) hours as needed for pain. In an interview on [DATE] at 7:30 AM, the emergency room Physician stated she was concerned regarding the severity of Resident # 5's fracture to the left femur. The emergency room Physician stated with the way the femur bone had fractured and the number of bone fragments observed on the x-ray it could have only occurred with a traumatic event. She stated she applied a splint to Resident # 5's leg in an attempt to assist with pain control, but felt Resident # 3 would need pain medication related to the severity of the fracture. The emergency room Physician stated she notified Resident # 5's personal physician of her concerns regarding the severity and type of fracture. Review of the Texas Department of Aging and Disability Services Incident Investigation Worksheet reflected the DON of the facility reported Resident # 5 had a fracture of unknown origin on [DATE]. Review of Resident # 5's Nurses Notes dated [DATE] at 1:30 am Resident # 5 was described as awake, and had a grimace on her face. When LVN E asked if she was in pain, Resident # 5 nodded her head yes. Resident # 5 was documented to have received Tylenol 500 mg one (1) tablet instead of the ordered Tylenol # 3 one (1) tablet due to the Tylenol # 3 had not been delivered to the facility yet (over 9 hours after being readmitted to the facility). Review of Resident # 5's Nurses Notes dated [DATE] at 7:50 AM and 1:15 PM reflected Resident # 5 stated she was in pain when asked by LVN F. LVN F documented on both occasions she administered Tylenol 500 mg one (1) tablet instead of the Tylenol # 3 one (1) tablet. Review of Resident # 5's Nurses Notes reflected no other pain medication was given until [DATE] at 7:20 AM when LVN F administered Resident # 5 [MEDICATION NAME] 15 mg orally was administered. Further review of Resident # 5's Nurses Notes and Resident # 5's [DATE] Medication Administration Record [REDACTED]. In an interview on [DATE] LVN F stated she could not administer Resident # 5's Tylenol # 3 ordered on [DATE] from the hospital emergency room physician since it still was not in the facility on [DATE]. She stated since Resident # 5 had an order for [REDACTED].# 5 was in pain and realized no one had administered any pain medication to Resident # 5 since her shift had ended at 2:00 PM the previous day. LVN F stated she was going to administer Resident # 5 [MEDICATION NAME] 15 mg PO again for pain at 1:15 PM, but Resident # 5's daughter had refused to let her administer the [MEDICATION NAME] since the daughter wanted Resident # 5 awake for Resident # 5's 100th birthday party. LVN F stated when she discovered the pharmacy had not delivered the Tylenol # 3 on [DATE] she faxed the prescription to the facility pharmacy. LVN F stated she did not call the pharmacy to see why the Tylenol # 3 had not been delivered, or notified any nursing administrative staff of the problem. LVN F stated she did not notify hospice Resident # 5 had a new fracture with a new order for Tylenol # 3 since the pain medication was not related to her hospice [DIAGNOSES REDACTED]. In an interview on [DATE] at 9:36 AM, a representative of the contracted pharmacy stated the pharmacy received the order from the facility on [DATE] at 9:27 PM (over five (5) hours after Resident # 5 returned to the facility). The representative stated the pharmacy did not fill the Tylenol # 3 prescription since Resident # 5 was receiving hospice services. The representative stated the pharmacy would not have notified the facility since the facility was aware of this policy. In an interview on [DATE] at 11:07 AM the Hospice DON stated after reviewing Resident # 5's hospice record and all telephone correspondence with the facility that there was no documentation that the hospice agency was notified of Resident # 5's fracture or having a new prescription for pain (Tylenol # 3) until the Hospice Nurse made a routine scheduled visit on [DATE]. The Hospice DON stated if the facility had notified the hospice agency they would have obtained and provided the Tylenol # 3 for Resident # 5 and made a visit to assess Resident # 5's level of pain. In an interview on [DATE] at 3:08 PM the Hospice Nurse stated she was unaware Resident # 5 had a new fracture or a new order for Tylenol # 3 until she reviewed Resident # 5's nursing home clinical record on [DATE] at approximately 2:30 PM. The Hospice Nurse stated when she assessed Resident # 5 she had a grimace on her face and was clinching her hands into a fist, both indicators of pain. The Hospice Nurse stated she notified a facility staff member (did not have the employee name) who was standing at the medication cart that Resident # 5 needed medication for pain. The Hospice Nurse stated she did not see the facility staff member administer the pain medication. The Hospice Nurse stated she did write an order for [REDACTED]. In an interview on [DATE] at 2:15 PM, LVN G stated she worked the evenings of ,[DATE], ,[DATE] and [DATE]. She stated Resident # 5 did not appear in pain to her during her shift on any of the three (3) evening shifts she worked. LVN G stated Resident # 5 did not require any PRN pain medication for her after she was diagnosed with [REDACTED]. LVN G stated LVN's give all the PRN pain medications to residents so she would be aware if Resident # 5 needed or received any pain medication. LVN G stated on [DATE] she only administered the routine [MEDICATION NAME] 15 mg at 9:00 PM. Review of Resident # 5's Nurses Notes reflected she expired in the facility on [DATE] at 8:05 AM when she was found to not have a heart beat, blood pressure or respirations. In an interview on [DATE] at 1:10 PM, the DON stated she expected the nurses to obtain a mobile x-ray within three (3) to four (4) hours from when ordered by the physician if a resident is in pain. The DON stated the charge nurses are to notify hospice when a resident has a change in condition, which would include a new fracture or a new prescription for pain medication. The DON also stated if residents do not receive medication from the facility pharmacy the charge nurse should call the pharmacy and notify one of the ADON's or the DON. In an interview on [DATE] at 1:10 PM Resident # 5's physician stated he became aware of Resident # 5's fracture on [DATE] when he received a telephone call from the emergency room Physician. Resident # 5's physician stated he notified the facility in order to determine how the fracture had occurred. Resident # 5's physician stated he was informed the facility was unable to determine the cause of the fracture. Resident # 5's physician stated normally the type of fracture Resident # 5 sustained is caused by some sort of trauma. He stated even though he was informed Resident # 5 had no problems with pain control, he would have expected the facility to have had the Tylenol # 3 ordered by the emergency room Physician in the facility as soon as possible in case Resident # 5 experienced pain. Resident # 5's physician stated Resident # 5's death was related to her advanced age and not related to the recent fracture. Review of the facility policy entitled Abuse-Reportable Events last revised ,[DATE] reflected the following: .Neglect: The failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Review of the facility contract with the hospice agency dated [DATE] reflected the following: .Obligations of Provider .The Provider shall immediately notify the Hospice designated Patient Care Coordinator, Medical Director or other designated representative in the event of any of the following: Changes in the Patient's physical, mental, social or emotional status or condition(s); if clinical complications occur that suggest a need to alter the Hospice Plan of Care; if a need to transfer the Patient arises . The facility provided a list of 45 residents who receive routine and/or PRN pain medications. .

Based on observation, interview and record review the facility failed to ensure based on a comprehensive assessment residents maintained acceptable parameters of nutritional status, such as body weight, and received a therapeutic diet when there was a nutritional problem for one (1) of three (3) residents (Resident # 2) reviewed for significant weight loss. The facility failed to implement an order dated 09/22/2014 for [MEDICATION NAME], (an appetite stimulant) and failed to recognize and enact the Registered Dietician Recommendations dated 10/07/2014 for weight loss interventions including a mechanical soft diet, house shakes between meals, fortified juice with each meal and an increased calorie cereal for breakfast for Resident # 2. Resident #2 lost 27 pounds between 09/02/2014 and 10/01/2014. He lost 10.5 pounds between 10/01/2014 and 11/01/2014, in a period in which he should have had the [MEDICATION NAME], mechanical soft diet, house shakes, fortified juice and increased calorie breakfast cereal in place. Resident #2 had suffered a 17.1% total weight loss since admission to the facility. These failures affected one (1) resident and placed seven (7) residents who have experienced a significant weight loss at risk for further weight loss and a subsequent decline in health status. Findings Include: Review of the Face Sheet for Resident #2 reflected a [AGE] year old male admitted on [DATE] with the [DIAGNOSES REDACTED]. [MEDICAL CONDITIONS] affecting the Non-Dominant side, [MEDICAL CONDITION] Disease, Prostate Hypertrophy Benign with Urinary Obstruction, Urine Retention and Personal Fall. Review of Resident #2's Quarterly MDS assessment dated [DATE] reflected Resident #2's Brief Interview for Mental Status score was 14 indicating he was cognitively intact. He was assessed as requiring limited assistance with eating, and moderate assistance with transfers, dressing, hygiene and bathing. His weight was recorded to be 185 pounds and weight loss was marked. Review of Resident #2's Telephone Orders for 09/22/2014 reflected an order for [REDACTED]. Review of Resident #2's Medication Administration Record [REDACTED]. There were no initials recorded for the initial dose that was to be administered by a nurse and there were no initials recorded indicating that he received the daily [MEDICATION NAME] to stimulate his appetite from 09/22/2014 through 11/12/2014. Review of Resident #2's Nutrition Assessment by the Registered Dietician on 10/07/2014 reflected that Resident #2 usual weight was "220.2 and his current weight was 193.8. Resident #2 had lost 12.0% (of his weight) x 1 month, ...his intake is poor ... started [MEDICATION NAME] on 09/22/2014 to stimulate his appetite." She recommended "house shakes three times a day between meals, fortified juice three times a day with meals, begin a regular mechanical soft diet (soft food due to dentures) and supercereal (increased calorie cereal) every breakfast." Review of Resident #2's Care Plan dated 10/08/2014 reflected interventions: "I need to be weighed weekly to closely monitor...I need to have my intake monitored...I need to thave my tray set-up and be offered encouragement to eat...Offer me food/fluid with each interaction...Please give me an appetitie stimulant per MD order and monitor." Review of Resident #2's Care Plan dated 11/11/2014 (during the annual survey) reflected a care plan for weight loss. Approaches included: Regular diet, monitor need for changing diet consistency to increase ease of eating, ...weigh weekly until stable and then monthly, obtain a dietary consult, follow the recommendations. Review of the facility provided Individual Weight Record for Resident #2 reflected: 09/02/2014 220.0 pounds, 10/01/2014 193.8 pounds, 11/01/2014 182.5 pounds. The facility provided weight record documented and scored the weight loss as 17.1% loss since admission on 08/14/2014, less than 90 days. Resident #2 was not weighed weekly per care plan dated 10/08/2014 Review of Resident #2's latest Consolidated Physician order [REDACTED]. No further orders regarding house shakes three times a day, fortified orange juice with meals, supercereal at breakfast or a mechanical soft diet was recorded. There was no order for an appetite stimulant. The Consolidated Physician order [REDACTED]. Review of Resident #2's Tray Card reflected his diet to be a Regular Diet, Regular texture. Breakfast: Milk 2% (used to prevent weight gain), Juice, orange four (4) fluid ounces. dislikes: eggs. Notes: DOUBLE BREAKFAST MEATS. No further orders regarding supplements or fortification of the diet was recorded on the tray card. In an interview on 11/13/2014 at 10:45 AM with the Corporate Consultant Dietary Manager U and Dietary Cook W, the Corporate Consultant Dietary Manager U stated, "We are not serving any supplements (to Resident # 2) or it would be printed on this sheet (tray card)." When asked if Resident # 2 was receiving the houseshakes, fortified juice or supercereal, she stated no and then asked "Does he have that?" Dietary Cook W stated the Dietary Staff is not told who is losing weight. Review of Resident #2's Telephone Orders revealed there was no Telephone Order regarding house shakes three times a day, fortified orange juice with meals, supercereal at breakfast or a mechanical soft diet. Observation on 11/10/2014 at 10:17 AM reflected Resident #2 in bed with head of bed elevated slightly. He was wearing a shirt, had facial hair over his face and neck approximately half of an inch long, no teeth in his mouth (but on his over bed table in a cup) and long brownish fingernails. His call light was attached to the privacy curtain on the other side of his bedside table. He had snacks from home, bananas and marshmallow cookies out of his sight and out of his reach on the bedside table and in the drawer. In an interview on 11/10/2014 at 10:22 AM, MA H stated she had worked for the facility for two years and currently gives Resident #2 his routine medications. MA H stated Resident # 2 was confused and liked to stay in the bed and had no interactions with others, he eats all meals in bed and she did not know if he had lost any weight or not. MA H stated she did not know what type of diet he was on. MA H stated he was total care and had no family that she knows of checking on him. Observation on 11/11/2014 at 08:36 AM reflected Resident #2 in bed with his breakfast tray in front of him. He was drinking orange juice, approximately four (4) ounces and took 100% of it. His biscuit was not prepared; the butter and jelly were unopened. He stated he likes salt and pepper on his scrambled eggs, salt and pepper were unopened on the tray. He was served regular oatmeal. There was no sugar served for the oatmeal and no butter for the oatmeal if the one butter had been used on his biscuit. In an interview on 11/11/2014 at 8:40 AM, LVN C stated, "They didn't fix your plate up. It's just sitting there in front of you. He has lost five (5) maybe ten (10) pounds, he has lost a lot of girth. The weight book is in the therapy department. A weight meeting does occur but not including nursing staff. Nothing is given to staff in writing. Communication is a big problem here." Observation on 11/11/2014 at 1:00 PM reflected Resident #2 in bed with his cheeks shaved and his fingernails trimmed waiting for his lunch tray. Review of Resident #2's meal intake sheet for October 2014 reflected 15 meals were refused, 47 were 25% taken, seven were 50% taken and one (1) was recorded at 75% taken, for some meals there was no percentage recorded and the resident was in the hospital 10/09 thru 10/11. In an interview on 11/12/2014 at 8:30 AM the DON stated, "...I cannot see where the [MEDICATION NAME] or the supplements were ordered." The DON stated the ADON was in charge of ensuring the Dietary Recommendations are initiated. In an interview on 11/12/2014 at 9:15 AM the ADON stated, "I have a call in to the Practitioner regarding the [MEDICATION NAME] and it appears it has never been started. I am unsure why that happened. I don't see the healthshakes on the Medication Administration Record. The Medication Aides are responsible to give that." She further stated that she did not have a dietician recommendation sheet for 10/07/2014 (for Resident #2)." In an interview on 11/13/2014 at 10:10 AM the ADON stated, "We are going to weigh him weekly from now on. He did not get a weight loss care plan until 11/11/2014 and it should have been on the chart. In an interview on 11/13/2014 at 10:00 AM the DON stated "as soon as a significant weight loss is occurring, I would expect a care plan to be put in place." In an interview on 11/12/2014 at 10:00 AM the Registered Dietician stated, I printed my recommendation (for Resident #2) on 10/07/2014 but I don't know who I gave it to." She further stated, "They have three (3) days to get the order and enact it." In an interview on 11/13/2014 at 11:00 AM the Occupational Therapist Assistant stated Resident #2 did not complain of pain when she got him up but that he complained of "lightheadedness like they get when they don't get up for so long." She further stated, "It seems like he has given up." In an interview on 11/13/2014 at 11:00 AM the Speech Language Pathologist (who is a specialist in eating difficulties) and the Rehabilitation Director for the facility, who is also the Occupational Therapist (a specialist in self -feeding techniques) stated they were aware Resident #2 had lost weight in the past, but that they are unaware of his current status. They stated in general they currently do not receive direct notification of who is currently losing weight unless the ADON verbally tells them or if they look through the weight book page by page themselves. The Rehabilitation Department Director showed the surveyor an 802 form that reflected which residents had significant weight loss marked on their Minimum Data Set in the past. She stated that is how they can screen for weight problems. The form did not reflect weight information for the residents at the facility that had not reached the significant loss status. The Therapy Department Director stated Resident #2 is currently being treated by the Occupational Therapist and the Physical Therapy Departments. Review of the Incident/Accident Report (regarding the medication error of not giving the [MEDICATION NAME]) dated 11/12/2014 provided to the surveyor by the DON reflected the facility notified the Responsible Party, the Primary Physician and the Registered Dietician of the finding that Resident #2 had not received the [MEDICATION NAME] since it had been ordered 09/22/2014. The Incident/Accident final disposition report reflected that Resident #2 was placed on weekly weights and education and revision of how the dietary recommendations are delivered ocurred. Review of the Nurse's Notes dated 11/12/2014 at 10:42 AM reflected the facility had received orders to start a regular mechanical soft diet, house shakes three times a day between meals, fortified juice three times a day with meals and super cereal at breakfast. The [MEDICATION NAME] 400 milligrams daily was to begin as soon as the medication was available from the pharmacy. In an interview on 11/13/2014 at 11:25 AM with Resident #2's Nurse Practitioner, when asked whether or not the weight loss may have been slowed if the [MEDICATION NAME] had been given and the health shakes, and fortified juice and fortified oatmeal had been served, she stated, "Oh definitely it could have curbed his weight loss. When I knew he was losing (09/22/2014), I said he has to get the [MEDICATION NAME] going. That really frustrates me." Review of the Facility Provided Policy and Procedure for "Weight System" reflected: "It is the policy of this home to...identify residents with significant weight change and provide nutritional intervention to stabilize weights, unless otherwise indicated...Weekly weights will include: Residents with a significant weight change..." Review of the Facility Provided Policy and Procedure for "Weight-Guidelines for Ordering Appetite Stimulant Medications" dated 09/2010 and revised 03/2012 reflected: "Interventions to be tried...change in diet and/or texture...change in dining tables and /or dining rooms...assist with feeding...in between meal snacks, including house shakes or oral supplements...Fortified foods are included in diet (high calorie, high protein diet)." Review of the Facility Provided Policy and Procedure for "Nutritional Recommendations" dated 01/2008 and revised 03/2012 reflected: ...2. "The consultant dietitian will discuss the recommendations in exit conference with the Administrator, Director of Nursing and Dietary Service Manager for clarification. After completion of the discussion, each will sign the form...4. The Director of Nursing, or designee, will contact the physician for the orders...8. On the consultant dietitian's next visit, the recommendations will be reviewed..and a follow up will be made in the medical record. 9. It is the Administrator's responsibility to see that recommendations are addressed within three (3) business days..." The facility provided a list of seven (7) residents with significant weight loss.

Based on observation, interview and record review the facility failed to implement policies and procedures that prohibit neglect for two (2) of eight (8) residents (Resident # 1 and Resident # 9) reviewed for inappropriate sexual behaviors. Facility Staff failed to supervise or monitor Resident # 1 who was cognitively impaired. Resident # 1was allowed by staff to have inappropriate sexual behaviors without supervison or monitoring to ensure she was safe. An Immediate Jeopardy (IJ) was identified on 07/25/2014. While the IJ was removed on 07/25//2014, the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice affected two (2) Residents (Resident # 1 and # 9) and placed an additional 22 residents with behavioral health needs at risk for injury and a decline in physical, mental and psychosocial well-being. Findings Include: Review of Resident #1's Face Sheet reflected an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected a Brief Interview for Mental Status (BIMS) score of seven (7) out of a possible 15 that indicated Resident #1 had severe cognitive impairment. Resident #1 was assessed to be independent in locomotion about the facility in her wheelchair. The assessment reflected Resident # 1 exhibited physical and verbal behaviors directed toward others, other behaviors not directed toward others, behaviors that put the resident and others at risk and behaviors that disrupt care or living environment. The assessment reflected these behaviors for Resident # 1 had gotten worse. Review of Resident #1's Comprehensive Care Plan dated 05/15/2014 and revised on 06/10/2014 reflected a problem, "I may express or desire intimate companionship as evidenced by asking others for intimate touch." Interventions included: "allow resident to not feel guilty about desires ... If approaching others who are not willing, redirect to other activities ...allow private time if needed." Resident # 1's Care Plan further reflected a problem of "I have cognitive impairment and memory impairments evidenced by confusion and difficulty with recalling; I am also inattentive at times related to [DIAGNOSES REDACTED]." Review of Resident #1's Daily Care Guide for July, 2014 reflected interventions to assist in choices in care, clothes and activities. An intervention for redirection immediately away from altercations or potential altercations is noted. There is no intervention listed for monitoring and redirection from inappropriate sexual behaviors. Review of Resident #1's Physical Therapy Rehabilitation Screen dated 05/01/2014 reflected the reason for not giving therapy is that Resident #1 is " unable to retain new information and training." Review of Resident # 1's history reflected the Resident was missing on 5/8/14 and found by facility staff on the floor of the kitchen janitor's closet (approximately 45 minutes after she was discovered missing). Review of Resident # 9's Face Sheet reflected a [AGE] year old male who entered the facility on 04/04/2012 and readmitted on [DATE]. Resident # 9's [DIAGNOSES REDACTED]. Review of Resident # 9's Quarterly MDS assessment dated [DATE] reflected the Resident scored 15 out of a possible 15 for the BIMS test and indicated he was cognitively intact. The assessment listed no behaviors for Resident # 9. Review of Resident # 9's Comprehensive Care Plan updated 05/28/2014 reflected no plan of care for inappropriate sexual behavior. Review of Resident #1's Nurses Notes dated 05/14/2014 at 8:15 PM reflected "Res (resident) in room. Laundry Aide witnessed inappropriate behavior of res with another res. DON notified. Per DON ask Res if wanted other Res to touch. 0 bruises/marks noted on Res. except for bruises from fall from previous days. When asking Res of about unwanted touch Res states 'It doesn't matter' Asked Res does she want the other res in her room or touching her stated 'his peenis this big it doesn't matter' Res held up index finger to show measuring gesture while speaking. Reported statement to DON. Per DON ' If she says it doesn't matter then she can't say it's unwanted...I will let (name of employee) know.'...." Review of Resident # 1's Nurse's Note dated 05/15/2014 reflected "Responsible party notified of intimate touching that occurred in her room the previous evening. Responsible party aware of relationship between residents. RP noted her mother told her this was her "boyfriend & to not be surprised if she goes off to Chicago with him." RP aware that this occurred and is okay with relationship as long as there is no harm to her mother. Resident was assessed for injury and no injury was noted physically or mentally....Resident's wander guard cont. (continues) to function appropriately. Motion detector in room near bed was noted to be functioning but resident knows how to shut off alarms. Staff cont to observe for wandering & potential fall risks." Review of Resident # 1's Nurse's Note dated 05/26/2014 reflected "Resident at the nurse's station pretending to get some snacks...with Resident (name of other resident - Resident # 9). Resident raised her shirt (dress up) exposed her breast and verbalized "get it, you want it, touch it, take it", nurse was able to stop both resident & (Resident # 9) walked away towards dining room area." Review of Resident # 1's Nurse's Note dated 06/30/2014 reflected "summoned to room by daughter, noted increased redness to groins - L (left) and R (right)....small bruise on L outer upper shin...." The nurse followed up with a call to Resident # 1's physician who ordered an antifungal cream. Review of Resident # 1's Nurse's Note dated 07/13/2014 reflected "Resident in the dining room, sitting at the same table with (Resident # 9). Resident held hands with Resident # 9 and Resident # 9 grab (name of Resident # 1) left breast and kiss her by her mouth. Nurse intervened by asking resident to leave (Resident # 1's first name) alone and that this is inappropriate behavior in the dining area. Resident # 9 verbalized "shut up, I say shut up, it is not your business." There was no additional note regarding Resident # 1's Responsible Party or Physician being notified of this behavior. There was no evidence of an incident report or investigation occurred. Review of the facility Incident Log for May, 2014 through present, July 25, 2014 reflected no incident report or investigation of any inappropriate sexual activity between Resident # 1 and Resident # 9. In an interview on 07/24/2014 at approximately 9:45 PM the Regional Nurse Consultant stated Resident #1 has the right to have a sexual relationship within the facility and her rights to do so cannot be taken from her. Review of Resident #1's Nurse Notes dated 07/14/2014 at 5:45 AM reflected " Resident observed wheeling self to front lobby from back of Hall #3 (where Resident #9 resides). When asked where she had been, she stated, " just wandering." When asked again, she stated, "That's a man's room." No documentation of monitoring present. Observation on 07/24/2014 at 3:00 PM revealed Resident #1 to be rolling about the facility independently in a wheelchair. There was no supervision of Resident # 1. Observation on 07/24/2014 at 4:10 PM revealed Resident #1 lying on the bed with Responsible Party (RP) present in the room. Resident #1 would not communicate with the surveyor but repeatedly asked the RP who the surveyor was. The RP assisted Resident #1 to transfer from the bed to the wheelchair and the RP propelled Resident #1 to the bathroom. While Resident #1 was in the bathroom, Resident #9 knocked on the door and asked the RP if he could talk to Resident #1. The RP told Resident #9 that Resident #1 was in the bathroom. Resident #9 left the doorway. The RP then used the call light for Resident #1 for assistance in the bathroom. The staff answered the call light and assisted Resident #1 with personal hygiene. The RP then asked the staff to assist Resident #1 with dressing into another outfit. The RP asked the staff to place two briefs on Resident #1 because the RP was taking Resident #1 out to eat at a restaurant. The staff explained to the RP that they were not supposed to double brief Resident #1. The RP placed the additional brief on Resident #1. Observation on 07/24/2014 at 8:37 PM Resident #1 was propelling her wheelchair in Hall 2. There was no staff visible in Hall 2 near Resident #1. Observation on 07/25/2014 at 6:00 PM revealed Resident # 1 sitting on her bed. Resident # 1 insisted Surveyor remove her shoes. Surveyor advised Resident # 1 that was not allowed and would ask someone to assist her. Resident # 1 hollered several times. Interview on 07/24/2014 at 4:10 PM Resident # 1 could answer only simple questions but denied all inappropriate sexual behaviors. Interview on 07/24/2014 at 7:55 M Resident # 9 denied ever touching or kissing a Resident in the dining room. Resident # 9 stated he does like Resident # 1. Interview on 07/25/2014 at 12:00 Noon Resident # 9 stated "Resident # 1 did try to show him her top half a couple of times but we were not in public, it was in her room but I don't know about closed doors." Resident # 9 stated Resident # 1 seemed kind of interested in her but he couldn't speak for her. Resident # 9 stated "she has come to my room and I have stopped by her room." In an interview on 07/24/2014 at 7:45 PM Registered Nurse (RN) A stated on 07/13/2014 she observed Resident #9 approach Resident #1 at the dining table. Resident #9 bent down and kissed Resident #1 on the cheek and placed his hand on her breast. RN A stated she approached the table and redirected Resident #9 to please not do that. RN A stated Resident #9 yelled at her and he got upset. RN A stated as she began an incident report, RN B told her an incident report was not necessary as the DON had informed staff the Responsible Party for Resident # 1 had previously consented to the relationship between Resident #1 and a male resident. RN A stated RN B assured her consent had been given by the daughter some time ago for Resident #1 to have a relationship. RN A further stated Resident #9 goes to Resident #1's room and closes the door at times. RN A stated she does not supervise the visits and does not time how long Resident # 9 stays in Resident # 1's room. In an interview on 07/25/2014 at 1:15 PM RN B stated Resident #1 invites men to her room but Resident #9 is the only one that has gone to the room and, at times, had the door closed while he was in the room. RN B stated the DON, Assistant Director of Nurses (ADON) and Responsible Party have conversed regarding the matter and as a result a care plan was developed regarding a sexual relationship for Resident #1. RN B stated she knows for certain she informed the Responsible Party that Resident #9 touched the breast of Resident #1. In an interview on 07/24/2014 at 8:00 PM, Licensed Vocational Nurse (LVN) C stated she had seen Resident # 1 exhibit sexual connotations such as she takes her breasts in her hands and lifts them and looks straight at Resident # 9. In an interview on 07/25/2014 at 2:00 PM, when asked if she had ever observed inappropriate sexual behaviors within the facility, Housekeeping Aide (HK) D stated she had heard Resident # 1 and Resident # 9 had been caught two (2) or three (3) times but she had not seen it. In an interview on 07/24/2014 at 8:17PM Resident #1's Responsible Party (RP) stated, "He likes her and she likes him. They need to do an in-service about people's feelings for each other don't die at the door when they are admitted here." Resident # 1's RP further stated she was never made aware of what was care planned for her mother and relationships in the facility. Resident # 1's RP stated she had never told staff not to notify her of sexual behaviors between her mother and Resident # 9 because she thought it was just a one-time occurrence. Resident # 1's RP stated she was aware of a male resident in her mother's room one night but she thought the resident had been moved to another hall. Resident # 1's RP stated the facility did advise her a male resident kissed Resident # 1 in the dining room but she was not told he touched her breast. Resident # 1's RP stated she was just aware Resident # 1 and Resident # 9 kissed and held hands. Review of Resident #1's Nurse's Note dated 07/24/2014 at 6:30 PM reflected Resident # 1's physician was notified on 07/24/2014 of the incident that occurred on 07/13/2014 with Resident #1 and Resident #9 "consensually" kissing and touching in the dining room. In an interview on 07/24/2014 at 8:15 PM, when asked why the facility had not supervised Resident # 1 to ensure inappropriate sexual behavior did not occur, the DON stated the daughter consented to Resident # 1 having a relationship with Resident # 9 in May, 2014 and a care plan was developed. The DON stated the facility allowed Resident # 1's RP to make sexual relationship decisions for the resident. The DON stated there was no incident report or investigation of the incident that occurred on 07/13/2014 because the RP allowed the relationship. Interview on 07/24/2014 at 7:29 PM the Administrator stated he had been made aware of the incident that occurred on 07/13/2014 today and had reported it to the State Agency. Interview on 07/25/2014 at 1:30 PM Resident # 1's Primary Care Physician (PCP) stated he had gotten information from the facility this morning regarding Resident # 1 and behaviors but could not remember if he had been advised before. Resident # 1's PCP stated the Resident did not have the cognitive ability to make healthy decisions regarding sexual conduct. Review of the facility policy regarding Sexual Behavior - Inappropriate dated 01/2008 and revised 11/2013 reflected: Policy It is the policy of this home that allegations of sexually inappropriate behavior toward an individual shall be thoroughly investigated. Any sexual behavior directed toward a particular individual, which results in an allegation and constitutes cause to believe sexual abuse occurred after the investigation, shall be reported to the state regulatory services and thoroughly investigated. Procedure 1. Examples of inappropriate sexual behavior include but are not limited to: ? Touching private area of an individual, fondling, kissing and hugging of an individual without consent. ? Exposing oneself to an individual to satisfy self or to arouse others in a public or private area without consent by the other individual. 2. Consensual sexual behavior ? This is defined as - both individuals have the ability to consent. ? If the individual has been adjudicated incompetent, the guardian should provide written consent... 3. Inappropriate sexual behaviors should be redirected immediately by the staff in a calm and collective manner and should be reported to the immediate supervisor and documented by a licensed nurse. 4. If it constitutes cause to believe that sexual abuse has taken place, a complete head to toe assessment should be completed by the Licensed Nurse. 5. Assessment and evaluation of cognitive status is done as soon as possible by appropriate personnel. 6. Notify the physician and follow any new orders. 7. Notify family members. 8. Notify Administrator/Director of Nursing. 9. Obtain statements from witnesses. 10. Notification to state and local authorities as directed by the Administrator. 11. Provide additional supervision for involved individuals to ensure safety of all residents of home... 15. Care Plan to reflect current needs and approaches to minimize further incidences... 18. An individual behavior management program should be written for each individual with the help of a Psychologist when necessary. Review of the facility Abuse - Reportable Events Policy dated 01/2008 and revised 05/2014 reflected the following: "Policy It is the policy of this home to prohibit resident abuse or neglect in any form and to report in accordance with the law any incident/event in which there is cause to believe a resident's physical or mental health or welfare has been adversely affected by abuse or neglect caused by another person. Definitions...Sexual abuse: Any touching or exposure of the anus, breast, or any part of the genitals of a resident without the voluntary, informed consent of the resident and with the intent to arouse or gratify the sexual desire of any person and includes but is not limited to sexual harassment, sexual coercion or sexual assault. Neglect: The failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness... The home's administration will prohibit neglect...including...sexual abuse of residents caused by another person. The home's administration will conduct and investigate allegations of crimes, suspected abuse, neglect or misappropriation of property, and will provide notification and release of information to the proper authorities, in accordance with federal and state regulations... 5. Investigation: a. When an employee becomes aware of an allegation of suspicion of abuse the employee should: Immediately report the allegation or suspicion to the charge nurse on the unit on which the resident resides immediately. b. The charge nurse will: Assess the resident or resident(s). Notify the Administrator or person on-call if after hours... Begin taking written statements from the person reporting the allegation or suspicion and any witnesses including staff, family and/or residents... Ask any witness to wait for the Administrator or the person on-call to arrive at the home... 7. Reporting a. All alleged allegations of abuse will be reported to the appropriate state agency and to all other agencies as required by regulation. b. Local law enforcement will be notified of any... A resident has been a victim of any act or attempted act of deviate sexual behavior... Resident to Resident Abuse - Procedure 1. The charge nurse will:... ? Immediately notify the Administrator and/or the Director of Nursing. ? If the alleged perpetrator is placed on location monitoring, staff will be instructed on reason for monitoring and targeted behaviors being monitored. ? Complete an incident/accident report for the alleged perpetrator and the victim... ? Notify the responsible party/guardian and physician of each resident... 2. The Administrator will: ? Notify state agency as required. ? Notify local law enforcement as required...." The Administrator and DON were notified on 07/25/2014 at 1:40 PM an IJ was identified due to the above situation. A Plan of Removal was received and accepted by the facility on 07/25/2014 at 4:55 PM as follows: Problem: Resident being allowed to participate in sexual activities without the cognitive ability to give consent. Plan: 1. The Administrator/designee will place the female resident involved on 1/1 supervision immediately to ensure no sexual activity occurs since resident is not cognitively able to give consent. Completion date 7/25/2014 3:00 PM until evaluated by a Psychiatrist and a decision to evaluate her status as a resident will be made at that time. 2. Administrator/designee will interview staff to determine if staff has knowledge of any other residents may be engaging in any sexual contact that has not been reported. If any are identified then an immediate assessment will be done to determine the residents' ability to provide consent. Completion date: 7/25/2014 3:00 PM. 3. Administrator, Director of Nurses, and Business Office Manager will be educated by Director of Clinical Services on reportable sexual activity between residents in the home to include: ? Resident must have capacity to make decisions to give consent for sexual activity. ? Sexual activity without consent or cognitive ability to give consent is a reportable event. ? Sexual abuse is defined as "Any touching or exposure of the anus, breast, or any part of the genitals of a resident without the voluntary, informed consent for the resident and with the intent to arouse or gratify the sexual desire of any person and includes but is not limited to sexual harassment, sexual coercion, or sexual assault."... ? Durable POA must specifically include the language in the POA to have authority to give consent for sexual activity. Completion date 7/25/2014. 4:30. 4. DON/designee will provide training for all staff on reportable sexual activity between residents in the home to include: ? Resident must have capacity to make decisions to give consent for sexual activity. ? Sexual activity without consent or cognitive ability to give consent is a reportable event. ? Sexual abuse is defined as "Any touching or exposure of the anus, breast, or any part of the genitals of a resident without the voluntary, informed consent for the resident and with the intent to arouse or gratify the sexual desire of any person and includes but is not limited to sexual harassment, sexual coercion, or sexual assault."... ? Training will include to report all sexual activities to Adm/DON immediately and intervene to prevent any sexual activities till resident assessments can be completed to assure proper consent can be provided. Staff not working will receive training prior to working their next scheduled shift. Newly hired employees will receive training during the orientation process on:...Completion date July 26, 2014. 5. DON/designee will monitor for process compliance and understanding daily for the remainder of this week, three times a week for one week, weekly for two weeks then randomly thereafter. Completion date August 25th, 5:00 PM. 6. Medical Director (Name of Physician) will be contacted and informed of the IJ situation. Completion date July 25, 3:30 PM. 7. Results of training, interviews will be reviewed during QA meeting scheduled on August 13, 2014. The Plan of Removal was monitored by the survey team as follows: Observation was made of Resident # 1 on 07/25/2014 at 5:45 PM. Resident # 1 had a one-on-one sitter with a schedule. The sitter had a schedule that provided documentation areas for sitters to complete for a 24 hour time period. In an interview on 067/25/2014 at 6:26 PM CNA D stated she was instructed to provide one-on-one assistance to Resident # 1 until 10:00 PM this evening and at that time someone would relieve her. The facility provided documented evidence of the Administrative staff had been in serviced and that 70% of staff had been in-serviced according to the POR. Interviews were conducted with eight (8) licensed staff who all knew the definition of sexual abuse, what to watch for and what to do in the instance of an allegation of sexual abuse. Interviews were conducted with three (3) Certified Nurse Aides who all knew the definition of sexual abuse, what to watch for and what to do in the instance of an allegation of sexual abuse. On 07/25/2014 at 6:30 PM the Administrator was informed the IJ was removed. However, the facility remained out of compliance at a severity of no actual harm with a potential for more than minimal harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. The facility provided CMS Form 672 that reflected 24 residents with behavioral health needs.

Based on observation, interview and record review the facility failed to implement written policies and procedures that prohibit neglect for two (2) of eight (8) residents (Resident # 1 and Resident # 9) reviewed for inappropriate sexual behaviors. Facility Staff failed to supervise or monitor Resident # 1 who was cognitively impaired. Resident # 1was allowed by staff to have inappropriate sexual behaviors without supervison or monitoring to ensure she was safe. An Immediate Jeopardy (IJ) was identified on 07/25/2014. While the IJ was removed on 07/25//2014, the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice affected two (2) Residents (Resident # 1 and # 9) and placed an additional 22 residents with behavioral health needs at risk for injury and a decline in physical, mental and psychosocial well-being. Findings Include: Review of the facility policy regarding Sexual Behavior - Inappropriate dated 01/2008 and revised 11/2013 reflected: Policy It is the policy of this home that allegations of sexually inappropriate behavior toward an individual shall be thoroughly investigated. Any sexual behavior directed toward a particular individual, which results in an allegation and constitutes cause to believe sexual abuse occurred after the investigation, shall be reported to the state regulatory services and thoroughly investigated. Procedure 1. Examples of inappropriate sexual behavior include but are not limited to: ? Touching private area of an individual, fondling, kissing and hugging of an individual without consent. ? Exposing oneself to an individual to satisfy self or to arouse others in a public or private area without consent by the other individual. 2. Consensual sexual behavior ? This is defined as - both individuals have the ability to consent. ? If the individual has been adjudicated incompetent, the guardian should provide written consent... 3. Inappropriate sexual behaviors should be redirected immediately by the staff in a calm and collective manner and should be reported to the immediate supervisor and documented by a licensed nurse. 4. If it constitutes cause to believe that sexual abuse has taken place, a complete head to toe assessment should be completed by the Licensed Nurse. 5. Assessment and evaluation of cognitive status is done as soon as possible by appropriate personnel. 6. Notify the physician and follow any new orders. 7. Notify family members. 8. Notify Administrator/Director of Nursing. 9. Obtain statements from witnesses. 10. Notification to state and local authorities as directed by the Administrator. 11. Provide additional supervision for involved individuals to ensure safety of all residents of home... 15. Care Plan to reflect current needs and approaches to minimize further incidences... 18. An individual behavior management program should be written for each individual with the help of a Psychologist when necessary. Review of the facility Abuse - Reportable Events Policy dated 01/2008 and revised 05/2014 reflected the following: "Policy It is the policy of this home to prohibit resident abuse or neglect in any form and to report in accordance with the law any incident/event in which there is cause to believe a resident's physical or mental health or welfare has been adversely affected by abuse or neglect caused by another person. Definitions...Sexual abuse: Any touching or exposure of the anus, breast, or any part of the genitals of a resident without the voluntary, informed consent of the resident and with the intent to arouse or gratify the sexual desire of any person and includes but is not limited to sexual harassment, sexual coercion or sexual assault. Neglect: The failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness... The home's administration will prohibit neglect...including...sexual abuse of residents caused by another person. The home's administration will conduct and investigate allegations of crimes, suspected abuse, neglect or misappropriation of property, and will provide notification and release of information to the proper authorities, in accordance with federal and state regulations... 5. Investigation: a. When an employee becomes aware of an allegation of suspicion of abuse the employee should: Immediately report the allegation or suspicion to the charge nurse on the unit on which the resident resides immediately. b. The charge nurse will: Assess the resident or resident(s). Notify the Administrator or person on-call if after hours... Begin taking written statements from the person reporting the allegation or suspicion and any witnesses including staff, family and/or residents... Ask any witness to wait for the Administrator or the person on-call to arrive at the home... 7. Reporting a. All alleged allegations of abuse will be reported to the appropriate state agency and to all other agencies as required by regulation. b. Local law enforcement will be notified of any... A resident has been a victim of any act or attempted act of deviate sexual behavior... Resident to Resident Abuse - Procedure 1. The charge nurse will:... ? Immediately notify the Administrator and/or the Director of Nursing. ? If the alleged perpetrator is placed on location monitoring, staff will be instructed on reason for monitoring and targeted behaviors being monitored. ? Complete an incident/accident report for the alleged perpetrator and the victim... ? Notify the responsible party/guardian and physician of each resident... 2. The Administrator will: ? Notify state agency as required. Notify local law enforcement as required...." Review of Resident #1's Face Sheet reflected an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected a Brief Interview for Mental Status (BIMS) score of seven (7) out of a possible 15 that indicated Resident #1 had severe cognitive impairment. Resident #1 was assessed to be independent in locomotion about the facility in her wheelchair. The assessment reflected Resident # 1 exhibited physical and verbal behaviors directed toward others, other behaviors not directed toward others, behaviors that put the resident and others at risk and behaviors that disrupt care or living environment. The assessment reflected these behaviors for Resident # 1 had gotten worse. Review of Resident #1's Comprehensive Care Plan dated 05/15/2014 and revised on 06/10/2014 reflected a problem, "I may express or desire intimate companionship as evidenced by asking others for intimate touch." Interventions included: "allow resident to not feel guilty about desires ... If approaching others who are not willing, redirect to other activities ...allow private time if needed." Resident # 1's Care Plan further reflected a problem of "I have cognitive impairment and memory impairments evidenced by confusion and difficulty with recalling; I am also inattentive at times related to [DIAGNOSES REDACTED]." Review of Resident #1's Daily Care Guide for July, 2014 reflected interventions to assist in choices in care, clothes and activities. An intervention for redirection immediately away from altercations or potential altercations is noted. There is no intervention listed for monitoring and redirection from inappropriate sexual behaviors. Review of Resident #1's Physical Therapy Rehabilitation Screen dated 05/01/2014 reflected the reason for not giving therapy is that Resident #1 is " unable to retain new information and training." Review of Resident # 1's history reflected the Resident was missing on 5/8/14 and found by facility staff on the floor of the kitchen janitor's closet (approximately 45 minutes after she was discovered missing). Review of Resident # 9's Face Sheet reflected a [AGE] year old male who entered the facility on 04/04/2012 and readmitted on [DATE]. Resident # 9's [DIAGNOSES REDACTED]. Review of Resident # 9's Quarterly MDS assessment dated [DATE] reflected the Resident scored 15 out of a possible 15 for the BIMS test and indicated he was cognitively intact. The assessment listed no behaviors for Resident # 9. Review of Resident # 9's Comprehensive Care Plan updated 05/28/2014 reflected no plan of care for inappropriate sexual behavior. Review of Resident #1's Nurses Notes dated 05/14/2014 at 8:15 PM reflected "Res (resident) in room. Laundry Aide witnessed inappropriate behavior of res with another res. DON notified. Per DON ask Res if wanted other Res to touch. 0 bruises/marks noted on Res. except for bruises from fall from previous days. When asking Res of about unwanted touch Res states 'It doesn't matter' Asked Res does she want the other res in her room or touching her stated 'his peenis this big it doesn't matter' Res held up index finger to show measuring gesture while speaking. Reported statement to DON. Per DON ' If she says it doesn't matter then she can't say it's unwanted...I will let (name of employee) know.'...." Review of Resident # 1's Nurse's Note dated 05/15/2014 reflected "Responsible party notified of intimate touching that occurred in her room the previous evening. Responsible party aware of relationship between residents. RP noted her mother told her this was her "boyfriend & to not be surprised if she goes off to Chicago with him." RP aware that this occurred and is okay with relationship as long as there is no harm to her mother. Resident was assessed for injury and no injury was noted physically or mentally....Resident's wander guard cont. (continues) to function appropriately. Motion detector in room near bed was noted to be functioning but resident knows how to shut off alarms. Staff cont to observe for wandering & potential fall risks." Review of Resident # 1's Nurse's Note dated 05/26/2014 reflected "Resident at the nurse's station pretending to get some snacks...with Resident (name of other resident - Resident # 9). Resident raised her shirt (dress up) exposed her breast and verbalized "get it, you want it, touch it, take it", nurse was able to stop both resident & (Resident # 9) walked away towards dining room area." Review of Resident # 1's Nurse's Note dated 06/30/2014 reflected "summoned to room by daughter, noted increased redness to groins - L (left) and R (right)....small bruise on L outer upper shin...." The nurse followed up with a call to Resident # 1's physician who ordered an antifungal cream. Review of Resident # 1's Nurse's Note dated 07/13/2014 reflected "Resident in the dining room, sitting at the same table with (Resident # 9). Resident held hands with Resident # 9 and Resident # 9 grab (name of Resident # 1) left breast and kiss her by her mouth. Nurse intervened by asking resident to leave (Resident # 1's first name) alone and that this is inappropriate behavior in the dining area. Resident # 9 verbalized "shut up, I say shut up, it is not your business." There was no additional note regarding Resident # 1's Responsible Party or Physician being notified of this behavior. There was no evidence of an incident report or investigation occurred. Review of the facility Incident Log for May, 2014 through present, July 25, 2014 reflected no incident report or investigation of any inappropriate sexual activity between Resident # 1 and Resident # 9. In an interview on 07/24/2014 at approximately 9:45 PM the Regional Nurse Consultant stated Resident #1 has the right to have a sexual relationship within the facility and her rights to do so cannot be taken from her. Review of Resident #1's Nurse Notes dated 07/14/2014 at 5:45 AM reflected " Resident observed wheeling self to front lobby from back of Hall #3 (where Resident #9 resides). When asked where she had been, she stated, " just wandering." When asked again, she stated, "That's a man's room." No documentation of monitoring present. Observation on 07/24/2014 at 3:00 PM revealed Resident #1 to be rolling about the facility independently in a wheelchair. There was no supervision of Resident # 1. Observation on 07/24/2014 at 4:10 PM revealed Resident #1 lying on the bed with Responsible Party (RP) present in the room. Resident #1 would not communicate with the surveyor but repeatedly asked the RP who the surveyor was. The RP assisted Resident #1 to transfer from the bed to the wheelchair and the RP propelled Resident #1 to the bathroom. While Resident #1 was in the bathroom, Resident #9 knocked on the door and asked the RP if he could talk to Resident #1. The RP told Resident #9 that Resident #1 was in the bathroom. Resident #9 left the doorway. The RP then used the call light for Resident #1 for assistance in the bathroom. The staff answered the call light and assisted Resident #1 with personal hygiene. The RP then asked the staff to assist Resident #1 with dressing into another outfit. The RP asked the staff to place two briefs on Resident #1 because the RP was taking Resident #1 out to eat at a restaurant. The staff explained to the RP that they were not supposed to double brief Resident #1. The RP placed the additional brief on Resident #1. Observation on 07/24/2014 at 8:37 PM Resident #1 was propelling her wheelchair in Hall 2. There was no staff visible in Hall 2 near Resident #1. Observation on 07/25/2014 at 6:00 PM revealed Resident # 1 sitting on her bed. Resident # 1 insisted Surveyor remove her shoes. Surveyor advised Resident # 1 that was not allowed and would ask someone to assist her. Resident # 1 hollered several times. Interview on 07/24/2014 at 4:10 PM Resident # 1 could answer only simple questions but denied all inappropriate sexual behaviors. Interview on 07/24/2014 at 7:55 M Resident # 9 denied ever touching or kissing a Resident in the dining room. Resident # 9 stated he does like Resident # 1. Interview on 07/25/2014 at 12:00 Noon Resident # 9 stated "Resident #1 did try to show him her top half a couple of times but we were not in public, it was in her room but I don't know about closed doors." Resident # 9 stated Resident # 1 seemed kind of interested in her but he couldn't speak for her. Resident # 9 stated "she has come to my room and I have stopped by her room." In an interview on 07/24/2014 at 7:45 PM Registered Nurse (RN) A stated on 07/13/2014 she observed Resident #9 approach Resident #1 at the dining table. Resident #9 bent down and kissed Resident #1 on the cheek and placed his hand on her breast. RN A stated she approached the table and redirected Resident #9 to please not do that. RN A stated Resident #9 yelled at her and he got upset. RN A stated as she began an incident report, RN B told her an incident report was not necessary as the DON had informed staff the Responsible Party for Resident # 1 had previously consented to the relationship between Resident #1 and a male resident. RN A stated RN B assured her consent had been given by the daughter some time ago for Resident #1 to have a relationship. RN A further stated Resident #9 goes to Resident #1's room and closes the door at times. RN A stated she does not supervise the visits and does not time how long Resident # 9 stays in Resident # 1's room. In an interview on 07/25/2014 at 1:15 PM RN B stated Resident #1 invites men to her room but Resident #9 is the only one that has gone to the room and, at times, had the door closed while he was in the room. RN B stated the DON, Assistant Director of Nurses (ADON) and Responsible Party have conversed regarding the matter and as a result a care plan was developed regarding a sexual relationship for Resident #1. RN B stated she knows for certain she informed the Responsible Party that Resident #9 touched the breast of Resident #1. In an interview on 07/24/2014 at 8:00 PM, Licensed Vocational Nurse (LVN) C stated she had seen Resident # 1 exhibit sexual connotations such as she takes her breasts in her hands and lifts them and looks straight at Resident # 9. In an interview on 07/25/2014 at 2:00 PM, when asked if she had ever observed inappropriate sexual behaviors within the facility, Housekeeping Aide (HK) D stated she had heard Resident # 1 and Resident # 9 had been caught two (2) or three (3) times but she had not seen it. In an interview on 07/24/2014 at 8:17PM Resident #1's Responsible Party (RP) stated, " He likes her and she likes him. They need to do an in-service about people's feelings for each other don't die at the door when they are admitted here." Resident # 1's RP further stated she was never made aware of what was care planned for her mother and relationships in the facility. Resident # 1's RP stated she had never told staff not to notify her of sexual behaviors between her mother and Resident # 9 because she thought it was just a one-time occurrence. Resident # 1's RP stated she was aware of a male resident in her mother's room one night but she thought the resident had been moved to another hall. Resident # 1's RP stated the facility did advise her a male resident kissed Resident # 1 in the dining room but she was not told he touched her breast. Resident # 1's RP stated she was just aware Resident # 1 and Resident # 9 kissed and held hands. Review of Resident #1's Nurse's Note dated 07/24/2014 at 6:30 PM reflected Resident # 1's physician was notified on 07/24/2014 of the incident that occurred on 07/13/2014 with Resident #1 and Resident #9 "consensually" kissing and touching in the dining room. In an interview on 07/24/2014 at 8:15 PM, when asked why the facility had not supervised Resident # 1 to ensure inappropriate sexual behavior did not occur, the DON stated the daughter consented to Resident # 1 having a relationship with Resident # 9 in May, 2014 and a care plan was developed. The DON stated the facility allowed Resident # 1's RP to make sexual relationship decisions for the resident. The DON stated there was no incident report or investigation of the incident that occurred on 07/13/2014 because the RP allowed the relationship. Interview on 07/24/2014 at 7:29 PM the Administrator stated he had been made aware of the incident that occurred on 07/13/2014 today and had reported it to the State Agency. Interview on 07/25/2014 at 1:30 PM Resident # 1's Primary Care Physician (PCP) stated he had gotten information from the facility this morning regarding Resident # 1 and behaviors but could not remember if he had been advised before. Resident # 1's PCP stated the Resident did not have the cognitive ability to make healthy decisions regarding sexual conduct. The Administrator and DON were notified on 07/25/2014 at 1:40 PM an IJ was identified due to the above situation. A Plan of Removal was received and accepted by the facility on 07/25/2014 at 4:55 PM as follows: Problem: Resident being allowed to participate in sexual activities without the cognitive ability to give consent. Plan: 1. The Administrator/designee will place the female resident involved on 1/1 supervision immediately to ensure no sexual activity occurs since resident is not cognitively able to give consent. Completion date 7/25/2014 3:00 PM until evaluated by a Psychiatrist and a decision to evaluate her status as a resident will be made at that time. 2. Administrator/designee will interview staff to determine if staff has knowledge of any other residents may be engaging in any sexual contact that has not been reported. If any are identified then an immediate assessment will be done to determine the residents' ability to provide consent. Completion date: 7/25/2014 3:00 PM. 3. Administrator, Director of Nurses, and Business Office Manager will be educated by Director of Clinical Services on reportable sexual activity between residents in the home to include: ? Resident must have capacity to make decisions to give consent for sexual activity. ? Sexual activity without consent or cognitive ability to give consent is a reportable event. ? Sexual abuse is defined as "Any touching or exposure of the anus, breast, or any part of the genitals of a resident without the voluntary, informed consent for the resident and with the intent to arouse or gratify the sexual desire of any person and includes but is not limited to sexual harassment, sexual coercion, or sexual assault."... ? Durable POA must specifically include the language in the POA to have authority to give consent for sexual activity. Completion date 7/25/2014. 4:30. 4. DON/designee will provide training for all staff on reportable sexual activity between residents in the home to include: ? Resident must have capacity to make decisions to give consent for sexual activity. ? Sexual activity without consent or cognitive ability to give consent is a reportable event. ? Sexual abuse is defined as "Any touching or exposure of the anus, breast, or any part of the genitals of a resident without the voluntary, informed consent for the resident and with the intent to arouse or gratify the sexual desire of any person and includes but is not limited to sexual harassment, sexual coercion, or sexual assault."... ? Training will include to report all sexual activities to Adm/DON immediately and intervene to prevent any sexual activities till resident assessments can be completed to assure proper consent can be provided. Staff not working will receive training prior to working their next scheduled shift. Newly hired employees will receive training during the orientation process on:...Completion date July 26, 2014. 5. DON/designee will monitor for process compliance and understanding daily for the remainder of this week, three times a week for one week, weekly for two weeks then randomly thereafter. Completion date August 25th, 5:00 PM. 6. Medical Director (Name of Physician) will be contacted and informed of the IJ situation. Completion date July 25, 3:30 PM. 7. Results of training, interviews will be reviewed during QA meeting scheduled on August 13, 2014. The Plan of Removal was monitored by the survey team as follows: Observation was made of Resident # 1 on 07/25/2014 at 5:45 PM. Resident # 1 had a one-on-one sitter with a schedule. The sitter had a schedule that provided documentation areas for sitters to complete for a 24 hour time period. In an interview on 067/25/2014 at 6:26 PM CNA D stated she was instructed to provide one-on-one assistance to Resident # 1 until 10:00 PM this evening and at that time someone would relieve her. The facility provided documented evidence of the Administrative staff had been in serviced and that 70% of staff had been in-serviced according to the POR. Interviews were conducted with eight (8) licensed staff who all knew the definition of sexual abuse, what to watch for and what to do in the instance of an allegation of sexual abuse. Interviews were conducted with three (3) Certified Nurse Aides who all knew the definition of sexual abuse, what to watch for and what to do in the instance of an allegation of sexual abuse. On 07/25/2014 at 6:30 PM the Administrator was informed the IJ was removed. However, the facility remained out of compliance at a severity of no actual harm with a potential for more than minimal harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. The facility provided CMS Form 672 that reflected 24 residents with behavioral health needs.

Based on observation, interview, and record review the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents for four (4) of 32 residents (Residents #4, #9, #12, and #26) when: A) Resident #4 was admitted to the facility on [DATE] with a Stage II sacral and left heel ulcer per hospital discharge records. The facility did not assess, measure, stage or implement/clarify physician ordered treatments to Resident #4's left heel pressure sores resulting in worsening of Resident #4's left heel and sacral pressure sores. The facility failed to address Resident #4's pain associated with wound care treatment. Resident #4 ' s left heel became infected and was cultured on 10/08/13 with results received on 10/11/13 not conveyed to the physician until 10/14/13, an additional 3 days, resulting in a delay of antibiotic treatment. Resident #4 ' s sacral ulcer treatment order ended on 08/14/13 and was not clarified until 10/01/13 resulting in 40 days of treatment without orders while the wound worsened from a stage II to multiple stage III wounds. Resident #4 ' s physician was not notified of the worsening sacral ulcers until Surveyors brought it to his attention on 10/23/13. Resident #4 was ordered to have a consult with a wound care specialist on 8/07/13, Resident #4 had not seen the wound care specialist as of 10/23/13. B.) Resident #9 was admitted to the facility on [DATE] with a Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough.) to right heel surrounded by areas of deep tissue injury (DTI) (A pressure-related injury to subcutaneous tissues under intact skin. Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear) and an unstageable (meaning that the stage is not clear. In these cases, the base of the sore is covered by a thick layer of other tissue and pus that may be yellow, gray, green, brown, or black. The doctor cannot see the base of the sore to determine the stage.) DTI to left heel per discharge hospital records. The facility did not assess, properly stage or implement physician ordered treatments to Resident #9's bilateral heel pressure sores resulting in worsening of Resident #9's bilateral heel pressure sores. C.) Resident #12 was admitted to the facility on [DATE] with a Stage IV (Stage IV-Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling ). The facility did not routinely assess Resident #12's left ischium pressure sore, obtain a physician ordered wound culture or physician ordered referral to a wound care physician resulting in the worsening of Resident #12's left ischium Stage IV pressure sore. This failure further resulted in an identification of an Immediate Jeopardy (IJ) on 10/23/2013. While the IJ was removed on 10/25/2013, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope identified as pattern due to the facility ' s need to evaluate the effectiveness of the corrective systems. This deficient practice affected three (3) residents and placed 22 residents at risk for developing new or worsening pressure sores, [MEDICAL CONDITION] (skin infection), Osteomylitis (infection of the bone),[MEDICAL CONDITION] (infection of the blood), severe pain and death. D.) Resident #26's left ankle abrasion the staff identified on 09/12/2013, which developed into an infection and resulted in [MEDICAL CONDITION] to the left ankle, was not investigated implementing written policies and procedures using the incident report by facility staff and was neglected. This deficient practice placed 90 residents at risk for neglect due to facility did not follow written policies and procedures that prohibit neglect of residents resulting in a delay in appropriate medical treatment, the development of new or worsening medical conditions, and diminished quality of life for any resident who may have a new clinical condition. Findings include: Review of the Policy and Procedure entitled Abuse and Neglect revised 07/2010 reflected "It is the policy of this facility that each resident has the right to be free from mistreatment, neglect, abuse, and misappropriation of property by anyone, including, but not limited to, facility staff, other residents, consultants, or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals." The Policy reflected under Definitions: "'Verbal Abuse' is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to: threats of harm, saying things to frighten a resident; such as telling a resident that he/she will never be able to see his/her family again." The Policy reflected the definition of "'Neglect' means the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. This presumes that instances of abuse or neglect of all residents, even those in coma, cause physical harm or pain, mental anguish or mental illness." The Policy reflected the facility should screen potential employees, train employees, provide information on how and to whom to report concerns, identify events like suspicious bruising that may be abuse or neglect, investigate incidents or reports of abuse or neglect thoroughly, protect the resident from harm, and to report all alleged violations to State agencies. The Policy reflected "Abuse Investigations" and under "Policy Statement" reflected "All reports of alleged resident abuse, neglect, and injuries of unknown source shall be promptly and thoroughly investigated by facility management." The Policy reflected "Policy Interpretation and Implementation" that "The individual conducting the investigation will, as a minimum: Review the resident's medical record to determine events leading up to the alleged incident; Interview the person(s) reporting the incident; Interview any witness to the incident; Interview the resident (as medically appropriate); Interview the resident's Attending Physician as needed to determine the resident's current level of cognitive function and medical condition; Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; Interview the resident's roommate, family members, and visitors; Interview other residents with whom the individual provides care or services and/or interacts; and Review all events leading up to the alleged incident." The Policy reflected "Witness reports will be obtained in writing. Witnesses will be required to sign and date such reports." The Policy also reflected "Employees of this facility who have been accused of resident abuse will be suspended from duty until the results of the investigation have been reviewed by the Administrator." The Policy reflected the investigator has five (5) days to complete the investigation and report to the administrator. The Policy reflected the administrator has to provide a written report to the State agency within five (5) working days of the reported incident. Review of the facility provided policy for pressure sores reflected " Skin and Wound Care Program. Policy: The facility will follow steps to minimize the risk of skin breakdown from occurring in the facility and maintain good skin integrity. Procedure: 1.) The Wound and Skin Care Program must be implemented in order to maintain good skin integrity and to prevent skin breakdown. 2.) By using this program, correctly assessing the risk factors and monitoring appropriately, skin problems will be prevented and/ or identified, treated and healed quickly. 3.) The Body Audit and Hydration Report should be completed on admission and a risk level assigned based on the Resident Assessment Profile. This will initiate a tracking system to monitor for skin breakdown on a routine basis; daily, weekly or monthly. 4.) If skin breakdown occurs, medical justification must be documented. If the wounds do not heal, documentation by the physician must justify the reason for the occurrence of the breakdown .... " " If a pressure sore of other skin breakdown occurs, the Weekly Pressure Sore Progress Report should be initiated. Evaluation of the risk should also include determination if the mattress is sufficient to reduce pressure. The facility mattresses are pressure reducing, but residents with several pressure sores or Stage III or IV on the coccyx or trunk may require low air loss overly... " A.) Review of Resident #4 ' s face sheet reflected a [AGE] year old woman admitted to the facility on [DATE] and then readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #4 ' s discharge summary from the hospital to the facility, dated 08/07/13 reflected Resident #4 ' s admitting [DIAGNOSES REDACTED]. Hospital course: The patient was admitted with the above said [DIAGNOSES REDACTED]. Her blood cultures have remained negative and her wound culture from the left heel decubiti and sacrum was growing proteus mirabilis and staphylococcus aureus. Observation on 10/22/13 at 9:17 AM revealed Resident #4 in bed. Resident #4 was wearing blue foam boots on both feet. When the Medical Records LVN opened the boot on the left foot a pervasive odor was noted, also a creamy yellow dried substance was noted on the inside of the left boot near the bandage. Resident #4 cried out as the LVN was opening the boot, Resident #4 stated " Ill slap you, " and raised her hand. The Medical Records LVN asked if Resident #4 was in pain and the Resident nodded. Medical Records LVN stated she would get Tylenol. In an interview on 10/22/13 at 2:10 PM LVN B stated that Resident #4 came in with a stage 4 heel ulcer and a stage 1 that had progressed to a scattered stage 2 ulcer on the coccyx. In an interview on 10/23/13 at 4:15 PM LVN B stated that she had worked with Resident #4 previously at a group home. LVN B stated that Resident #4 came in with an open area to the coccyx and that it then closed and has reopened. She stated that the new Director of Nursing instituted different assessment sheets and that the previous Assistant Director of Nursing had done the previous assessments. Review of Resident #4 ' s admission MDS dated [DATE], reflected Resident #4 to have both short term and long term memory problems per staff assessment. Resident #4 was coded as requiring extensive assistance of one person for bed mobility and extensive two person assistance with transfers. Resident #4 was coded as always incontinent for both bowel and bladder. In the skin condition section Resident #4 was coded as having 3 stage 2 pressure ulcers, with 3 present at admission. The tissue type listed for " ulcer at most advanced stage " was " granulation tissue-pink or red tissue with shiny, moist, granular appearance. No additional wounds were coded. Observation on 10/23/2013 at 4:15 PM revealed LVN B in Resident #4 ' s room to perform wound care on Resident #4 with the CSC RN present at bedside. Resident #4 was lying on her back, on a regular foam mattress. A blue pillow style boot was noted to Resident #4's left foot. LVN B removed a duoderm dressing (A [MEDICATION NAME] dressing that is biodegradable, non-breathable and adheres to the skin) from Resident #4 ' s sacral area to reveal a Stage III (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.) pressure sore to Resident #4 ' s right sacral area approximately 3 cm (centimeters) in length by 1 cm width with a depth of >0.2 cm. The right sacral Stage III pressure sore was covered by approximately 20% yellow slough. There was a Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough) to Resident #4 ' s lateral right sacral area approximately 1 cm by 0.5 cm with a pink wound bed. On Resident #4 ' s right lower lateral right buttock was a Stage III pressure sore approximately 3 cm x 0.5 cm x >0.2 cm, the wound bed was 50% covered in yellow slough. Resident #4 ' s had a Stage III pressure sore to her mid sacral area approximately 6.5 cm x 2.5 cm with >0.2 cm depth 60 % of the wound was covered in yellow slough. There was approximately a 10 cm x 8cm area of macerated silver/ white colored tissue surrounding all the wounds. LVN B, without cleaning Resident #4 ' s pressure sores to sacral and right buttock areas, and without applying new gloves applied a thin duoderm over the pressure sores. LVN B then went to the treatment cart to get supplies to do wound care on Resident #4 ' s left heel Stage IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling.) LVN B removed Resident #4 ' s pillow style boot from left foot. There was a prevalent foul odor coming from Resident #4 ' s left foot. The inside of the pillow style boot was noted to have serosanguineous stains where Resident #4 ' s heel was. LVN B then removed the dressing from Resident #4 left heel. Serosanguineous drainage was noted to dressing. Resident #4's left heel pressure sore was approximately 2 cm by 2.5 cm with an undetermined depth, the area was 95% covered in a yellow to brown colored slough. LVN B washed her hands and changed gloves. LVN B then used a needle-less syringe and squirted the open portion of resident left heel. Resident #4 flinched her whole body away from LVN B and stated " Leave me alone f***ers. " The Surveyor asked Resident #4 if she hurt and Resident #4 responded " Yeah, that hurts! " LVN B then took a stack of two (2) by two (2) gauze and patted the area three times with the same gauze. LVN B then placed [MEDICATION NAME] Ag (silver impregnated antimicrobial dressing) to open area of Resident #4's left heel, LVN B then placed a bordered dressing over heel. (approximations by surveyor as LVN B did not measure the wound during care.) LVN B stated that Resident #4 does not have orders for pain medication. She stated that there are no standing orders for pain medication as the Medical Director says absolutely not. Review of Resident #4 ' s Telephone Orders dated 10/01/13 reflected the following orders: Duoderm to sacral/coccyx area change every 3 days and prn soilage. Clarification: cleanse left heel, normal saline, apply [MEDICATION NAME] Ag dressing every day until healed. Review of Resident #4 ' s Physician Communication Form dated 10/06/13 reflected a concern/assessment: Left heel clean with normal saline apply [MEDICATION NAME] AG QD ([MEDICATION NAME] silver every day - a wound treatment) area not progressing. Requesting Santyl QD (every day) (Santyl is an active enzymatic therapy that continuously removes necrotic tissue from wounds at the microscopic level.) Cleans with normal saline, apply santyl cover with 2x2 cover with Allevyn Matrix every day. Signed by Licensed Vocational Nurse (LVN) B. Further down the page is written " Will eval, " with an initial. (No information regarding sacral pressure ulcers was noted on this communication.) Review of Resident #4 ' s Telephone Orders dated 10/07/13 reflected an order to culture wound left heel, signed by the Nurse Practitioner (NP) for Resident #4. Review of Resident #4 ' s Telephone Orders dated 10/11/13 reflected the following order: Apply santyl topical to left heel QOD (every other day) times 10 days, alternating with [MEDICATION NAME] AG. In an interview on 10/23/2013 at 4:45 PM CNA G stated that Resident #4 ' s sacral area had been getting worse for the past month. CNA G further stated she has told the nurses the area was getting worse. CNA G stated the only thing she was told to do for Resident #4's left heel to to keep the boot on it. CNA G stated that there was not a regular schedule for changing the boot or washing it. She stated " I guess we could send them to laundry. " In an interview on 10/23/2013 at 5:50 PM the CSC RN stated LVN B would not be doing treatments anymore. The CSC RN further stated she felt LVN B was disorganized. The CSC RN further stated if there is a change to a wound the physician needs to be called. The CSC RN stated that the current treatment for [REDACTED]. The CSC RN returned at 6:20 PM and stated that there are no measurements for Resident #4's sacral wounds and that this is a deficit. Review of Resident #4 ' s readmission assessment, dated 08/07/13, reflected: Section 13: Integumentary/feet: 1. Skin/wound condition present? Yes. 1a. Is there pain associated with the wound/skin condition? Yes. An anatomical figure had the following markings to indicate the following: a circled " 2 " across the buttocks. The key on the side of the form indicated " 2 " represents " Stage II. " The left heel was circled and written beside it " debrided 8-01-13 4cm x 4.2cm. Drawings of feet inside and outside did not reflect any markings to indicate wounds, no staging, wound depth or wound bed description information was included. 4. Feet status: nothing was checked Section 14: Pain: Had pain of hurting? Yes. Signed as completed by RN U Review of the readmission assessment " Norton Plus Pressure Ulcer Scale " dated 08/07/13 reflected the following: Risk Factor: Physical condition: 3 - fair Mental state: 2 - confused Activity: 2 - chair bound Mobility: 2 - very limited Incontinence: 1 - double incontinence Total Norton Scale: 10 Total Norton Plus Score (score 10 or less = high risk): 7 Signed as completed by RN U Review of Resident #4 ' s Readmission " Pain Assessment, " dated 08/08/13 reflected: Diagnosis: [REDACTED]. 2. Pain Assessment in Advanced Dementia Scare (PAINAD) Breathing independent of vocalization: 0 - normal Negative vocalization: 1 - Occasional moan or groan. Low level speech with a negative or disapproving quality. Facial expression: 1 - Sad. Frightened. Frown. Body language: 1 - Tense. Distressed pacing. Fidgeting. Consolability: 1 - Distracted or reassured by voice or touch. Total: 4 Score of 4 or higher indicates intervention may be needed. 3. History of pain and what relieves it: (include known cause and/or need for palliative care) Debridement of left heel on 08/06/13 per wound care MD at hospital. 4. Physical assessment by nurse if any of the below observations are identified: Tenderness is checked Anatomical illustration has a line pointing to the left heel " surgical debridement 4cm x 4.2 cm. 6. How does the pain affect: e. Ability to concentrate: Easily agitated, unable to determine if due to pain f. Enjoyment of life? Anxious, may be due to psych dx (diagnoses): [MEDICAL CONDITIONS] disorder Summary: Unable to make all needs known, may verbalize pain occasionally, example " it hurts " at other times cries out or screams when touched. Some screams may not indicate pain. Has dx: [MEDICAL CONDITIONS] disorder. Wound care nurse reported resident tolerated treatment well today. Signed as completed by RN U Review of Resident #4 ' s admission orders [REDACTED] [MEDICATION NAME] 1 mg, po bid [MEDICATION NAME] ER 300 mg, po bid [MEDICATION NAME] 1mg tab, give 4 qhs [MEDICATION NAME] Chloride 5 mg, po bid [MEDICATION NAME] 125 mcg, po qd [MEDICATION NAME] 50 mcg, po qd [MEDICATION NAME] 17g in H2O bid Bactirm DS 1 tab, po bid times 10 days Tylenol 325 mg two tabs, po q 4hours prn [MEDICATION NAME] 1 mg, po q 6 hours prn Bisac-evac 10 mg suppository, qd prn Cleanse left heel with normal saline, pat dry, apply [MEDICATION NAME] Ag dressing qd x 1 week. Other: Follow up with wound care doctor within one week Review of Resident #4 ' s Telephone Orders dated 08/07/13 reflected readmit to facility, Bactrim DS one tab po bid for 10 days. Physical Therapy, Occupational Therapy and Speech Therapy evaluate and treatment as indicated. Follow up with wound care doctor within one week. Review of Resident #4 ' s Telephone Orders dated 08/15/13 reflected an order for [REDACTED]. Review of Resident #4 ' s Telephone Orders dated 08/27/13, signed by Physician (DR) AA reflected the following orders: 1) Multivitamin with minerals 2) Vitamin A 8,000 IU 1 tab bid x 14 days 3) Stress tab with zinc 1 tab x 14 days 4) Argimaid 1 packet with 4-6 ounces water bid x 14 days 5) Add large meat portions to all meals x 60 days. Review of Resident #4 ' s 30 day MDS dated [DATE], reflected Resident #4 to have both short term and long term memory problems per staff assessment. Resident #4 was coded as requiring extensive assistance of one person for bed mobility and extensive two person assistance with transfers. Resident #4 was coded as always incontinent for both bowel and bladder. In the skin condition section Resident #4 was coded as having 3 stage 2 pressure ulcers, with 3 present at admission. The tissue type listed for " ulcer at most advanced stage " was " granulation tissue-pink or red tissue with shiny, moist, granular appearance. No additional wounds were coded. Review of Resident #4 ' s most current " Pain Assessment, " dated 09/05/13 reflected: 1. Pain intensity in the past 5 days (circle score) " 2 " is circled. 2. Pain Assessment in Advanced Dementia Scare (PAINAD) Breathing independent of vocalization: 2 - Noisy labored breathing. Short periods of hyperventilation. Negative vocalization: no score written Facial expression: 2 - Facial grimacing Body language: 1 - Tense. Distressed pacing. Fidgeting. Consolability: 1 - Distracted or reassured by voice or touch. Total: 6 3. History of pain and what relieves it: Administration of [MEDICATION NAME] and change in position with placement of supportive equipment. 4. Physical assessment by nurse if any of the below observations are identified: Aching and Tenderness are checked Anatomical illustration has no markings to indicate physical examination of painful areas. 6. How does the pain affect: a. Sleep: Mild to moderately c. Mobility: mild to moderately restricted d. General activity: reduced e. Ability to concentrate: not known f: Enjoyment of life: not known Summary: Resident respond fairly well to treatment plan. Completed by: No signature on this line. Review of Resident #4 ' s Comprehensive Care Plan, dated as being reviewed and updated on 10/15/13 to continue plan of care, reflected: Problem/need of: Potential for and real pressure ulcers, problem onset 08/07/13. Positive culture report for area left heel, 10/14/13. Goal and target date reflected: 10/14/13 Skin on left heel will heal by 1 cm by next review date in 92 days. 10/14/12 No new pressure developments x 92 days. Approaches listed: - Provide ulcer cares per orders. Monitor for changes in wounds. Report changes to MD. - Provide diet as ordered - Bed and chair pressure relief devices in place - Provide turning and repositioning while in bed, and chair - Encourage resident to make frequent changes in bed and chair - Keep feet elevated when in bed - Protective boots at all times - 10/14/13 ABT (2) per orders, update MD / Family with any sign of changes - 10/14/13 Review treatment and assess left heel weekly Problem/need of: Has chronic pain, potential for breakthrough pain, problem onset 08/07/13. Goal and target date reflected: Pain will remain at Resident ' s level of comfort daily, 11/15/13. Approaches listed: - Medications as ordered - Monitor for nonverbal and verbal indicators of pain - Provide positioning to prevent pain This plan of care did not reflect any information regarding sacral/coccyx wounds, pain assessment with wound care, or any information regarding wound care consults. Review of Resident #4 ' s Wound Assessment Report dated 8/8/13 reflected the wound type and location to be a pressure ulcer of the left heel. Date the wound was identified was listed as 8/8/13. Stage: unstageable due to suspected deep tissue injury. Measurements: Length 4.00 cm, Width 4.20 cm, depth (blank). Pain with wound treatment: no. No information was entered in the sections what described the wound bed or wound edges. Treatments: Pending treatment orders. Review of Resident #4 ' s Weekly Pressure Sore Progress Report dated 10/7/13 contained no information. All boxes were blank on the form pertaining to wounds. Review of Resident #4 ' s Daily/Weekly/Monthly body Audit and Hydration Report dated October 2013 reflected an anatomical illustration with a circle over the buttocks. Comment dated 10/15/13 by LVN B: Area red no drainage noted, continue with treatment as directed. Comment dated 10/14/13 by LVN B (which is under the 10/15/13 comment on the form) 3.0 left heel 4.0 discolered tissue surrounding area. Painful to patient, expresses. Review of Resident #4 ' s Daily/Weekly/Monthly body Audit and Hydration Report dated October 2013 reflected an anatomical illustration with a circle over the buttocks. Comment dated 10/22/13 by LVN B: 3.5 x 1.5 left lat, 1.5 x 0.5 left med. Stage 3 to buttocks, no drainage or odor. Current treatment duoderm, requesting new treatment to nurse practitioner today. Review of lab results dated 10/11/13 at 12:27 PM reflected " prelim wound lt heel " results Escerichia coli: many (Escerichia coli or E. Coli is a bacterium that is commonly found in the lower intestine of warm-blooded organisms) Proteus mirabills: many , (Proteus mirabills, Proteus species are part of the [MEDICATION NAME] family of gram-negative bacilli. Proteus organisms are implicated as serious causes of infections in humans.) Gram positive cocci: many. Review of Resident #4 ' s Telephone Orders dated 10/14/13 reflected an order for [REDACTED]. Diagnosis, wound infection. Signed by the NP. Review of Resident #4 ' s Physician Communication Form dated 10/16/13 reflected a concern/assessment: patient with area to left heel - not progressing, surrounding area red, very painful to the touch, patient does not handle treatment well. Crep - no pain med noted can she have pain meds. (admission orders [REDACTED]. Telephone Orders dated 08/15/13 reflected an order for [REDACTED]. Signed by LVN B. In the physician ' s section reflected the following notes: Wound was cultured and now she is on ABT (antibiotic therapy). Review of Resident # 4 ' s Wound Care Record, dated August 2013, reflected the following: Cleanse left heel with normal saline, pat dry, apply [MEDICATION NAME] Ag dressing QD times one week, start date 08/07/13. This treatment is signed as given from 08/08/13-08/31/13, an additional 10 days past the ordered end date. Duoderm to buttocks q 3 days - PRN, written on 08/16/13 is " one week. " " Drs appt " is then written with an arrow pointing to 08/22/13. The treatment is then signed as given for an additional 6 times from 08/24/13-08/31/13. In an interview on 10/23/13 at 3:45 PM the Office Manager for the Wound Care Specialist stated that Resident #4 was scheduled with the wound care clinic for an appointment on 08/22/13 however clinic notes state that Resident #4 never showed up for the appointment. She stated that Resident #4 has not been seen by anyone in the wound care clinic and has not made another appointment since the 08/22/13 date. Review of Resident #4 ' s current clinical record, over flow clinical record and " all medical records files for Resident #4 " reflected that physician's order [REDACTED]. Review of Resident # 4 ' s Wound Care Record, dated September 2013, reflected the following: Cleanse left heel with normal saline, pat dry, apply [MEDICATION NAME] Ag dressing QD times one week, start date 08/07/13. This treatment is signed as given from 09/01/13-09/30/13, an additional 30 days past the ordered end date during the month of September. Duoderm to sacrum q 3 days & PRN, no start date or order date is written. The treatment is then signed as given on 9/3, 9/4, 9/6, 9/9, 9/12, 9/15, 9/18, 9/21, 9/24, 9/27, 9/30. Review of Resident #4 ' s current clinical record, over flow clinical record and " all medical records files for Resident #4 " reflected that physician's order [REDACTED]. Review of Resident # 4 ' s Wound Care Record, dated October 2013, reflected the following: Cleanse left heel with normal saline, pat dry, apply [MEDICATION NAME] Ag dressing QD times one week, start date 08/07/13. A line was drawn through " times one week " and " until healed " was added. This treatment is signed as given from 10/01/13-10/9/13, (New physician's order [REDACTED]. 10/11/13 Apply Santyl top to left heel QOD x 10 days alternating with [MEDICATION NAME] silver. This treatment was signed as given on 10/11, 10/13, 10/15, 10/17, 10/19, 10/21 Cleanse sacral/coccyx wound with normal saline, pat dry, apply Duoderm q 3 days & PRN soilage with the start date 10/01/13. Review of the MAR indicated [REDACTED]. The scheduled [MEDICATION NAME] 400mg was signed as administered every 6 hours at 2 AM, 8 AM, 2 PM and 8 PM for pain. Review of Nurse's Notes dated reflected: 08/07/13 12:55 admitting and continuing [DIAGNOSES REDACTED]. Has duoderm to coccyx; area pink without drainage. 08/07/13 16:40 Transfer from Hospital via ems ... note readmit nursing assessment. No additional wound information is noted. 08/08/13 - 08/26/13 no information noted regarding wound care or pressure ulcers. 08/27/13 at 09:51 new orders received 1) Multivitamin with minerals2) Vitamin A 8,000 IU 1 tab bid x 14 days 3) Stress tab with zinc 1 tab x 14 days 4) Argimaid 1 packet with 4-6 ounces water bid x 14 days 5) Add large meat portions to all meals x 60 days. Dietary notified of dietary changes. New orders noted on MARs ... 08/27/13- 09/27/13 no information noted regarding wound care or pressure ulcers. 09/28/13 " 6-2 " Pt in bed supine position, able to voice concerns will continue to monitor. Left foot complaint of pain during treatment. Requires 2-3 person for transfer and ADL ' s (activities of daily living). Requires numerous prompts for food intake. Signed LVN B 09/29/13 - 10/07/13 no information noted regarding wound care or pressure ulcers. 10/08/13 at 11:30 AM Collected left heel wound culture obtained this AM & ready for pick up. Signed LVN C 10/13/13 " 2-6 " ...heel offload due to redness of left heel. Pt upset while changing bandage - cursing calling names. Area cleaned, [MEDICATION NAME] and bandage reapplied. Able to voice concerns at times. Cognitive process somewhat jumbled at times. Required total assist with ADLs ... Signed LVN B. 10/15/13 " 2-10 " Continue ABT for left heel wound. No swelling or complaint of pain at this time. 10/16/13 " 2-10 " Continue ABT for wound ... no swelling or complaint of pain unless tx (treatment) wound. Unable to make needs known due to confusion. In an interview on 10/23/13 at 9:58 AM the NP for resident #4 stated that she had seen Resident #4 on 10/07/13 and written an order for [REDACTED].

Based on observation, interview and record review the facility failed to ensure three (3) of 14 Residents (Resident #4, #9, and #12) reviewed for pressure sores received necessary treatment and services to promote healing, accurately assess and stage, and once developed, failed to ensure necessary treatment and services to promote healing. A.) Resident #4 was admitted to the facility on [DATE] with a Stage II sacral and left heel ulcer per hospital discharge records. The facility did not assess, properly measure, stage or implement/clarify physician ordered treatments to Resident #4's left heel pressure sores or sacral ulcers resulting in worsening of Resident #4's left heel and sacral pressure sores. The facility failed to address Resident #4's pain associated with wound care treatment. Resident #4 ' s left heel became infected and was cultured on 10/08/13 with results received on 10/11/13 not conveyed to the physician until 10/14/13, an additional 3 days, resulting in a delay of antibiotic treatment. Resident #4 ' s sacral ulcer treatment order ended on 08/14/13 and was not clarified until 10/01/13 resulting in 40 days of treatment without orders while the wound worsened from a stage II to multiple stage III wounds. Resident #4 ' s physician was not notified of the worsening sacral ulcers until Surveyors brought it to his attention on 10/23/13. Resident #4 was ordered to have a consult with a wound care specialist on 8/07/13, Resident #4 had not seen the wound care specialist as of 10/23/13. B.) Resident #9 was admitted to the facility on [DATE] with a Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough.) to right heel surrounded by areas of deep tissue injury (DTI) (A pressure-related injury to subcutaneous tissues under intact skin. Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear) and an unstageable (meaning that the stage is not clear. In these cases, the base of the sore is covered by a thick layer of other tissue and pus that may be yellow, gray, green, brown, or black. The doctor cannot see the base of the sore to determine the stage.) DTI to left heel per discharge hospital records. The facility did not assess, properly stage or implement physician ordered treatments to Resident #9's bilateral heel pressure sores resulting in worsening of Resident #9's bilateral heel pressure sores. C.) Resident #12 was admitted to the facility on [DATE] with a Stage IV (Stage IV-Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling ). The facility did not routinely assess Resident #12's left ischium pressure sore, obtain a physician ordered wound culture or physician ordered referral to a wound care physician resulting in the worsening of Resident #12's left ischium Stage IV pressure sore. This failure further resulted in an identification of an Immediate Jeopardy (IJ) on 10/23/2013. While the IJ was removed on 10/25/2013, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope identified as pattern due to the facility ' s need to evaluate the effectiveness of the corrective systems. This deficient practice affected three (3) residents and placed 22 residents at risk for developing new or worsening pressure sores, [MEDICAL CONDITION] (skin infection), Osteomylitis (infection of the bone),[MEDICAL CONDITION] (infection of the blood), severe pain and death. Finding Include: A.) Review of Resident #4 ' s face sheet reflected a [AGE] year old woman admitted to the facility on [DATE] and then readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #4 ' s discharge summary from the hospital to the facility, dated 08/07/13 reflected Resident #4 ' s admitting [DIAGNOSES REDACTED]. Hospital course: The patient was admitted with the above said [DIAGNOSES REDACTED]. Her blood cultures have remained negative and her wound culture from the left heel decubiti and sacrum was growing proteus mirabilis and staphylococcus aureus. Observation on 10/22/13 at 9:17 AM revealed Resident #4 in bed. Resident #4 was wearing blue foam boots on both feet. When the Medical Records LVN opened the boot on the left foot a pervasive odor was noted, also a creamy yellow dried substance was noted on the inside of the left boot near the bandage. Resident #4 cried out as the LVN was opening the boot, Resident #4 stated " Ill slap you, " and raised her hand. The Medical Records LVN asked if Resident #4 was in pain and the Resident nodded. Medical Records LVN stated she would get Tylenol. In an interview on 10/22/13 at 2:10 PM LVN B stated that Resident #4 came in with a stage 4 heel ulcer and a stage 1 that had progressed to a scattered stage 2 ulcer on the coccyx. In an interview on 10/23/13 at 4:15 PM LVN B stated that she had worked with Resident #4 previously at a group home. LVN B stated that Resident #4 came in with an open area to the coccyx and that it then closed and has reopened. She stated that the new Director of Nursing instituted different assessment sheets and that the previous Assistant Director of Nursing had done the previous assessments. Review of Resident #4 ' s admission MDS dated [DATE], reflected Resident #4 to have both short term and long term memory problems per staff assessment. Resident #4 was coded as requiring extensive assistance of one person for bed mobility and extensive two person assistance with transfers. Resident #4 was coded as always incontinent for both bowel and bladder. In the skin condition section Resident #4 was coded as having 3 stage 2 pressure ulcers, with 3 present at admission. The tissue type listed for " ulcer at most advanced stage " was " granulation tissue-pink or red tissue with shiny, moist, granular appearance. No additional wounds were coded. Observation on 10/23/2013 at 4:15 PM revealed LVN B in Resident #4 ' s room to perform wound care on Resident #4 with the CSC RN present at bedside. Resident #4 was lying on her back, on a regular foam mattress. A blue pillow style boot was noted to Resident #4's left foot. LVN B removed a duoderm dressing (A [MEDICATION NAME] dressing that is biodegradable, non-breathable and adheres to the skin) from Resident #4 ' s sacral area to reveal a Stage III (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.) pressure sore to Resident #4 ' s right sacral area approximately 3 cm (centimeters) in length by 1 cm width with a depth of >0.2 cm. The right sacral Stage III pressure sore was covered by approximately 20% yellow slough. There was a Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough) to Resident #4 ' s lateral right sacral area approximately 1 cm by 0.5 cm with a pink wound bed. On Resident #4 ' s right lower lateral right buttock was a Stage III pressure sore approximately 3 cm x 0.5 cm x >0.2 cm, the wound bed was 50% covered in yellow slough. Resident #4 ' s had a Stage III pressure sore to her mid sacral area approximately 6.5 cm x 2.5 cm with >0.2 cm depth 60 % of the wound was covered in yellow slough. There was approximately a 10 cm x 8cm area of macerated silver/ white colored tissue surrounding all the wounds. LVN B, without cleaning Resident #4 ' s pressure sores to sacral and right buttock areas, and without applying new gloves applied a thin duoderm over the pressure sores. LVN B then went to the treatment cart to get supplies to do wound care on Resident #4 ' s left heel Stage IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling.) LVN B removed Resident #4 ' s pillow style boot from left foot. There was a prevalent foul odor coming from Resident #4 ' s left foot. The inside of the pillow style boot was noted to have serosanguineous stains where Resident #4 ' s heel was. LVN B then removed the dressing from Resident #4 left heel. Serosanguineous drainage was noted to dressing. Resident #4's left heel pressure sore was approximately 2 cm by 2.5 cm with an undetermined depth, the area was 95% covered in a yellow to brown colored slough. LVN B washed her hands and changed gloves. LVN B then used a needle-less syringe and squirted the open portion of resident left heel. Resident #4 flinched her whole body away from LVN B and stated " Leave me alone f***ers. " The Surveyor asked Resident #4 if she hurt and Resident #4 responded " Yeah, that hurts! " LVN B then took a stack of two (2) by two (2) gauze and patted the area three times with the same gauze. LVN B then placed [MEDICATION NAME] Ag (silver impregnated antimicrobial dressing) to open area of Resident #4's left heel, LVN B then placed a bordered dressing over heel. (approximations by surveyor as LVN B did not measure the wound during care.) LVN B stated that Resident #4 does not have orders for pain medication. She stated that there are no standing orders for pain medication as the Medical Director says absolutely not. Review of Resident #4 ' s Telephone Orders dated 10/01/13 reflected the following orders: Duoderm to sacral/coccyx area change every 3 days and prn soilage. Clarification: cleanse left heel, normal saline, apply [MEDICATION NAME] Ag dressing every day until healed. Review of Resident #4 ' s Physician Communication Form dated 10/06/13 reflected a concern/assessment: Left heel clean with normal saline apply [MEDICATION NAME] AG QD ([MEDICATION NAME] silver every day - a wound treatment) area not progressing. Requesting Santyl QD (every day) (Santyl is an active enzymatic therapy that continuously removes necrotic tissue from wounds at the microscopic level.) Cleans with normal saline, apply santyl cover with 2x2 cover with Allevyn Matrix every day. Signed by Licensed Vocational Nurse (LVN) B. Further down the page is written " Will eval, " with an initial. (No information regarding sacral pressure ulcers was noted on this communication.) Review of Resident #4 ' s Telephone Orders dated 10/07/13 reflected an order to culture wound left heel, signed by the Nurse Practitioner (NP) for Resident #4. Review of Resident #4 ' s Telephone Orders dated 10/11/13 reflected the following order: Apply santyl topical to left heel QOD (every other day) times 10 days, alternating with [MEDICATION NAME] AG. In an interview on 10/23/2013 at 4:45 PM CNA G stated that Resident #4 ' s sacral area had been getting worse for the past month. CNA G further stated she has told the nurses the area was getting worse. CNA G stated the only thing she was told to do for Resident #4's left heel to to keep the boot on it. CNA G stated that there was not a regular schedule for changing the boot or washing it. She stated " I guess we could send them to laundry. " In an interview on 10/23/2013 at 5:50 PM the CSC RN stated LVN B would not be doing treatments anymore. The CSC RN further stated she felt LVN B was disorganized. The CSC RN further stated if there is a change to a wound the physician needs to be called. The CSC RN stated that the current treatment for [REDACTED]. The CSC RN returned at 6:20 PM and stated that there are no measurements for Resident #4's sacral wounds and that this is a deficit. Review of Resident #4 ' s readmission assessment, dated 08/07/13, reflected: Section 13: Integumentary/feet: 1. Skin/wound condition present? Yes. 1a. Is there pain associated with the wound/skin condition? Yes. An anatomical figure had the following markings to indicate the following: a circled " 2 " across the buttocks. The key on the side of the form indicated " 2 " represents " Stage II. " The left heel was circled and written beside it " debrided 8-01-13 4cm x 4.2cm. Drawings of feet inside and outside did not reflect any markings to indicate wounds, no staging, wound depth or wound bed description information was included. 4. Feet status: nothing was checked Section 14: Pain: Had pain of hurting? Yes. Signed as completed by RN U Review of the readmission assessment " Norton Plus Pressure Ulcer Scale " dated 08/07/13 reflected the following: Risk Factor: Physical condition: 3 - fair Mental state: 2 - confused Activity: 2 - chair bound Mobility: 2 - very limited Incontinence: 1 - double incontinence Total Norton Scale: 10 Total Norton Plus Score (score 10 or less = high risk): 7 Signed as completed by RN U Review of Resident #4 ' s Readmission " Pain Assessment, " dated 08/08/13 reflected: Diagnosis: [REDACTED]. 2. Pain Assessment in Advanced Dementia Scare (PAINAD) Breathing independent of vocalization: 0 - normal Negative vocalization: 1 - Occasional moan or groan. Low level speech with a negative or disapproving quality. Facial expression: 1 - Sad. Frightened. Frown. Body language: 1 - Tense. Distressed pacing. Fidgeting. Consolability: 1 - Distracted or reassured by voice or touch. Total: 4 Score of 4 or higher indicates intervention may be needed. 3. History of pain and what relieves it: (include known cause and/or need for palliative care) Debridement of left heel on 08/06/13 per wound care MD at hospital. 4. Physical assessment by nurse if any of the below observations are identified: Tenderness is checked Anatomical illustration has a line pointing to the left heel " surgical debridement 4cm x 4.2 cm. 6. How does the pain affect: e. Ability to concentrate: Easily agitated, unable to determine if due to pain f. Enjoyment of life? Anxious, may be due to psych dx (diagnoses): [MEDICAL CONDITIONS] disorder Summary: Unable to make all needs known, may verbalize pain occasionally, example " it hurts " at other times cries out or screams when touched. Some screams may not indicate pain. Has dx: [MEDICAL CONDITIONS] disorder. Wound care nurse reported resident tolerated treatment well today. Signed as completed by RN U Review of Resident #4 ' s admission orders [REDACTED] [MEDICATION NAME] 1 mg, po bid [MEDICATION NAME] ER 300 mg, po bid [MEDICATION NAME] 1mg tab, give 4 qhs [MEDICATION NAME] Chloride 5 mg, po bid [MEDICATION NAME] 125 mcg, po qd [MEDICATION NAME] 50 mcg, po qd [MEDICATION NAME] 17g in H2O bid Bactirm DS 1 tab, po bid times 10 days Tylenol 325 mg two tabs, po q 4hours prn [MEDICATION NAME] 1 mg, po q 6 hours prn Bisac-evac 10 mg suppository, qd prn Cleanse left heel with normal saline, pat dry, apply [MEDICATION NAME] Ag dressing qd x 1 week. Other: Follow up with wound care doctor within one week Review of Resident #4 ' s Telephone Orders dated 08/07/13 reflected readmit to facility, Bactrim DS one tab po bid for 10 days. Physical Therapy, Occupational Therapy and Speech Therapy evaluate and treatment as indicated. Follow up with wound care doctor within one week. Review of Resident #4 ' s Telephone Orders dated 08/15/13 reflected an order for [REDACTED]. Review of Resident #4 ' s Telephone Orders dated 08/27/13, signed by Physician (DR) AA reflected the following orders: 1) Multivitamin with minerals 2) Vitamin A 8,000 IU 1 tab bid x 14 days 3) Stress tab with zinc 1 tab x 14 days 4) Argimaid 1 packet with 4-6 ounces water bid x 14 days 5) Add large meat portions to all meals x 60 days. Review of Resident #4 ' s 30 day MDS dated [DATE], reflected Resident #4 to have both short term and long term memory problems per staff assessment. Resident #4 was coded as requiring extensive assistance of one person for bed mobility and extensive two person assistance with transfers. Resident #4 was coded as always incontinent for both bowel and bladder. In the skin condition section Resident #4 was coded as having 3 stage 2 pressure ulcers, with 3 present at admission. The tissue type listed for " ulcer at most advanced stage " was " granulation tissue-pink or red tissue with shiny, moist, granular appearance. No additional wounds were coded. Review of Resident #4 ' s most current " Pain Assessment, " dated 09/05/13 reflected: 1. Pain intensity in the past 5 days (circle score) " 2 " is circled. 2. Pain Assessment in Advanced Dementia Scare (PAINAD) Breathing independent of vocalization: 2 - Noisy labored breathing. Short periods of hyperventilation. Negative vocalization: no score written Facial expression: 2 - Facial grimacing Body language: 1 - Tense. Distressed pacing. Fidgeting. Consolability: 1 - Distracted or reassured by voice or touch. Total: 6 3. History of pain and what relieves it: Administration of [MEDICATION NAME] and change in position with placement of supportive equipment. 4. Physical assessment by nurse if any of the below observations are identified: Aching and Tenderness are checked Anatomical illustration has no markings to indicate physical examination of painful areas. 6. How does the pain affect: a. Sleep: Mild to moderately c. Mobility: mild to moderately restricted d. General activity: reduced e. Ability to concentrate: not known f: Enjoyment of life: not known Summary: Resident respond fairly well to treatment plan. Completed by: No signature on this line. Review of Resident #4 ' s Comprehensive Care Plan, dated as being reviewed and updated on 10/15/13 to continue plan of care, reflected: Problem/need of: Potential for and real pressure ulcers, problem onset 08/07/13. Positive culture report for area left heel, 10/14/13. Goal and target date reflected: 10/14/13 Skin on left heel will heal by 1 cm by next review date in 92 days. 10/14/12 No new pressure developments x 92 days. Approaches listed: - Provide ulcer cares per orders. Monitor for changes in wounds. Report changes to MD. - Provide diet as ordered - Bed and chair pressure relief devices in place - Provide turning and repositioning while in bed, and chair - Encourage resident to make frequent changes in bed and chair - Keep feet elevated when in bed - Protective boots at all times - 10/14/13 ABT (2) per orders, update MD / Family with any sign of changes - 10/14/13 Review treatment and assess left heel weekly Problem/need of: Has chronic pain, potential for breakthrough pain, problem onset 08/07/13. Goal and target date reflected: Pain will remain at Resident ' s level of comfort daily, 11/15/13. Approaches listed: - Medications as ordered - Monitor for nonverbal and verbal indicators of pain - Provide positioning to prevent pain This plan of care did not reflect any information regarding sacral/coccyx wounds, pain assessment with wound care, or any information regarding wound care consults. Review of Resident #4 ' s Wound Assessment Report dated 8/8/13 reflected the wound type and location to be a pressure ulcer of the left heel. Date the wound was identified was listed as 8/8/13. Stage: unstageable due to suspected deep tissue injury. Measurements: Length 4.00 cm, Width 4.20 cm, depth (blank). Pain with wound treatment: no. No information was entered in the sections what described the wound bed or wound edges. Treatments: Pending treatment orders. Review of Resident #4 ' s Weekly Pressure Sore Progress Report dated 10/7/13 contained no information. All boxes were blank on the form pertaining to wounds. Review of Resident #4 ' s Daily/Weekly/Monthly body Audit and Hydration Report dated October 2013 reflected an anatomical illustration with a circle over the buttocks. Comment dated 10/15/13 by LVN B: Area red no drainage noted, continue with treatment as directed. Comment dated 10/14/13 by LVN B (which is under the 10/15/13 comment on the form) 3.0 left heel 4.0 discolered tissue surrounding area. Painful to patient, expresses. Review of Resident #4 ' s Daily/Weekly/Monthly body Audit and Hydration Report dated October 2013 reflected an anatomical illustration with a circle over the buttocks. Comment dated 10/22/13 by LVN B: 3.5 x 1.5 left lat, 1.5 x 0.5 left med. Stage 3 to buttocks, no drainage or odor. Current treatment duoderm, requesting new treatment to nurse practitioner today. Review of lab results dated 10/11/13 at 12:27 PM reflected " prelim wound lt heel " results Escerichia coli: many (Escerichia coli or E. Coli is a bacterium that is commonly found in the lower intestine of warm-blooded organisms) Proteus mirabills: many , (Proteus mirabills, Proteus species are part of the [MEDICATION NAME] family of gram-negative bacilli. Proteus organisms are implicated as serious causes of infections in humans.) Gram positive cocci: many. Review of Resident #4 ' s Telephone Orders dated 10/14/13 reflected an order for [REDACTED]. Diagnosis, wound infection. Signed by the NP. Review of Resident #4 ' s Physician Communication Form dated 10/16/13 reflected a concern/assessment: patient with area to left heel - not progressing, surrounding area red, very painful to the touch, patient does not handle treatment well. Crep - no pain med noted can she have pain meds. (admission orders [REDACTED]. Telephone Orders dated 08/15/13 reflected an order for [REDACTED]. Signed by LVN B. In the physician ' s section reflected the following notes: Wound was cultured and now she is on ABT (antibiotic therapy). Review of Resident # 4 ' s Wound Care Record, dated August 2013, reflected the following: Cleanse left heel with normal saline, pat dry, apply [MEDICATION NAME] Ag dressing QD times one week, start date 08/07/13. This treatment is signed as given from 08/08/13-08/31/13, an additional 10 days past the ordered end date. Duoderm to buttocks q 3 days - PRN, written on 08/16/13 is " one week. " " Drs appt " is then written with an arrow pointing to 08/22/13. The treatment is then signed as given for an additional 6 times from 08/24/13-08/31/13. In an interview on 10/23/13 at 3:45 PM the Office Manager for the Wound Care Specialist stated that Resident #4 was scheduled with the wound care clinic for an appointment on 08/22/13 however clinic notes state that Resident #4 never showed up for the appointment. She stated that Resident #4 has not been seen by anyone in the wound care clinic and has not made another appointment since the 08/22/13 date. Review of Resident #4 ' s current clinical record, over flow clinical record and " all medical records files for Resident #4 " reflected that physician's order [REDACTED]. Review of Resident # 4 ' s Wound Care Record, dated September 2013, reflected the following: Cleanse left heel with normal saline, pat dry, apply [MEDICATION NAME] Ag dressing QD times one week, start date 08/07/13. This treatment is signed as given from 09/01/13-09/30/13, an additional 30 days past the ordered end date during the month of September. Duoderm to sacrum q 3 days & PRN, no start date or order date is written. The treatment is then signed as given on 9/3, 9/4, 9/6, 9/9, 9/12, 9/15, 9/18, 9/21, 9/24, 9/27, 9/30. Review of Resident #4 ' s current clinical record, over flow clinical record and " all medical records files for Resident #4 " reflected that physician's order [REDACTED]. Review of Resident # 4 ' s Wound Care Record, dated October 2013, reflected the following: Cleanse left heel with normal saline, pat dry, apply [MEDICATION NAME] Ag dressing QD times one week, start date 08/07/13. A line was drawn through " times one week " and " until healed " was added. This treatment is signed as given from 10/01/13-10/9/13, (New physician's order [REDACTED]. 10/11/13 Apply Santyl top to left heel QOD x 10 days alternating with [MEDICATION NAME] silver. This treatment was signed as given on 10/11, 10/13, 10/15, 10/17, 10/19, 10/21 Cleanse sacral/coccyx wound with normal saline, pat dry, apply Duoderm q 3 days & PRN soilage with the start date 10/01/13. Review of the MAR indicated [REDACTED]. The scheduled [MEDICATION NAME] 400mg was signed as administered every 6 hours at 2 AM, 8 AM, 2 PM and 8 PM for pain. Review of Nurse's Notes dated reflected: 08/07/13 12:55 admitting and continuing [DIAGNOSES REDACTED]. Has duoderm to coccyx; area pink without drainage. 08/07/13 16:40 Transfer from Hospital via ems ... note readmit nursing assessment. No additional wound information is noted. 08/08/13 - 08/26/13 no information noted regarding wound care or pressure ulcers. 08/27/13 at 09:51 new orders received 1) Multivitamin with minerals2) Vitamin A 8,000 IU 1 tab bid x 14 days 3) Stress tab with zinc 1 tab x 14 days 4) Argimaid 1 packet with 4-6 ounces water bid x 14 days 5) Add large meat portions to all meals x 60 days. Dietary notified of dietary changes. New orders noted on MARs ... 08/27/13- 09/27/13 no information noted regarding wound care or pressure ulcers. 09/28/13 " 6-2 " Pt in bed supine position, able to voice concerns will continue to monitor. Left foot complaint of pain during treatment. Requires 2-3 person for transfer and ADL ' s (activities of daily living). Requires numerous prompts for food intake. Signed LVN B 09/29/13 - 10/07/13 no information noted regarding wound care or pressure ulcers. 10/08/13 at 11:30 AM Collected left heel wound culture obtained this AM & ready for pick up. Signed LVN C 10/13/13 " 2-6 " ...heel offload due to redness of left heel. Pt upset while changing bandage - cursing calling names. Area cleaned, [MEDICATION NAME] and bandage reapplied. Able to voice concerns at times. Cognitive process somewhat jumbled at times. Required total assist with ADLs ... Signed LVN B. 10/15/13 " 2-10 " Continue ABT for left heel wound. No swelling or complaint of pain at this time. 10/16/13 " 2-10 " Continue ABT for wound ... no swelling or complaint of pain unless tx (treatment) wound. Unable to make needs known due to confusion. In an interview on 10/23/13 at 9:58 AM the NP for resident #4 stated that she had seen Resident #4 on 10/07/13 and written an order for [REDACTED]. She stated that the date of the order for the antibiotics is the date that she received the lab results, 10/14/13. The NP stated that she would have liked to have received the lab results the same day they were returned to the facility, especially if they indicated a positive result and would have indicated the need for antibiotic treatment as an order would need to be written. She stated that she had not seen Resident #4 ' s sacral ulcers recently and had not received any communication regarding the sacral ulcers. She stated that she had not written any new orders for sacral ulcers. In an interview on 10/23/13 at 12:16 PM a RN with the Medical Director ' s office, also Resident #4 ' s Primary Care Physician stated that the Medical Director " absolutely does not know anything regarding this Resident. He has not seen this patient. The Medical Director will be at the facility this afternoon to assess the patient. " She then stated that the Medical Director had just acquired this facility approximately one month ago. In an interview on 10/23/2013 at 5:30 PM Resident #4's Physician stated he was not informed about Resident #4 ' s pressure sores to sacral area. Resident #4 ' s Physician stated he had just seen her left heel but has not seen her sacral pressure sores. Resident #4 ' s Physician stated that if the pressure sores were macerated that was not good. Resident #4 ' s Physician further stated that if there was slough in the wounds then it needed to be debrided. Resident #4 ' s Physician stated that after seeing the boot that was on Resident #4 he told the facility that it was not the right kind of boot. Resident #4 ' s Physician stated if the boot was not washed after soiling it could contribute to an infection in Resident #4 ' s pressure sore. Resident #4 ' s Physician stated he expected the nurses to notify him if any wound has a foul odor so antibiotics could be initiated. Resident #4 ' s Physician also expected Resident #4 to be on an air mattress. Observation on 10/23/2013 at 6:15 PM the CSC RN and LVN B were turning Resident #4 on left side so Resident #4's Physician could examine Resident #4 ' s sacral pressure sores. Resident #4 started to cry and was calling out incoherently. In an interview on 10/23/2013 at 6:25 PM Resident #4's Physician stated Resident #4 was definitely in pain and he would be ordering more pain medication for Resident #4. In an interview on 10/24/2013 at 10:25 AM LVN C stated Resident #4's sacral area was just excoriated when she saw it last. LVN C stated it has gotten worse. LVN C stated she has been off for a week and LVN B was filling in for her. LVN C further stated Resident #4 should have been on an air mattress and was not sure why she was not. In an interview on 10/24/13 at 11:15 AM the MDS Coordinator stated that she found additional care plans in her office. She presented surveyors with 4 care plans pages: Care Plan A, Antibiotics, Skin, and Pressure Area. When asked how staff were to follow these plans of care if they were not in Resident #4 ' s chart the MDS Coordinator did not answer. Review of Resident #4 ' s Care Plan A reflected 1. Mobility/Ambulation: wheel chair via staff, 10/14/13 float heels when in bed (this was intervention was lined through), 10/22/13 pravolon boots at all times except when bathing every shift. Review of Resident #4 ' s Comprehensive Plan of Care (three pages) Problem/need: Resident is on Antibiotic(s) and is at risk for adverse reactions. Med: ABT as ordered. Other: left heel. Dated 10/14/13 Approach: -Give meds per order - monitor labs, cultures, reports abnormals to MD -Monitor resident for adverse reactions specific to the medication -Follow universal /standard precaution to prevent cross contamination and spread infection -Encourage fluids and P.O. -Serve Diet as ordered -Low Air Loss mattress - Prevlon boots at all times except bathing and skin sheets -treatment per MD order -Wound Care Consult -PT/OT to eval and treat Problem/need: Resident has current skin condition. Other: left heel. Dated 08/07/13. Approach: -Perform treatments per order, if no improvement x2 weeks - report to MD -Monitor areas for increase in breakdown, signs and symptoms of infection - report to MD -Monitor for pain, give med per order, monitor for relief -Encourage P.O. and fluid intake within dietary limits -Keep MD and RP informed of resident ' s progress -Assess skin weekly and records findings in clinical record -Vitamin supplement -Prevalon boots - 10/22/13 -Low Air Loss mattress - 10/23/13 -Culture left heel - 10/13 Problem/need: Resident has a pressure Area: blank, Stage: blank, Location: Sacral/Coccyx community acquired. Dated 08/17/13. Approach: -Perform treatments per order, if no improvement x2 weeks - report to MD -Encourage P.O. and fluid intake within dietary limits -Keep family/responsible party and MD informed of resident ' s progress -Assist with turn/repositioning every two hours and prn -Use padding between pressure areas and positioning devices for proper body alignment -Provide pressure relieving device for bed and wheel chair -Monitor labs and report abnormals to MD -Dietary consult for proper nutrition to resolve pressure area In an interview on 10/24/13 at 6:10 PM the CSC RN was presented with the 4 care

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to maintain the highest practicable physical, mental, and psychosocial well-being for three (3) of 14 residents (Resident #4 ,#9 and #12) reviewed for pain management with pressure sores. A.) The facility did not accurately or routinely assess Resident #4 for pain. The facility failed to ensure Resident #4 was administered pain medication available for breakthrough pain resulting in Resident #4 having pain with wound treatments. B) The facility did not accurately or routinely assess Resident #9 for pain. The facility failed to ensure Resident #9 had pain medication available for breakthrough pain resulting in Resident #9 having daily pain. C.) The facility failed to routinely assess Resident #12 for pain during pressure sore treatments resulting in Resident #12 refusing treatments. This deficient practice affected three (3) residents and placed 22 residents at risk for enduring painful pressure sore treatments and unrelieved pain. This failure further resulted in an identification of an Immediate Jeopardy (IJ) on 10/23/2013. While the IJ was removed on 10/25/2013, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. Finding Include: A.) Review of Resident #4 ' s face sheet reflected a [AGE] year old woman admitted to the facility on [DATE] and then readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #4 ' s discharge summary from the hospital to the facility, dated 08/07/13 reflected Resident #4 ' s admitting [DIAGNOSES REDACTED]. Hospital course: The patient was admitted with the above said [DIAGNOSES REDACTED]. Her blood cultures have remained negative and her wound culture from the left heel decubiti and sacrum was growing proteus mirabilis and staphylococcus aureus. Observation on 10/22/13 at 9:17 AM revealed Resident #4 in bed. Resident #4 was wearing blue foam boots on both feet. When the Medical Records LVN opened the boot on the left foot a pervasive odor was noted, also a creamy yellow dried substance was noted on the inside of the left boot near the bandage. Resident #4 cried out as the LVN was opening the boot, Resident #4 stated " Ill slap you, " and raised her hand. The Medical Records LVN asked if Resident #4 was in pain and the Resident nodded. Medical Records LVN stated she would get Tylenol. In an interview on 10/22/13 at 2:10 PM LVN B stated that Resident #4 came in with a stage 4 heel ulcer and a stage 1 that had progressed to a scattered stage 2 ulcer on the coccyx. In an interview on 10/23/13 at 4:15 PM LVN B stated that she had worked with Resident #4 previously at a group home. LVN B stated that Resident #4 came in with an open area to the coccyx and that it then closed and has reopened. She stated that the new Director of Nursing instituted different assessment sheets and that the previous Assistant Director of Nursing had done the previous assessments. Review of Resident #4 ' s admission MDS dated [DATE], reflected Resident #4 to have both short term and long term memory problems per staff assessment. Resident #4 was coded as requiring extensive assistance of one person for bed mobility and extensive two person assistance with transfers. Resident #4 was coded as always incontinent for both bowel and bladder. In the skin condition section Resident #4 was coded as having 3 stage 2 pressure ulcers, with 3 present at admission. The tissue type listed for " ulcer at most advanced stage " was " granulation tissue-pink or red tissue with shiny, moist, granular appearance. No additional wounds were coded. Observation on 10/23/2013 at 4:15 PM revealed LVN B in Resident #4 ' s room to perform wound care on Resident #4 with the CSC RN present at bedside. Resident #4 was lying on her back, on a regular foam mattress. A blue pillow style boot was noted to Resident #4's left foot. LVN B removed a duoderm dressing (A [MEDICATION NAME] dressing that is biodegradable, non-breathable and adheres to the skin) from Resident #4 ' s sacral area to reveal a Stage III (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.) pressure sore to Resident #4 ' s right sacral area approximately 3 cm (centimeters) in length by 1 cm width with a depth of >0.2 cm. The right sacral Stage III pressure sore was covered by approximately 20% yellow slough. There was a Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough) to Resident #4 ' s lateral right sacral area approximately 1 cm by 0.5 cm with a pink wound bed. On Resident #4 ' s right lower lateral right buttock was a Stage III pressure sore approximately 3 cm x 0.5 cm x >0.2 cm, the wound bed was 50% covered in yellow slough. Resident #4 ' s had a Stage III pressure sore to her mid sacral area approximately 6.5 cm x 2.5 cm with >0.2 cm depth 60 % of the wound was covered in yellow slough. There was approximately a 10 cm x 8cm area of macerated silver/ white colored tissue surrounding all the wounds. LVN B, without cleaning Resident #4 ' s pressure sores to sacral and right buttock areas, and without applying new gloves applied a thin duoderm over the pressure sores. LVN B then went to the treatment cart to get supplies to do wound care on Resident #4 ' s left heel Stage IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling.) LVN B removed Resident #4 ' s pillow style boot from left foot. There was a prevalent foul odor coming from Resident #4 ' s left foot. The inside of the pillow style boot was noted to have serosanguineous stains where Resident #4 ' s heel was. LVN B then removed the dressing from Resident #4 left heel. Serosanguineous drainage was noted to dressing. Resident #4's left heel pressure sore was approximately 2 cm by 2.5 cm with an undetermined depth, the area was 95% covered in a yellow to brown colored slough. LVN B washed her hands and changed gloves. LVN B then used a needle-less syringe and squirted the open portion of resident left heel. Resident #4 flinched her whole body away from LVN B and stated " Leave me alone f***ers. " The Surveyor asked Resident #4 if she hurt and Resident #4 responded " Yeah, that hurts! " LVN B then took a stack of two (2) by two (2) gauze and patted the area three times with the same gauze. LVN B then placed [MEDICATION NAME] Ag (silver impregnated antimicrobial dressing) to open area of Resident #4's left heel, LVN B then placed a bordered dressing over heel. (approximations by surveyor as LVN B did not measure the wound during care.) LVN B stated that Resident #4 does not have orders for pain medication. She stated that there are no standing orders for pain medication as the Medical Director says absolutely not. Review of Resident #4 ' s Physician Communication Form dated 10/06/13 reflected a concern/assessment: Left heel clean with normal saline apply [MEDICATION NAME] AG QD ([MEDICATION NAME] silver every day - a wound treatment) area not progressing. Requesting Santyl QD (every day) (Santyl is an active enzymatic therapy that continuously removes necrotic tissue from wounds at the microscopic level.) Cleans with normal saline, apply santyl cover with 2x2 cover with Allevyn Matrix every day. Signed by Licensed Vocational Nurse (LVN) B. Further down the page is written " Will eval, " with an initial. (No information regarding sacral pressure ulcers was noted on this communication.) In an interview on 10/23/2013 at 4:45 PM CNA G stated that Resident #4 ' s sacral area had been getting worse for the past month. CNA G further stated she has told the nurses the area was getting worse. CNA G stated the only thing she was told to do for Resident #4's left heel to to keep the boot on it. In an interview on 10/23/2013 at 5:50 PM the CSC RN stated LVN B would not be doing treatments anymore. The CSC RN further stated she felt LVN B was disorganized. The CSC RN further stated if there is a change to a wound the physician needs to be called. The CSC RN stated that the current treatment for [REDACTED]. The CSC RN returned at 6:20 PM and stated that there are no measurements for Resident #4's sacral wounds and that this is a deficit. Review of Resident #4 ' s readmission assessment, dated 08/07/13, reflected: Section 13: Integumentary/feet: 1. Skin/wound condition present? Yes. 1a. Is there pain associated with the wound/skin condition? Yes. Section 14: Pain: Had pain of hurting? Yes. Signed as completed by RN U Review of Resident #4 ' s Readmission " Pain Assessment, " dated 08/08/13 reflected: Diagnosis: [REDACTED]. 2. Pain Assessment in Advanced Dementia Scare (PAINAD) Breathing independent of vocalization: 0 - normal Negative vocalization: 1 - Occasional moan or groan. Low level speech with a negative or disapproving quality. Facial expression: 1 - Sad. Frightened. Frown. Body language: 1 - Tense. Distressed pacing. Fidgeting. Consolability: 1 - Distracted or reassured by voice or touch. Total: 4 Score of 4 or higher indicates intervention may be needed. 3. History of pain and what relieves it: (include known cause and/or need for palliative care) Debridement of left heel on 08/06/13 per wound care MD at hospital. 4. Physical assessment by nurse if any of the below observations are identified: Tenderness is checked Anatomical illustration has a line pointing to the left heel " surgical debridement 4cm x 4.2 cm. 6. How does the pain affect: e. Ability to concentrate: Easily agitated, unable to determine if due to pain f. Enjoyment of life? Anxious, may be due to psych dx (diagnoses): [MEDICAL CONDITIONS] disorder Summary: Unable to make all needs known, may verbalize pain occasionally, example " it hurts " at other times cries out or screams when touched. Some screams may not indicate pain. Has dx: [MEDICAL CONDITIONS] disorder. Wound care nurse reported resident tolerated treatment well today. Signed as completed by RN U Review of Resident #4 ' s admission orders [REDACTED] Tylenol 325 mg two tabs, po q 4hours prn Cleanse left heel with normal saline, pat dry, apply [MEDICATION NAME] Ag dressing qd x 1 week. Other: Follow up with wound care doctor within one week Review of Resident #4 ' s Telephone Orders dated 08/07/13 reflected readmit to facility, Bactrim DS one tab po bid for 10 days. Physical Therapy, Occupational Therapy and Speech Therapy evaluate and treatment as indicated. Follow up with wound care doctor within one week. Review of Resident #4 ' s Telephone Orders dated 08/15/13 reflected an order for [REDACTED]. Review of Resident #4 ' s 30 day MDS dated [DATE], reflected Resident #4 to have both short term and long term memory problems per staff assessment. Resident #4 was coded as requiring extensive assistance of one person for bed mobility and extensive two person assistance with transfers. Resident #4 was coded as always incontinent for both bowel and bladder. In the skin condition section Resident #4 was coded as having 3 stage 2 pressure ulcers, with 3 present at admission. The tissue type listed for " ulcer at most advanced stage " was " granulation tissue-pink or red tissue with shiny, moist, granular appearance. No additional wounds were coded. Review of Resident #4 ' s most current " Pain Assessment, " dated 09/05/13 reflected: 1. Pain intensity in the past 5 days (circle score) " 2 " is circled. 2. Pain Assessment in Advanced Dementia Scare (PAINAD) Breathing independent of vocalization: 2 - Noisy labored breathing. Short periods of hyperventilation. Negative vocalization: no score written Facial expression: 2 - Facial grimacing Body language: 1 - Tense. Distressed pacing. Fidgeting. Consolability: 1 - Distracted or reassured by voice or touch. Total: 6 3. History of pain and what relieves it: Administration of [MEDICATION NAME] and change in position with placement of supportive equipment. 4. Physical assessment by nurse if any of the below observations are identified: Aching and Tenderness are checked Anatomical illustration has no markings to indicate physical examination of painful areas. 6. How does the pain affect: a. Sleep: Mild to moderately c. Mobility: mild to moderately restricted d. General activity: reduced e. Ability to concentrate: not known f: Enjoyment of life: not known Summary: Resident respond fairly well to treatment plan. Completed by: No signature on this line. Review of Resident #4 ' s Comprehensive Care Plan, dated as being reviewed and updated on 10/15/13 to continue plan of care, reflected: Problem/need of: Potential for and real pressure ulcers, problem onset 08/07/13. Positive culture report for area left heel, 10/14/13. Goal and target date reflected: 10/14/13 Skin on left heel will heal by 1 cm by next review date in 92 days. 10/14/12 No new pressure developments x 92 days. Approaches listed: - Provide ulcer cares per orders. Monitor for changes in wounds. Report changes to MD. - Provide diet as ordered - Bed and chair pressure relief devices in place - Provide turning and repositioning while in bed, and chair - Encourage resident to make frequent changes in bed and chair - Keep feet elevated when in bed - Protective boots at all times - 10/14/13 ABT (2) per orders, update MD / Family with any sign of changes - 10/14/13 Review treatment and assess left heel weekly Problem/need of: Has chronic pain, potential for breakthrough pain, problem onset 08/07/13. Goal and target date reflected: Pain will remain at Resident ' s level of comfort daily, 11/15/13. Approaches listed: - Medications as ordered - Monitor for nonverbal and verbal indicators of pain - Provide positioning to prevent pain This plan of care did not reflect any information regarding sacral/coccyx wounds, pain assessment with wound care, or any information regarding wound care consults. Review of Resident #4 ' s Wound Assessment Report dated 8/8/13 reflected the wound type and location to be a pressure ulcer of the left heel. Date the wound was identified was listed as 8/8/13. Stage: unstageable due to suspected deep tissue injury. Measurements: Length 4.00 cm, Width 4.20 cm, depth (blank). Pain with wound treatment: no. No information was entered in the sections what described the wound bed or wound edges. Treatments: Pending treatment orders. Review of Resident #4 ' s Weekly Pressure Sore Progress Report dated 10/7/13 contained no information. All boxes were blank on the form pertaining to wounds. Review of Resident #4 ' s Daily/Weekly/Monthly body Audit and Hydration Report dated October 2013 reflected an anatomical illustration with a circle over the buttocks. Comment dated 10/15/13 by LVN B: Area red no drainage noted, continue with treatment as directed. Comment dated 10/14/13 by LVN B (which is under the 10/15/13 comment on the form) 3.0 left heel 4.0 discolered tissue surrounding area. Painful to patient, expresses. Review of lab results dated 10/11/13 at 12:27 PM reflected " prelim wound lt heel " results Escerichia coli: many (Escerichia coli or E. Coli is a bacterium that is commonly found in the lower intestine of warm-blooded organisms) Proteus mirabills: many , (Proteus mirabills, Proteus species are part of the [MEDICATION NAME] family of gram-negative bacilli. Proteus organisms are implicated as serious causes of infections in humans.) Gram positive cocci: many. Review of Resident #4 ' s Telephone Orders dated 10/14/13 reflected an order for [REDACTED]. Diagnosis, wound infection. Signed by the NP. Review of Resident #4 ' s Physician Communication Form dated 10/16/13 reflected a concern/assessment: patient with area to left heel - not progressing, surrounding area red, very painful to the touch, patient does not handle treatment well. Crep - no pain med noted can she have pain meds. (admission orders [REDACTED]. Telephone Orders dated 08/15/13 reflected an order for [REDACTED]. Signed by LVN B. In the physician ' s section reflected the following notes: Wound was cultured and now she is on ABT (antibiotic therapy). In an interview on 10/23/13 at 3:45 PM the Office Manager for the Wound Care Specialist stated that Resident #4 was scheduled with the wound care clinic for an appointment on 08/22/13 however clinic notes state that Resident #4 never showed up for the appointment. She stated that Resident #4 has not been seen by anyone in the wound care clinic and has not made another appointment since the 08/22/13 date. Review of the MAR indicated [REDACTED]. The scheduled [MEDICATION NAME] 400mg was signed as administered every 6 hours at 2 AM, 8 AM, 2 PM and 8 PM for pain. Review of Nurse's Notes dated reflected: 08/07/13 12:55 admitting and continuing [DIAGNOSES REDACTED]. Has duoderm to coccyx; area pink without drainage. 08/07/13 16:40 Transfer from Hospital via ems ... note readmit nursing assessment. No additional wound information is noted. 09/28/13 " 6-2 " Pt in bed supine position, able to voice concerns will continue to monitor. Left foot complaint of pain during treatment. Requires 2-3 person for transfer and ADL ' s (activities of daily living). Requires numerous prompts for food intake. Signed LVN B 10/13/13 " 2-6 " ...heel offload due to redness of left heel. Pt upset while changing bandage - cursing calling names. Area cleaned, [MEDICATION NAME] and bandage reapplied. Able to voice concerns at times. Cognitive process somewhat jumbled at times. Required total assist with ADLs ... Signed LVN B. 10/16/13 " 2-10 " Continue ABT for wound ... no swelling or complaint of pain unless tx (treatment) wound. Unable to make needs known due to confusion. In an interview on 10/23/13 at 9:58 AM the NP for resident #4 stated that she had seen Resident #4 on 10/07/13 and written an order for [REDACTED]. She stated that the date of the order for the antibiotics is the date that she received the lab results, 10/14/13. The NP stated that she would have liked to have received the lab results the same day they were returned to the facility, especially if they indicated a positive result and would have indicated the need for antibiotic treatment as an order would need to be written. She stated that she had not seen Resident #4 ' s sacral ulcers recently and had not received any communication regarding the sacral ulcers. She stated that she had not written any new orders for sacral ulcers. In an interview on 10/23/13 at 12:16 PM a RN with the Medical Director ' s office, also Resident #4 ' s Primary Care Physician stated that the Medical Director " absolutely does not know anything regarding this Resident. He has not seen this patient. The Medical Director will be at the facility this afternoon to assess the patient. " She then stated that the Medical Director had just acquired this facility approximately one month ago. In an interview on 10/23/2013 at 5:30 PM Resident #4's Physician stated he was not informed about Resident #4 ' s pressure sores to sacral area. Resident #4 ' s Physician stated he had just seen her left heel but has not seen her sacral pressure sores. Resident #4 ' s Physician stated that if the pressure sores were macerated that was not good. Resident #4 ' s Physician further stated that if there was slough in the wounds then it needed to be debrided. Resident #4 ' s Physician stated that after seeing the boot that was on Resident #4 he told the facility that it was not the right kind of boot. Resident #4 ' s Physician stated if the boot was not washed after soiling it could contribute to an infection in Resident #4 ' s pressure sore. Resident #4 ' s Physician stated he expected the nurses to notify him if any wound has a foul odor so antibiotics could be initiated. Resident #4 ' s Physician also expected Resident #4 to be on an air mattress. Observation on 10/23/2013 at 6:15 PM the CSC RN and LVN B were turning Resident #4 on left side so Resident #4's Physician could examine Resident #4 ' s sacral pressure sores. Resident #4 started to cry and was calling out incoherently. In an interview on 10/23/2013 at 6:25 PM Resident #4's Physician stated Resident #4 was definitely in pain and he would be ordering more pain medication for Resident #4. In an interview on 10/24/2013 at 10:25 AM LVN C stated Resident #4's sacral area was just excoriated when she saw it last. LVN C stated it has gotten worse. LVN C stated she has been off for a week and LVN B was filling in for her. LVN C further stated Resident #4 should have been on an air mattress and was not sure why she was not. In an interview on 10/24/13 at 11:15 AM the MDS Coordinator stated that she found additional care plans in her office. She presented surveyors with 4 care plans pages: Care Plan A, Antibiotics, Skin, and Pressure Area. When asked how staff were to follow these plans of care if they were not in Resident #4 ' s chart the MDS Coordinator did not answer. Review of Resident #4 ' s Care Plan A reflected 1. Mobility/Ambulation: wheel chair via staff, 10/14/13 float heels when in bed (this was intervention was lined through), 10/22/13 pravolon boots at all times except when bathing every shift. Review of Resident #4 ' s Comprehensive Plan of Care (three pages) Problem/need: Resident is on Antibiotic(s) and is at risk for adverse reactions. Med: ABT as ordered. Other: left heel. Dated 10/14/13 Approach: -Give meds per order - monitor labs, cultures, reports abnormals to MD -Monitor resident for adverse reactions specific to the medication -Follow universal /standard precaution to prevent cross contamination and spread infection -Encourage fluids and P.O. -Serve Diet as ordered -Low Air Loss mattress - Prevlon boots at all times except bathing and skin sheets -treatment per MD order -Wound Care Consult -PT/OT to eval and treat Problem/need: Resident has current skin condition. Other: left heel. Dated 08/07/13. Approach: -Perform treatments per order, if no improvement x2 weeks - report to MD -Monitor areas for increase in breakdown, signs and symptoms of infection - report to MD -Monitor for pain, give med per order, monitor for relief -Encourage P.O. and fluid intake within dietary limits -Keep MD and RP informed of resident ' s progress -Assess skin weekly and records findings in clinical record -Vitamin supplement -Prevalon boots - 10/22/13 -Low Air Loss mattress - 10/23/13 -Culture left heel - 10/13 Problem/need: Resident has a pressure Area: blank, Stage: blank, Location: Sacral/Coccyx community acquired. Dated 08/17/13. Approach: -Perform treatments per order, if no improvement x2 weeks - report to MD -Encourage P.O. and fluid intake within dietary limits -Keep family/responsible party and MD informed of resident ' s progress -Assist with turn/repositioning every two hours and prn -Use padding between pressure areas and positioning devices for proper body alignment -Provide pressure relieving device for bed and wheel chair -Monitor labs and report abnormals to MD -Dietary consult for proper nutrition to resolve pressure area In an interview on 10/24/13 at 6:10 PM the CSC RN was presented with the 4 care plans pages: Care Plan A, Antibiotics, Skin, and Pressure Area. The CSC RN stated o, those care plans were not in the chart, let me look at them ... CSC RN reviewed the care plans. The CSC RN then stated, no, these were not there yesterday when we were looking at the chart and we copied the whole thing. In an interview on 10/25/13 at 4:20 PM the Medical Records LVN was asked for documents pertaining to Resident #4. All thinned records, previous admission records, wound care records, physician's order [REDACTED]. The Medical Records LVN stated, " No, this is everything, we gave it all to you yesterday. " B.) Review of Resident #9's Face Sheet reflected an [AGE] year old male admitted to the facility on [DATE] with the following Diagnosis: [REDACTED]. Review of Resident #9's Initial Nursing Summary assessment dated [DATE] not time signed by LVN E reflected Resident #9 was severely cognitively impaired and was able to make self-understood. Resident #9's assessment further reflected Resident #9 had a Foley Catheter. The section for bowel incontinence was blank. Under the skin condition section of Resident #9's assessment reflected "Bil heel Stage 2 decbs (decubitus)". No other assessment information was noted. The rest of the skin condition section of the assessment was blank. Under the nursing intervention/initial care plan section for skin condition on the assessment was also left blank. The pain, nutritional, and medication sections of the assessment were blank. Review of Resident #9's Admission Care Plan dated 10/22/2013, no time, no signature reflected "23. Pain, Goal Resident will be as comfortable as possible, Monitor pain, Administer pain medications as ordered. " Review of the Pain Assessment for Resident #9 dated 10/21/2013, no time, signed by LVN E reflected section one (1) Pain Intensity in the Past five (5) days was blank. Section two (2) of the assessment Pain Assessment in Advanced Dementia Scale (PAINAD) was marked with a score of zero. The rest of the Assessment was blank. Review of the admission orders [REDACTED]. Observation on 10/22/2013 at 9:30 AM on initial tour revealed Resident #9 in bed on back. Head of bed elevated 30 degrees. Resident #9's bilateral feet were sticking out of the sheet. Blood was noted on sheet under Resident #9's right heel and multiple areas at the foot of the bed. Resident #9 was on a regular foam mattress. Resident #9's heels were on the mattress, not floated, no dressings were noted. In an interview on 10/22/2013 at 9:35 AM Resident #9 stated "I am not doing to good, baby. I hurt." When asked where he hurt Resident #9 stated everywhere. Observation on 10/23/2013 at 11:35 revealed CNA O turning Resident #9 in bed. Resident #9 stated "ow", "ow". When ask if he was hurting he stated "yeah it hurts, it hurts bad". In an interview on 10/23/2013 at 4:45 PM CNA H stated she gave Resident #9 a bed bath on 10/22/2013. CNA H stated after cleaning Resident #9's feet she saw that Resident #9's right heel was bleeding. CNA H stated the Resident #9 was complaining of pain when she moved his legs. CNA H stated she told LVN E and LVN E went to check on Resident #9. Review of Resident #9's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Further review of the MAR indicated [REDACTED]. In an interview on 10/23/2013 at 4:50 PM LVN F stated Resident #9 did not have any [MEDICATION NAME]es for pain at the facility or any [MEDICATION NAME] for pain at the facility. LVN F stated Resident #9 came with an order for [REDACTED]. Review of the Nurses Notes for Resident #9 dated 10/23/2013 at 12:35 PM reflected "Call to NP IE: [MEDICATION NAME] and [MEDICATION NAME] for scripts/call to pharmacy for delivery, awaiting return call." In an interview on 10/23/2013 at 4:55 PM the ADON stated Resident #9 had on a [MEDICATION NAME] on his upper right chest dated 10/21/2013 from the hospital. The ADON stated the nurse was ordering the [MEDICATION NAME] from the pharmacy now. Observation on 10/24/2013 at 12:20 PM revealed Resident #9 in bed on a regular foam mattress. Resident #9 had foam heel lift boots. Resident #9's heels were on the foam of the boots not in the open area meant for floating. CNA P was turning Resident #9 in bed to right side. Resident #9 stated his heels hurt, bad, bad, bad. CNA P rolled Resident #9 back. In an interview on 10/24/2013 at 12:25 PM CNA P stated Resident #9's heel boots were not on right that Resident #9's heels should be in the open portion of the boot so there was no pressure on them. CNA P stated she would tell Resident #9's nurse about his pain. In an interview on 10/23/2013 at 5:30 PM Resident #9's Physician stated he expected the nurses to monitor and assess residents frequently for pain. Staff should pre-medicate residents prior to painful treatments. C.) Review of Resident #12's Face Sheet reflected a [AGE] year old male admitted to the facility on [DATE] with the following Diagnosis: [REDACTED]. Review of Resident #12's Admission Minimum Data Set (MDS) assessment dated [DATE] reflected Resident #12 had Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating Resident #12 was cognitively intact. Resident #12 was coded to have no behaviors. Resident #12 was coded to require extensive one person assist with bed mobility, transfer, dressing and bathing. Resident #12 was coded to have an indwelling urinary catheter and was coded to always be incontinent of bowel. Resident #12 was coded to have occasional pain rated at 5 on a zero to 10 scale. Resident #12 was coded to be at risk for developing pressure sores and was coded to have one Stage IV pressure sore with a length of 1.2 cm (centimeters), width of 0.7 cm and a depth of 0.8 cm. The tissue type was described as slough-yellow or white tissue that adheres to the ulcer bed in strings or thick clumps or is mucinous. Review of Resident #12's Comprehensive Care Plan dated 07/17/2013 and updated on 10/1/2013 reflected "Had pressure ulcer upon admission. At risk for further skin breakdown, related to [MEDICAL CONDITION], poor mobility, reduced appetite and weakness. " Interventions included: "Provide wound care per orders. Monitor skin with care and full body assessments weekly. Report changes to skin integrity to the physician ". Review of Resident #12's Consolidated Physician orders [REDACTED]." "Skin check by licensed nurse weekly with a start date of 07/31/2013." Review of the Wound Assessment Report dated 07/18/2013 at 4:03 PM for Resident #12 reflected "Pressure Ulcer, Left Buttock Stage IV, Length 3.5 cm, width 3.5 cm, depth 2 cm, 100 % granulation tissue, no slough or eschar, with a well-defined border." The assessment was signed by RN Q. Review of the Wound Assessment Report dated 09/25/2013 at 10:41 AM for Resident #12 reflected "Pressure Ulcer, Left Buttock, Stage IV, Length 0.5 cm, width 1 cm, depth 2.4 cm, 100% granulation tissue, no slough or eschar, with a well-defined border." The assessment was signed by RN Q. Review of Resident #12's Medical Record reflected no other wound assessments were completed on Resident #12's Stage IV pressure sore to

Based on observation, interview, and record review the facility failed to immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention; a significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications); a need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) for two (2) of 32 residents (Resident #4, and #26) reviewed for notifying the physician when: A) The facility failed to consult Resident #4 ' s physician of changes in Resident #4 ' s worsening sacral pressure ulcers. Resident #4 was admitted to the facility on [DATE] with a Stage II sacral and left heel ulcer per hospital discharge records. The facility did not assess, properly measure, stage or implement/clarify physician ordered treatments to Resident #4's left heel pressure sores resulting in worsening of Resident #4's left heel and sacral pressure sores. Resident #4 ' s left heel became infected and was cultured on 10/08/13 with results received on 10/11/13 not conveyed to the physician until 10/14/13, an additional 3 days, resulting in a delay of antibiotic treatment. Resident #4 ' s sacral ulcer treatment order ended on 08/14/13 and was not clarified until 10/01/13 resulting in 40 days of treatment without orders while the wound worsened from a stage II to multiple stage III wounds. Resident #4 ' s physician was not notified of the worsening sacral ulcers until Surveyors brought it to his attention on 10/23/13. This failure further resulted in an identification of an Immediate Jeopardy (IJ) on 10/23/2013. While the IJ was removed on 10/25/2013, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope identified as pattern due to the facility ' s need to evaluate the effectiveness of the corrective systems. B) Resident #26's Physician was not consulted by the facility pertaining to the abrasion the staff identified on 09/12/2013 which developed into an infection and resulted in [MEDICAL CONDITION] to the left ankle. This deficient practice affected two (2) residents and placed 22 residents identified as having pressure ulcers at risk for their physicians and/or family members not being notified resulting in a delay in appropriate medical treatment, the development of new or worsening medical conditions, and diminished quality of life for any resident who may have a new clinical condition. Findings include: A) Review of Resident #4 ' s face sheet reflected a [AGE] year old woman admitted to the facility on [DATE] and then readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #4 ' s discharge summary from the hospital to the facility, dated 08/07/13 reflected Resident #4 ' s admitting [DIAGNOSES REDACTED]. Hospital course: The patient was admitted with the above said [DIAGNOSES REDACTED]. Her blood cultures have remained negative and her wound culture from the left heel decubiti and sacrum was growing proteus mirabilis and staphylococcus aureus. Observation on 10/22/13 at 9:17 AM revealed Resident #4 in bed. Resident #4 was wearing blue foam boots on both feet. When the Medical Records LVN opened the boot on the left foot a pervasive odor was noted, also a creamy yellow dried substance was noted on the inside of the left boot near the bandage. Resident #4 cried out as the LVN was opening the boot, Resident #4 stated " Ill slap you, " and raised her hand. The Medical Records LVN asked if Resident #4 was in pain and the Resident nodded. Medical Records LVN stated she would get Tylenol. In an interview on 10/22/13 at 2:10 PM LVN B stated that Resident #4 came in with a stage 4 heel ulcer and a stage 1 that had progressed to a scattered stage 2 ulcer on the coccyx. In an interview on 10/23/13 at 4:15 PM LVN B stated that she had worked with Resident #4 previously at a group home. LVN B stated that Resident #4 came in with an open area to the coccyx and that it then closed and has reopened. She stated that the new Director of Nursing instituted different assessment sheets and that the previous Assistant Director of Nursing had done the previous assessments. Review of Resident #4 ' s admission MDS dated [DATE], reflected Resident #4 to have both short term and long term memory problems per staff assessment. Resident #4 was coded as requiring extensive assistance of one person for bed mobility and extensive two person assistance with transfers. Resident #4 was coded as always incontinent for both bowel and bladder. In the skin condition section Resident #4 was coded as having 3 stage 2 pressure ulcers, with 3 present at admission. The tissue type listed for " ulcer at most advanced stage " was " granulation tissue-pink or red tissue with shiny, moist, granular appearance. No additional wounds were coded. Observation on 10/23/2013 at 4:15 PM revealed LVN B in Resident #4 ' s room to perform wound care on Resident #4 with the CSC RN present at bedside. Resident #4 was lying on her back, on a regular foam mattress. A blue pillow style boot was noted to Resident #4's left foot. LVN B removed a duoderm dressing (A [MEDICATION NAME] dressing that is biodegradable, non-breathable and adheres to the skin) from Resident #4 ' s sacral area to reveal a Stage III (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.) pressure sore to Resident #4 ' s right sacral area approximately 3 cm (centimeters) in length by 1 cm width with a depth of >0.2 cm. The right sacral Stage III pressure sore was covered by approximately 20% yellow slough. There was a Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough) to Resident #4 ' s lateral right sacral area approximately 1 cm by 0.5 cm with a pink wound bed. On Resident #4 ' s right lower lateral right buttock was a Stage III pressure sore approximately 3 cm x 0.5 cm x >0.2 cm, the wound bed was 50% covered in yellow slough. Resident #4 ' s had a Stage III pressure sore to her mid sacral area approximately 6.5 cm x 2.5 cm with >0.2 cm depth 60 % of the wound was covered in yellow slough. There was approximately a 10 cm x 8cm area of macerated silver/ white colored tissue surrounding all the wounds. LVN B, without cleaning Resident #4 ' s pressure sores to sacral and right buttock areas, and without applying new gloves applied a thin duoderm over the pressure sores. LVN B then went to the treatment cart to get supplies to do wound care on Resident #4 ' s left heel Stage IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling.) LVN B removed Resident #4 ' s pillow style boot from left foot. There was a prevalent foul odor coming from Resident #4 ' s left foot. The inside of the pillow style boot was noted to have serosanguineous stains where Resident #4 ' s heel was. LVN B then removed the dressing from Resident #4 left heel. Serosanguineous drainage was noted to dressing. Resident #4's left heel pressure sore was approximately 2 cm by 2.5 cm with an undetermined depth, the area was 95% covered in a yellow to brown colored slough. LVN B washed her hands and changed gloves. LVN B then used a needle-less syringe and squirted the open portion of resident left heel. Resident #4 flinched her whole body away from LVN B and stated " Leave me alone f***ers. " The Surveyor asked Resident #4 if she hurt and Resident #4 responded " Yeah, that hurts! " LVN B then took a stack of two (2) by two (2) gauze and patted the area three times with the same gauze. LVN B then placed [MEDICATION NAME] Ag (silver impregnated antimicrobial dressing) to open area of Resident #4's left heel, LVN B then placed a bordered dressing over heel. (approximations by surveyor as LVN B did not measure the wound during care.) LVN B stated that Resident #4 does not have orders for pain medication. She stated that there are no standing orders for pain medication as the Medical Director says absolutely not. Review of Resident #4 ' s Telephone Orders dated 10/01/13 reflected the following orders: Duoderm to sacral/coccyx area change every 3 days and prn soilage. Clarification: cleanse left heel, normal saline, apply [MEDICATION NAME] Ag dressing every day until healed. Review of Resident #4 ' s Physician Communication Form dated 10/06/13 reflected a concern/assessment: Left heel clean with normal saline apply [MEDICATION NAME] AG QD ([MEDICATION NAME] silver every day - a wound treatment) area not progressing. Requesting Santyl QD (every day) (Santyl is an active enzymatic therapy that continuously removes necrotic tissue from wounds at the microscopic level.) Cleans with normal saline, apply santyl cover with 2x2 cover with Allevyn Matrix every day. Signed by Licensed Vocational Nurse (LVN) B. Further down the page is written " Will eval, " with an initial. (No information regarding sacral pressure ulcers was noted on this communication.) Review of Resident #4 ' s Telephone Orders dated 10/07/13 reflected an order to culture wound left heel, signed by the Nurse Practitioner (NP) for Resident #4. Review of Resident #4 ' s Telephone Orders dated 10/11/13 reflected the following order: Apply santyl topical to left heel QOD (every other day) times 10 days, alternating with [MEDICATION NAME] AG. In an interview on 10/23/2013 at 4:45 PM CNA G stated that Resident #4 ' s sacral area had been getting worse for the past month. CNA G further stated she has told the nurses the area was getting worse. CNA G stated the only thing she was told to do for Resident #4's left heel to to keep the boot on it. CNA G stated that there was not a regular schedule for changing the boot or washing it. She stated " I guess we could send them to laundry. " In an interview on 10/23/2013 at 5:50 PM the CSC RN stated LVN B would not be doing treatments anymore. The CSC RN further stated she felt LVN B was disorganized. The CSC RN further stated if there is a change to a wound the physician needs to be called. The CSC RN stated that the current treatment for [REDACTED]. The CSC RN returned at 6:20 PM and stated that there are no measurements for Resident #4's sacral wounds and that this is a deficit. Review of Resident #4 ' s readmission assessment, dated 08/07/13, reflected: Section 13: Integumentary/feet: 1. Skin/wound condition present? Yes. 1a. Is there pain associated with the wound/skin condition? Yes. An anatomical figure had the following markings to indicate the following: a circled " 2 " across the buttocks. The key on the side of the form indicated " 2 " represents " Stage II. " The left heel was circled and written beside it " debrided 8-01-13 4cm x 4.2cm. Drawings of feet inside and outside did not reflect any markings to indicate wounds, no staging, wound depth or wound bed description information was included. 4. Feet status: nothing was checked Section 14: Pain: Had pain of hurting? Yes. Signed as completed by RN U Review of the readmission assessment " Norton Plus Pressure Ulcer Scale " dated 08/07/13 reflected the following: Risk Factor: Physical condition: 3 - fair Mental state: 2 - confused Activity: 2 - chair bound Mobility: 2 - very limited Incontinence: 1 - double incontinence Total Norton Scale: 10 Total Norton Plus Score (score 10 or less = high risk): 7 Signed as completed by RN U Review of Resident #4 ' s Readmission " Pain Assessment, " dated 08/08/13 reflected: Diagnosis: [REDACTED]. 2. Pain Assessment in Advanced Dementia Scare (PAINAD) Breathing independent of vocalization: 0 - normal Negative vocalization: 1 - Occasional moan or groan. Low level speech with a negative or disapproving quality. Facial expression: 1 - Sad. Frightened. Frown. Body language: 1 - Tense. Distressed pacing. Fidgeting. Consolability: 1 - Distracted or reassured by voice or touch. Total: 4 Score of 4 or higher indicates intervention may be needed. 3. History of pain and what relieves it: (include known cause and/or need for palliative care) Debridement of left heel on 08/06/13 per wound care MD at hospital. 4. Physical assessment by nurse if any of the below observations are identified: Tenderness is checked Anatomical illustration has a line pointing to the left heel " surgical debridement 4cm x 4.2 cm. 6. How does the pain affect: e. Ability to concentrate: Easily agitated, unable to determine if due to pain f. Enjoyment of life? Anxious, may be due to psych dx (diagnoses): [MEDICAL CONDITIONS] disorder Summary: Unable to make all needs known, may verbalize pain occasionally, example " it hurts " at other times cries out or screams when touched. Some screams may not indicate pain. Has dx: [MEDICAL CONDITIONS] disorder. Wound care nurse reported resident tolerated treatment well today. Signed as completed by RN U Review of Resident #4 ' s admission orders [REDACTED] [MEDICATION NAME] 1 mg, po bid [MEDICATION NAME] ER 300 mg, po bid [MEDICATION NAME] 1mg tab, give 4 qhs [MEDICATION NAME] Chloride 5 mg, po bid [MEDICATION NAME] 125 mcg, po qd [MEDICATION NAME] 50 mcg, po qd [MEDICATION NAME] 17g in H2O bid Bactirm DS 1 tab, po bid times 10 days Tylenol 325 mg two tabs, po q 4hours prn [MEDICATION NAME] 1 mg, po q 6 hours prn Bisac-evac 10 mg suppository, qd prn Cleanse left heel with normal saline, pat dry, apply [MEDICATION NAME] Ag dressing qd x 1 week. Other: Follow up with wound care doctor within one week Review of Resident #4 ' s Telephone Orders dated 08/07/13 reflected readmit to facility, Bactrim DS one tab po bid for 10 days. Physical Therapy, Occupational Therapy and Speech Therapy evaluate and treatment as indicated. Follow up with wound care doctor within one week. Review of Resident #4 ' s Telephone Orders dated 08/15/13 reflected an order for [REDACTED]. Review of Resident #4 ' s Telephone Orders dated 08/27/13, signed by Physician (DR) AA reflected the following orders: 1) Multivitamin with minerals 2) Vitamin A 8,000 IU 1 tab bid x 14 days 3) Stress tab with zinc 1 tab x 14 days 4) Argimaid 1 packet with 4-6 ounces water bid x 14 days 5) Add large meat portions to all meals x 60 days. Review of Resident #4 ' s 30 day MDS dated [DATE], reflected Resident #4 to have both short term and long term memory problems per staff assessment. Resident #4 was coded as requiring extensive assistance of one person for bed mobility and extensive two person assistance with transfers. Resident #4 was coded as always incontinent for both bowel and bladder. In the skin condition section Resident #4 was coded as having 3 stage 2 pressure ulcers, with 3 present at admission. The tissue type listed for " ulcer at most advanced stage " was " granulation tissue-pink or red tissue with shiny, moist, granular appearance. No additional wounds were coded. Review of Resident #4 ' s most current " Pain Assessment, " dated 09/05/13 reflected: 1. Pain intensity in the past 5 days (circle score) " 2 " is circled. 2. Pain Assessment in Advanced Dementia Scare (PAINAD) Breathing independent of vocalization: 2 - Noisy labored breathing. Short periods of hyperventilation. Negative vocalization: no score written Facial expression: 2 - Facial grimacing Body language: 1 - Tense. Distressed pacing. Fidgeting. Consolability: 1 - Distracted or reassured by voice or touch. Total: 6 3. History of pain and what relieves it: Administration of [MEDICATION NAME] and change in position with placement of supportive equipment. 4. Physical assessment by nurse if any of the below observations are identified: Aching and Tenderness are checked Anatomical illustration has no markings to indicate physical examination of painful areas. 6. How does the pain affect: a. Sleep: Mild to moderately c. Mobility: mild to moderately restricted d. General activity: reduced e. Ability to concentrate: not known f: Enjoyment of life: not known Summary: Resident respond fairly well to treatment plan. Completed by: No signature on this line. Review of Resident #4 ' s Comprehensive Care Plan, dated as being reviewed and updated on 10/15/13 to continue plan of care, reflected: Problem/need of: Potential for and real pressure ulcers, problem onset 08/07/13. Positive culture report for area left heel, 10/14/13. Goal and target date reflected: 10/14/13 Skin on left heel will heal by 1 cm by next review date in 92 days. 10/14/12 No new pressure developments x 92 days. Approaches listed: - Provide ulcer cares per orders. Monitor for changes in wounds. Report changes to MD. - Provide diet as ordered - Bed and chair pressure relief devices in place - Provide turning and repositioning while in bed, and chair - Encourage resident to make frequent changes in bed and chair - Keep feet elevated when in bed - Protective boots at all times - 10/14/13 ABT (2) per orders, update MD / Family with any sign of changes - 10/14/13 Review treatment and assess left heel weekly Problem/need of: Has chronic pain, potential for breakthrough pain, problem onset 08/07/13. Goal and target date reflected: Pain will remain at Resident ' s level of comfort daily, 11/15/13. Approaches listed: - Medications as ordered - Monitor for nonverbal and verbal indicators of pain - Provide positioning to prevent pain This plan of care did not reflect any information regarding sacral/coccyx wounds, pain assessment with wound care, or any information regarding wound care consults. Review of Resident #4 ' s Wound Assessment Report dated 8/8/13 reflected the wound type and location to be a pressure ulcer of the left heel. Date the wound was identified was listed as 8/8/13. Stage: unstageable due to suspected deep tissue injury. Measurements: Length 4.00 cm, Width 4.20 cm, depth (blank). Pain with wound treatment: no. No information was entered in the sections what described the wound bed or wound edges. Treatments: Pending treatment orders. Review of Resident #4 ' s Weekly Pressure Sore Progress Report dated 10/7/13 contained no information. All boxes were blank on the form pertaining to wounds. Review of Resident #4 ' s Daily/Weekly/Monthly body Audit and Hydration Report dated October 2013 reflected an anatomical illustration with a circle over the buttocks. Comment dated 10/15/13 by LVN B: Area red no drainage noted, continue with treatment as directed. Comment dated 10/14/13 by LVN B (which is under the 10/15/13 comment on the form) 3.0 left heel 4.0 discolered tissue surrounding area. Painful to patient, expresses. Review of Resident #4 ' s Daily/Weekly/Monthly body Audit and Hydration Report dated October 2013 reflected an anatomical illustration with a circle over the buttocks. Comment dated 10/22/13 by LVN B: 3.5 x 1.5 left lat, 1.5 x 0.5 left med. Stage 3 to buttocks, no drainage or odor. Current treatment duoderm, requesting new treatment to nurse practitioner today. Review of lab results dated 10/11/13 at 12:27 PM reflected " prelim wound lt heel " results Escerichia coli: many (Escerichia coli or E. Coli is a bacterium that is commonly found in the lower intestine of warm-blooded organisms) Proteus mirabills: many , (Proteus mirabills, Proteus species are part of the [MEDICATION NAME] family of gram-negative bacilli. Proteus organisms are implicated as serious causes of infections in humans.) Gram positive cocci: many. Review of Resident #4 ' s Telephone Orders dated 10/14/13 reflected an order for [REDACTED]. Diagnosis, wound infection. Signed by the NP. Review of Resident #4 ' s Physician Communication Form dated 10/16/13 reflected a concern/assessment: patient with area to left heel - not progressing, surrounding area red, very painful to the touch, patient does not handle treatment well. Crep - no pain med noted can she have pain meds. (admission orders [REDACTED]. Telephone Orders dated 08/15/13 reflected an order for [REDACTED]. Signed by LVN B. In the physician ' s section reflected the following notes: Wound was cultured and now she is on ABT (antibiotic therapy). Review of Resident # 4 ' s Wound Care Record, dated August 2013, reflected the following: Cleanse left heel with normal saline, pat dry, apply [MEDICATION NAME] Ag dressing QD times one week, start date 08/07/13. This treatment is signed as given from 08/08/13-08/31/13, an additional 10 days past the ordered end date. Duoderm to buttocks q 3 days - PRN, written on 08/16/13 is " one week. " " Drs appt " is then written with an arrow pointing to 08/22/13. The treatment is then signed as given for an additional 6 times from 08/24/13-08/31/13. In an interview on 10/23/13 at 3:45 PM the Office Manager for the Wound Care Specialist stated that Resident #4 was scheduled with the wound care clinic for an appointment on 08/22/13 however clinic notes state that Resident #4 never showed up for the appointment. She stated that Resident #4 has not been seen by anyone in the wound care clinic and has not made another appointment since the 08/22/13 date. Review of Resident #4 ' s current clinical record, over flow clinical record and " all medical records files for Resident #4 " reflected that physician's order [REDACTED]. Review of Resident # 4 ' s Wound Care Record, dated September 2013, reflected the following: Cleanse left heel with normal saline, pat dry, apply [MEDICATION NAME] Ag dressing QD times one week, start date 08/07/13. This treatment is signed as given from 09/01/13-09/30/13, an additional 30 days past the ordered end date during the month of September. Duoderm to sacrum q 3 days & PRN, no start date or order date is written. The treatment is then signed as given on 9/3, 9/4, 9/6, 9/9, 9/12, 9/15, 9/18, 9/21, 9/24, 9/27, 9/30. Review of Resident #4 ' s current clinical record, over flow clinical record and " all medical records files for Resident #4 " reflected that physician's order [REDACTED]. Review of Resident # 4 ' s Wound Care Record, dated October 2013, reflected the following: Cleanse left heel with normal saline, pat dry, apply [MEDICATION NAME] Ag dressing QD times one week, start date 08/07/13. A line was drawn through " times one week " and " until healed " was added. This treatment is signed as given from 10/01/13-10/9/13, (New physician's order [REDACTED]. 10/11/13 Apply Santyl top to left heel QOD x 10 days alternating with [MEDICATION NAME] silver. This treatment was signed as given on 10/11, 10/13, 10/15, 10/17, 10/19, 10/21 Cleanse sacral/coccyx wound with normal saline, pat dry, apply Duoderm q 3 days & PRN soilage with the start date 10/01/13. Review of the MAR indicated [REDACTED]. The scheduled [MEDICATION NAME] 400mg was signed as administered every 6 hours at 2 AM, 8 AM, 2 PM and 8 PM for pain. Review of Nurse's Notes dated reflected: 08/07/13 12:55 admitting and continuing [DIAGNOSES REDACTED]. Has duoderm to coccyx; area pink without drainage. 08/07/13 16:40 Transfer from Hospital via ems ... note readmit nursing assessment. No additional wound information is noted. 08/08/13 - 08/26/13 no information noted regarding wound care or pressure ulcers. 08/27/13 at 09:51 new orders received 1) Multivitamin with minerals2) Vitamin A 8,000 IU 1 tab bid x 14 days 3) Stress tab with zinc 1 tab x 14 days 4) Argimaid 1 packet with 4-6 ounces water bid x 14 days 5) Add large meat portions to all meals x 60 days. Dietary notified of dietary changes. New orders noted on MARs ... 08/27/13- 09/27/13 no information noted regarding wound care or pressure ulcers. 09/28/13 " 6-2 " Pt in bed supine position, able to voice concerns will continue to monitor. Left foot complaint of pain during treatment. Requires 2-3 person for transfer and ADL ' s (activities of daily living). Requires numerous prompts for food intake. Signed LVN B 09/29/13 - 10/07/13 no information noted regarding wound care or pressure ulcers. 10/08/13 at 11:30 AM Collected left heel wound culture obtained this AM & ready for pick up. Signed LVN C 10/13/13 " 2-6 " ...heel offload due to redness of left heel. Pt upset while changing bandage - cursing calling names. Area cleaned, [MEDICATION NAME] and bandage reapplied. Able to voice concerns at times. Cognitive process somewhat jumbled at times. Required total assist with ADLs ... Signed LVN B. 10/15/13 " 2-10 " Continue ABT for left heel wound. No swelling or complaint of pain at this time. 10/16/13 " 2-10 " Continue ABT for wound ... no swelling or complaint of pain unless tx (treatment) wound. Unable to make needs known due to confusion. In an interview on 10/23/13 at 9:58 AM the NP for resident #4 stated that she had seen Resident #4 on 10/07/13 and written an order for [REDACTED]. She stated that the date of the order for the antibiotics is the date that she received the lab results, 10/14/13. The NP stated that she would have liked to have received the lab results the same day they were returned to the facility, especially if they indicated a positive result and would have indicated the need for antibiotic treatment as an order would need to be written. She stated that she had not seen Resident #4 ' s sacral ulcers recently and had not received any communication regarding the sacral ulcers. She stated that she had not written any new orders for sacral ulcers. In an interview on 10/23/13 at 12:16 PM a RN with the Medical Director ' s office, also Resident #4 ' s Primary Care Physician stated that the Medical Director " absolutely does not know anything regarding this Resident. He has not seen this patient. The Medical Director will be at the facility this afternoon to assess the patient. " She then stated that the Medical Director had just acquired this facility approximately one month ago. In an interview on 10/23/2013 at 5:30 PM Resident #4's Physician stated he was not informed about Resident #4 ' s pressure sores to sacral area. Resident #4 ' s Physician stated he had just seen her left heel but has not seen her sacral pressure sores. Resident #4 ' s Physician stated that if the pressure sores were macerated that was not good. Resident #4 ' s Physician further stated that if there was slough in the wounds then it needed to be debrided. Resident #4 ' s Physician stated that after seeing the boot that was on Resident #4 he told the facility that it was not the right kind of boot. Resident #4 ' s Physician stated if the boot was not washed after soiling it could contribute to an infection in Resident #4 ' s pressure sore. Resident #4 ' s Physician stated he expected the nurses to notify him if any wound has a foul odor so antibiotics could be initiated. Resident #4 ' s Physician also expected Resident #4 to be on an air mattress. Observation on 10/23/2013 at 6:15 PM the CSC RN and LVN B were turning Resident #4 on left side so Resident #4's Physician could examine Resident #4 ' s sacral pressure sores. Resident #4 started to cry and was calling out incoherently. In an interview on 10/23/2013 at 6:25 PM Resident #4's Physician stated Resident #4 was definitely in pain and he would be ordering more pain medication for Resident #4. In an interview on 10/24/2013 at 10:25 AM LVN C stated Resident #4's sacral area was just excoriated when she saw it last. LVN C stated it has gotten worse. LVN C stated she has been off for a week and LVN B was filling in for her. LVN C further stated Resident #4 should have been on an air mattress and was not sure why she was not. In an interview on 10/24/13 at 11:15 AM the MDS Coordinator stated that she found additional care plans in her office. She presented surveyors with 4 care plans pages: Care Plan A, Antibiotics, Skin, and Pressure Area. When asked how staff were to follow these plans of care if they were not in Resident #4 ' s chart the MDS Coordinator did not answer. Review of Resident #4 ' s Care Plan A reflected 1. Mobility/Ambulation: wheel chair via staff, 10/14/13 float heels when in bed (this was intervention was lined through), 10/22/13 pravolon boots at all times except when bathing every shift. Review of Resident #4 ' s Comprehensive Plan of Care (three pages) Problem/need: Resident is on Antibiotic(s) and is at risk for adverse reactions. Med: ABT as ordered. Other: left heel. Dated 10/14/13 Approach: -Give meds per order - monitor labs, cultures, reports abnormals to MD -Monitor resident for adverse reactions specific to the medication -Follow universal /standard precaution to prevent cross contamination and spread infection -Encourage fluids and P.O. -Serve Diet as ordered -Low Air Loss mattress - Prevlon boots at all times except bathing and skin sheets -treatment per MD order -Wound Care Consult -PT/OT to eval and treat Problem/need: Resident has current skin condition. Other: left heel. Dated 08/07/13. Approach: -Perform treatments per order, if no improvement x2 weeks - report to MD -Monitor areas for increase in breakdown, signs and symptoms of infection - report to MD -Monitor for pain, give med per order, monitor for relief -Encourage P.O. and fluid intake within dietary limits -Keep MD and RP informed of resident ' s progress -Assess skin weekly and records findings in clinical record -Vitamin supplement -Prevalon boots - 10/22/13 -Low Air Loss mattress - 10/23/13 -Culture left heel - 10/13 Problem/need: Resident has a pressure Area: blank, Stage: blank, Location: Sacral/Coccyx community acquired. Dated 08/17/13. Approach: -Perform treatments per order, if no improvement x2 weeks - report to MD -Encourage P.O. and fluid intake within dietary limits -Keep family/responsible party and MD informed of resident ' s progress -Assist with turn/repositioning every two hours and prn -Use padding between pressure areas and positioning devices for proper body alignment -Provide pressure relieving device for bed and wheel chair -Monitor labs and report abnormals to MD -Dietary consult for proper nutrition to resolve pressure area In an interview on 10/24/13 at 6:10 PM the CSC RN was presented with the 4 care plans pages: Care Plan A, Antibiotics, Skin, and Pressure Area. The CSC RN stated o, those care plans were not in the chart, let me look at them ... CSC RN reviewed the care plans. The CSC RN then stated, no, these were not there yesterday when we were looking at the chart and we copied the whole thing. In an interview on 10/25/13 at 4:20 PM the Medical Records LVN was asked for documents pertaining to Resident #4. All thinned records, previous admission records, wound care records, physician's order [REDACTED]. The Medical Records LVN stated, " No, this is everything, we gave it all to you yesterday. " B) Review of Resident #26's Face Sheet reflected an [AGE] year old female admitted on [DATE] and readmitted [DATE].

Based on observation, interview and record review the facility Administrator and DON failed to administer in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The Administrator also failed to conduct Quality Assurance Committee meetings as required quarterly, supervise, monitor and consult with the DON to ensure residents received the care and services to meet their individual needs and ensure the nursing staff was provided pertinent information and education relating to the care and needs of each resident to ensure residents received care to attain and maintain their highest practicable physical, mental, and psychosocial well-being. The DON failed to monitor the wound care program and nursing staff responsible for providing quality care for residents reviewed for pressure sores, pain, notification of physician for change of condition were competent to perform nursing tasks when: A.) Residents #4, #9 and #12 did not receive necessary treatment and services to promote healing, pressure sores were not accurately assessed and staged, and once developed, did not receive necessary treatment and services to promote healing. 1.) Resident #4 was admitted to the facility on [DATE] with a Stage II sacral and left heel ulcer per hospital discharge records. The facility did not assess, properly measure, stage or implement/clarify physician ordered treatments to Resident #4's left heel pressure sores or sacral ulcers resulting in worsening of Resident #4's left heel and sacral pressure sores. The facility failed to address Resident #4's pain associated with wound care treatment. Resident #4 ' s left heel became infected and was cultured on 10/08/13 with results received on 10/11/13 not conveyed to the physician until 10/14/13, an additional 3 days, resulting in a delay of antibiotic treatment. Resident #4 ' s sacral ulcer treatment order ended on 08/14/13 and was not clarified until 10/01/13 resulting in 40 days of treatment without orders while the wound worsened from a stage II to multiple stage III wounds. Resident #4 ' s physician was not notified of the worsening sacral ulcers until Surveyors brought it to his attention on 10/23/13. Resident #4 was ordered to have a consult with a wound care specialist on 8/07/13, Resident #4 had not seen the wound care specialist as of 10/23/13. 2.) Resident #9 was admitted to the facility on [DATE] with a Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough.) to right heel surrounded by areas of deep tissue injury (DTI) (A pressure-related injury to subcutaneous tissues under intact skin. Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear) and an unstageable (meaning that the stage is not clear. In these cases, the base of the sore is covered by a thick layer of other tissue and pus that may be yellow, gray, green, brown, or black. The doctor cannot see the base of the sore to determine the stage.) DTI to left heel per discharge hospital records. The facility did not assess, properly stage or implement physician ordered treatments to Resident #9's bilateral heel pressure sores resulting in worsening of Resident #9's bilateral heel pressure sores. 3.) Resident #12 was admitted to the facility on [DATE] with a Stage IV (Stage IV-Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling ). The facility did not routinely assess Resident #12's left ischium pressure sore, obtain a physician ordered wound culture or physician ordered referral to a wound care physician resulting in the worsening of Resident #12's left ischium Stage IV pressure sore. B) The facility failed to ensure the Quality Assessment and Assurance Committee (QA&A) met at least quarterly to identify issues with respect to which quality assessment and assurance activities are necessary and develop and implement appropriate plans of action to correct identified quality deficiencies. This failure further resulted in an identification of an Immediate Jeopardy (IJ) on 10/23/2013. While the IJ was removed on 10/25/2013, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope identified as pattern due to the facility ' s need to evaluate the effectiveness of the corrective systems. This deficient practice affected three (3) residents and placed 22 residents at risk for developing new or worsening pressure sores, [MEDICAL CONDITION] (skin infection), Osteomylitis (infection of the bone),[MEDICAL CONDITION] (infection of the blood), severe pain and death. Finding Include: A 1.) Review of Resident #4 ' s face sheet reflected a [AGE] year old woman admitted to the facility on [DATE] and then readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #4 ' s discharge summary from the hospital to the facility, dated 08/07/13 reflected Resident #4 ' s admitting [DIAGNOSES REDACTED]. Hospital course: The patient was admitted with the above said [DIAGNOSES REDACTED]. Her blood cultures have remained negative and her wound culture from the left heel decubiti and sacrum was growing proteus mirabilis and staphylococcus aureus. Observation on 10/22/13 at 9:17 AM revealed Resident #4 in bed. Resident #4 was wearing blue foam boots on both feet. When the Medical Records LVN opened the boot on the left foot a pervasive odor was noted, also a creamy yellow dried substance was noted on the inside of the left boot near the bandage. Resident #4 cried out as the LVN was opening the boot, Resident #4 stated " Ill slap you, " and raised her hand. The Medical Records LVN asked if Resident #4 was in pain and the Resident nodded. Medical Records LVN stated she would get Tylenol. In an interview on 10/22/13 at 2:10 PM LVN B stated that Resident #4 came in with a stage 4 heel ulcer and a stage 1 that had progressed to a scattered stage 2 ulcer on the coccyx. In an interview on 10/23/13 at 4:15 PM LVN B stated that she had worked with Resident #4 previously at a group home. LVN B stated that Resident #4 came in with an open area to the coccyx and that it then closed and has reopened. She stated that the new Director of Nursing instituted different assessment sheets and that the previous Assistant Director of Nursing had done the previous assessments. Observation on 10/23/2013 at 4:15 PM revealed LVN B in Resident #4 ' s room to preform wound care on Resident #4 with the Clinical Service Coordinator (CSC) Registered Nurse (RN) present at bedside. Resident #4 was lying on her back, on a regular foam mattress. A blue pillow style boot was noted to Resident #4 ' s left foot. LVN B removed a duoderm dressing (A [MEDICATION NAME] dressing that is biodegradable, non-breathable and adheres to the skin) from Resident #4 ' s sacral area to reveal a Stage III (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.) pressure sore to Resident #4 ' s right sacral area approximately 3 cm (centimeters) in length by 1 cm width with a depth of >0.2 cm. The right sacral Stage III pressure sore was covered by approximately 20% yellow slough. There was a Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough) to Resident #4 ' s lateral right sacral area approximately 1 cm by 0.5 cm with a pink wound bed. On Resident #4 ' s right lower lateral right buttock was a Stage III pressure sore approximately 3 cm x 0.5 cm x >0.2 cm, the wound bed was 50% covered in yellow slough. Resident #4 ' s had a Stage III pressure sore to her mid sacral area approximately 6.5 cm x 2.5 cm with >0.2 cm depth 60 % of the wound was covered in yellow slough. There was approximately a 10 cm x 8cm area of macerated silver/ white colored tissue surrounding all the wounds. LVN B, without cleaning Resident #4 ' s pressure sores to sacral and right buttock areas, and without applying new gloves applied a thin duoderm over the pressure sores. LVN B then went to the treatment cart to get supplies to do wound care on Resident #4 ' s left heel Stage IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling.) LVN B removed Resident #4 ' s pillow style boot from left foot. There was a prevalent foul odor coming from Resident #4 ' s left foot. The inside of the pillow style boot was noted to have serosanguineous stains where Resident #4 ' s heel was. LVN B then removed the dressing from Resident #4 left heel. Serosanguineous drainage was noted to dressing. Resident #4's left heel pressure sore was approximately 2 cm by 2.5 cm with an undetermined depth, the area was 95% covered in a yellow to brown colored slough. LVN B washed her hands and changed gloves. LVN B then used a needless syringe and squirted the open portion of resident left heel. Resident #4 flinched her whole body away from LVN B and stated " Leave me alone [***] s. " The Surveyor asked Resident #4 if she hurt and Resident #4 responded " Yeah, that hurts! " LVN B then took a stack of two (2) by two (2) gauze and patted the area three times with the same gauze. LVN B then placed [MEDICATION NAME] Ag (silver impregnated antimicrobial dressing) to open area of Resident #4's left heel, LVN B then placed a bordered dressing over heel. (approximations by surveyor as LVN B did not measure the wound during care.) LVN B stated that Resident #4 does not have orders for pain medication. She stated that there are no standing orders for pain medication as the Medical Director says absolutely not. Review of Resident #4 ' s Telephone Orders dated 10/01/13 reflected the following orders: Duoderm to sacral/coccyx area change every 3 days and prn soilage. Clarification: cleanse left heel, normal saline, apply [MEDICATION NAME] Ag dressing every day until healed. Review of Resident #4 ' s Physician Communication Form dated 10/06/13 reflected a concern/assessment: Left heel clean with normal saline apply [MEDICATION NAME] AG QD ([MEDICATION NAME] silver every day - a wound treatment) area not progressing. Requesting Santyl QD (every day) (Santyl is an active enzymatic therapy that continuously removes necrotic tissue from wounds at the microscopic level.) Cleans with normal saline, apply santyl cover with 2x2 cover with Allevyn Matrix every day. Signed by Licensed Vocational Nurse (LVN) B. Further down the page is written " Will eval, " with an initial. (No information regarding sacral pressure ulcers was noted on this communication.) Review of Resident #4 ' s Telephone Orders dated 10/07/13 reflected an order to culture wound left heel, signed by the Nurse Practitioner (NP) for Resident #4. Review of Resident #4 ' s Telephone Orders dated 10/11/13 reflected the following order: Apply santyl topical to left heel QOD (every other day) times 10 days, alternating with [MEDICATION NAME] AG. In an interview on 10/23/2013 at 4:45 PM CNA G stated that Resident #4 ' s sacral area had been getting worse for the past month. CNA G further she has told the nurses the area was getting worse. CNA G stated the only thing she was told to do for Resident #4's left heel to to keep the boot on it. CNA G stated that there was not a regular schedule for changing the boot or washing it. She stated " I guess we could send them to laundry. " In an interview on 10/23/2013 at 5:50 PM the CSC RN stated LVN B would not be doing treatments anymore. The CSC RN further stated she felt LVN B was disorganized. The CSC RN further stated if there is a change to a wound the physician needs to be called. The CSC RN stated that the current treatment for [REDACTED]. The CSC RN returned at 6:20 PM and stated that there are no measurements for Resident #4's sacral wounds and that this is a deficit. Review of Resident #4 ' s admission Minimum Data Set ((MDS) dated [DATE], reflected Resident #4 to have both short term and long term memory problems per staff assessment. Resident #4 was coded as requiring extensive assistance of one person for bed mobility and extensive two person assistance with transfers. Resident #4 was coded as always incontinent for both bowel and bladder. In the skin condition section Resident #4 was coded as having 3 stage 2 pressure ulcers, with 3 present at admission. The tissue type listed for " ulcer at most advanced stage " was " granulation tissue-pink or red tissue with shiny, moist, granular appearance. No additional wounds were coded. Review of Resident #4 ' s 30 day MDS dated [DATE], reflected Resident #4 to have both short term and long term memory problems per staff assessment. Resident #4 was coded as requiring extensive assistance of one person for bed mobility and extensive two person assistance with transfers. Resident #4 was coded as always incontinent for both bowel and bladder. In the skin condition section Resident #4 was coded as having 3 stage 2 pressure ulcers, with 3 present at admission. The tissue type listed for " ulcer at most advanced stage " was " granulation tissue-pink or red tissue with shiny, moist, granular appearance. No additional wounds were coded. Review of Resident #4 ' s readmission assessment, dated 08/07/13, reflected: Section 13: Integumentary/feet: 1. Skin/wound condition present? Yes. 1a. Is there pain associated with the wound/skin condition? Yes. An anatomical figure had the following markings to indicate the following: a circled " 2 " across the buttocks. The key on the side of the form indicated " 2 " represents " Stage II. " The left heel was circled and written beside it " debrided 8-01-13 4cm x 4.2cm. Drawings of feet inside and outside did not reflect any markings to indicate wounds, no staging, wound depth or wound bed description information was included. 2. Skin description: checked boxes were: pink, dry, warm 3. Skin Turgor: no tenting 4. Feet status: nothing was checked 5. Primary risk factors checked: Chronic Urinary Incontinence, Chronic Bowel Incontinence, Diseased or Drug Related Immunosuppression. Section 14: Pain: Had pain of hurting? Yes. Signed as completed by RN U Review of the readmission assessment " Norton Plus Pressure Ulcer Scale " dated 08/07/13 reflected the following: Risk Factor: Physical condition: 3 - fair Mental state: 2 - confused Activity: 2 - chair bound Mobility: 2 - very limited Incontinence: 1 - double incontinence Total Norton Scale: 10 Norton Plus Deductions (check only if yes) Hematocrit (F) < 36% : Checked Hemoglobin (F) < 12g/dl (Gram/deciliter) : Checked 5 (or more) Medications: Checked Total Number of Check Marks: 3 Norton Scale Score (from above): 10 Minus Total Check Marks: 7 Total Norton Plus Score (score 10 or less = high risk): 7 Signed as completed by RN U Review of Resident #4 ' s Readmission " Pain Assessment, " dated 08/08/13 reflected: Diagnosis: [REDACTED]. 2. Pain Assessment in Advanced Dementia Scare (PAINAD) Breathing independent of vocalization: 0 - normal Negative vocalization: 1 - Occasional moan or groan. Low level speech with a negative or disapproving quality. Facial expression: 1 - Sad. Frightened. Frown. Body language: 1 - Tense. Distressed pacing. Fidgeting. Consolability: 1 - Distracted or reassured by voice or touch. Total: 4 Score of 4 or higher indicates intervention may be needed. 3. History of pain and what relieves it: (include known cause and/or need for palliative care) Debridement of left heel on 08/06/13 per wound care MD at hospital. 4. Physical assessment by nurse if any of the below observations are identified: Tenderness is checked Anatomical illustration has a line pointing to the left heel " surgical debridement 4cm x 4.2 cm. 6. How does the pain affect: e. Ability to concentrate: Easily agitated, unable to determine if due to pain f. Enjoyment of life? Anxious, may be due to psych dx (diagnoses): [MEDICAL CONDITIONS] disorder Summary: Unable to make all needs known, may verbalize pain occasionally, example " it hurts " at other times cries out or screams when touched. Some screams may not indicate pain. Has dx: [MEDICAL CONDITIONS] disorder. Wound care nurse reported resident tolerated treatment well today. Signed as completed by RN U Review of Resident #4 ' s most current " Pain Assessment, " dated 09/05/13 reflected: 1. Pain intensity in the past 5 days (circle score) " 2 " is circled. 2. Pain Assessment in Advanced Dementia Scare (PAINAD) Breathing independent of vocalization: 2 - Noisy labored breathing. Short periods of hyperventilation. Negative vocalization: no score written Facial expression: 2 - Facial grimacing Body language: 1 - Tense. Distressed pacing. Fidgeting. Consolability: 1 - Distracted or reassured by voice or touch. Total: 6 3. History of pain and what relieves it: Administration of [MEDICATION NAME] and change in position with placement of supportive equipment. 4. Physical assessment by nurse if any of the below observations are identified: Aching and Tenderness are checked Anatomical illustration has no markings to indicate physical examination of painful areas. 6. How does the pain affect: a. Sleep: Mild to moderately c. Mobility: mild to moderately restricted d. General activity: reduced e. Ability to concentrate: not known f: Enjoyment of life: not known Summary: Resident respond fairly well to treatment plan. Completed by: No signature on this line. Review of Resident #4 ' s Comprehensive Care Plan, dated as being reviewed and updated on 10/15/13 to continue plan of care, reflected: Problem/need of: Potential for and real pressure ulcers, problem onset 08/07/13. Positive culture report for area left heel, 10/14/13. Goal and target date reflected: 10/14/13 Skin on left heel will heal by 1 cm by next review date in 92 days. 10/14/12 No new pressure developments x 92 days. Approaches listed: - Provide ulcer cares per orders. Monitor for changes in wounds. Report changes to MD. - Provide diet as ordered - Bed and chair pressure relief devices in place - Provide turning and repositioning while in bed, and chair - Encourage resident to make frequent changes in bed and chair - Keep feet elevated when in bed - Protective boots at all times - 10/14/13 ABT (2) per orders, update MD / Family with any sign of changes - 10/14/13 Review treatment and assess left heel weekly Problem/need of: Has chronic pain, potential for breakthrough pain, problem onset 08/07/13. Goal and target date reflected: Pain will remain at Resident ' s level of comfort daily, 11/15/13. Approaches listed: - Medications as ordered - Monitor for nonverbal and verbal indicators of pain - Provide positioning to prevent pain This plan of care did not reflect any information regarding sacral/coccyx wounds, pain assessment with wound care, or any information regarding wound care consults. Review of Resident #4 ' s Wound Assessment Report dated 8/8/13 reflected the wound type and location to be a pressure ulcer of the left heel. Date the wound was identified was listed as 8/8/13. Stage: unstageable due to suspected deep tissue injury. Measurements: Length 4.00 cm, Width 4.20 cm, depth (blank). Pain with wound treatment: no. No information was entered in the sections what described the wound bed or wound edges. Treatments: Pending treatment orders. Review of Resident #4 ' s Weekly Pressure Sore Progress Report dated 10/7/13 contained no information. All boxes were blank on the form pertaining to wounds. Review of Resident #4 ' s Daily/Weekly/Monthly body Audit and Hydration Report dated October 2013 reflected an anatomical illustration with a circle over the buttocks. Comment dated 10/15/13 by LVN B: Area red no drainage noted, continue with treatment as directed. Comment dated 10/14/13 by LVN B (which is under the 10/15/13 comment on the form) 3.0 left heel 4.0 discolered tissue surrounding area. Painful to patient, expresses. Review of Resident #4 ' s Daily/Weekly/Monthly body Audit and Hydration Report dated October 2013 reflected an anatomical illustration with a circle over the buttocks. Comment dated 10/22/13 by LVN B: 3.5 x 1.5 left lat, 1.5 x 0.5 left med. Stage 3 to buttocks, no drainage or odor. Current treatment duoderm, requesting new treatment to nurse practitioner today. Review of Resident #4 ' s admission orders [REDACTED] [MEDICATION NAME] 1 mg, po bid [MEDICATION NAME] ER 300 mg, po bid [MEDICATION NAME] 1mg tab, give 4 qhs [MEDICATION NAME] Chloride 5 mg, po bid [MEDICATION NAME] 125 mcg, po qd [MEDICATION NAME] 50 mcg, po qd [MEDICATION NAME] 17g in H2O bid Bactirm DS 1 tab, po bid times 10 days Tylenol 325 mg two tabs, po q 4hours prn [MEDICATION NAME] 1 mg, po q 6 hours prn Bisac-evac 10 mg suppository, qd prn Cleanse left heel with normal saline, pat dry, apply [MEDICATION NAME] Ag dressing qd x 1 week. Other: Follow up with wound care doctor within one week Review of Resident #4 ' s Telephone Orders dated 08/07/13 reflected readmit to facility, Bactrim DS one tab po bid for 10 days. Physical Therapy, Occupational Therapy and Speech Therapy evaluate and treatment as indicated. Follow up with wound care doctor within one week. Review of Resident #4 ' s Telephone Orders dated 08/15/13 reflected an order for [REDACTED]. Review of Resident #4 ' s Telephone Orders dated 08/27/13, signed by Physician (DR) AA reflected the following orders: 1) Multivitamin with minerals 2) Vitamin A 8,000 IU 1 tab bid x 14 days 3) Stress tab with zinc 1 tab x 14 days 4) Argimaid 1 packet with 4-6 ounces water bid x 14 days 5) Add large meat portions to all meals x 60 days. Review of lab results dated 10/11/13 at 12:27 PM reflected " prelim wound lt heel " results Escerichia coli: many (Escerichia coli or E. Coli is a bacterium that is commonly found in the lower intestine of warm-blooded organisms) Proteus mirabills: many , (Proteus mirabills, Proteus species are part of the [MEDICATION NAME] family of gram-negative bacilli. Proteus organisms are implicated as serious causes of infections in humans.) Gram positive cocci: many. Review of Resident #4 ' s Telephone Orders dated 10/14/13 reflected an order for [REDACTED]. Diagnosis, wound infection. Signed by the NP. Review of Resident #4 ' s Physician Communication Form dated 10/16/13 reflected a concern/assessment: patient with area to left heel - not progressing, surrounding area red, very painful to the touch, patient does not handle treatment well. Crep - no pain med noted can she have pain meds. Request referral to wound care doctor. Signed by LVN B. In the physician ' s section reflected the following notes: Wound was cultured and now she is on ABT (antibiotic therapy). Review of Resident # 4 ' s Wound Care Record, dated August 2013, reflected the following: Cleanse left heel with normal saline, pat dry, apply [MEDICATION NAME] Ag dressing QD times one week, start date 08/07/13. This treatment is signed as given from 08/08/13-08/31/13, an additional 10 days past the ordered end date. Duoderm to buttocks q 3 days - PRN, written on 08/16/13 is " one week. " " Drs appt " is then written with an arrow pointing to 08/22/13. The treatment is then signed as given for 6 times from 08/24/13-08/31/13. Review of Resident #4 ' s current clinical record, over flow clinical record and " all medical records files for Resident #4 " reflected that physician's order [REDACTED]. Review of Resident # 4 ' s Wound Care Record, dated September 2013, reflected the following: Cleanse left heel with normal saline, pat dry, apply [MEDICATION NAME] Ag dressing QD times one week, start date 08/07/13. This treatment is signed as given from 09/01/13-09/30/13, an additional 30 days past the ordered end date during the month of September. Duoderm to sacrum q 3 days & PRN, no start date or order date is written. The treatment is then signed as given on 9/3, 9/4, 9/6, 9/9, 9/12, 9/15, 9/18, 9/21, 9/24, 9/27, 9/30. Review of Resident #4 ' s current clinical record, over flow clinical record and " all medical records files for Resident #4 " reflected that physician's order [REDACTED]. Review of Resident # 4 ' s Wound Care Record, dated October 2013, reflected the following: Cleanse left heel with normal saline, pat dry, apply [MEDICATION NAME] Ag dressing QD times one week, start date 08/07/13. A line was drawn through " times one week " and " until healed " was added. This treatment is signed as given from 10/01/13-10/9/13, 10/12, 10/14, 10/16, 10/18, 10/20, 10/22, 10/24. " See below " is written in date boxes under 10/15-10/19. 10/11/13 Apply Santyl top to left heel QOD x 10 days alternating with [MEDICATION NAME] silver. This treatment was signed as given on 10/11, 10/13, 10/15, 10/17, 10/19, 10/21 Cleanse sacral/coccyx wound with normal saline, pat dry, apply Duoderm q 3 days & PRN soilage with the start date 10/01/13. Review of the MAR indicated [REDACTED]. The scheduled [MEDICATION NAME] 400mg was signed as administered every 6 hours at 2 AM, 8 AM, 2 PM and 8 PM for pain. Review of Nurse ' s Notes dated reflected: 08/07/13 12:55 admitting and continuing [DIAGNOSES REDACTED]. Has duoderm to coccyx; area pink without drainage. 08/07/13 16:40 Transfer from Hospital via ems ... note readmit nursing assessment. No additional wound information is noted. 08/08/13 - 08/26/13 no information noted regarding wound care or pressure ulcers. 08/27/13 at 09:51 new orders received 1) Multivitamin with minerals2) Vitamin A 8,000 IU 1 tab bid x 14 days 3) Stress tab with zinc 1 tab x 14 days 4) Argimaid 1 packet with 4-6 ounces water bid x 14 days 5) Add large meat portions to all meals x 60 days. Dietary notified of dietary changes. New orders noted on MARs ... 08/27/13- 09/27/13 no information noted regarding wound care or pressure ulcers. 09/28/13 " 6-2 " Pt in bed supine position, able to voice concerns will continue to monitor. Left foot complaint of pain during treatment. Requires 2-3 person for transfer and ADL ' s (activities of daily living). Requires numerous prompts for food intake. Signed LVN B 09/29/13 - 10/07/13 no information noted regarding wound care or pressure ulcers. 10/08/13 at 11:30 AM Collected left heel wound culture obtained this AM & ready for pick up. Signed LVN C 10/13/13 " 2-6 " ...heel offload due to redness of left heel. Pt upset while changing bandage - cursing calling names. Area cleaned, [MEDICATION NAME] and bandage reapplied. Able to voice concerns at times. Cognitive process somewhat jumbled at times. Required total assist with ADLs ... Signed LVN B. 10/15/13 " 2-10 " Continue ABT for left heel wound. No swelling or complaint of pain at this time. 10/16/13 " 2-10 " Continue ABT for wound ... no swelling or complaint of pain unless tx (treatment) wound. Unable to make needs known due to confusion. In an interview on 10/23/13 at 9:58 AM the NP for resident #4 stated that she had seen Resident #4 on 10/07/13 and written an order for [REDACTED]. She stated that the date of the order for the antibiotics is the date that she received the lab results, 10/14/13. The NP stated that she would have liked to have received the lab results the same day they were returned to the facility, especially if they indicated a positive result and would have indicated the need for antibiotic treatment as an order would need to be written. She stated that she had not seen Resident #4 ' s sacral ulcers recently and had not received any communication regarding the sacral ulcers. She stated that she had not written any new orders for sacral ulcers. In an interview on 10/23/13 at 12:16 PM a RN with the Medical Director ' s office, also Resident #4 ' s Primary Care Physician stated that the Medical Director " absolutely does not know anything regarding this Resident. He has not seen this patient. The Medical Director will be at the facility this afternoon to assess the patient. " She then stated that the Medical Director had just acquired this facility approximately one month ago. In an interview on 10/23/13 at 3:45 PM the Office Manager for the Wound Care Specialist stated that Resident #4 was scheduled with the wound care clinic for an appointment on 08/22/13 however clinic notes state that Resident #4 never showed up for the appointment. She stated that Resident #4 has not been seen by anyone in the wound care clinic and has not made another appointment since the 08/22/13 date. In an interview on 10/23/2013 at 5:30 PM Resident #4's Physician stated he was not informed about Resident #4 ' s pressure sores to sacral area. Resident #4 ' s Physician stated he had just seen her left heel but has not seen her sacral pressure sores. Resident #4 ' s Physician stated that if the pressure sores were macerated that was not good. Resident #4 ' s Physician further stated that if there was slough in the wounds then it needed to be debrided. Resident #4 ' s Physician stated that after seeing the boot that was on Resident #4 he told the facility that it was not the right kind of boot. Resident #4 ' s Physician stated if the boot was not washed after soiling it could contribute to an infection in Resident #4 ' s pressure sore. Resident #4 ' s Physician stated he expected the nurses to notify him if any wound has a foul odor so antibiotics could be initiated. Resident #4 ' s Physician also expected Resident #4 to be on an air mattress. Observation on 10/23/2013 at 6:15 PM the CSC RN and LVN B were turning Resident #4 on left side so Resident #4's Physician could examine Resident #4 ' s sacral pressure sores. Resident #4 started to cry and was calling out incoherently. In an interview on 10/23/2013 at 6:25 PM Resident #4's Physician stated Resident #4 was definitely in pain and he would be ordering more pain medication for Resident #4. In an interview on 10/24/2013 at 10:25 AM LVN C stated Resident #4's sacral area was just excoriated when she saw it last. LVN C stated it has gotten worse. LVN C stated she has been off for a week and LVN B was filling in for her. LVN C further stated Resident #4 should have been on an air mattress and was not sure why she was not. A 2.) Review of Resident #9's Face Sheet reflected an [AGE] year old male admitted to the facility on [DATE] with the following Diagnosis: [REDACTED]. Review of Resident #9's Initial Nursing Summary assessment dated [DATE], not timed, signed by LVN E reflected Resident #9 was severely cognitively impaired and was able to make self-understood. Resident #9's assessment further reflected Resident #9 had a Foley Catheter. The section for bowel incontinence was blank. Under the skin condition section of Resident #9's assessment reflected "Bil heel Stage 2 decbs (decubitus)". No other assessment information was noted. The rest of the skin condition section of the assessment was blank. Under the nursing intervention/initial care plan section for skin condition on the assessment was also left blank. The pain, nutritional, and medication sections of the assessment were blank. Review o

Based on observation, interview, and record review the facility failed to prohibit mistreatment, neglect, and abuse of residents for four (4) of 32 residents (Residents #4, #9, #12, and #26) when: A) Resident #4 was admitted to the facility on [DATE] with a Stage II sacral and left heel ulcer per hospital discharge records. The facility did not assess, measure, stage or implement/clarify physician ordered treatments to Resident #4's left heel pressure sores resulting in worsening of Resident #4's left heel and sacral pressure sores. The facility failed to address Resident #4's pain associated with wound care treatment. Resident #4 ' s left heel became infected and was cultured on 10/08/13 with results received on 10/11/13 not conveyed to the physician until 10/14/13, an additional 3 days, resulting in a delay of antibiotic treatment. Resident #4 ' s sacral ulcer treatment order ended on 08/14/13 and was not clarified until 10/01/13 resulting in 40 days of treatment without orders while the wound worsened from a stage II to multiple stage III wounds. Resident #4 ' s physician was not notified of the worsening sacral ulcers until Surveyors brought it to his attention on 10/23/13. Resident #4 was ordered to have a consult with a wound care specialist on 8/07/13, Resident #4 had not seen the wound care specialist as of 10/23/13. B.) Resident #9 was admitted to the facility on [DATE] with a Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough.) to right heel surrounded by areas of deep tissue injury (DTI) (A pressure-related injury to subcutaneous tissues under intact skin. Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear) and an unstageable (meaning that the stage is not clear. In these cases, the base of the sore is covered by a thick layer of other tissue and pus that may be yellow, gray, green, brown, or black. The doctor cannot see the base of the sore to determine the stage.) DTI to left heel per discharge hospital records. The facility did not assess, properly stage or implement physician ordered treatments to Resident #9's bilateral heel pressure sores resulting in worsening of Resident #9's bilateral heel pressure sores. C.) Resident #12 was admitted to the facility on [DATE] with a Stage IV (Stage IV-Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling ). The facility did not routinely assess Resident #12's left ischium pressure sore, obtain a physician ordered wound culture or physician ordered referral to a wound care physician resulting in the worsening of Resident #12's left ischium Stage IV pressure sore. This failure further resulted in an identification of an Immediate Jeopardy (IJ) on 10/23/2013. While the IJ was removed on 10/25/2013, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope identified as pattern due to the facility ' s need to evaluate the effectiveness of the corrective systems. This deficient practice affected three (3) residents and placed 22 residents at risk for developing new or worsening pressure sores, [MEDICAL CONDITION] (skin infection), Osteomylitis (infection of the bone),[MEDICAL CONDITION] (infection of the blood), severe pain and death. D.) Resident #26's left ankle abrasion the staff identified on 09/12/2013, which developed into an infection and resulted in [MEDICAL CONDITION] to the left ankle, was not investigated implementing written policies and procedures using the incident report by facility staff and was neglected. This deficient practice placed 90 residents at risk for neglect due to facility did not follow written policies and procedures that prohibit neglect of residents resulting in a delay in appropriate medical treatment, the development of new or worsening medical conditions, and diminished quality of life for any resident who may have a new clinical condition. Findings include: A.) Review of Resident #4 ' s face sheet reflected a [AGE] year old woman admitted to the facility on [DATE] and then readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #4 ' s discharge summary from the hospital to the facility, dated 08/07/13 reflected Resident #4 ' s admitting [DIAGNOSES REDACTED]. Hospital course: The patient was admitted with the above said [DIAGNOSES REDACTED]. Her blood cultures have remained negative and her wound culture from the left heel decubiti and sacrum was growing proteus mirabilis and staphylococcus aureus. Observation on 10/22/13 at 9:17 AM revealed Resident #4 in bed. Resident #4 was wearing blue foam boots on both feet. When the Medical Records LVN opened the boot on the left foot a pervasive odor was noted, also a creamy yellow dried substance was noted on the inside of the left boot near the bandage. Resident #4 cried out as the LVN was opening the boot, Resident #4 stated " Ill slap you, " and raised her hand. The Medical Records LVN asked if Resident #4 was in pain and the Resident nodded. Medical Records LVN stated she would get Tylenol. In an interview on 10/22/13 at 2:10 PM LVN B stated that Resident #4 came in with a stage 4 heel ulcer and a stage 1 that had progressed to a scattered stage 2 ulcer on the coccyx. In an interview on 10/23/13 at 4:15 PM LVN B stated that she had worked with Resident #4 previously at a group home. LVN B stated that Resident #4 came in with an open area to the coccyx and that it then closed and has reopened. She stated that the new Director of Nursing instituted different assessment sheets and that the previous Assistant Director of Nursing had done the previous assessments. Review of Resident #4 ' s admission MDS dated [DATE], reflected Resident #4 to have both short term and long term memory problems per staff assessment. Resident #4 was coded as requiring extensive assistance of one person for bed mobility and extensive two person assistance with transfers. Resident #4 was coded as always incontinent for both bowel and bladder. In the skin condition section Resident #4 was coded as having 3 stage 2 pressure ulcers, with 3 present at admission. The tissue type listed for " ulcer at most advanced stage " was " granulation tissue-pink or red tissue with shiny, moist, granular appearance. No additional wounds were coded. Observation on 10/23/2013 at 4:15 PM revealed LVN B in Resident #4 ' s room to perform wound care on Resident #4 with the CSC RN present at bedside. Resident #4 was lying on her back, on a regular foam mattress. A blue pillow style boot was noted to Resident #4's left foot. LVN B removed a duoderm dressing (A [MEDICATION NAME] dressing that is biodegradable, non-breathable and adheres to the skin) from Resident #4 ' s sacral area to reveal a Stage III (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.) pressure sore to Resident #4 ' s right sacral area approximately 3 cm (centimeters) in length by 1 cm width with a depth of >0.2 cm. The right sacral Stage III pressure sore was covered by approximately 20% yellow slough. There was a Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough) to Resident #4 ' s lateral right sacral area approximately 1 cm by 0.5 cm with a pink wound bed. On Resident #4 ' s right lower lateral right buttock was a Stage III pressure sore approximately 3 cm x 0.5 cm x >0.2 cm, the wound bed was 50% covered in yellow slough. Resident #4 ' s had a Stage III pressure sore to her mid sacral area approximately 6.5 cm x 2.5 cm with >0.2 cm depth 60 % of the wound was covered in yellow slough. There was approximately a 10 cm x 8cm area of macerated silver/ white colored tissue surrounding all the wounds. LVN B, without cleaning Resident #4 ' s pressure sores to sacral and right buttock areas, and without applying new gloves applied a thin duoderm over the pressure sores. LVN B then went to the treatment cart to get supplies to do wound care on Resident #4 ' s left heel Stage IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling.) LVN B removed Resident #4 ' s pillow style boot from left foot. There was a prevalent foul odor coming from Resident #4 ' s left foot. The inside of the pillow style boot was noted to have serosanguineous stains where Resident #4 ' s heel was. LVN B then removed the dressing from Resident #4 left heel. Serosanguineous drainage was noted to dressing. Resident #4's left heel pressure sore was approximately 2 cm by 2.5 cm with an undetermined depth, the area was 95% covered in a yellow to brown colored slough. LVN B washed her hands and changed gloves. LVN B then used a needle-less syringe and squirted the open portion of resident left heel. Resident #4 flinched her whole body away from LVN B and stated " Leave me alone f***ers. " The Surveyor asked Resident #4 if she hurt and Resident #4 responded " Yeah, that hurts! " LVN B then took a stack of two (2) by two (2) gauze and patted the area three times with the same gauze. LVN B then placed [MEDICATION NAME] Ag (silver impregnated antimicrobial dressing) to open area of Resident #4's left heel, LVN B then placed a bordered dressing over heel. (approximations by surveyor as LVN B did not measure the wound during care.) LVN B stated that Resident #4 does not have orders for pain medication. She stated that there are no standing orders for pain medication as the Medical Director says absolutely not. Review of Resident #4 ' s Telephone Orders dated 10/01/13 reflected the following orders: Duoderm to sacral/coccyx area change every 3 days and prn soilage. Clarification: cleanse left heel, normal saline, apply [MEDICATION NAME] Ag dressing every day until healed. Review of Resident #4 ' s Physician Communication Form dated 10/06/13 reflected a concern/assessment: Left heel clean with normal saline apply [MEDICATION NAME] AG QD ([MEDICATION NAME] silver every day - a wound treatment) area not progressing. Requesting Santyl QD (every day) (Santyl is an active enzymatic therapy that continuously removes necrotic tissue from wounds at the microscopic level.) Cleans with normal saline, apply santyl cover with 2x2 cover with Allevyn Matrix every day. Signed by Licensed Vocational Nurse (LVN) B. Further down the page is written " Will eval, " with an initial. (No information regarding sacral pressure ulcers was noted on this communication.) Review of Resident #4 ' s Telephone Orders dated 10/07/13 reflected an order to culture wound left heel, signed by the Nurse Practitioner (NP) for Resident #4. Review of Resident #4 ' s Telephone Orders dated 10/11/13 reflected the following order: Apply santyl topical to left heel QOD (every other day) times 10 days, alternating with [MEDICATION NAME] AG. In an interview on 10/23/2013 at 4:45 PM CNA G stated that Resident #4 ' s sacral area had been getting worse for the past month. CNA G further stated she has told the nurses the area was getting worse. CNA G stated the only thing she was told to do for Resident #4's left heel to to keep the boot on it. CNA G stated that there was not a regular schedule for changing the boot or washing it. She stated " I guess we could send them to laundry. " In an interview on 10/23/2013 at 5:50 PM the CSC RN stated LVN B would not be doing treatments anymore. The CSC RN further stated she felt LVN B was disorganized. The CSC RN further stated if there is a change to a wound the physician needs to be called. The CSC RN stated that the current treatment for [REDACTED]. The CSC RN returned at 6:20 PM and stated that there are no measurements for Resident #4's sacral wounds and that this is a deficit. Review of Resident #4 ' s readmission assessment, dated 08/07/13, reflected: Section 13: Integumentary/feet: 1. Skin/wound condition present? Yes. 1a. Is there pain associated with the wound/skin condition? Yes. An anatomical figure had the following markings to indicate the following: a circled " 2 " across the buttocks. The key on the side of the form indicated " 2 " represents " Stage II. " The left heel was circled and written beside it " debrided 8-01-13 4cm x 4.2cm. Drawings of feet inside and outside did not reflect any markings to indicate wounds, no staging, wound depth or wound bed description information was included. 4. Feet status: nothing was checked Section 14: Pain: Had pain of hurting? Yes. Signed as completed by RN U Review of the readmission assessment " Norton Plus Pressure Ulcer Scale " dated 08/07/13 reflected the following: Risk Factor: Physical condition: 3 - fair Mental state: 2 - confused Activity: 2 - chair bound Mobility: 2 - very limited Incontinence: 1 - double incontinence Total Norton Scale: 10 Total Norton Plus Score (score 10 or less = high risk): 7 Signed as completed by RN U Review of Resident #4 ' s Readmission " Pain Assessment, " dated 08/08/13 reflected: Diagnosis: [REDACTED]. 2. Pain Assessment in Advanced Dementia Scare (PAINAD) Breathing independent of vocalization: 0 - normal Negative vocalization: 1 - Occasional moan or groan. Low level speech with a negative or disapproving quality. Facial expression: 1 - Sad. Frightened. Frown. Body language: 1 - Tense. Distressed pacing. Fidgeting. Consolability: 1 - Distracted or reassured by voice or touch. Total: 4 Score of 4 or higher indicates intervention may be needed. 3. History of pain and what relieves it: (include known cause and/or need for palliative care) Debridement of left heel on 08/06/13 per wound care MD at hospital. 4. Physical assessment by nurse if any of the below observations are identified: Tenderness is checked Anatomical illustration has a line pointing to the left heel " surgical debridement 4cm x 4.2 cm. 6. How does the pain affect: e. Ability to concentrate: Easily agitated, unable to determine if due to pain f. Enjoyment of life? Anxious, may be due to psych dx (diagnoses): [MEDICAL CONDITIONS] disorder Summary: Unable to make all needs known, may verbalize pain occasionally, example " it hurts " at other times cries out or screams when touched. Some screams may not indicate pain. Has dx: [MEDICAL CONDITIONS] disorder. Wound care nurse reported resident tolerated treatment well today. Signed as completed by RN U Review of Resident #4 ' s admission orders [REDACTED] [MEDICATION NAME] 1 mg, po bid [MEDICATION NAME] ER 300 mg, po bid [MEDICATION NAME] 1mg tab, give 4 qhs [MEDICATION NAME] Chloride 5 mg, po bid [MEDICATION NAME] 125 mcg, po qd [MEDICATION NAME] 50 mcg, po qd [MEDICATION NAME] 17g in H2O bid Bactirm DS 1 tab, po bid times 10 days Tylenol 325 mg two tabs, po q 4hours prn [MEDICATION NAME] 1 mg, po q 6 hours prn Bisac-evac 10 mg suppository, qd prn Cleanse left heel with normal saline, pat dry, apply [MEDICATION NAME] Ag dressing qd x 1 week. Other: Follow up with wound care doctor within one week Review of Resident #4 ' s Telephone Orders dated 08/07/13 reflected readmit to facility, Bactrim DS one tab po bid for 10 days. Physical Therapy, Occupational Therapy and Speech Therapy evaluate and treatment as indicated. Follow up with wound care doctor within one week. Review of Resident #4 ' s Telephone Orders dated 08/15/13 reflected an order for [REDACTED]. Review of Resident #4 ' s Telephone Orders dated 08/27/13, signed by Physician (DR) AA reflected the following orders: 1) Multivitamin with minerals 2) Vitamin A 8,000 IU 1 tab bid x 14 days 3) Stress tab with zinc 1 tab x 14 days 4) Argimaid 1 packet with 4-6 ounces water bid x 14 days 5) Add large meat portions to all meals x 60 days. Review of Resident #4 ' s 30 day MDS dated [DATE], reflected Resident #4 to have both short term and long term memory problems per staff assessment. Resident #4 was coded as requiring extensive assistance of one person for bed mobility and extensive two person assistance with transfers. Resident #4 was coded as always incontinent for both bowel and bladder. In the skin condition section Resident #4 was coded as having 3 stage 2 pressure ulcers, with 3 present at admission. The tissue type listed for " ulcer at most advanced stage " was " granulation tissue-pink or red tissue with shiny, moist, granular appearance. No additional wounds were coded. Review of Resident #4 ' s most current " Pain Assessment, " dated 09/05/13 reflected: 1. Pain intensity in the past 5 days (circle score) " 2 " is circled. 2. Pain Assessment in Advanced Dementia Scare (PAINAD) Breathing independent of vocalization: 2 - Noisy labored breathing. Short periods of hyperventilation. Negative vocalization: no score written Facial expression: 2 - Facial grimacing Body language: 1 - Tense. Distressed pacing. Fidgeting. Consolability: 1 - Distracted or reassured by voice or touch. Total: 6 3. History of pain and what relieves it: Administration of [MEDICATION NAME] and change in position with placement of supportive equipment. 4. Physical assessment by nurse if any of the below observations are identified: Aching and Tenderness are checked Anatomical illustration has no markings to indicate physical examination of painful areas. 6. How does the pain affect: a. Sleep: Mild to moderately c. Mobility: mild to moderately restricted d. General activity: reduced e. Ability to concentrate: not known f: Enjoyment of life: not known Summary: Resident respond fairly well to treatment plan. Completed by: No signature on this line. Review of Resident #4 ' s Comprehensive Care Plan, dated as being reviewed and updated on 10/15/13 to continue plan of care, reflected: Problem/need of: Potential for and real pressure ulcers, problem onset 08/07/13. Positive culture report for area left heel, 10/14/13. Goal and target date reflected: 10/14/13 Skin on left heel will heal by 1 cm by next review date in 92 days. 10/14/12 No new pressure developments x 92 days. Approaches listed: - Provide ulcer cares per orders. Monitor for changes in wounds. Report changes to MD. - Provide diet as ordered - Bed and chair pressure relief devices in place - Provide turning and repositioning while in bed, and chair - Encourage resident to make frequent changes in bed and chair - Keep feet elevated when in bed - Protective boots at all times - 10/14/13 ABT (2) per orders, update MD / Family with any sign of changes - 10/14/13 Review treatment and assess left heel weekly Problem/need of: Has chronic pain, potential for breakthrough pain, problem onset 08/07/13. Goal and target date reflected: Pain will remain at Resident ' s level of comfort daily, 11/15/13. Approaches listed: - Medications as ordered - Monitor for nonverbal and verbal indicators of pain - Provide positioning to prevent pain This plan of care did not reflect any information regarding sacral/coccyx wounds, pain assessment with wound care, or any information regarding wound care consults. Review of Resident #4 ' s Wound Assessment Report dated 8/8/13 reflected the wound type and location to be a pressure ulcer of the left heel. Date the wound was identified was listed as 8/8/13. Stage: unstageable due to suspected deep tissue injury. Measurements: Length 4.00 cm, Width 4.20 cm, depth (blank). Pain with wound treatment: no. No information was entered in the sections what described the wound bed or wound edges. Treatments: Pending treatment orders. Review of Resident #4 ' s Weekly Pressure Sore Progress Report dated 10/7/13 contained no information. All boxes were blank on the form pertaining to wounds. Review of Resident #4 ' s Daily/Weekly/Monthly body Audit and Hydration Report dated October 2013 reflected an anatomical illustration with a circle over the buttocks. Comment dated 10/15/13 by LVN B: Area red no drainage noted, continue with treatment as directed. Comment dated 10/14/13 by LVN B (which is under the 10/15/13 comment on the form) 3.0 left heel 4.0 discolered tissue surrounding area. Painful to patient, expresses. Review of Resident #4 ' s Daily/Weekly/Monthly body Audit and Hydration Report dated October 2013 reflected an anatomical illustration with a circle over the buttocks. Comment dated 10/22/13 by LVN B: 3.5 x 1.5 left lat, 1.5 x 0.5 left med. Stage 3 to buttocks, no drainage or odor. Current treatment duoderm, requesting new treatment to nurse practitioner today. Review of lab results dated 10/11/13 at 12:27 PM reflected " prelim wound lt heel " results Escerichia coli: many (Escerichia coli or E. Coli is a bacterium that is commonly found in the lower intestine of warm-blooded organisms) Proteus mirabills: many , (Proteus mirabills, Proteus species are part of the [MEDICATION NAME] family of gram-negative bacilli. Proteus organisms are implicated as serious causes of infections in humans.) Gram positive cocci: many. Review of Resident #4 ' s Telephone Orders dated 10/14/13 reflected an order for [REDACTED]. Diagnosis, wound infection. Signed by the NP. Review of Resident #4 ' s Physician Communication Form dated 10/16/13 reflected a concern/assessment: patient with area to left heel - not progressing, surrounding area red, very painful to the touch, patient does not handle treatment well. Crep - no pain med noted can she have pain meds. (admission orders [REDACTED]. Telephone Orders dated 08/15/13 reflected an order for [REDACTED]. Signed by LVN B. In the physician ' s section reflected the following notes: Wound was cultured and now she is on ABT (antibiotic therapy). Review of Resident # 4 ' s Wound Care Record, dated August 2013, reflected the following: Cleanse left heel with normal saline, pat dry, apply [MEDICATION NAME] Ag dressing QD times one week, start date 08/07/13. This treatment is signed as given from 08/08/13-08/31/13, an additional 10 days past the ordered end date. Duoderm to buttocks q 3 days - PRN, written on 08/16/13 is " one week. " " Drs appt " is then written with an arrow pointing to 08/22/13. The treatment is then signed as given for an additional 6 times from 08/24/13-08/31/13. In an interview on 10/23/13 at 3:45 PM the Office Manager for the Wound Care Specialist stated that Resident #4 was scheduled with the wound care clinic for an appointment on 08/22/13 however clinic notes state that Resident #4 never showed up for the appointment. She stated that Resident #4 has not been seen by anyone in the wound care clinic and has not made another appointment since the 08/22/13 date. Review of Resident #4 ' s current clinical record, over flow clinical record and " all medical records files for Resident #4 " reflected that physician's order [REDACTED]. Review of Resident # 4 ' s Wound Care Record, dated September 2013, reflected the following: Cleanse left heel with normal saline, pat dry, apply [MEDICATION NAME] Ag dressing QD times one week, start date 08/07/13. This treatment is signed as given from 09/01/13-09/30/13, an additional 30 days past the ordered end date during the month of September. Duoderm to sacrum q 3 days & PRN, no start date or order date is written. The treatment is then signed as given on 9/3, 9/4, 9/6, 9/9, 9/12, 9/15, 9/18, 9/21, 9/24, 9/27, 9/30. Review of Resident #4 ' s current clinical record, over flow clinical record and " all medical records files for Resident #4 " reflected that physician's order [REDACTED]. Review of Resident # 4 ' s Wound Care Record, dated October 2013, reflected the following: Cleanse left heel with normal saline, pat dry, apply [MEDICATION NAME] Ag dressing QD times one week, start date 08/07/13. A line was drawn through " times one week " and " until healed " was added. This treatment is signed as given from 10/01/13-10/9/13, (New physician's order [REDACTED]. 10/11/13 Apply Santyl top to left heel QOD x 10 days alternating with [MEDICATION NAME] silver. This treatment was signed as given on 10/11, 10/13, 10/15, 10/17, 10/19, 10/21 Cleanse sacral/coccyx wound with normal saline, pat dry, apply Duoderm q 3 days & PRN soilage with the start date 10/01/13. Review of the MAR indicated [REDACTED]. The scheduled [MEDICATION NAME] 400mg was signed as administered every 6 hours at 2 AM, 8 AM, 2 PM and 8 PM for pain. Review of Nurse's Notes dated reflected: 08/07/13 12:55 admitting and continuing [DIAGNOSES REDACTED]. Has duoderm to coccyx; area pink without drainage. 08/07/13 16:40 Transfer from Hospital via ems ... note readmit nursing assessment. No additional wound information is noted. 08/08/13 - 08/26/13 no information noted regarding wound care or pressure ulcers. 08/27/13 at 09:51 new orders received 1) Multivitamin with minerals2) Vitamin A 8,000 IU 1 tab bid x 14 days 3) Stress tab with zinc 1 tab x 14 days 4) Argimaid 1 packet with 4-6 ounces water bid x 14 days 5) Add large meat portions to all meals x 60 days. Dietary notified of dietary changes. New orders noted on MARs ... 08/27/13- 09/27/13 no information noted regarding wound care or pressure ulcers. 09/28/13 " 6-2 " Pt in bed supine position, able to voice concerns will continue to monitor. Left foot complaint of pain during treatment. Requires 2-3 person for transfer and ADL ' s (activities of daily living). Requires numerous prompts for food intake. Signed LVN B 09/29/13 - 10/07/13 no information noted regarding wound care or pressure ulcers. 10/08/13 at 11:30 AM Collected left heel wound culture obtained this AM & ready for pick up. Signed LVN C 10/13/13 " 2-6 " ...heel offload due to redness of left heel. Pt upset while changing bandage - cursing calling names. Area cleaned, [MEDICATION NAME] and bandage reapplied. Able to voice concerns at times. Cognitive process somewhat jumbled at times. Required total assist with ADLs ... Signed LVN B. 10/15/13 " 2-10 " Continue ABT for left heel wound. No swelling or complaint of pain at this time. 10/16/13 " 2-10 " Continue ABT for wound ... no swelling or complaint of pain unless tx (treatment) wound. Unable to make needs known due to confusion. In an interview on 10/23/13 at 9:58 AM the NP for resident #4 stated that she had seen Resident #4 on 10/07/13 and written an order for [REDACTED]. She stated that the date of the order for the antibiotics is the date that she received the lab results, 10/14/13. The NP stated that she would have liked to have received the lab results the same day they were returned to the facility, especially if they indicated a positive result and would have indicated the need for antibiotic treatment as an order would need to be written. She stated that she had not seen Resident #4 ' s sacral ulcers recently and had not received any communication regarding the sacral ulcers. She stated that she had not written any new orders for sacral ulcers. In an interview on 10/23/13 at 12:16 PM a RN with the Medical Director ' s office, also Resident #4 ' s Primary Care Physician stated that the Medical Director " absolutely does not know anything regarding this Resident. He has not seen this patient. The Medical Director will be at the facility this afternoon to assess the patient. " She then stated that the Medical Director had just acquired this facility approximately one month ago. In an interview on 10/23/2013 at 5:30 PM Resident #4's Physician stated he was not informed about Resident #4 ' s pressure sores to sacral area. Resident #4 ' s Physician stated he had just seen her left heel but has not seen her sacral pressure sores. Resident #4 ' s Physician stated that if the pressure sores were macerated that was not good. Resident #4 ' s Physician further stated that if there was slough in the wounds then it needed to be debrided. Resident #4 ' s Physician stated that after seeing the boot that was on Resident #4 he told the facility that it was not the right kind of boot. Resident #4 ' s Physician stated if the boot was not washed after soiling it could contribute to an infection in Resident #4 ' s pressure sore. Resident #4 ' s Physician stated he expected the nurses to notify him if any wound has a foul odor so antibiotics could be initiated. Resident #4 ' s Physician also expected Resident #4 to be on an air mattress. Observation on 10/23/2013 at 6:15 PM the CSC RN and LVN B were turning Resident #4 on left side so Resident #4's Physician could examine Resident #4 ' s sacral pressure sores. Resident #4 started to cry and was calling out incoherently. In an interview on 10/23/2013 at 6:25 PM Resident #4's Physician stated Resident #4 was definitely in pain and he would be ordering more pain medication for Resident #4. In an interview on 10/24/2013 at 10:25 AM LVN C stated Resident #4's sacral area was just excoriated when she saw it last. LVN C stated it has gotten worse. LVN C stated she has been off for a week and LVN B was filling in for her. LVN C further stated Resident #4 should have been on an air mattress and was not sure why she was not. In an interview on 10/24/13 at 11:15 AM the MDS Coordinator stated that she found additional care plans in her office. She presented surveyors with 4 care plans pages: Care Plan A, Antibiotics, Skin, and Pressure Area. When asked how staff were to follow these plans of care if they were not in Resident #4 ' s chart the MDS Coordinator did not answer. Review of Resident #4 ' s Care Plan A reflected 1. Mobility/Ambulation: wheel chair via staff, 10/14/13 float heels when in bed (this was intervention was lined through), 10/22/13 pravolon boots at all times except when bathing every shift. Review of Resident #4 ' s Comprehensive Plan of Care (three pages) Problem/need: Resident is on Antibiotic(s) and is at risk for adverse reactions. Med: ABT as ordered. Other: left heel. Dated 10/14/13 Approach: -Give meds per order - monitor labs, cultures, reports abnormals to MD -Monitor resident for adverse reactions specific to the medication -Follow universal /standard precaution to prevent cross contamination and spread infection -Encourage fluids and P.O. -Serve Diet as ordered -Low Air Loss mattress - Prevlon boots at all times except bathing and skin sheets -treatment per MD order -Wound Care Consult -PT/OT to eval and treat Problem/need: Resident has current skin condition. Other: left heel. Dated 08/07/13. Approach: -Perform treatments per order, if no improvement x2 weeks - report to MD -Monitor areas for increase in breakdown, signs and symptoms of infection - report to MD -Monitor for pain, give med per order, monitor for relief -Encourage P.O. and fluid intake within dietary limits -Keep MD and RP informed of resident ' s progress -Assess skin weekly and records findings in clinical record -Vitamin supplement -Prevalon boots - 10/22/13 -Low Air Loss mattress - 10/23/13 -Culture left heel - 10/13 Problem/need: Resident has a pressure Area: blank, Stage: blank, Location: Sacral/Coccyx community acquired. Dated 08/17/13. Approach: -Perform treatments per order, if no improvement x2 weeks - report to MD -Encourage P.O. and fluid intake within

Based observation, interview and record review the facility failed to ensure that one (1) of 13 residents, (Resident #5) reviewed for accidents received adequate supervision and assistive devices to prevent accidents. Resident #5 was ambulating in front of the nurses' station and tripped on a staff members crutches causing Resident #5 to fall. The fall resulted in a fractured right femur. This deficient practice affected one (1) resident and had the potential to affect 13 residents at risk for falls by placing them at risk of injury and/or decline in functional abilities. Findings include: Review of Resident #5's Facesheet reflected an [AGE] year old female admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #5's Quarterly MDS dated [DATE] reflected the resident was independently ambulatory with set-up. Review of Resident #5's Quarterly MDS dated [DATE] reflected the resident required extensive assistance from one person for ambulation. Review of Resident #5's Care Plan for Falls last reviewed 05/26/2013 reflected falls occurred on 05/14/2013, 05/15/2013 and 05/17/2013. Further review reflected "5/14 therapy staff to monitor when walking in therapy room and neuro checks, 5/15 encourage res to remain by t.v. area and watch for unsteadiness, 5/17 send to ER for eval." Review also reflected "Assist with mobility as needed if observed unsteady or with increased confusion/frustration." Review of Resident #5's Fall Risk assessment dated [DATE] through 05/14/2013 reflected the resident ' s fall risk score increased from 15 to 17 between 02/26/2013 and 05/14/2013 due to an increase in the number of falls in three months. No Fall Risk Assessment was completed between 02/26/2013 and 05/14/2013. Observation of Resident #5 on 10/23/2013 at 12:30 PM revealed the resident sitting in her wheelchair in the dining room being assisted with eating lunch. Review of Resident #5's Nurses Notes dated 05/17/2013 at 2:00 PM reflected "This nurse was redirecting res. to room when res ambulated ahead of nurse and tripped on an employee ' s crutch and fell forward landing on right side. Res voiced complaint of pain to right hip. Unable to assess ROM due to inability to move res. Obtained vs (vital signs): BP (blood pressure) 117/86, P (pulse) 72, R (respirations) 20, T (temperature) 97.6. Notified 911 EMS or transfer to hospital for eval/tx: fall. Res transferred to hospital via stretcher with 911. Notified RP of incident. MD Dr. McCullough notified." Note was signed by LVN D. Review of Resident #5's Incident Report dated 05/17/2013 reflected Resident #5's fall was witnessed by LVN J and the Van Driver. Resident #5 was lying on her right side and unable to move. Resident #5 was assessed, voiced pain to the right hip and was sent out to the hospital. Review of Resident #5's Incident Investigation dated 05/17/2013 reflected the resident was wearing appropriate footwear and the floor was dry. Further review reflected LVN J was redirecting Resident #5 to the resident ' s room when the resident ripped over the Van Driver ' s crutch and fell on the right side. Resident #5 was sent to the hospital for evaluation and treatment for [REDACTED]. In an interview on 10/24/2013 at 3:30 PM the Van Driver stated she was working at the facility on crutches related to an on-the-job injury. The Van Driver stated she was walking with crutches from the front by the nurses' station to the break room for lunch. The Van Driver stated Resident #5 walked unsteadily towards her and bumped against the crutch. The Van Driver stated Resident #5 fell after bumping into the crutch. The Van Driver stated Resident #5 was assessed by LVN D and sent to the hospital. The Van Driver stated the previous Administrator had told her to come to work regardless of needing to use the crutches to walk. In a telephone interview on 10/24/2013 at 3:50 PM LVN D stated she was walking with Resident #5 from the dining room back to the resident's room. LVN D stated the Van Driver was assisting with bringing supplies in. LVN D stated Resident #5 was just ahead of her when she tripped over the Van Driver's crutch and fell . LVN D stated she assessed Resident #5 and determined the resident needed to go to the hospital. Review of Resident #5's x-ray report dated 05/17/2013 reflected "AP view pelvis demonstrates an intertrochanteric fracture in the proximal right femur." Review of Resident #5's Hospital History and Physical dated 05/17/2013 reflected "sent from nursing home after sustaining a fall while she tripped into the walker of another resident at nursing home. The patient sustained a right intertrochanteric femur fracture." Review of Resident #5 ' s Hospital Radiology Report , dated 05/17/2013, reflected that the Anterior/Posterior view of the pelvis demonstrated an intertrochanteric fracture in the proximal right femur. The lesser trochanter had been avulsed (forcibly detached from its normal point of insertion). Review of Resident #5 ' s Hospital History and Physical report, dated 5/18/2013, reflected, " at this point, we are going to go ahead and proceed to the operation room today for a trochanteric femoral nail to the right proximal femur. Telephone consent was obtained from her nephew who is next of kin ...then she will be stabilized for a couple of days and then taken back to the nursing facility. " Review of Resident #5 ' s Hospital Operative Report, dated 5/18/2013, reflected: Preoperative Diagnosis: [REDACTED]. Procedure: right trochanteric femoral nail Implant: Synthes short trochanteric femoral nail with a 95 lag screw and a 48 distal locking screw. Operative indication: unstable right hip. In an interview on 10/24/2013 at 4:00 PM the Administrator stated she would not allow an employee using crutches to work around residents. The Administrator stated she would have the injured employee work in an office or stay home if they needed to use crutches. Review of the facility's Accidents and Incidents Policy dated 07/10 reflected: 1. Accident: any unexpected or unintentional incident o chain of events, which may or may not result in injury or illness to a resident. 2. Unusual Occurrence or Event: any event not consistent with routine resident care or an event involving a resident with unintended, undesirable or unexpected results or outcomes. The Administrator stated 13 residents were at high risk for falls.

Based on observation, interview, and record review the facility failed to provide services that meet professional standards of quality for: A) One (1) of two (2) LVNs reviewed for wound care, when LVN B provided improper wound care to Resident #4's sacral and left heel pressure sores. B) One (1) of three (3) LVN's reviewed for assessments when LVN E failed to thoroughly assess Resident #9 on admission, and failed to carry out physician orders [REDACTED]. This deficient practice affected two(2) residents and placed 22 residents at risk for developing new or worsening pressure sores, [MEDICAL CONDITION] (skin infection), Osteomylitis (infection of the bone),[MEDICAL CONDITION] (infection of the blood), severe pain and death. Finding Include: Texas Administrative Code, Title 22, Part 11, Chapter 217, Rule 217.11 Standards of Nursing Practice (1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: (A) Know and conform to the Texas Nursing Practice Act and the board's rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse's current area of nursing practice; (D) Accurately and completely report and document: (i) the client's status including signs and symptoms; (ii) nursing care rendered; (iii) physician, dentist or podiatrist orders; (iv) administration of medications and treatments; (v) client response(s); and (vi) contacts with other health care team members concerning significant events regarding client's status; (G) Obtain instruction and supervision as necessary when implementing nursing procedures or practices; (M) Institute appropriate nursing interventions that might be required to stabilize a client's condition and/or prevent complications; (O) Implement measures to prevent exposure to infectious pathogens and communicable conditions; (P) Collaborate with the client, members of the health care team and, when appropriate, the client's significant other(s) in the interest of the client's health care; (Q) Consult with, utilize, and make referrals to appropriate community agencies and health care resources to provide continuity of care; (U) Supervise nursing care provided by others for whom the nurse is professionally responsible; (2) Standards Specific to Vocational Nurses. The licensed vocational nurse practice is a directed scope of nursing practice under the supervision of a registered nurse, advanced practice registered nurse, physician's assistant, physician, podiatrist, or dentist. Supervision is the process of directing, guiding, and influencing the outcome of an individual's performance of an activity. The licensed vocational nurse shall assist in the determination of predictable healthcare needs of clients within healthcare settings and: (A) Shall utilize a systematic approach to provide individualized, goal-directed nursing care by: (i) collecting data and performing focused nursing assessments; (ii) participating in the planning of nursing care needs for clients; (iii) participating in the development and modification of the comprehensive nursing care plan for assigned clients; (iv) implementing appropriate aspects of care within the LVN's scope of practice; and (v) assisting in the evaluation of the client's responses to nursing interventions and the identification of client needs; (B) Shall assign specific tasks, activities and functions to unlicensed personnel commensurate with the educational preparation, experience, knowledge, and physical and emotional ability of the person to whom the assignments are made and shall maintain appropriate supervision of unlicensed personnel. (C) May perform other acts that require education and training as prescribed by board rules and policies, commensurate with the licensed vocational nurse's experience, continuing education, and demonstrated licensed vocational nurse competencies. (3) Standards Specific to Registered Nurses. The registered nurse shall assist in the determination of healthcare needs of clients and shall: (A) Utilize a systematic approach to provide individualized, goal-directed, nursing care by: (i) performing comprehensive nursing assessments regarding the health status of the client; (ii) making nursing [DIAGNOSES REDACTED]. (iii) developing a plan of care based on the assessment and nursing diagnosis; (iv) implementing nursing care; and (v) evaluating the client's responses to nursing interventions; (B) Delegate tasks to unlicensed personnel in compliance with Chapter 224 of this title, relating to clients with acute conditions or in acute are environments, and Chapter 225 of this title, relating to independent living environments for clients with stable and predictable conditions. A.) Review of Resident #4 ' s face sheet reflected a [AGE] year old woman admitted to the facility on [DATE] and then readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #4 ' s discharge summary from the hospital to the facility, dated 08/07/13 reflected Resident #4 ' s admitting [DIAGNOSES REDACTED]. Hospital course: The patient was admitted with the above said [DIAGNOSES REDACTED]. Her blood cultures have remained negative and her wound culture from the left heel decubiti and sacrum was growing proteus mirabilis and staphylococcus aureus. Observation on 10/23/2013 at 4:15 PM revealed LVN B in Resident #4 ' s room to preform wound care on Resident #4. Resident #4 was lying on her back, on a regular foam mattress. A blue pillow style boot was noted to Resident #4 ' s left foot. LVN B removed a duoderm dressing (A [MEDICATION NAME] dressing that is biodegradable, non-breathable and adheres to the skin) from Resident #4 ' s sacral area to reveal a Stage III (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.) pressure sore to Resident #4 ' s right sacral area approximately 3 cm in length by 1 cm width with a depth of >0.2 cm. The right sacral Stage III pressure sore was covered by approximately 20% yellow slough. There was a Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough) to Resident #4 ' s lateral right sacral area approximately 1 cm by 0.5 cm with a pink wound bed. On Resident #4 ' s right lower lateral right buttock was a Stage III pressure sore approximately 3 cm x 0.5 cm x >0.2 cm, the wound bed was 50% covered in yellow slough. Resident #4 ' s had a Stage III pressure sore to her mid sacral area approximately 6.5 cm x 2.5 cm with >0.2 cm depth 60 % of the wound was covered in yellow slough. There was approximately a 10 cm x 8cm area of macerated silver/ white colored tissue surrounding all the wounds. LVN B, without cleaning Resident #4 ' s pressure sores to sacral and right buttock areas, and without applying new gloves applied a thin duoderm over the pressure sores. LVN B then went to the treatment cart to get supplies to do wound care on Resident #4 ' s left heel Stage IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling.) LVN B removed Resident #4 ' s pillow style boot from left foot. There was a prevalent foul odor coming from Resident #4 ' s left foot. The inside of the pillow style boot was noted to have serosanguineous stains where Resident #4 ' s heel was. LVN B then removed the dressing from Resident #4 left heel. Serosanguineous drainage was noted to dressing. Resident #4's left heel pressure sore was approximately 2 cm by 2.5 cm with an undetermined depth, the area was 95% covered in a yellow to brown colored slough. LVN B washed her hands and changed gloves. LVN B then used a needless syringe and squirted the open portion of resident left heel. LVN B then took a stack of two (2) by two (2) gauze and patted the area three times with the same gauze. LVN B then placed [MEDICATION NAME] Ag (silver impregnated antimicrobial dressing) to open area of Resident #4's left heel, LVN B then placed a bordered dressing over heel. (approximations by surveyor) In an interview on 10/23/2013 at 4:30 PM LVN B stated the Resident #4's sacral pressure sores should have been cleaned prior to applying the dressing. Review of Resident #4 ' s Telephone Orders dated 10/01/13 reflected the following orders: Duoderm to sacral/coccyx area change every 3 days and prn soilage. Clarification: cleanse left heel, normal saline, apply [MEDICATION NAME] Ag dressing every day until healed. Review of Resident #4 ' s Physician Communication Form dated 10/06/13 reflected a concern/assessment: Left heel clean with normal saline apply [MEDICATION NAME] AG QD ([MEDICATION NAME] silver every day - a wound treatment) area not progressing. Requesting Santyl QD (every day) (Santyl is an active enzymatic therapy that continuously removes necrotic tissue from wounds at the microscopic level.) Cleans with normal saline, apply santyl cover with 2x2 cover with Allevyn Matrix every day. Signed by Licensed Vocational Nurse (LVN) B. Further down the page is written " Will eval, " with an initial. (No information regarding sacral pressure ulcers was noted on this communication.) Review of Resident #4 ' s Telephone Orders dated 10/07/13 reflected an order to culture wound left heel, signed by the NP for Resident #4. Review of Resident #4 ' s Telephone Orders dated 10/11/13 reflected the following order: Apply santyl topical to left heel QOD times 10 days, alternating with [MEDICATION NAME] AG. In an interview on 10/23/2013 at 5:50 PM the CSC RN stated LVN B would not be doing treatments anymore. The CSC RN further stated she felt LVN B was disorganized. The CSC RN further stated if there is a change to a wound the physician needed to be called. The CSC RN stated that the current treatment for [REDACTED]. In an interview on 10/24/2013 at 10:25 AM LVN C stated Resident #4's sacral area was just excoriated when she saw it last. LVN C stated it has gotten worse. LVN C stated she has been off for a week and LVN B was filling in for her. LVN C further stated Resident #4 should have been on an air mattress and was not sure why she was not. B.) Review of Resident #9's Face Sheet reflected an [AGE] year old male admitted to the facility on [DATE] with the following Diagnosis: [REDACTED]. Review of Resident #9's Initial Nursing Summary assessment dated [DATE], not timed, signed by LVN E reflected Resident #9 was severely cognitively impaired and was able to make self-understood. Resident #9's assessment further reflected Resident #9 had a Foley Catheter. The section for bowel incontinence was blank. Under the skin condition section of Resident #9's assessment reflected "Bil heel Stage 2 decbs (decubitus)". No other assessment information was noted. The rest of the skin condition section of the assessment was blank. Under the nursing intervention/initial care plan section for skin condition on the assessment was also left blank. The pain, nutritional, and medication sections of the assessment were blank. Review of Resident #9's Nurses Notes dated 10/21/2013 at 4:15 PM "Pt. (Patient) arrived via EMS ... Pt. has bilateral Stage II decubs (decubitus) on heels." Nurses note was signed by LVN E. In an interview on 10/23/2013 at 2:00 PM LVN E stated she did not complete Resident #9's admission assessment on 10/21/2013. LVN E gave no explanation as to why she did not complete Resident #9's admission assessment or address Resident #9's heels. LVN E further stated she remembered seeing the order to float Resident #9's heels. LVN E stated she did not know she had to transcribe the order to float Resident #9's heels. LVN E further stated that Resident #9's heels were not open when he was admitted . Review of Resident #9's admission orders [REDACTED]. Observation on 10/22/2013 at 9:30 AM on initial tour revealed Resident #9 in bed on back. Head of bed elevated 30 degrees. Resident #9's bilateral feet were sticking out of the sheet. Blood was noted on sheet under Resident #9's right heel and multiple areas at the foot of the bed. Resident #9 was on a regular foam mattress. Resident #9's heels were on the mattress, not floated, no dressings were noted. Review of Resident #9's TAR for October 2013 on 10/23/2013 at 9:00 AM reflected no TAR for Resident #9. Review of Resident #9's Discharge orders to the facility from the hospital dated 10/21/2013, no time, reflected "Wound care Preventative, weekly skin assessment, use body diagram to document, Wound care Bilateral heels, deep tissue: Keep offloaded at all times. Apply barrier ointment." In an interview on 10/23/2013 at 9:05 AM LVN C stated there was no TAR for Resident #9. LVN C further stated there were no treatments for Resident #9 that she knew of. In an interview on 10/23/2013 at 10:15 AM the NP stated that Resident #9's heels were dry and flaky when she saw them on 10/21/2013. The NP stated she had not been contacted by the facility or notified of changes in Resident #9's heels since Resident #9 was admitted . Observation on 10/23/2013 at 11:30 AM revealed Resident #9 in bed on back. Resident #9 was on a regular foam mattress. Resident #9's heels were on pillows. Resident #9's heels were not floated. Resident #9 had no dressing to right or left heel. Blood was noted on the pillow cases. Resident #9's Stage III (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.) pressure sore to right heel was approximately 5 centimeters (cm) X 6 cm with a 1 cm area of DTI surrounding the wound bed. The center of the wound had beefy red granulation tissue with approximately 0.3 cm depth. From 3 o'clock to 9 o'clock the wound bed was beefy red. From 9 o'clock to 2 o'clock the wound bed was covered with a sloughy skin flap. From 2 o'clock to 3 o'clock wound bed was covered by dry eschar. Resident #9's Left lateral heel had 5 cm x 4 cm unstageable pressure sore with dry eschar. (approximation by surveyor) In an interview on 10/23/2013 at 4:45 PM CNA H stated she gave Resident #9 a bed bath on 10/22/2013. CNA H stated after cleaning Resident #9's feet she saw that Resident #9's right heel was bleeding. CNA H stated the Resident #9 was complaining of pain when she moved his legs. CNA H stated she told LVN E and LVN E went to check on Resident #9. Review of Resident #9 Clinical Record reflected no assessment of Resident #9's heels on 10/21/2013 or 10/22/2013. The first noted assessment was 10/23/2013 at 3:45 PM. Review of the Skin Alert/Body Alert dated 10/23/2013 at 3:45 PM reflected an assessment of Resident #9's heels. "Right unstageable 12 o'clock to 6 o'clock area of red dry-approx. 3 cm x 2 cm, no drainage, 6 o'clock to 12 o'clock 2 cm circular, hardened, non-moveable-skin peeling outer edge. Left unstageable area- darkened 3 x 3.5 cm noted 0.2 cm circular area with scant serous drainage." Assessment signed by ADON. In an interview with the DON on 10/23/2013 at 9:20 AM the DON stated that Resident #9's admission assessment should have been completed on 10/21/2013 and signed by a RN within 24 hours. The DON further stated Resident #9's heels should have been addressed. The DON stated the facility did not have protocols or policy for pressure sores. The DON stated treatment of [REDACTED]. The DON stated the facility followed nursing standards and handed surveyor the 10th edition Lipincot Nursing Manual as the facilities policy. Review of the facility provided policy for Assessments no dated reflected "Functional Impairment - Clinical Protocol. Policy: Upon admission to the facility, at any time a significant change of condition occurs, and periodically during a resident's stay, the physician and staff will assess the resident's physical condition and functional status." Review of the facility provided policy for pressure sores reflected " Skin and Wound Care Program. Policy: The facility will follow steps to minimize the risk of skin breakdown from occurring in the facility and maintain good skin integrity. Procedure: 1.) The Wound and Skin Care Program must be implemented in order to maintain good skin integrity and to prevent skin breakdown. 2.) By using this program, correctly assessing the risk factors and monitoring appropriately, skin problems will be prevented and/ or identified, treated and healed quickly. 3.) The Body Audit and Hydration Report should be completed on admission and a risk level assigned based on the Resident Assessment Profile. This will initiate a tracking system to monitor for skin breakdown on a routine basis; daily, weekly or monthly. 4.) If skin breakdown occurs, medical justification must be documented. If the wounds do not heal, documentation by the physician must justify the reason for the occurrence of the breakdown .... " " If a pressure sore of other skin breakdown occurs, the Weekly Pressure Sore Progress Report should be initiated. Evaluation of the risk should also include determination if the mattress is sufficient to reduce pressure. The facility mattresses are pressure reducing, but residents with several pressure sores or Stage III or IV on the coccyx or trunk may require low air loss overly... " The facility provided a list of 22 residents with wounds.

Based on observation, interview, and record review the facility failed to ensure that 2 of 19 residents, reviewed for medications, were free of a significant medication error (Resident #17 and Resident #40). A) Resident #17 received [MEDICATION NAME] (a medication for [MEDICAL CONDITION], low blood pressure) when her blood pressure was higher than the physician prescribed parameters to receive this medication causing Resident #17 to experience increased blood pressure, shortness of breath, dizziness, headache, and unresponsive behavior resulting in an emergency department visit on 08/01/12. This medication had been given outside physician prescribed parameters for a period of over 7 months. B) Resident #40 received [MEDICATION NAME] for a period of four months without blood pressure monitoring. This resulted in an Immediate Jeopardy (IJ) on 8/3/12. While the IJ was lowered on 8/4/12, the facility remained out of compliance at a severity level of potential for more than minimal harm that is not an IJ at a scope of widespread because the facility had not had time to implement, monitor and evaluate the effectiveness of their Plan of Removal. This deficient practice placed 56 residents receiving blood pressure medications at risk for for hypertensive episodes, dizziness, [MEDICAL CONDITION], chest pain, headache, shortness of breath, and episodes of unresponsiveness or death. Findings include: A.) Review of Resident #17 Face Sheet reflected a [AGE] year old woman originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #17's Care Plan reflected the plan of care for "risk for [MEDICAL CONDITION] related to my medications, complaints of pain, and medical diagnoses," dated 08/09/11, included the following approaches: 1. Monitor my response to my medication carefully. 2. Administer my medication as ordered. 3. Report any changes in my mental or cognitive status to the physician. The Care Plan did not reflect any specific interventions related to Resident #17's use of blood pressure medications. Review of Resident #17's original physician order [REDACTED]. Review of Resident #17's consolidated physician's orders [REDACTED]. "Check BP before administration hold if BP is 120/80 or > (greater) 12/19/12 order." In an interview on 08/01/12 at 8:51 AM Resident #17 stated that she had not yet received her medications for the morning. She stated that she was concerned about her [MEDICAL CONDITION] medication and is supposed to be given the medications at 7 AM. Resident #17 stated that she has received her medications 5 or 6 times over two hours late. Observation on 08/01/12 at 9:01 AM revealed Medication Aide (MA) F to arrive at Resident #17's room and stated that she needed to give Resident #17 her medications. Resident #17 told MA F that she was not feeling well. MA F took Resident #17's blood pressure at 160/87 millimeters of mercury (mm Hg). In an interview on 08/01/12 at 10:15 AM MA F stated that she documented the blood pressure of 160/87 mm Hg taken at 9:00 AM on the Medication Administration Record (MAR) in the 7:00 AM space. MA F stated that she gave all of Resident #17's 08/01/12 7:00 AM medications at that time the blood pressure was taken (9:00 AM). MA F was asked if she was to notify anyone if a resident's blood pressure was high. MA F stated that she is supposed to notify the nurse, but that she had not done that yet. In an interview on 08/01/12 at 10:31 AM LVN C stated that today Resident #17 had "a [MEDICAL CONDITION] spell and Parkinson-like jitters." LVN C stated that Resident #17 was on the toilet when she had one of her "dizzy spells." LVN C stated that he took Resident #17's vital signs and got a doctor's order to send Resident #17 to the ER. LVN C stated that because Resident #17's room is "toward the front of the hallway she should have gotten her medications before breakfast and most definitely before 8:00 AM." LVN C stated that if medications are late, over an hour after the scheduled time; the medication is to be held until the physician is notified to get an order to give the medication late. LVN C stated that Resident #17's [MEDICATION NAME] should have been held for any blood pressure above 120/80 mm Hg. Observation on 08/01/12 at 9:40 AM revealed an ambulance to have arrived at the facility to transport Resident #17 to the hospital. Observation on 8/1/12 at 9:43 AM revealed Ambulance staff attending to Resident #17 who was lying in bed with tremors. Her eyes were open however; she was not responding to questions. In an interview on 8/1/12 at 9:45 AM the interim DON stated that Resident #17 "does this all the time." She stated that Resident #17 "will have a syncopal spell but will come right out of it with a sternal rub and then she will say, "send me to the emergency room (ER)." Review of Resident #17's Emergency Department Physician's Documentation dated 08/01/12 reflected a clinical impression of: [MEDICAL CONDITION], Generalized Weakness, and Acute non-specific headache. Nurse documentation of blood pressures revealed the following: 10:30 AM 136/66 mm Hg 11:00 AM 115/75 mm Hg 11:30 AM 93/46 mm Hg 12:30 PM 99/59 mm Hg Review of Resident #17's Nurse's Notes dated 08/01/12 reflected the following entries: 10:00 AM: CNA called charge nurse down to patient room. Upon assessment resident was sitting on toilet and having severe tremors. Resident was assisted to her bed where she continued to have severe tremors. Blood pressure 182/104 mm Hg, pulse 90. Resident was alert times three and requested to be transferred to the hospital. Nurse Practitioner notified and gave order to send resident to ER to be evaluated and treated. 10:10 AM: emergency medical services (EMS) arrived and transported resident to ER 11:00 AM Reported by charge nurse that resident stated that she received her meds (AM) late while she was being assessed by emergency medical technicians. Spoke with medication aide and meds due at 7:00 AM were passed at 9:00 AM. Notified Nurse Practitioner and she did not think this was contributing to her tremors. In an interview on 08/03/12 at 4:00 PM the Medical Director who is also the Attending Physician for Resident #17 stated that she wanted to continue the use of [MEDICATION NAME] for Resident #17. She stated that [MEDICATION NAME] was used to raise the blood pressure and it was only to be given when the resident ' s blood pressure was below 120/80 mm Hg. The Medical Director stated that she was not made aware that Resident #17's [MEDICATION NAME] had been given when Resident #17's blood pressure was above 120/80 mm Hg. The Medical Director stated that "if the [MEDICATION NAME] was given above 120/80 mm Hg it could have caused the symptoms expressed" by Resident #17. In an interview on 08/03/12 at 4:09 PM LVN MM stated that the facility found out about the medication error on 08/01/12 after Resident #17 went to the hospital. She stated that they then reviewed Resident #17's chart and noticed that the [MEDICATION NAME] was not being given as prescribed. LVN MM stated that the ADON did a chart audit. She stated after the audit the facility changed greater than and less than symbols on the MAR to words. In an interview on 08/03/12 at 4:30 PM the Consulting Pharmacist Manager stated that the facility has been aware of medication pass problems in the facility and had increased medication pass observations from once per quarter to once monthly beginning in December 2011. The Pharmacist stated that each MA and Nurse has had a one to one teaching medication pass observation with the Pharmacy Consultant. She stated that anyone who passed medication should be familiar with the greater than and less than symbols. She stated that the regular pharmacist that she manages "has made the same recommendations regarding corrections or changes over and over" to the facility. The Pharmacist stated that [MEDICATION NAME] is a very common medication to make an error with. She stated giving this medication incorrectly can result in major complications such as "the blood pressure being way too high," dizziness, increased heart rate, sweating, and [MEDICAL CONDITION]. She stated that [MEDICATION NAME]'s onset of action (how quickly the medication takes effect) was about 30 minutes to one hour after ingestion. In an interview on 08/04/12 at 10:45 AM the Administrator stated that when Resident #17 went out to the emergency roiagnom on [DATE] is when the facility became aware that the MA's did not know the greater than and less than symbols on the MARs. Review of Resident #17's MAR dated January 2012 reflected that Resident #17's medication [MEDICATION NAME] was held on 01/07/12 due to her blood pressure being 124/70 mm Hg, held on 01/14/12 due to her blood pressure being 124/88 mm Hg, and held on 01/22/12 due to her blood pressure being 129/90 mm Hg. The January MAR does not reflect any other blood pressures were recorded. Physcians orders indicated that blood pressures were to be taken before administration of this medication. Review of Resident #17's MAR dated February 2012 reflected "[MEDICATION NAME] 2.5 mg tab po bid, BP reading before giving [MEDICATION NAME] BID, hold [MEDICATION NAME] if BP is 120/80 or > (greater than)." This medication was signed as given on 30 occasions when the recorded blood pressure exceeded 120/80 mm Hg. The medication was signed as held on 9 occasions when the recorded blood pressure was lower than 120/80 mm Hg. The back page of the MAR noted two occasions when the medication was held due to "blood pressure less than 120/80," the 02/16/12 pressure recorded as 94/58 mm Hg and the 02/27/12 pressure recorded as 111/77 mm Hg. Review of Resident # 17's MAR dated March 2012 reflected "[MEDICATION NAME] 2.5 mg tab po bid, BP reading before giving [MEDICATION NAME] BID, hold [MEDICATION NAME] if BP is 120/80 or > (greater than)" This medication was signed as given on 26 occasions when then recorded blood pressure exceeded 120/80 mm Hg. The medication was signed as held on 29 occasions when the recorded blood pressure was lower than 120/80 mm Hg. The medication was given incorrectly 55 of the 62 opportunities to pass the medication. The back page of the MAR noted: 03/01/12 7 AM "[MEDICATION NAME] 2.5 mg held b/p 111/72" 03/10/12 7 AM "held [MEDICATION NAME] 2.5 mg b/p 108/71" 03/14/12 7 AM "held [MEDICATION NAME] 2.5 mg b/p 99/71 per orders" 03/15/12 7 AM "held [MEDICATION NAME] 2.5 mg per orders b/p 109/71" 03/19/12 7 AM "held [MEDICATION NAME] 2.5 mg per orders b/p 115/76" 03/20/12 7 AM "held [MEDICATION NAME] 2.5 mg per orders b/p 111/78" 03/21/12 7 AM "held [MEDICATION NAME] 2.5 mg per orders b/p 109/71" 03/27/12 7 AM "med held [MEDICATION NAME] 2.5 po pt b/p 101/58" Review of Resident # 17's MAR dated April 2012 reflected "[MEDICATION NAME] 2.5 mg tab po bid, BP reading before giving [MEDICATION NAME] BID, hold [MEDICATION NAME] if BP is 120/80 or > (greater than)." This medication was signed as given on 11 occasions when the recorded blood pressure exceeded 120/80 mm Hg from 04/01/12-04/12/12. The medication was signed as held on 11 occasions when the recorded blood pressure was lower than 120/80 mm Hg. One medication pass on 04/09/12 has no information recorded on the MAR. The medication was given incorrectly 22 of the 24 opportunities to pass the medication. Continued review of Resident #17's April 2012 MAR reflected the physician's orders [REDACTED]. An additional note was added to the description of the medication "If pt passes out. Put her in bed, lower head & raise legs - Do not rush pt out to ER." From 04/13/12-04/30/12 the medication was signed as given on 20 occasions when then recorded blood pressure exceeded 120/80 mm Hg and was then signed as held on 32 occasions when the recorded blood pressure was lower than 120/80 mm Hg. The medication was given incorrectly 52 of the 54 opportunities to pass the medication. There are no nurse's notes on the reverse side of the MAR to document why the medication was given outside of the physician ordered parameters. Review of Resident # 17's MAR dated May 2012 reflected "[MEDICATION NAME] 2.5 mg tab po tid, check BP TID and hold [MEDICATION NAME] if BP is 120/80 or > (greater than)." The MAR did not include a space to record the 7 AM blood pressure. This medication was signed as given on 26 occasions when then recorded blood pressure exceeded 120/80 mm Hg. The medication was signed as held on 31 occasions when the recorded blood pressure was lower than 120/80 mm Hg. The medication was given incorrectly 57 of the 62 opportunities to pass the medication during the 11:00 AM and 3:00 PM medication passes. No blood pressures were recorded for 3 of the passes. Documentation on the reverse side of the MAR noted the medication was incorrectly held on at least 12 occasions for blood pressures less than 120/80 mm Hg during the 7:00 AM medication pass. Review of Resident #17's June and July 2012 MAR reflected recorded blood pressures and medications signed as held and as given however there were no times associated with the blood pressures to show which medication pass they belong to. Review of Resident #17's August 2012 MAR reflected "[MEDICATION NAME] 2.5 mg tab po tid, check BP TID and hold [MEDICATION NAME] if BP is 120/80 or >" and "greater than" was hand written beside the medication information. On 08/01/12 Resident #17 received a 7:00 AM dose of the medication with a blood pressure of 160/87 mm Hg. The remaining two doses were not given as the resident was in the hospital. On 08/02/12 the 11:00 AM dose was given with a blood pressure of 134/82 mm Hg. On 08/03/12 the 7:00 AM dose was given with a blood pressure of 148/93 mm Hg. B) Review of the Face Sheet reflected Resident # 40 was admitted on [DATE] and readmitted on [DATE] with the [DIAGNOSES REDACTED]. " Review of the Medication Administration Record (MAR) dated April, May, June, and July 2012 for Resident # 40 reflected that he was receiving the medication [MEDICATION NAME] ([MEDICATION NAME]) 5 mg three times a day (TID) with no documented blood pressure (BP). Review of the MAR, revised after the IJ was identified, dated August 2012 reflected for [MEDICATION NAME] to hold medication if BP was more then 160/100. Also on the row for [MEDICATION NAME] were rows to document the systolic and diastolic of the blood pressure, with the times 9:00 AM, 5:00 PM and 9:00 PM. Review of the admission orders [REDACTED]. Review of the Telephone Orders dated 7/23/12 reflected that Resident #40 had a clarification order for [MEDICATION NAME] 5 mg to hold the [MEDICATION NAME] if BP > 160/100. In an interview on 08/04/12 at 10:45 AM the Administrator stated that the ADON has been frustrated by physician order [REDACTED]. She stated that the previous person responsible for medical records had multiple transcription issues and did not correct medication orders to reflect resident movement within the facility. The Administrator stated that the hallways were split into two medication pass times so that all the medications were not due at the same time. When residents would change hallways the medication orders would not get updated to reflect the change in times for those hallways. She stated that she believed this was a portion of the problem for issues with medication timing. Review of [MEDICATION NAME] Dosage and Administration reflected: Dosing should take place during the daytime hours when the patient needs to be upright, pursuing the activities of daily life. A suggested dosing schedule of approximately 4-hour intervals is as follows: shortly before or upon arising in the morning, midday, and late afternoon (not later than 6 P.M.). <http://www.drugs.com/pro/[MEDICATION NAME].html> Review of facility policy and procedure titled 7.1 'GENERAL GUIDELINES' dated 09/10 reflected the following: POLICY Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after the have familiarized themselves with the medication. PROCEDURES Medication Preparation:... Medication Administration: 1. Medications are administered in accordance with written orders of the prescriber. If a dose seems excessive considering the resident's age and condition, or a medication order seems to be unrelated to the resident's current [DIAGNOSES REDACTED]. If necessary, the nurse contacts the prescriber for clarification. This interaction with the pharmacy and the resulting order clarification are documented in the nursing notes and elsewhere in the medical record as appropriate. 2. Obtain and record any vital signs as necessary prior to medication administration. 14. Medications are administered within 60 minutes of scheduled time, except before or after meal orders, which are administered, based on meal times. Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the nursing care center. The facility's Administrator, interim DON, ADON and Vice President of Operations were informed that an IJ existed on 8/3/12 at 6:20 PM due to the facility's failure to ensure that Resident #17 and Resident #40 who received [MEDICATION NAME] for Hypotention were free from significant medication errors. The facility provided the following plan of removal on 8/4/12 at 12:05 PM and accepted on 8/4/12 at 1:15 PM. Plan of Removal Resident #17 has an order for [REDACTED]. The order requires that the medication be held if the blood pressure is greater than 120/80 but medication was given when blood pressure was over 120/80. This medication is for the treatment of [REDACTED]. This resident was re-assessed by a Registered Nurse (RN) on 8/3/2012 and the attending physician was updated with the re-assessment findings. The MD gave new order for parameters and times of dose for [MEDICATION NAME]. The care plan was updated 8/3/2012 to reflect approaches to prevent falls related to [MEDICAL CONDITION]. The re-assessment was documented and care plans updated by the RN on 8/3/2012. A list of residents on blood pressure medications was reviewed by the Director of Nurses (DON) or designee on 8/4/2012 to determine other residents on blood pressure medications requiring parameters to be monitored. The number of residents in the facility receiving blood pressure medications totaled 58. The 2 residents specifically identified with MD orders for [MEDICATION NAME] have been re-assessed by RNs on 8/3/2012 to update the plan of care. Medication Order Review Audits to clarify orders were started on 8/2/2012 by visiting DON on 8/3/2012. The re-education by DON of nurses and medication aides was started on 8/2/2012 on Medication Administration, Following MD orders and Med Pass procedures with copies of policies and procedures given to the employees. Med Pass observations by DON were started with nurses and med aides. Med Pass observations by Pharmacist were conducted on 8/3/12 with 5 nurses and medication aides and individual re-education was done during that med pass regarding identified concerns. The Pharmacist identified one med aide that needed further training and she will be individually re-educated by the Nurse Consultant from pharmacy on 8/4/12. Re-education by Nurse Consultant for pharmacy was started on 8/3/12 and will continue thru 8/4/12 with nurses and med aides on medication administration, following MD orders, MD orders with parameters including blood pressure medications, medication error reporting and adverse drug reaction prevention and detection and notification of MD when MD orders including parameters are not followed with copies of inservice, policies and procedures given to the employee. The Nurse Consultant for pharmacy will complete med pass observations and re-education individually based on results of observations with nurses and medication aides starting on 8/3/12 thru 8/4/12. Ongoing, Med Pass observations and individual re-education based on results of observation will be completed three times per week covering each shift by DON or designee with facility nurses and medication aides. The med pass observations with nurses and medication aides will randomly include but not be limited to oral medications, injections, tube feedings, eye drops, nasal sprays or any other MD order that is included on the MAR (Medication Administration Record). MARs audits for in-house residents will be conducted weekly by DON or designee to include MD orders listed on each residents' MARs in order to identify potential medication errors. The MAR audits will compare the MD orders noted on the MAR to the administration recorded by nurses or med aides to verify parameters of medications have been followed per MD order. A Quality Assurance (QA) meeting was held on 8/4/12 at 12:45 AM to review and approve the corrective action taken with no policy changes identified. The Medical Director was notified on 8/4/12 at 12:15 AM of the IJ regarding the resident's medication orders and parameters with no further recommendations were made. The DON is responsible for ongoing compliance through review of corrective actions taken and reporting results of review to QA team for any needed revision. Continuing QA will include review of corrective actions for further interventions monthly for three months. Staff were inserviced on medication errors and physician ordered medication with parameters on 8/3/12 and 8/4/12. The Consultant Pharmacy Manager began observation medication passes on 8/3/12. The DON conducted an observation/teaching medication pass on 8/3/12. MARs audit was conducted by the DON to identify medication orders with parameters. Observation on 8/4/12 at 1:30 revealed Resident # 17 and # 40 MARS had a spot to put the systolic and dystolic blood pressure reading. The [MEDICATION NAME] was moved from the Medication Aid giving the medication to the Licensed Vocational Nurse giving the medication. Both MARS reflected the medication given or held at the specified time, within the appropriate parameters specified by the physician. While the IJ was removed on 8/4/12 at 4:30 PM the facility remained out of compliance at a severity level of potential for more than minimal harm that is not an IJ at a scope of widespread. The facility had not had time to implement, monitor and evaluate the effectiveness of their Plan of Removal. Review of the facility's CMS 672 reflected a facility census of 105. The Facility provided a list of 58 residents receiving blood pressure medications and 2 residents receiving [MEDICATION NAME]. Refer to F 332 for additional evidence of MA F ' s multiple failures to administer medication appropriately leading to the immediate jeopardy. Refer to F 425 for additional evidence of pharmacy procedure failures to administer medication appropriately following 7 months of pharmacy review and one on one medication pass observations by the pharmacy consultant leading to the immediate jeopardy.

Based on observation, interview, and record review the facility failed to ensure that it was free of a medication error rate of five percent or greater when three (3) Medication Aides (MA) ( F, G and E) and three (3) Licensed Vocational Nurses (LVN) (H and A) were observed during medication pass resulting in ten (10) errors out of 40 opportunities for five (5) of seven (7) residents (Residents # 41, #42, #43, #44, and #45) observed which resulted in a 25% medication error rate. 1. MA F failed to administer [MEDICATION NAME] instead administered [MEDICATION NAME]+D for Resident #41. 2. MA F failed to administer Polyethylene [MEDICATION NAME] ([MEDICATION NAME]) 17 grams with eight (8) ounces of water for Resident #41. 3. MA F failed to administer [MEDICATION NAME] 50 mg with food for Resident #41. 4. MA F failed to administer [MEDICATION NAME] appropriately for Resident #41. 5. MA F failed to administer [MEDICATION NAME] 5/325 with food for Resident #41. 6. MA G failed to administer Polyethylene [MEDICATION NAME] ([MEDICATION NAME]) 17 grams with eight (8) ounces of water for Resident #42 . 7. LVN H failed to administer [MEDICATION NAME] 7.5 mg with food for Resident #43. 8. LVN H failed to take Resident #43's blood pressure before administering [MEDICATION NAME] 100 mg. 9. LVN A failed to administer [MEDICATION NAME] R with food for Resident #44. 10. MA E failed to administer Caredilol 125mg with food for Resident #45. This resulted in an Immediate Jeopardy (IJ) on 8/3/12. While the IJ was lowered on 8/4/12, the facility remained out of compliance at a severity level of potential for more than minimal harm that is not an IJ at a scope of widespread because the facility had not had time to implement, monitor and evaluate the effectiveness of their Plan of Removal. This deficient practice could cause adverse drug reactions and could affect 105 residents who are administered medications by facility staff. Findings include: A. Observation on 7/31/12 at 7:55 AM revealed MA F was in Resident #41's room handing a medication cup to the resident when the surveyor stopped her and asked to to come into the hall. The surveyor asked MA F what she should do before giving the medication [MEDICATION NAME], and the MA replied "I don't understand. What do I need to do?" The surveyor asked MA F to re-read the medication sheet and look at the order. MA F still was unsure of what to do, so the surveyor prompted her to take the resident's blood pressure. MA F then took the blood pressure and administered Resident #41 her medications. The medications were as follows: 1. [MEDICATION NAME] + D 250 units/315mg (wrong medication given) 2. Polyethylene [MEDICATION NAME] ([MEDICATION NAME])17 grams with five (5) ounces (oz) of water (should be 8 oz of water) 3. [MEDICATION NAME] 50mg, [MEDICATION NAME] Propionate (no food given, no blood pressure taken) 4. [MEDICATION NAME] Propionate 50 mcg (did not blow nose before administering, did not have resident plug one side of her nostril before administering, and did not wipe off tip before recapping ) 5. [MEDICATION NAME] - Acetominophen 5-325 mg (no breakfast given) In an interview on 7/31/12 at 8:05 AM MA F stated breakfast should be on its way soon. Review of Resident # 41's Physician Orders dated July - 2012 reflected as follows: * [MEDICATION NAME] 1 tablet by mouth every day * [MEDICATION NAME] 17 grams by mouth every day mix with eight (8) ounces of water * [MEDICATION NAME] 50 mg one (1) tablet twice a day (BID) after blood pressure is taken and with meals *[MEDICATION NAME] Propionate 50 mcg one (1) spray each nostril BID, and *[MEDICATION NAME]-Acetominophen 5-325 mg give after breakfast. In an interview on 8/2/12 at 6:20 PM the Assistant Director of Nursing (ADON) stated that [MEDICATION NAME] is not the same as [MEDICATION NAME] + D, and that if the [MEDICATION NAME] is not mixed with the appropriate amount of water it could "become a brick in the residents bowel." She further stated that in order for the resident to get the appropriate dose of the [MEDICATION NAME] Propionate the resident would need to blow his/her nose before spraying into the nose and also hold one side of the nostril closed when spraying into the opposite nostril. The ADON went on to say that the [MEDICATION NAME] should only be given after a BP is taken on the resident and only with in the parameters given by the physician. B. Observation on 7/31/12 at 8:30 AM revealed MA G administered to Resident #42 the following: 6. Polyethylene [MEDICATION NAME] ([MEDICATION NAME]) 17 grams with four and a quarter ( 4 ? ) ounces of water. (needed 8 oz of water) Review of Resident #42 ' s Physician Orders dated July 2012 reflected : *[MEDICATION NAME] 17 gram mixed with eight (8) ounces of water every day. C. Observation on 7/31/12 at 9:30 AM revealed LVN H administered to Resident #43: 7. [MEDICATION NAME] ([MEDICATION NAME]) 7.5 mg, (no feeding given) 8. [MEDICATION NAME] 100 mg. (no blood pressure was taken) In an interview on 7/31/12 at 9:20 AM LVN H stated that Resident #43's tube feeding is turned off from 7:00 AM until 11:00 AM so that he can receive his [MEDICATION NAME] medication without food. In an interview on 7/31/12 at 10:25 AM LVN H stated that "I just remembered I forgot to take his BP." Review of Resident #43's Physician Orders dated July 2012 reflected : * [MEDICATION NAME] 7.5 mg one (1) tablet every day, and * Lorpressor ([MEDICATION NAME]) 100 mg BID. Check BP BID before giving Anti-hypertensive medications, hold if BP is less than 100/60. D. Observation on 8/1/12 at 6:45 AM revealed LVN A checking Resident #44's blood sugar (BS), which was 172, and administered: 9. [MEDICATION NAME]- R 4 units to Resident #44 with no food given. Observation on 8/1/12 at 8:05 AM revealed breakfast was served to Resident # 44. Review of Resident #44's Physician Orders dated July 2012 reflected a Sliding Scale with *Regular Insulin BS 151-200 give 4 units. In an interview on 8/2/12 at 6:20 PM the ADON stated that when giving [MEDICATION NAME] R the resident should always receive a snack or breakfast within 20-30 minutes of receiving the insulin. She further stated that if they don't receive food with the insulin they could have major adverse reactions. E. Observation on 8/1/12 at 3:05 PM revealed MA E administered Resident # 45: 10. Carvedilol ([MEDICATION NAME]) 12.5 mg (without food). Review of Resident #45's dated July 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] *Carvedilol 12.5 mg by mouth BID with food, Check BP BID and record. In an interview with Resident #45 on 8/1/12 at 3:15 PM he stated that he had not eaten since lunch. In an interview on 08/04/12 at 10:45 AM the Administrator stated that the ADON has been frustrated by physician order issues in regard to medication times. She stated that the previous person responsible for medical records had multiple transcription issues and did not correct medication orders to reflect resident movement within the facility. The Administrator stated that the hallways were split into two medication pass times so that all the medications were not due at the same time. When residents would change hallways the medication orders would not get updated to reflect the change in times for those hallways. She stated that she believed this was a portion of the problem for issues with medication timing. Review of the facility policy and procedure titled 7.15 'NASAL ADMINISTRATION' dated 09/10 reflected the following: POLICY To administer nasal medications in a safe, accurate and effective manner. PROCEDURE 1. Refer to Section 7.1 Medication Administration-General Guidelines. 2. Provide privacy. 3. Perform hand hygiene... 7. Have resident gently blow nose to clear the nostrils... 9. Administer medication to resident or help resident to do so if capable, using the following directions: a. Have resident keep head upright. Keeping mouth closed, insert tip of pump, spray or inhaler into the nostril. Point the spray tip in the nose toward the back and outer side of the nose. Press a finger against the side of the nose to close one nostril and lean the head slightly forward so the spray will aim toward the back of the nose. Have resident sniff gently in through the nostril while pump or inhaler is quickly and firmly squeezed or activated. b. Instruct resident to hold breath for a few seconds and the breathe out through mouth... g. Wipe any excess drainage with a clean tissue. Instruct resident to avoid blowing their nose for 15 minutes. 10. Clean container per manufacturer's instructions or wipe the spray tip with a tissue before putting on the protective cap. 11. Return medication container to medication cart for storage 12. Perform hand hygiene. Review of facility policy and procedure titled 7.1 'GENERAL GUIDELINES' dated 09/10 reflected the following: POLICY Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after the have familiarized themselves with the medication. PROCEDURES Medication Preparation:... Medication Administration: 1. Medications are administered in accordance with written orders of the prescriber. If a dose seems excessive considering the resident's age and condition, or a medication order seems to be unrelated to the resident's current [DIAGNOSES REDACTED]. If necessary, the nurse contacts the prescriber for clarification. This interaction with the pharmacy and the resulting order clarification are documented in the nursing notes and elsewhere in the medical record as appropriate. 2. Obtain and record any vital signs as necessary prior to medication administration. 3. Medication administration timing parameters include the following: a. Medication to be given on an empty stomach or before meals are to be scheduled for administration 30 minutes to 2 hours prior to meals. b. Medications to be given with meals are to be scheduled for administration at the resident's meal time. c. Medications to be given after meals or with food are to be scheduled for administration immediately after and up to 2 hours after meals or with a snack (a single serving of a food item) as defined by nursing care center dietitian... 11. Hands are washed with soap and water before and after administration of topical, ophthalmic, otic, [MEDICATION NAME], enteral, rectal and vaginal medications, and with any resident contact. Antimicrobial sanitizer may be used in place of soap and water as allowed per state nursing regulations and facility policy. Note: Soap and water should always be used after contact with resident with [MEDICAL CONDITION]("c. diff") as antimicrobial sanitizer does not kill the spores produced by c.diff, which may result in spread of infection. 12. At least (4 ounces) of water or other acceptable liquid should be given with oral medications unless a different amount is specified due to fluid restrictions or product manufacturer requirements. Please note some medications need to be given with more liquid. 13. Explain to the resident the type of medication being administered and the procedure. 14. Medications are administered within 60 minutes of scheduled time, except before or after meal orders, which are administered based on meal times. Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the nursing care center. Medications should not be given at mealtimes or in the dining room unless specifically ordered with meal... 18. Resident's health information needs to remain private. The pages of the MAR indicated [REDACTED] The facility's Administrator, interim DON, ADON and Vice President of Operations were informed that an IJ existed on 8/3/12 at 6:20 PM due to the facility's failure to ensure that residents were free from medication errors. The facility provided the following plan of removal on 8/4/12 at 12:05 PM and accepted on 8/4/12 at 1:15 PM. Plan of Removal Resident #17 has an order for [REDACTED]. This medication is for the treatment of [REDACTED]. This resident was re-assessed by a Registered Nurse (RN) on 8/3/2012 and the attending physician was updated with the re-assessment findings. The MD gave new order for parameters and times of dose for [MEDICATION NAME]. The care plan was updated 8/3/2012 to reflect approaches to prevent falls related to [MEDICAL CONDITION]. The re-assessment was documented and care plans updated by the RN on 8/3/2012. A list of residents on blood pressure medications was reviewed by the Director of Nurses (DON) or designee on 8/4/2012 to determine other residents on blood pressure medications requiring parameters to be monitored. The number of residents in the facility receiving blood pressure medications totaled 58. The 2 residents specifically identified with MD orders for [MEDICATION NAME] have been re-assessed by RNs on 8/3/2012 to update the plan of care. Medication Order Review Audits to clarify orders were started on 8/2/2012 by visiting DON on 8/3/2012. The re-education by DON of nurses and medication aides was started on 8/2/2012 on Medication Administration, Following MD orders and Med Pass procedures with copies of policies and procedures given to the employees. Med Pass observations by DON were started with nurses and med aides. Med Pass observations by Pharmacist were conducted on 8/3/12 with 5 nurses and medication aides and individual re-education was done during that med pass regarding identified concerns. The Pharmacist identified one med aide that needed further training and she will be individually re-educated by the Nurse Consultant from pharmacy on 8/4/12. Re-education by Nurse Consultant for pharmacy was started on 8/3/12 and will continue thru 8/4/12 with nurses and med aides on medication administration, following MD orders, MD orders with parameters including blood pressure medications, medication error reporting and adverse drug reaction prevention and detection and notification of MD when MD orders including parameters are not followed with copies of inservice, policies and procedures given to the employee. The Nurse Consultant for pharmacy will complete med pass observations and re-education individually based on results of observations with nurses and medication aides starting on 8/3/12 thru 8/4/12. Ongoing, Med Pass observations and individual re-education based on results of observation will be completed three times per week covering each shift by DON or designee with facility nurses and medication aides. The med pass observations with nurses and medication aides will randomly include but not be limited to oral medications, injections, tube feedings, eye drops, nasal sprays or any other MD order that is included on the MAR (Medication Administration Record). MARs audits for in-house residents will be conducted weekly by DON or designee to include MD orders listed on each residents' MARs in order to identify potential medication errors. The MAR indicated [REDACTED]. A Quality Assurance (QA) meeting was held on 8/4/12 at 12:45 AM to review and approve the corrective action taken with no policy changes identified. The Medical Director was notified on 8/4/12 at 12:15 AM of the IJ regarding the resident's medication orders and parameters with no further recommendations were made. The DON is responsible for ongoing compliance through review of corrective actions taken and reporting results of review to QA team for any needed revision. Continuing QA will include review of corrective actions for further interventions monthly for three months. Staff were inserviced on medication errors and physician ordered medication with parameters on 8/3/12 and 8/4/12. The Consultant Pharmacy Manager began observation medication passes on 8/3/12. The DON conducted an observation/teaching medication pass on 8/3/12. MARs audit was conducted by the DON to identify medication orders with parameters. Observation on 8/4/12 at 1:30 revealed Resident # 17 and # 40 MARS had a spot to put the systolic and dystolic blood pressure reading. The [MEDICATION NAME] was moved from the Medication Aid giving the medication to the Licensed Vocational Nurse giving the medication. Both MARS reflected the medication given or held at the specified time, within the appropriate parameters specified by the physician. While the IJ was removed on 8/4/12 at 4:30 PM the facility remained out of compliance at a severity level of potential for more than minimal harm that is not an IJ at a scope of widespread. The facility had not had time to implement, monitor and evaluate the effectiveness of their Plan of Removal. Review of the facility's CMS 672 reflected a facility census of 105. The Facility provided a list of 58 residents receiving blood pressure medications and 2 residents receiving [MEDICATION NAME].

Based on observation, interview and record review the facility failed to provide pharmaceutical services including not accurately following the correct procedure and administration of medications, and not providing routine medications during the observation of the medication pass for 1 of 4 Medication Aides (MA F) and 2 of 3 Licensed Vocational Nurses (LVN X and H) resulting in 4 procedure errors for 4 of 7 residents (Residents #9, #27, #41, and #43) when: A.) LVN X failed to use a 100 unit insulin syringe for Resident # 27, resulting in the resident receiving three (3) shots due to dosage ordered. B.) MA F failed to administer Fluticasone Propanate appropriately for Resident #41. C.) LNV H administer Metoprolol tartrate 100 mg before taking a blood pressure (BP) for Resident #43. D.) MA F failed to provide folic acid in prescription or over the counter forms. MA F stated that Resident #9 has not received folic acid since her admission to the facility. This resulted in an Immediate Jeopardy (IJ) on 8/3/12. While the IJ was lowered on 8/4/12, the facility remained out of compliance at a severity level of potential for more than minimal harm that is not an IJ at a scope of a widespread because the facility had not had time to implement, monitor and evaluate the effectiveness of their Plan of Removal. This deficient practice had the potential to affect 105 residents who receive medication administered by facility staff by causing increased anxiety, not receiving enough medication, and missed doses of prescribed medications. Findings include: A.) Observation on 8/1/12 at 7:39 AM revealed Resident # 27 receiving a Blood Sugar test, and receiving insulin. LVN X asked Resident which finger she would like her to use for the finger stick, Resident #27 answered her " none of them " she then cradled her hands to her chest and stated " they hurt too much " . LVN X then took the Resident ' s Left hand and used a dry piece of gauze to wipe off the Resident ' s left thumb and performed a finger stick to the top of thumb finger pad. Resident # 27 stated " it hurts, it hurts " . LVN X then went back to her medication cart and drew up three separate insulin syringes. The first syringe had Lantis 50 units of the 55 units ordered, the second syringe the remaining five (5) units of the Lantus. The third syringe had the six (6) units of Humalog that was ordered. When returning to the room LVN X informed Resident #27 that she would be receiving three (3) shots of insulin, the Resident cried out and asked "will it hurt?" LVN X then proceeded to give Resident the three (3) shots of insulin by pinching up the skin and injecting the insulin. The Resident cried out with each shot "ouch, it hurts". When looking at Resident # 27's fingertips they appeared to be raw and tender. In an interview with LVN X on 7/31/12 at 7:40 AM she stated that she had never looked for the 100 unit insulin syringes. She further stated that it would be better for the resident to have fewer shots by using a larger syringe. B.) Observation on 7/31/12 at 7:55 AM revealed MA F administering Resident # 41 Fluticasone Propionate 50 mcg. MA F sprayed the nose spray in the air two (2) times and handed it to the Resident. Resident # 41 then sprayed one spray in each nostril and then blew her nose with a tissue. MA F then recapped the nose spray without wiping it off. C.) Observation on 7/31/12 at 7:55 AM revealed MA F was in Resident #41's handing the medication cup to the Resident when the surveyor stopped her and asked to to come into hall. Surveyor asked MA F what she should do before giving the medication Metoprolol, and the MA replied "I don't understand. What do I need to do?" The surveyor asked MA F to re-read the Medication sheet and look at the order. MA F still was unsure of what to do, so the surveyor prompted her to take a blood pressure. MA F then took the blood pressure and administered Resident #41 her medications. In an interview on 8/2/12 at 6:20 PM the Assistant Director of Nursing (ADON) stated that in order for the resident to get the appropriate dose of the Fluticasone Propionate the resident would need to blow his/her nose before spraying into the nose and also hold one side of the nostril closed when spraying into the opposite nostril, the ADON went on to say that the Metoprolol should only be given after a BP is taken on the resident and only when in the parameters given by the physician. The ADON further stated that they have 100 unit insulin syringes and that there was no reason that Resident # 27 should have had three (3) separate shots given. D.) Review of Resident #9's Face Sheet reflected a [AGE] year old woman admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #9's Admission physician's orders [REDACTED]. Review of Resident #9's Medication Administration Record (MAR) dated July 2012 reflected that the MAR had initials that were circled indicating the medication was not given from July 20 through July 31, 2012. The back page of the MAR did not reflect any indication as to why the medication was not given. In an interview on 07/31/12 at 12:10 PM Medication Aide (MA) F stated that the Medication cart that contains Resident #9's medications does not have any folic acid in prescription or over the counter forms. She stated that Resident #9 has not received folic acid since her admission to the facility. MA F stated that she has spoken to the hall charge nurse and the nurse supervisor regarding not giving the medication. She stated that she has not documented the missing medication on the back side of the MAR and "we should be, but we haven't." Review of the Medication Administration Observation Reports dated 8/3/12, completed by the Consultant Pharmacist Manager reflected five staff members were observed passing medications. Her observations revealed that 20% of MA AA's medication pass was in error. MA AA administered medications at the wrong time and with food when they were to be administered 30 minutes prior to food. MA F was not observed by the Consultant Pharmacist Manager. In an interview on 08/03/12 at 4:30 PM the Consulting Pharmacist Manager stated that the facility has been aware of medication pass problems in the facility and had increased medication pass observations from once per quarter to once monthly beginning in December 2011. The Pharmacist stated that each MA and Nurse has had a one to one teaching medication pass observation with the Pharmacy Consultant. She stated that anyone who passed medication should be familiar with the greater than and less than symbols. She stated that the facility has not had a consistent Director of Nurses which provides a challenge as the regular pharmacist consultant that reviews the facility "has made the same recommendations regarding corrections or changes over and over" to the facility. The Pharmacist stated that the facility creates their own MARs and does not have the pharmacist review them for accuracy prior to them being used. In a continued interview with the Consulting Pharmacist Manager stated that she would expect the facility to monitor blood pressure medications and as a pharmacist she would recommend monitoring of blood pressure, especially if the resident ' s blood pressure is not stable or there has been a change in the medication or condition of the resident. She stated that neither herself nor the consulting pharmacist have participated in the facility ' s quality assurance meetings. She stated she has noticed that the facility is " having a lot more med errors this year. " In an interview on 08/04/12 at 10:45 AM the Administrator stated that the ADON has been frustrated by physician order [REDACTED]. She stated that the previous person responsible for medical records had multiple transcription issues and did not correct medication orders to reflect resident movement within the facility. The Administrator stated that the hallways were split into two medication pass times so that all the medications were not due at the same time. When residents would change hallways the medication orders would not get updated to reflect the change in times for those hallways. She stated that she believed this was a portion of the problem for issues with medication timing. Review of facility policy and procedure titled 7.15 'NASAL ADMINISTRATION' dated 09/10 reflected the following: POLICY To administer nasal medications in a safe, accurate and effective manner. PROCEDURE 1. Refer to Section 7.1 Medication Administration-General Guidelines. 2. Provide privacy. 3. Perform hand hygiene... 7. Have resident gently blow nose to clear the nostrils... 9. Administer medication to resident or help resident to do so if capable, using the following directions: a. Have resident keep head upright. Keeping mouth closed, insert tip of pump, spray or inhaler into the nostril. Point the spray tip in the nose toward the back and outer side of the nose. Press a finger against the side of the nose to close one nostril and lean the head slightly forward so the spray will aim toward the back of the nose. Have resident sniff gently in through the nostril while pump or inhaler is quickly and firmly squeezed or activated. b. Instruct resident to hold breath for a few seconds and the breathe out through mouth... g. Wipe any excess drainage with a clean tissue. Instruct resident to avoid blowing their nose for 15 minutes. 10. Clean container per manufacturer's instructions or wipe the spray tip with a tissue before putting on the protective cap. 11. Return medication container to medication cart for storage 12. Perform hand hygiene. Review of facility policy and procedure titled 7.1 'GENERAL GUIDELINES' dated 09/10 reflected the following: POLICY Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after the have familiarized themselves with the medication. PROCEDURES Medication Preparation:... Medication Administration: 1. Medications are administered in accordance with written orders of the prescriber. If a dose seems excessive considering the resident's age and condition, or a medication order seems to be unrelated to the resident's current [DIAGNOSES REDACTED]. If necessary, the nurse contacts the prescriber for clarification. This interaction with the pharmacy and the resulting order clarification are documented in the nursing notes and elsewhere in the medical record as appropriate. 2. Obtain and record any vital signs as necessary prior to medication administration. 3. Medication administration timing parameters include the following: a. Medication to be given on an empty stomach or before meals are to be scheduled for administration 30 minutes to 2 hours prior to meals. b. Medications to be given with meals are to be scheduled for administration at the resident's meal time. c. Medications to be given after meals or with food are to be scheduled for administration immediately after and up to 2 hours after meals or with a snack (a single serving of a food item) as defined by nursing care center dietitian... 11. Hands are washed with soap and water before and after administration of topical, ophthalmic, otic, parenteral, enteral, rectal and vaginal medications, and with any resident contact. Antimicrobial sanitizer may be used in place of soap and water as allowed per state nursing regulations and facility policy. Note: Soap and water should always be used after contact with resident with Clostridium difficile("c. diff") as antimicrobial sanitizer does not kill the spores produced by c.diff, which may result in spread of infection. 12. At least (4 ounces) of water or other acceptable liquid should be given with oral medications unless a different amount is specified due to fluid restrictions or product manufacturer requirements. Please note some medications need to be given with more liquid. 13. Explain to the resident the type of medication being administered and the procedure. 14. Medications are administered within 60 minutes of scheduled time, except before or after meal orders, which are administered based on meal times. Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the nursing care center. Medications should not be given at mealtimes or in the dining room unless specifically ordered with meal... 18. Resident's health information needs to remain private. The pages of the MAR notebook containing resident health information must remain closed or covered when not in direct use... The facility's Administrator, interim DON, ADON and Vice President of Operations were informed that an IJ existed on 8/3/12 at 6:20 PM due to the facility's failure to ensure pharmacy procedures were followed by staff administering medications. The facility provided the following plan of removal on 8/4/12 at 12:05 PM and accepted on 8/4/12 at 1:15 PM. Plan of Removal Resident #17 has an order for [REDACTED]. The order requires that the medication be held if the blood pressure is greater than 120/80 but medication was given when blood pressure was over 120/80. This medication is for the treatment of [REDACTED]. This resident was re-assessed by a Registered Nurse (RN) on 8/3/2012 and the attending physician was updated with the re-assessment findings. The MD gave new order for parameters and times of dose for Midodrine. The care plan was updated 8/3/2012 to reflect approaches to prevent falls related to hypotension. The re-assessment was documented and care plans updated by the RN on 8/3/2012. A list of residents on blood pressure medications was reviewed by the Director of Nurses (DON) or designee on 8/4/2012 to determine other residents on blood pressure medications requiring parameters to be monitored. The number of residents in the facility receiving blood pressure medications totaled 58. The 2 residents specifically identified with MD orders for Midodrine have been re-assessed by RNs on 8/3/2012 to update the plan of care. Medication Order Review Audits to clarify orders were started on 8/2/2012 by visiting DON on 8/3/2012. The re-education by DON of nurses and medication aides was started on 8/2/2012 on Medication Administration, Following MD orders and Med Pass procedures with copies of policies and procedures given to the employees. Med Pass observations by DON were started with nurses and med aides. Med Pass observations by Pharmacist were conducted on 8/3/12 with 5 nurses and medication aides and individual re-education was done during that med pass regarding identified concerns. The Pharmacist identified one med aide that needed further training and she will be individually re-educated by the Nurse Consultant from pharmacy on 8/4/12. Re-education by Nurse Consultant for pharmacy was started on 8/3/12 and will continue thru 8/4/12 with nurses and med aides on medication administration, following MD orders, MD orders with parameters including blood pressure medications, medication error reporting and adverse drug reaction prevention and detection and notification of MD when MD orders including parameters are not followed with copies of inservice, policies and procedures given to the employee. The Nurse Consultant for pharmacy will complete med pass observations and re-education individually based on results of observations with nurses and medication aides starting on 8/3/12 thru 8/4/12. Ongoing, Med Pass observations and individual re-education based on results of observation will be completed three times per week covering each shift by DON or designee with facility nurses and medication aides. The med pass observations with nurses and medication aides will randomly include but not be limited to oral medications, injections, tube feedings, eye drops, nasal sprays or any other MD order that is included on the MAR (Medication Administration Record). MARs audits for in-house residents will be conducted weekly by DON or designee to include MD orders listed on each residents' MARs in order to identify potential medication errors. The MAR audits will compare the MD orders noted on the MAR to the administration recorded by nurses or med aides to verify parameters of medications have been followed per MD order. A Quality Assurance (QA) meeting was held on 8/4/12 at 12:45 AM to review and approve the corrective action taken with no policy changes identified. The Medical Director was notified on 8/4/12 at 12:15 AM of the IJ regarding the resident's medication orders and parameters with no further recommendations were made. The DON is responsible for ongoing compliance through review of corrective actions taken and reporting results of review to QA team for any needed revision. Continuing QA will include review of corrective actions for further interventions monthly for three months. Staff were inserviced on medication errors and physician ordered medication with parameters on 8/3/12 and 8/4/12. The Consultant Pharmacy Manager began observation medication passes on 8/3/12. The DON conducted an observation/teaching medication pass on 8/3/12. MARs audit was conducted by the DON to identify medication orders with parameters. Observation on 8/4/12 at 1:30 revealed Resident # 17 and # 40 MARS had a spot to put the systolic and dystolic blood pressure reading. The Midodrine was moved from the Medication Aid giving the medication to the Licensed Vocational Nurse giving the medication. Both MARS reflected the medication given or held at the specified time, within the appropriate parameters specified by the physician. While the IJ was removed on 8/4/12 at 4:30 PM the facility remained out of compliance at a severity level of potential for more than minimal harm that is not an IJ at a scope of a widespread. The facility had not had time to implement, monitor and evaluate the effectiveness of their Plan of Removal. Review of the CMS 672 reflected a facility census of 105.

Based on observation, interview and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate administering of all drugs to meet the needs of each resident for two (2) of five (5) residents (Residents #6, and #7) reviewed for medication when facility nursing staff; A. Failed to administer Resident #6 Carvedilol, Hydralazine, and Amlodipine (medications for Hypertension) according to the physician ordered parameters. and B. Failed to administer Resident #7 Lisinopril and Zaroxylyn (medications for Hypertension) according to the physician ordered parameters. This deficient practice had the potential to affect 67 residents who receive blood pressure medication administered by facility staff by contributing to non-therapeutic doses of medication, uncontrolled blood pressure, and missed doses of prescribed medications. Findings include: A. Review of Resident #6 ' s Face Sheet reflected an [AGE] year old woman originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #6's Care Plan reflected the plan of care for " Cardiovascular Disease, Hypertension, post Dialysis Hypotension, leg cramping, " and dialysis three times weekly. The approaches included: " administer cardiovascular medication as ordered, " and " obtain blood pressure before giving Coreg (Carvedilol) and Hydralazine and follow orders to hold as indicated on the Medication Administration Record (MAR). " Review of Resident #6 ' s Consolidated physician's order [REDACTED]. Amlodipine (Norvasc) 10 milligram (mg) tab, 1 tab by mouth (po) daily. " ***Check pulse before administering Amlodipine, hold if systolic blood pressure (SBP) lower than 120, or hold if diastolic blood pressure (DBP) lower than 70, or hold if pulse lower than 60*** " Carvedilol (Coreg) 25 mg tab, 1 tab po twice daily (BID). " ***Hold if SBP lower than 100, or hold if DBP lower than 50*** " Hydralazine 25 mg tab (3) po three times daily (TID). Except on dialysis days. " ***hold if SBP lower than 120, or hold if DBP lower than 70*** " In an interview on 11/27/12 at 3:25 PM, the Assistant Director of Nurses (ADON) stated that each medication that was to be administered was to be also documented on the MAR. If the medication was held or not given the Medication Aide (MA) is to initial the MAR on the correct date and time and then circle their initials. On the back side of the MAR the MA should put an explanation as to why the medication was held or not given. The MA was to report to the nurse any medication that were held or not given. Review of Resident #6 ' s November 2012 MAR, in the presence of the with the ADON , reflected 16 documented incidents when a medication was not administered according to the physician's orders [REDACTED]. 11/03/12 at 7:00 AM Amlodipine was documented as administered with a recorded blood pressure of 106/80 millimeters of mercury (mmHg). 11/04/12 at 7:00 AM Amlodipine was documented as administered with a recorded blood pressure of 118/66 mmHg. At 11:00 AM Hydralazine was documented as administered with a recorded blood pressure of 122/62 mmHg. 11/06/12 at 11:00 AM Hydralazine was documented as administered with a recorded blood pressure of 122/62 mmHg. At 3:00 PM both Hydralazine and Carvedilol were documented as administered with a recorded blood pressure of 114/49 mmHg. 11/11/12 at 7:00 AM both Amlodipine and Hydralazine were documented as administered with a recorded blood pressure of 166/64 mmHg. 11:00 AM Hydralazine was documented as administered with a recorded blood pressure of 160/60 mmHg. 11/12/12 at 7:00 AM Amlodipine was documented as administered with a recorded blood pressure of 153/65 mmHg. 11/14/12 at 7:00 AM Amlodipine was documented as administered with a recorded blood pressure of 148/66 mmHg. 11/17/12 11:00 AM Hydralazine was documented as administered with a recorded blood pressure of 111/60 mmHg. 11/18/12 at 7:00 AM both Amlodipine and Hydralazine were documented as administered with a recorded blood pressure of 131/65 mmHg. 11:00 AM Hydralazine was documented as administered with a recorded blood pressure of 128/66 mmHg. 11/24/12 At 3:00 PM Hydralazine was documented as administered with a recorded blood pressure of 115/70 mmHg. In a continued interview on 11/27/12 at 3:25 PM, the ADON stated that she was unable to find documentation on the MAR or in the clinical record as to why the blood pressure medications were given outside of parameters. The ADON confirmed that the 16 doses of medications given outside parameters should have been held and reported to the charge nurse. Review of the November 2012 Nurses Notes for Resident #6 did not reflect any notes regarding blood pressure medications being given outside physician prescribed parameters. In an interview on 11/27/12 at 5:00 PM, Medication Aide (MA) A stated that she had passed medications to Resident #6 on 11/03/12 and 11/04/12. She stated each medication that was supposed to be administered was to be documented on the MAR. If the medication was given the MA was to initial the MAR on the correct date and time; this is to indicate the medication was administered correctly. If the medication was not given or held the MA is to initial the MAR on the correct date and time and then circle their initials. Then, on the back side of the MAR the MA needs to put an explanation as to why the medication was held or not given. The MA was to report to the nurse any medication that were held or not given. MA A stated she takes blood pressure on residents receiving blood pressure meds right before administration of the medication. She stated that the blood pressure medication is held if the blood pressure is lower than the set parameters. She further stated that if a medication is held due to low blood pressure, or for any other reason, she reports this information to the charge nurse immediately. She flags the MAR indicating a medication was held, then reports the information to the charge nurse again at the end of her shift. In an interview on 11/27/12 at 3:25 PM, the Director of Nurses (DON) stated that the facility had started a medication error report for Resident #6 and a facility action plan due to the blood pressure medications being given outside parameters. She stated that Resident #6 had been evaluated by her physician after the errors were found and the resident did not appear to have sustained any injury due to the medication errors. B. Review of Resident #7 ' s Face Sheet reflected a [AGE] year old woman originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #7's Care Plan reflected the plan of care for " Congestive Heart Failure, Atrial Fibrillation, Hypertension and [DIAGNOSES REDACTED]," dated on 09/27/12 to continue this plan of care, reflected the following approaches: " Monitor vital signs as ordered/needed, and administer cardiovascular meds as ordered. " Review of Resident #7 ' s Consolidated physician's order [REDACTED]. Zaroxolyn (Metolazone) 2.5 mg tab, 1 tab PO daily ***Monitor BP with each dose, hold if SBP is lower than 100 or DBP is lower than 60*** Lisinopril (Zestril) 5mg tab, 1 tab PO daily ***Hold if SBP is lower than 100 or DBP is lower than 60*** Review of Resident #7 ' s November 2012 MAR, with the DON, reflected 6 documented incidents when a medication was not administered according to the physician's orders [REDACTED]. 11/01/12 at 9:00 AM Lisinopril and Zaroxolyn were documented as administered with a recorded blood pressure of 127/54 millimeters of mercury (mmHg). 11/05/12 at 9:00 AM Zaroxolyn was documented as administered with a recorded blood pressure of 127/51 millimeters of mercury (mmHg). 11/06/12 at 9:00 AM Lisinopril and Zaroxolyn were documented as administered with a recorded blood pressure of 124/58 millimeters of mercury (mmHg). 11/21/12 at 9:00 AM Zaroxolyn was documented as administered with a recorded blood pressure of 124/58 millimeters of mercury (mmHg). In an interview on 11/27/12 at 5:00 PM, the DON stated that she was unable to find documentation on Resident #7 ' s MAR or in the clinical record as to why the blood pressure medications were given outside of parameters. She stated that on some occasions one medication was given and one medication was held however both medications had the same parameters. The DON confirmed that the 6 doses of medications given outside parameters should have been held. In an interview on 11/27/12 at 5:30 PM, Licensed Vocation Nurse (LVN) B stated she passes medications and was also a Charge Nurse. LVN B reviewed the MARs and confirmed that she passed medication to Resident #6 on 11/06/12 and to Resident #7 on 11/08/12. When asked what the parameters were for the medications she indicated they were printed on the MAR. When asked if the 11/06/12 and 11/08/12 medications were passed within parameters LVN B stated " no, I must have just missed them. " LVN B stated that she was hired " sometime in September, " and had been in orientation until approximately 2 weeks ago. She stated she was a new LVN, and this was her first job as a nurse. She stated that while she was in training and passing medications, she was supervised by a Medication Aide or a Nurse. In a continued interview on 11/27/12 at 5:00 PM, the DON stated that medication administration " is better than it was, but it is not 100% yet. " The DON stated that she had been employed with the facility for two weeks and had created a tool to audit MARs daily, however she had not yet implemented it. Review of in-service education records reflected that on 10/11/12 MA A and on 10/22/12 LVN B both attended the Medication Administration in-service presented by a pharmacy nurse consultant with the following objectives: 1) Med pass policy and procedure, 2) Educate nurses on medication administration, educated certified nurse aides on medication administration, 3) Re-educate regarding medication pass, technique checking the MAR related to the 5 rights of medication administration 4) Review of transcribing orders, clarification of orders, medication errors, ordering medications, and monitoring for adverse side effects. Review of facility policy and procedure on administration of medication titled 7.1 'GENERAL GUIDELINES' dated 09/10 reflected the following: POLICY Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after the have familiarized themselves with the medication. PROCEDURES Medication Administration: 1. Medications are administered in accordance with written orders of the prescriber. If a dose seems excessive considering the resident's age and condition, or a medication order seems to be unrelated to the resident's current [DIAGNOSES REDACTED]. If necessary, the nurse contacts the prescriber for clarification. This interaction with the pharmacy and the resulting order clarification are documented in the nursing notes and elsewhere in the medical record as appropriate. 2. Obtain and record any vital signs as necessary prior to medication administration. This deficiency was previously cited on 08/04/12 at an Immediate Jeopardy (IJ) level @ S/S: "L"/widespread and rewritten on the 1st Onsite revisit dated 10/05/12 @ S/S: "E"/pattern. This deficient practice remains uncorrected. Facility provided a list that reflected 67 residents who are receiving blood pressure medications.

Based on observation, interview, and record review the facility failed to consult and immediately notify 1 of 7 resident's (Resident #7) physician and responsible party when Resident #7 developed clinical signs and symptoms of aspiration while eating in the facility's dining room when he was served a diet of incorrect consistency. Resident #7, who was assessed by the facility as being at risk for aspiration, had an order from his physician to receive a mechanical soft diet with ground meat and nectar thickened liquids. For lunch, on 7/30/12 at 12:30 PM, he received large chunks of sliced tomatoes in juice, shredded turkey, slices of canned pears and an unthickened drink with ice. Resident #7 began coughing, and his eyes and nose began to run after beginning to eat his meal. The physician and the responsible party were not notified until 9:30 PM that same day. This resulted in an Immediate Jeopardy (IJ) on 7/30/12. While the IJ was lowered on 7/31/12, the facility remained out of compliance at a severity level of potential for more than minimal harm that is not an IJ at a scope of a pattern because the facility had not had time to implement, monitor and evaluate the effectiveness of their Plan of Removal. This deficient practice had the potential to result in delay of physician intervention and medical treatment and could place 22 additional residents at risk for aspiration pneumonia, who had orders to receive a mechanical soft diet. Findings include: Review of the Facesheet reflected Resident # 7 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the current Care Plan dated 5/31/12 reflected Resident #7 was at risk for aspiration due to Dysphagia. The onset date was 9/12/11. Approaches listed were as follows: *Staff Note: Resident has dysphagia - trouble swallowing. *Diet order: NAS (no added salt), Mechanically soft with nectar thick liquids/ NO STRAWS Texture: Ground Meat *Feed in upright position and maintain upright position for one (1) hour after eating when possible to reduce risk of aspiration/choking. Review of the [DIAGNOSES REDACTED]. Review of the current, consolidated, Physician order [REDACTED]. Texture: Ground Meat, Liquids: Nectar, with additional [DIAGNOSES REDACTED]. Review of the Diet Order Form dated 3/8/12 reflected Resident #7 was to be assisted while eating. He was to receive a mechanical diet with ground meat (dysphasia) and nectar thickened liquids. Review of the Comprehensive Nutritional assessment dated [DATE] reflected Resident #7 had [DIAGNOSES REDACTED]. The Diet order was NAS, Mechanically Soft with nectar thick liquids and no straws. Under the Oral Condition section it reflected that Resident #7 had difficulty swallowing. Observation of meal service on 7/30/12 at 12:15 PM revealed that Resident #7 was the fourth resident to be served. Resident #7 received large chunks of sliced tomatoes in juice and pulled apart, stringy turkey (shredded) on his plate. In a separate bowl, Resident #7 was served slices of canned pears. The red colored drink in front of Resident #7 had ice in it. The resident had a special spoon and was attempting to put whole pieces of tomato and large bites of turkey into his mouth. Review of Resident #7's diet card, located on the table next to his plate, on 7/30/12 at 12:15 PM, reflected Resident #7 was to have a mechanical soft, NAS, nectar liquids and fortified food diet with no straws. Resident #7's menu on the card reflected the following: Ground Roast Turkey, scalloped tomatoes, sage bread dressing, dinner roll/bread, margarine, applesauce and pureed nectar orange. Observation in the dining room on 7/30/12 at 12:30 PM revealed Resident #7 coughing with his eyes watering, and his nose running, Certified Nurses Aid (CNA) Q walked over to Resident #7's table after being alerted by a Surveyor. CNA Q stated, "looks like you need more napkins." Resident #7 had large amounts of food in his lap. Licensed Vocational Nurse (LVN) A walked over and looked at Resident #7. She then encouraged him to drink and take another bite, and walked away from the Resident #7. Observation on 7/30/12 at 1:00 PM revealed Resident #7 laying flat on his bed without supervision. Observation in the dining room on 7/30/12 at 5:30 PM, before he had received his evening meal, revealed CNA W served a glass of unthickened cranberry juice with ice in it to Resident #7. Observation on 7/30/12 at 5:40 PM revealed Resident #7 was served the following meal: an egg salad sandwich cut in half, a pickle spear, vegetable medley/"Creamy Ranch Medley" (chopped carrots, peas, corn, and lima beans and green beans mixed with ranch dressing), and ice cream. Resident was taking bites of the sandwich without swallowing or chewing, and large portions were falling out of his mouth onto his chin and lap. Resident #7 picked up the pickle spear and bit the end off, attempted to chew/swallow, causing him to cough with his eyes watering. There was no staff member near by monitoring Resident #7 while he was eating. A mechanically soft test tray was received on 7/30/12 at 5:50 PM. The vegetables in the vegetable medley were raw, stiff, hard and crunchy. Review of the Menu Guide Report dated 7/30/12 reflected the dinner menu as Cream of Mushroom Soup, Saltine Crackers, Egg Salad Sandwich, Creamy Vegetable Salad, Ice Cream, and Milk. In an interview on 7/30/12 at 6:45 PM the Registered Dietician (RD) stated that for a resident who was on a mechanically soft diet, a pickle spear, should not be on their meal tray. She further stated that generally raw vegetables would not be given with a mechanical soft diet, and that staff should always refer to the menu that says what those residents could have to eat. Review of the Nurses' Notes dated 7/30/12 at 9:30 PM "Late entry for 8:30 PM" reflected that the charge nurse assessed Resident #7 and he was noted with wheezing in his right upper lung and the physician was called. At 9:30 PM the on call physician returned the call and at 9:35 PM Resident #7's responsible party was notified of the incident. Review of the 24 Hour Report dated 7/30/12 reflected that the choking incident of Resident #7 was not documented on the report. In an interview on 8/01/12 LVN X stated that she heard about Resident #7's choking incident that happened on 7/30/12 on 7/31/12. She further stated that she was never notified on 7/30/12 of the choking incident. LVN X went on to state that she was assigned to Resident #7's hall the day that he choked in the dining room, but nobody told her about it. In an interview on 7/30/12 at 8:30 PM LVN C, who was assigned to Resident #7's hall, stated that nothing had been reported to him about an incident in the dining room regarding Resident #7. He further stated that during shift change they walk the halls with the preceding shift and give report of any changes with the residents. LVN C did not go assess Resident #7 at that time but went to the staff break room. In an interview on 7/31/12 at 5:23 PM LVN A stated that while in the dining room on 7/30/12 during lunch, a CNA came up to her and said that someone may be choking. Resident #7 coughed a few times, but she believed that he was Ok. She further stated that she reported what had happened to LVN H. LVN A stated that it was normal for Resident #7 to have a runny nose and watering eyes when he ate his meals. She further stated that LVN H took over for her in the dining room from 12:30 to 12:45 PM, and that LVN X was assigned to Resident # 7 ' s hall. LVN A stated that she did not report the choking incident to LVN X. When asked what the sign and symptoms of aspiration were LVN A stated that a person would have watery eyes and not be breathing. She further stated that she was responsible for checking residents trays to make sure that they received the appropriate diet ordered for them. She further stated that the way the turkey was at lunch on 7/30/12 was what the kitchen was calling ground. When asked what the turkey looked like to her, she stated that it looked chopped. In an interview on 7/30/12 at 8:45 PM the Assistant Director of Nursing (ADON) stated that she was told lunch had not gone well. She stated that a CNA told her that residents in the dining room had received chopped meat when they should have received ground meat. The ADON further stated that Resident #7 had a problem swallowing and that he may have choked on some of his food. She stated that the nurse from Resident #7's hall (LVN C) checked him out but he was fine. She further stated that Resident #7 did cough his food up at times. The ADON stated that if the nurse finds a resident choking they should make sure the resident was breathing and coughing, and that the nurse should listen to breath sounds and assess the resident's mouth to make sure everything was out. She further stated, "that's why we have a nurse in the dining room" in case there are any problems. The ADON stated, "we do have several residents that cough during meals." The ADON stated that coughing while eating could cause aspiration. When asked what the nurses role in the dining room was, she stated that the nurse should check the resident's diet card and make sure it matches what is on the resident's plate. When asked what the definition of aspiration was, she stated you would hear wet sounds in the lungs, possibly gurgly sounds, and that when someone does choke in the dining room that they would get an x-ray ordered and notify the physician. She further stated that the nurse who assessed the resident should chart in the residents chart, put it on the 24 hour report, and notify the oncoming nurse on rounds. The ADON stated that LVN A should have listened to Resident #7's breath sounds and taken his oxygen saturation level. She further stated that the resident should then be monitored closely for 24 hours. In an interview on 7/30/12 at 9:05 PM the Administrator stated she was told that Resident #7 choked a little in the dining room during lunch. She further stated that they would be getting a chest x-ray in the morning. The facility's Administrator and ADON were informed that an IJ existed on 7/30/12 at 9:07 PM due to the facility's failure to immediately notify Resident #7's physician and responsible party when Resident #7 displayed clinical signs and symptoms of Aspiration while eating his noon meal on 7/30/12. In an interview on 7/31/12 at 2:45 PM the Speech Language Pathologist (SLP) stated that she looked at Resident #7 during breakfast and lunch. He was eating large bites and eating very quickly. She further stated that his tray was not delivered until 12:45 PM so she figured he was pretty hungry. She stated that Resident #7 should be kept upright for at least 20 minutes after eating. She further stated that Resident #7 went to the hospital in March 2012 for Pneumonia. She stated that she gave the diet change to the kitchen and that his meat should be "very ground." The SLP further stated that "chopped" means that the chops should be no bigger than a ? inch. She stated that the vegetables should be very tender, no raw vegetables at all and that even green beans should be cut up smaller. The SLP further stated that with a resident on a Nectar thickened diet, the resident should not receive any ice in a glass, nor any jello or ice cream. Observation on 7/31/12 at 7:10 AM revealed Resident #7 sitting in his wheelchair at a table in the dining room with another resident. He was drinking an unthickened nutritional drink from a bottle. There were no staff members in the dining room to monitor him. Observation on 7/31/12 at 8:15 AM revealed staff in the dining room begin passing breakfast trays to the residents. Resident #7 was the fourth resident served. Included in Resident #7's breakfast meal was a whole slice of toast. In an interview on 7/31/12 at 3:10 PM the Nurse Practitioner (NP) stated that if a resident was suspected of aspirating, the nurse should assess the residents lung sounds, oxygen saturation and vital signs. She stated that signs and symptoms of aspiration could include, drooling, coughing, hoarseness and the resident's nose running. She stated that the drooling and runny nose would occur because the fluids had nowhere else to go. She stated that if aspiration was suspected, a chest x-ray could be done but probably would not show anything for about 24 hours. In an interview on 7/31/12 at 3:20 PM the interim Director of Nurses (DON) stated that she was being told that Resident #7 "does this all the time." Review of the Telephone Orders dated 7/31/12 reflected Resident #7's diet was changed to pureed. Observation on 8/1/12 at 12:50 PM revealed Resident #7 sitting in the dining room, using his butter knife to scoop a pureed sugar cookie out of a bowl. Food was dripping off of his chin and liquid was draining out of the right side of his mouth. Staff in the dining room were busy delivering trays at this time. Resident #7 had episodes of coughing throughout the meal with no supervision. Resident #7 did not receive any assistance or monitoring at this time. Observation on 8/1/12 at 1:00 PM the SLP walked over and sat next to Resident #7. She stated that she was going to try and set him up for a swallow study. In an interview on 8/1/12 at 12:50 PM the Medical Director stated that she was not Resident #7's primary physician. She stated that she had not really been informed of the incident with Resident #7 and was not informed that the facility was in an IJ situation. She stated that she had not spoken to staff yet. She further stated that signs and symptoms of aspiration included: cough, difficulty breathing, cyanosis, watery eyes, nasal drainage, and drooling. She stated that the staff should stop the resident from eating and drinking and assess the resident ' s respirations, oxygen saturation and vital signs. She stated that if the resident was stable a chest x-ray could be ordered but if not, the resident should be sent to the Emergency Department. The Medical Director further stated that the resident should be monitored for 24 to 48 hours for the development of fever or wheezing which may represent aspiration Pneumonia. In an interview on 8/4/12 at 11:50 AM the ADON stated that a follow up x-ray for Resident #7 had not been ordered by his physician. Review of a Food and Nutrition Services Department In-Service titled Mechanical Soft Diet dated 7/30/12 reflected the following brief outline of subject matter: *Meats are ground to ground meat consistency *Gravies, Broths, Sauces used to keep meat moist , tender *Fruits/Vegetables - served soft, diced, or chopped or shredded *Omit Nuts, Potato chips, coconut *CHECK MENU EXTENSIONS Resident may be restricted further upon speech therapy review Mechanical Soft Diet The mechanical soft diet is designed to minimize the amount of chewing necessary to ingest food and to increase the ease of swallowing. The facility provided the following final plan of removal on 7/31/12 at 6:00 PM and was accepted on 7/31/12 at 6:20 PM. Plan of Removal "Resident #7 was assessed on 7/30/12 by Respiratory Therapist (RT) and (LVN) at 8:30 PM and by the Assistant Director of Nurses (ADON), RN (Registered Nurse) at 9:45 PM for lung sounds, O2 (oxygen) saturation, vital signs and skin color changes. The MD was called at 9:30 PM and return call was received from another MD, the on call physician at 9:45 PM. A physician order [REDACTED]. Resident was sent out by EMS at 10:58 PM. Resident returned to the facility with no new orders at 2:20 AM. Per report of ER nurse, chest x-ray and all lab work done at ER "came back fine". The facility received the written results of the x-ray at 10:15 AM which reported "the lungs are well aerated. No evidence of active [MEDICATION NAME] (in the thorax or chest) disease seen". ADON audited facility residents (See Attachment #1) to determine those at high risk for aspiration/choking (See Attachment #2) based on altered diets,tracheotomy and tube feeding orders. Nursing Administration team members including Medical Records Clerk, LVN; Staff Development Coordinator, LVN; Treatment Nurse, LVN; and Nurse Supervisor, LVN assessed residents with potential high risk for aspiration starting on 7/30/12 at 11:15 PM to include vital signs, lung sounds, change in skin color and O2 saturation. Residents identified as potential high risk for aspiration will be evaluated by ST and/or RT beginning on 7/30/12 to be completed on 7/31/12. Care plans to be updated by MDS (Minimum Data Set) nurse, RN as appropriate based on assessment results on 7/31/12 which included updates to care plans for one of the following:potential for aspiration, [MEDICAL CONDITION], tube feedings or altered diets. Re-education started on 7/30/12 with dietary staff including Dietary Manager, cooks, and dietary aides regarding altered diets at approximately 1:30 PM by Registered Dietitian. Re-education was started 7/30/12 at approximately 10:00 PM by Staff Development Coordinator, LVN on notification of any potential aspiration/choking incidents, signs & symptoms of aspiration (University of Wisconsin Hospitals and Clinicals Authority), monitoring for 72 hours following incident, notification of physician and responsible party (RP) as practicable following incident and physician diet order and tray card reconciliation by dietary manager at least monthly and with new order changes. Evaluation of the training will be done by completing skills assessments with nurses for appropriate follow up for potential aspirations including vital signs, skin color changes, O2 saturation and lung sounds as well as RP and MD notification to determine effectiveness of education. These skills assessments will be initiated on 7/31/12 and ongoing by the Staff Development Coordinator, LVN with facility nurses. Staff re-education on 7/31/12 to include education of care plan approaches for those identified at high risk of aspiration such as time frames of staying up after meals. Dietary tray cards will be reconciled with the meal plated prior to serving resident meal by dietary staff preparing tray and nursing/CNA (Certified Nurse Aide) staff receiving tray from kitchen. Physician diet orders and dietary tray card reconciliation was completed on 7/30/12 by the Registered Dietitian and Dietary Manager. Meal observations by nursing administration and department heads to include Nurse Supervisor, Treatment Nurse, Social Services, Staff Development Coordinator, Medical Records Clerk, RN Supervisor, DON and Administrator will be initiated on 7/31/12. Meal Observations will be completed three times a day for two weeks and then at minimum once daily thereafter. A Quality Assurance (QA) meeting was held on 7/31/12 at 2:00 AM to review and approve the corrective actions taken with no policy changes identified. The Medical Director was notified on 7/30/12 at 10:15 PM of the corrective actions being implemented were with no recommendations made. The DON is responsible for ongoing compliance through review of corrective actions taken and reporting results of review to QA team for any needed revision. Continuing Quality Assurance will include review of corrective actions for further interventions monthly for three months." Review of inservices reflected the facility began inservicing all staff about Signs and Symptoms of Aspiration, Policy and Procedure for Choking, Diet Accuracy, Mechanical Soft Diets and Physician Notification on 7/30/12. The facility began a chart audit to identify any residents at risk for aspiration/choking on 7/30/12. Forty three residents were identified by the facility as potentially high risk for aspiration. During an interview on 7/31/12 at 3:00 PM, CNA R stated that she attended the mandatory staff in-service on choking and aspiration. She described signs and symptoms of choking and aspiration as runny nose, watery eyes, cough, and difficulty breathing. When asked what she would do if she saw a resident with these signs and symptoms, she stated she would pull the call light in a room for help, put the head of the bed up, or go for a nurse for assistance. She also stated she would see if she could remove what is in the resident ' s mouth. During an interview 07/31/12 at 3:20 PM, Medication Aid (MA) S stated that she had attended the mandatory staff in-service on choking and aspiration. MA S described the signs and symptoms of choking and aspiration as red face, change in demeanor, drooling, and nasal drainage. When asked what she would do if she saw a resident with these signs and symptoms, she stated she would call for a nurse and attempt to remove food or an object out of the resident ' s mouth. During an interview 07/31/12 at 3:35 PM, Restorative Nurses Aide (RNA) T stated that she had attended the mandatory staff in-service on choking and aspiration. RNA T described the signs and symptoms of choking and aspiration as runny nose and coughing. When asked what she would do if she saw a resident with these signs and symptoms she stated she would call for a nurse would not give the resident anything else to eat. During an interview on 7/31/12 at 3:40 PM, CNA U stated that she attended the mandatory staff in-service on choking and aspiration. CNA U described signs and symptoms of choking and aspiration as runny nose, red watery eyes, coughing, gurgle or hoarse voice. When asked what she would do if she saw a resident with these signs and symptoms, she stated she would call for the nurse, keep the resident away from the food and attempt to remove the food. During an interview on 7/31/12 at 3:45 PM, CNA V stated that she attended the mandatory staff in-service on choking and aspiration. CNA V described signs and symptoms as hand to throat, red face, coughing, labored breathing and drooling. When asked what she would do if she saw a resident with these signs and symptoms, she stated she would call for a nurse and attempt to remove the food or object from the resident's mouth. While the IJ was removed on 7/31/12 at 6:20 PM the facility remained out of compliance at a severity level of potential for more than minimal harm that is not an IJ at a scope of a pattern. The facility had not had time to implement, monitor and evaluate the effectiveness of their Plan of Removal. Review of the CMS 672 reflected a facility census of 105. The facility provided a list of 22 residents with physician orders [REDACTED].

Based on observation, interview and record review the facility failed to ensure 4 of 7 residents (Residents #7, #10, #12 and #34) received food prepared in a form designed to meet their individual needs when: 1.) Resident #7 had a [DIAGNOSES REDACTED]. He was served large chunks of sliced tomatoes in juice, shreaded turkey, slices of canned pears and an unthickened drink with ice in it by facility staff. Resident #7 developed clinical symptoms of aspiration (coughing, and his eyes and nose began to run) during this meal. 2.) Resident #10 had a [DIAGNOSES REDACTED]. He had a Physician order [REDACTED]. On 7/30/12 Resident #10 received an evening meal of an egg salad sandwich, pickle spear, vegetable medley (undercooked chopped carrots, peas, corn, green beans and lima beans mixed with a thick ranch dressing), and ice cream. He exhibited coughing during the meal and was taken to his room without finishing the vegetable medley. 3.) Resident #12 required total care, was hand fed by staff and was to receive a mechanical soft diet with ground meat. She was served large canned sliced tomatoes, shredded turkey and a bowl of canned, sliced pears by facility staff. 4.) Resident #34 had a [DIAGNOSES REDACTED]. She was served large, canned, sliced tomatoes, shreaded turkey, and a bowl of canned, sliced pears by facility staff. This resulted in an Immediate Jeopardy (IJ) on 7/30/12. While the IJ was lowered on 7/31/12, the facility remained out of compliance at a severity level of potential for more than minimal harm that is not an IJ at a scope of a pattern because the facility had not had time to implement, monitor and evaluate the effectiveness of their Plan of Removal. This deficient practice could result in choking or aspiration for 22 residents identified by the facility as having physician's orders [REDACTED]. Findings include: 1.) Review of the Facesheet reflected Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED]. Review of the current Care Plan dated 5/31/12 reflected Resident #7 was at risk for aspiration due to Dysphagia. The onset date was 9/12/11. Approaches listed were as follows: *Staff Note: Resident has dysphagia - trouble swallowing. *Diet order: NAS (no added salt), Mechanically soft with nectar thick liquids/ NO STRAWS Texture: Ground Meat *Feed in upright position and maintain upright position for one (1) hour after eating when possible to reduce risk of aspiration/choking. Review of the current, consolidated Physician order [REDACTED]. Texture: Ground Meat, Liquids: Nectar, with additional [DIAGNOSES REDACTED]. Review of the Diet Order Form dated 3/8/12 reflected Resident #7 was to be assisted while eating. He was to receive a mechanical diet with ground meat (dysphasia) and nectar thickened liquids. Review of the Comprehensive Nutritional assessment dated [DATE] reflected Resident #7 had [DIAGNOSES REDACTED]. Under the Oral Condition section it reflected that Resident #7 had difficulty swallowing. Observation of meal service on 7/30/12 at 12:15 PM revealed that Resident #7 was the fourth resident to be served. Resident #7 received large chunks of sliced tomatoes in juice and pulled apart, stringy turkey on his plate. In a separate bowl, Resident #7 was served slices of canned pears. The red colored drink in front of Resident #7 had ice in it. The resident had a special spoon and was attempting to put whole pieces of tomato and large bites of turkey in his mouth. Review of Resident #7's diet card, located on the table next to his plate, on 7/30/12 at 12:15 PM reflected Resident #7 was to have a mechanical soft, NAS, nectar liquids and fortified food diet with no straws. Resident #7's menu on the card reflected the following: Ground Roast Turkey, scalloped tomatoes, sage bread dressing, dinner roll/bread, Margarine, applesauce and pureed nectar orange. Observation on 7/30/12 at 12:30 PM revealed Resident #7 coughing with his eyes watering, and his nose running, CNA Q walked to Resident #7's table after being alerted by the RN Surveyor. CNA Q stated, "looks like you need more napkins." Resident #7 had large amounts of food in his lap. LVN A walked over and looked at Resident #7. She then encouraged him to drink and take another bite, and walked away from the Resident #7. Observation in the dining room on 7/30/12 at 5:30 PM, before he had received his evening meal, revealed CNA W serve a glass of unthickened cranberry juice with ice in it to Resident #7. Observation on 7/30/12 at 5:40 PM revealed Resident #7 was served the following meal: an egg salad sandwich cut in half, a pickle spear, vegetable medley/"Creamy Ranch Medley" (chopped carrots, peas, corn, and lima beans and green beans mixed with ranch dressing), and ice cream. Resident was taking bites of the sandwich without swallowing or chewing, large portions falling out of his mouth onto his chin and lap. Resident #7 picked up the pickle spear and bit the end off, attempted to chew/swallow, causing him to cough with his eyes watering. There was no staff member near by monitoring Resident #7 while eating. A mechanical soft test tray was received on 7/30/12 at 5:50 PM. The vegetables in the vegetable medley were raw; stiff, hard and crunchy. In an interview on 7/30/12 at 6:45 PM the Registered Dietician (RD) stated that for a resident who was on a mechanically soft diet, a pickle spear, should not be on their meal tray. She further stated that generally raw vegetables would not be given with a mechanical soft diet, and that staff should always refer to the menu that says what those residents could have. Review of the 24 Hour Report dated 7/30/12 reflected that the choking incident of Resident #7 was not documented on the report. In an interview on 8/01/12 LVN X stated that she heard about Resident #7's choking incident yesterday on 7/31/12. She further stated that she was never notified on 7/30/12 of the choking incident. LVN X went on to state that she was assigned to Resident #7's hall the day that he choked in the dining room, but nobody told her about it. In an interview on 7/30/12 at 8:30 PM LVN C, who was assigned to Resident #7's hall, stated that nothing had been reported to him about an incident in the dining room regarding Resident #7. He further stated that during shift change they walk the halls with the preceding shift and give report of any changes with the residents. LVN C did not go assess Resident #7 at that time but went to the staff break room. In an interview on 7/30/12 at 8:45 PM the Assistant Director of Nursing (ADON) stated that she was told lunch hadn't gone well. She stated that a CNA told her that residents in the dining room had received chopped meat when they should have received ground meat. The ADON further stated that Resident #7 had a problem swollowing and that he may have choked on some of his food. She stated that the nurse from Resident #7's hall (LVN C) checked him out but he was fine. She further stated that Resident #7 did cough his food up at times. The ADON stated that if the nurse finds a resident choking they should make sure the resident was breathing and coughing, and that the nurse should listen to breath sounds and assess the resident's mouth to make sure everything was out. She further stated, "that's why we have a nurse in the dining room" in case there are any problems. The ADON stated, "we do have several residents that cough during meals." The ADON stated that coughing while eating could cause aspiration. When asked what the nurses role in the dining room was, she stated that the nurse should check the resident's diet card and make sure it matches what is on the resident's plate. When asked what the definition of aspiration was, she stated you would hear wet sounds in the lungs, possibly gurgly sounds, and that when someone does choke in the dining room that they would get an x-ray ordered and notify the physician. She further stated that the nurse who assessed the resident should chart in the residents chart, put it on the 24 hour report, and notify the oncoming nurse on rounds. The ADON stated that LVN A should have listened to Resident #7's breath sounds and taken his Oxygen saturation level. She further stated that the resident should then be monitored closely for 24 hours. In an interview on 7/30/12 at 9:05 PM the Administrator stated she was told that Resident #7 choked a little in the dining room during lunch, she further stated that they would be getting a chest x-ray in the morning. In an interview on 7/31/12 at 2:45 PM the Speech Language Pathologist (SLP) stated that she looked at Resident #7 during breakfast and lunch. He was eating large bites and eating very quickly. She further stated that his tray was not delivered until 12:45 PM so she figured he was pretty hungry. She stated that Resident #7 should be kept upright for at least 20 minutes after eating. She further stated that Resident #7 went to the hospital in March 2012 for Pneumonia. She stated that she gave the diet change to the kitchen and that his meat should be "very ground." The SLP further stated that "chopped" means that the chops should be no bigger than a ? inch. She stated that the vegetables should be very tender, no raw vegetables at all and that even green beans should be cut up smaller. The SLP further stated that with a resident on a Nectar thickened diet, the resident should not receive any ice in a glass, jello or ice cream. In an interview on 7/31/12 at 5:23 PM LVN A stated that while in the dining room on 7/30/12 during lunch, a CNA came up to her and said that someone may be choking. Resident #7 coughed a few times, but she believed that he was ok. She further stated that she reported what had happened to LVN H. LVN A stated that it was normal for Resident #7 to have a runny nose and watering eyes when he ate his meals. She further stated that LVN H took over for her in the dining room from 12:30 PM to 12:45 PM, and that LVN X was assigned to Resident # 7's hall. LVN A stated that she did not report the choking incident to LVN X. When asked what the sign and symptoms of aspiration were LVN A stated that a person would have watery eyes and not be breathing. She further stated that she was responsible for checking residents trays to make sure that they received the appropriate diet ordered for them. She further stated that the way the turkey was at lunch on 7/30/12 was what the kitchen was calling ground. When asked what the turkey looked like to her, she stated that it looked chopped. Observation on 7/31/12 at 7:10 AM revealed Resident #7 sitting in his wheelchair at a table in the dining room with another resident. He was drinking a nutritional milk shake from a bottle. There were no staff members in the dining room at the time. Observation on 7/31/12 at 8:15 AM revealed staff in the dining room begin passing breakfast trays to the residents. Resident #7 was the fourth resident served. Included in Resident #7's breakfast meal was a whole slice of toast. In an interview on 7/31/12 at 3:10 PM the Nurse Practitioner (NP) stated that if a resident was suspected of aspirating, the nurse should assess the residents lung sounds, oxygen saturation and vital signs. She stated that signs and symptoms of aspiration could include, drooling, coughing, hoarseness and the resident's nose running. She stated that the drooling and runny nose would occur because the fluids had nowhere else to go. She stated that if aspiration was suspected, a chest x-ray could be done but probably would not show anything for about 24 hours. In an interview on 7/31/12 at 3:20 PM the interim Director of Nurses (DON) stated that she was being told that Resident #7 "does this all the time." Review of the Telephone Orders dated 7/31/12 reflected Resident #7's diet was changed to a pureed diet. Observation on 8/1/12 at 12:50 PM revealed Resident #7 sitting in the dining room, using his butter knife to scoop a pureed sugar cookie out of a bowl. Food was dripping off of his chin and liquid was draining out of the right side of his mouth. Resident #7 had episodes of coughing throughout the meal. Observation on 8/1/12 at 1:00 PM the LSP walked over and sat next to Resident #7. She stated that she was going to try and set him up for a swallow study. In an interview on 8/1/12 at 12:50 PM the Medical Director stated that signs and symptoms of aspiration included: cough, difficulty breathing, cyanosis, watery eyes, nasal drainage, and drooling. She stated that the staff should stop the resident from eating and drinking and assess the resident ' respirations, oxygen saturation and vital signs. She stated that if the resident was stable a chest x-ray could be ordered but if not, the resident should be sent to the Emergency Department. The Medical Director further stated that the resident should be monitored for 24 to 48 hours for the development of fever or wheezing which may represent aspiration Pneumonia. Review of the Nurses' Notes dated 7/30/12 at 9:30 PM "Late entry for 8:30 PM" reflected Resident #7 was noted with wheezing in his right upper lung. In an interview on 8/4/12 at 11:50 AM the ADON stated that a follow up x-ray for Resident #7 had not been ordered by his physician. Review of a Food and Nutrition Services Department In-Service titled Mechanical Soft Diet dated 7/30/12 reflected the following brief outline of subject matter: *Meats are ground to ground meat consistency *Gravies, Broths, Sauces used to keep meat moist , tender *Fruits/Vegetables - served soft, diced, or chopped or shredded *Omit Nuts, Potato chips, coconut *CHECK MENU EXTENSIONS Resident may be restricted further upon speech therapy review Mechanical Soft Diet The mechanical soft diet is designed to minimize the amount of chewing necessary to ingest food and to increase the ease of swallowing. 2.) Review of Resident #10'S Consolidated physician's orders [REDACTED]. Review of Resident #10's Consolidated physician's orders [REDACTED]. Review of Resident #10's Quarterly Minimum Data Set ((MDS) dated [DATE] reflected that Resident #10 requires "Supervision: oversight, encouragement, or cueing" while eating. The MDS also reflects that Resident #10 is coded as having a swallowing disorder and has a mechanically altered therapeutic diet. Review of Resident #10's Care Plan dated 12/06/11 for the problem/need "At low nutritional risk due to therapeutic diet. Resident is on a heart healthy, no salt added diet. Resident meets ideal body weight and eats 100% at most meals." Approaches listed 'Diet Order: mechanical soft diet with fortified foods, ground meat, regular liquids, large portions, plate guard, specialized bowl, and may not have a regular diet on special occasions'. Resident #10 does not have a specific plan of care related to his [DIAGNOSES REDACTED]. Observation on 7/30/12 at 5:09 PM revealed Resident #10 in his wheelchair in the dining room receiving oxygen by nasal cannula. He was coughing at intervals however; was not eating his meal of an egg salad sandwich, pickle spear, vegetable medley (chopped carrots, peas, corn, green beans and lima beans mixed with a thick ranch dressing), which appeared undercooked and ice cream. The vegetable medley contained green bean pieces, some over half an inch long. RNA P was encouraging him to eat and attempting to assist however; Resident #10 was trying to leave the table. Observation on 07/30/12 at 5:27 PM revealed Resident #10 at a dining room table. Resident #10 began coughing and his eyes were watery. Resident #10 was moved from the dining room to his bedroom by an unidentified staff member without finishing his meal. Resident #10 was left in his room without monitoring or assessment. Review of Resident #10's Nurses Notes did not reflect any assessment on 07/30/12 following the dinner meal. 3.) Record Review of Resident #12's Facesheet, dated 07/11/11, reflected she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record Review of Resident #12's Minimum Data Set ((MDS) dated [DATE] reflected that Resident #12 was total care, non-verbal and was required to be fed by staff. Review of the most current physician ordered diet for Resident #12 dated 6/7/11 reflected she was to receive a mechanical soft diet with ground meat. Observation in the dining room on 7/30/12 at 12:20 PM revealed Resident #12 was served large canned, sliced tomatoes, shredded turkey, and a bowl of canned sliced pears. Observation on 07/30/12 at 12:45 PM revealed the Resident had a diet card on her table which read "Regular Mechanical Soft Fortified Diet" and listed on the card was "Ground Roast Turkey". Resident #12 had shredded turkey instead of ground turkey on her plate. Record review of Resident #12's current consolidated Physician order [REDACTED]." 4. Review of the Facesheet reflected Resident #34 was admitted on [DATE] and readmitted on [DATE] with the [DIAGNOSES REDACTED]. Review of the most current physician ordered diet for Resident #34 dated 5/4/12 reflected she was to receive a mechanical soft diet with ground meat. Review of the diet card dated 7/30/12 reflected that Resident #34 was on a Mechanically Soft diet with Ground meat. Observation on 7/30/12 at 12:23 PM revealed Resident #34 received large, canned, sliced tomatoes, shreaded turkey, and a bowl of canned, sliced pears. Review of the undated policy on Emergency Care - Obstructed Airway - Choking reflected the following: Policy: Emergency care will be given by staff instructed on procedure. Purpose: To relieve foreign body airway obstruction. Symptoms: Wheezing, gasping, coughing. Cannot speak or breathe, places hands to throat to signal choking, collapse. A person who has completely blocked airway - cannot breathe, cough or speak. Charge Nurse will notify physician. Charge Nurse will notify family of the resident. Charge Nurse will document observations, notifications, and procedures completed, in the resident's Medical Record. Review of the undated Diet Accuracy policy reflected the following: Tray cards are to be used on the tray line for service and checked prior to leaving the kitchen for accuracy. Prior to serving the tray, the nurse aide must check the tray card to assure that the correct tray is being served to the resident. If there is doubt, the charge nurse should be notified and the chart checked for the current physician's orders [REDACTED]. The Director of Nursing Services and the Nutrition Services Director with input from the Dietitian must review the resident's nutritional problems and coordinate all resolutions. Recommendations must be presented to the attending physician for his or her approval. Review of the undated policy on Mechanical Soft Diet's reflected the following: The mechanical soft diet is designed to minimize the amount of chewing necessary to ingest food and to increase the ease of swallowing. The diet is used for those individuals with chewing and swallowing problems due to irritation of the mouth, lack of teeth, surgery, therapy or dysphagia. Candidates for this diet can tolerate a greater variety and texture of foods than a blenderized or pureed diet offers. Grinding foods with a commercial food processor can modify the texture of foods. If dysphagia is suspected, a swallowing evaluation should be performed and the diet individualized based on swallowing alterations. MEAL PLANNING GUIDELINES Follow the Regular Diet with the following changes: ? Meats are ground to the consistency of ground meat. ? Gravies, broths, and sauces may be added to meats to moisten ? Serve soft, diced, chopped, slices or shredded fruits and vegetables ? Omit nuts, seeds, coconut and potato chips ? Dietitian/Speech Therapist will customize foods based on individual tolerance. The facility's Administrator and ADON were informed that an IJ existed on 7/30/12 at 9:07 PM due to the facility's failure to ensure residents at risk for choking and aspiration were served food of the appropriate consistency. The facility provided the following plan of removal on 7/31/12 at 6:00 PM and accepted on 7/31/12 at 6:20 PM. Plan of Removal Resident #7 was assessed on 7/30/12 by Respiratory Therapist (RT) and Licensed Vocational Nurse (LVN) at 8:30 PM and by the Assistant Director of Nurses (ADON), RN (Registered Nurse) at 9:45 PM for lung sounds, O2 (oxygen) saturation, vital signs and skin color changes. The MD was called at 9:30 PM and return call was received from another MD, the on call physician at 9:45 PM. A physician order [REDACTED]. Resident was sent out by EMS at 10:58 PM. Resident returned to the facility with no new orders at 2:20 AM. Per report of ER nurse, chest x-ray and all lab work done at ER "came back fine". The facility received the written results of the x-ray at 10:15 AM which reported "the lungs are well aerated. No evidence of active [MEDICATION NAME] disease seen". ADON audited facility residents (See Attachment #1) to determine those at high risk for aspiration/choking (See Attachment #2) based on altered diets,tracheotomy and tube feeding orders. Nursing Administration team members including Medical Records Clerk, LVN (Licensed Vocational Nurse); Staff Development Coordinator, LVN; Treatment Nurse, LVN; and Nurse Supervisor, LVN assessed residents with potential high risk for aspiration starting on 7/30/12 at 11:15 PM to include vital signs, lung sounds, change in skin color and O2 saturation. Residents identified as potential high risk for aspiration will be evaluated by ST and/or RT beginning on 7/30/12 to be completed on 7/31/12. Care plans to be updated by MDS (Minimum Data Set) nurse, RN as appropriate based on assessment results on 7/31/12 which included updates to care plans for one of the following:potential for aspiration, tracheotomy, tube feedings or altered diets. Re-education started on 7/30/12 with dietary staff including Dietary Manager, cooks, and dietary aides regarding altered diets at approximately 1:30 PM by Registered Dietitian. Re-education was started 7/30/12 at approximately 10:00 PM by Staff Development Coordinator, LVN on notification of any potential aspiration/choking incidents, signs & symptoms of aspiration (University of Wisconsin Hospitals and Clinicals Authority), monitoring for 72 hours following incident, notification of physician and responsible party (RP) as practicable following incident and physician diet order and tray card reconciliation by dietary manager at least monthly and with new order changes. Evaluation of the training will be done by completing skills assessments with nurses for appropriate follow up for potential aspirations including vital signs, skin color changes, O2 saturation and lung sounds as well as RP and MD notification to determine effectiveness of education. These skills assessments will be initiated on 7/31/12 and ongoing by the Staff Development Coordinator, LVN with facility nurses. Staff re-education on 7/31/12 to include education of care plan approaches for those identified at high risk of aspiration such as time frames of staying up after meals. Dietary tray cards will be reconciled with the meal plated prior to serving resident meal by dietary staff preparing tray and nursing/CNA (Certified Nurse Aide) staff receiving tray from kitchen. Physician diet orders and dietary tray card reconciliation was completed on 7/30/12 by the Registered Dietitian and Dietary Manager. Meal observations by nursing administration and department heads to include Nurse Supervisor, Treatment Nurse, Social Services, Staff Development Coordinator, Medical Records Clerk, RN Supervisor, DON and Administrator will be initiated on 7/31/12. Meal Observations will be completed three times a day for two weeks and then at minimum once daily thereafter. A Quality Assurance (QA) meeting was held on 7/31/12 at 2 AM to review and approve the corrective actions taken with no policy changes identified. The Medical Director was notified on 7/30/12 at 10:15 PM of the corrective actions being implemented were with no recommendations made. The DON is responsible for ongoing compliance through review of corrective actions taken and reporting results of review to QA team for any needed revision. Continuing Quality Assurance will include review of corrective actions for further interventions monthly for three months. Review of inservices reflected the facility began inservicing all staff about Signs and Symptoms of Aspiration, Policy and Procedure for Choking, Diet Accuracy, Mechanical Soft Diets and Physician Notification on 7/30/12. The facility began a chart audit to identify any residents at risk for aspiration/choking on 7/30/12. Forty three residents were identified by the facility as potentially high risk for aspiration. During an interview on 7/31/12 at 3:00 PM, CNA R stated that she attended the mandatory staff in-service on choking and aspiration. She described signs and symptoms of choking and aspiration as runny nose, watery eyes, cough, and difficulty breathing. When asked what she would do if she saw a resident with these signs and symptoms, she stated she would pull the call light in a room for help, put the head of the bed up, or go for a nurse for assistance. She also stated she would see if she could remove what is in the resident ' s mouth. During an interview 07/31/12 at 3:20 PM, Medication Aid (MA) S stated that she had attended the mandatory staff in-service on choking and aspiration. MA S described the signs and symptoms of choking and aspiration as red face, change in demeanor, drooling, and nasal drainage. When asked what she would do if she saw a resident with these signs and symptoms, she stated she would call for a nurse and attempt to remove food or an object out of the resident ' s mouth. During an interview 07/31/12 at 3:35 PM, Restorative Nurses Aide (RNA) T stated that she had attended the mandatory staff in-service on choking and aspiration. RNA T described the signs and symptoms of choking and aspiration as runny nose and coughing. When asked what she would do if she saw a resident with these signs and symptoms she stated she would call for a nurse would not give the resident anything else to eat. During an interview on 7/31/12 at 3:40 PM, CNA U stated that she attended the mandatory staff in-service on choking and aspiration. CNA U described signs and symptoms of choking and aspiration as runny nose, red watery eyes, coughing, gurgle or hoarse voice. When asked what she would do if she saw a resident with these signs and symptoms, she stated she would call for the nurse, keep the resident away from the food and attempt to remove the food. During an interview on 7/31/12 at 3:45 PM, CNA V stated that she attended the mandatory staff in-service on choking and aspiration. CNA V described signs and symptoms as hand to throat, red face, coughing, labored breathing and drooling. When asked what she would do if she saw a resident with these signs and symptoms, she stated she would call for a nurse and attempt to remove the food or object from the resident's mouth. While the IJ was removed on 7/31/12 at 6:20 PM the facility remained out of compliance at a severity level of potential for more than minimal harm that is not an IJ at a scope of a pattern. The facility had not had time to implement, monitor and evaluate the effectiveness of their Plan of Removal. Review of the CMS 672 reflected a facility census of 105. The facility provided a list of 22 residents with physician orders [REDACTED].

Based on observation, interview and record review the facility Administrator, Assistant Director of Nursing (ADON) failed to administer the facility in a manner to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident as evidenced by the facility ' s failure to: A) The ADON failed to ensure nursing staff responsible for administering medication were monitored and supervised in the procedures following instruction, training and observation medication pass conducted by the Pharmacy Consultant prior to the survey. This deficient practice placed 105 residents receiving medication in the facility at risk of serious consequences of hypotensive or hypertensive (high blood pressure) crisis, dizziness, increased falls, stroke, episodes of unresponsiveness, medication related side effects and complications or death. B) The ADON failed to ensure nursing staff were reviewing resident dining cards for appropriate physician ordered diet texture, conducting resident assessments and immediately consulting with the physician when residents had a change of condition. This deficient practice placed 22 residents receiving mechanical diets at risk for choking and aspiration. C. The Administrator failed to supervise,monitor and consult with the ADON to ensure the 105 residents residing in the facility received the care and services to meet their individual needs. This resulted in an Immediate Jeopardy (IJ) on 7/30/12 and a second IJ on 08/03/12. While the IJs were lowered prior to exit the facility remained out of compliance at a severity level of potential for more than minimal harm that is not IJ and a Scope of widespread as the facility had not had time to implement, monitor and evaluate the effectiveness of their Plan of Removal. Findings were: A.) Review of Resident #17 Face Sheet reflected a [AGE] year old woman originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #17's Care Plan reflected the plan of care for "risk for [MEDICAL CONDITION] related to my medications, complaints of pain, and medical diagnoses," dated 08/09/11, included the following approaches: 1. Monitor my response to my medication carefully. 2. Administer my medication as ordered. 3. Report any changes in my mental or cognitive status to the physician. The Care Plan did not reflect any specific interventions related to Resident #17's use of blood pressure medications. Review of Resident #17's original physician order [REDACTED]. Review of Resident #17's consolidated physician's orders [REDACTED]. "Check BP before administration hold if BP is 120/80 or > (greater) 12/19/12 order." In an interview on 08/01/12 at 8:51 AM Resident #17 stated that she had not yet received her medications for the morning. She stated that she was concerned about her [MEDICAL CONDITION] medication and is supposed to be given the medications at 7 AM. Resident #17 stated that she has received her medications 5 or 6 times over two hours late. Observation on 08/01/12 at 9:01 AM revealed Medication Aide (MA) F to arrive at Resident #17's room and stated that she needed to give Resident #17 her medications. Resident #17 told MA F that she was not feeling well. MA F took Resident #17's blood pressure at 160/87 millimeters of mercury (mm Hg). In an interview on 08/01/12 at 10:15 AM MA F stated that she documented the blood pressure of 160/87 mm Hg taken at 9:00 AM on the Medication Administration Record (MAR) in the 7:00 AM space. MA F stated that she gave all of Resident #17's 08/01/12 7:00 AM medications at that time the blood pressure was taken (9:00 AM). MA F was asked if she was to notify anyone if a Resident's blood pressure was high. MA F stated that she is supposed to notify the nurse, but that she had not done that yet. Observation on 08/01/12 at 9:40 AM revealed an ambulance to have arrived at the facility to transport Resident #17 to the hospital. In an interview on 08/01/12 at 10:31 AM LVN C stated that today Resident #17 had "a [MEDICAL CONDITION] spell and Parkinson-like jitters." LVN C stated that Resident #17 was on the toilet when she had one of her "dizzy spells." LVN C stated that he took Resident #17's vital signs and got a doctor's order to send Resident #17 to the ER. LVN C stated that because Resident #17's room is "toward the front of the hallway she should have gotten her medications before breakfast and most definitely before 8:00 AM." LVN C stated that if medications are late, over an hour after the scheduled time; the medication is to be held until the physician is notified to get an order to give the medication late. LVN C stated that Resident #17's [MEDICATION NAME] should have been held for any blood pressure above 120/80 mm Hg. Observation on 8/1/12 at 9:43 AM revealed Ambulance staff attending to Resident #17 who was lying in bed with tremors. Her eyes were open however; she was not responding to questions. In an interview on 8/1/12 at 9:45 AM the interim DON stated that Resident #17 "does this all the time." She stated that Resident #17 "will have a syncopal spell but will come right out of it with a sternal rub and then she will say, "send me to the emergency room (ER)." Review of Resident #17's Emergency Department Physician's Documentation dated 08/01/12 reflected a clinical impression of: [MEDICAL CONDITION], Generalized Weakness, and Acute non-specific headache. Nurse documentation of blood pressures revealed the following: 10:30 AM 136/66 mm Hg 11:00 AM 115/75 mm Hg 11:30 AM 93/46 mm Hg 12:30 PM 99/59 mm Hg Review of Resident #17's Nurse's Notes dated 08/01/12 reflected the following entries: 10:00 AM: CNA called charge nurse down to patient room. Upon assessment resident was sitting on toilet and having severe tremors. Resident was assisted to her bed where she continued to have severe tremors. Blood pressure 182/104 mm Hg, pulse 90. Resident was alert times three and requested to be transferred to the hospital. Nurse Practitioner notified and gave order to send resident to ER to be evaluated and treated. 10:10 AM: emergency medical services (EMS) arrived and transported resident to ER 11:00 AM Reported by charge nurse that resident stated that she received her meds (AM) late while she was being assessed by emergency medical technicians. Spoke with medication aide and meds due at 7:00 AM were passed at 9:00 AM. Notified Nurse Practitioner and she did not think this was contributing to her tremors. In an interview on 08/03/12 at 4:00 PM the Medical Director who is also the Attending Physician for Resident #17 stated that she wanted to continue the use of [MEDICATION NAME] for Resident #17. She stated that [MEDICATION NAME] was used to raise the blood pressure and it was only to be given when the resident ' s blood pressure was below 120/80 mm Hg. The Medical Director stated that she was not made aware that Resident #17's [MEDICATION NAME] had been given when Resident #17's blood pressure was above 120/80 mm Hg. The Medical Director stated that "if the [MEDICATION NAME] was given above 120/80 mm Hg it could have caused the symptoms expressed" by Resident #17. In an interview on 08/03/12 at 4:09 PM LVN MM stated that the facility found out about the medication error on 08/01/12 after Resident #17 went to the hospital. She stated that they then reviewed Resident #17's chart and noticed that the [MEDICATION NAME] was not being given as prescribed. LVN MM stated that the ADON did a chart audit. She stated after the audit the facility changed greater than and less than symbols on the MAR to words. In an interview on 08/03/12 at 4:30 PM the Consulting Pharmacist Manager stated that the facility has been aware of medication pass problems in the facility and had increased medication pass observations from once per quarter to once monthly beginning in December 2011. The Pharmacist stated that each MA and Nurse has had a one to one teaching medication pass observation with the Pharmacy Consultant. She stated that anyone who passed medication should be familiar with the greater than and less than symbols. She stated that the facility has not had a consistent Director of Nurses which provides a challenge as the regular pharmacist consultant that reviews the facility "has made the same recommendations regarding corrections or changes over and over" to the facility. The Pharmacist stated that the facility creates their own MARs and does not have the pharmacist review them for accuracy prior to them being used. The Pharmacist stated that [MEDICATION NAME] is a very common medication to make an error with. She stated giving this medication incorrectly can result in major complications such as "the blood pressure being way too high," dizziness, increased heart rate, sweating, and [MEDICAL CONDITION]. She stated that [MEDICATION NAME]'s onset of action (how quickly the medication takes effect) was about 30 minutes to one hour after ingestion. In a continued interview with the Consulting Pharmacist Manager stated that she would expect the facility to monitor blood pressure medications and as a pharmacist she would recommend monitoring of blood pressure, especially if the resident ' s blood pressure is not stable or there has been a change in the medication or condition of the resident. She stated that neither herself nor the consulting pharmacist have participated in the facility ' s quality assurance meetings. She stated she has noticed that the facility is " having a lot more med errors this year. " Review of the Medication Administration Observation Reports dated 8/3/12, completed by the Consultant Pharmacist Manager reflected five staff members were observed passing medications. Her observations revealed that 20% of MA AA's medication pass was in error. MA AA administered medications at the wrong time and with food when they were to be administered 30 minutes prior to food. MA F was not observed by the Consultant Pharmacist Manager. In an interview on 08/04/12 at 10:45 AM the Administrator stated that when Resident #17 went out to the emergency roiagnom on [DATE] is when the facility became aware that the MA's did not know the greater than and less than symbols on the MARs. Review of Resident #17's MAR dated January 2012 reflected that Resident #17's medication [MEDICATION NAME] was held on 01/07/12 due to her blood pressure being 124/70 mm Hg, held on 01/14/12 due to her blood pressure being 124/88 mm Hg, and held on 01/22/12 due to her blood pressure being 129/90 mm Hg. The January MAR does not reflect any other blood pressures were recorded. Physcians orders indicated that blood pressures were to be taken before administration of this medication. Review of Resident #17's MAR dated February 2012 reflected "[MEDICATION NAME] 2.5 mg tab po bid, BP reading before giving [MEDICATION NAME] BID, hold [MEDICATION NAME] if BP is 120/80 or > (greater than)." This medication was signed as given on 30 occasions when the recorded blood pressure exceeded 120/80 mm Hg. The medication was signed as held on 9 occasions when the recorded blood pressure was lower than 120/80 mm Hg. The back page of the MAR noted two occasions when the medication was held due to "blood pressure less than 120/80," the 02/16/12 pressure recorded as 94/58 mm Hg and the 02/27/12 pressure recorded as 111/77 mm Hg. Review of Resident # 17's MAR dated March 2012 reflected "[MEDICATION NAME] 2.5 mg tab po bid, BP reading before giving [MEDICATION NAME] BID, hold [MEDICATION NAME] if BP is 120/80 or > (greater than)" This medication was signed as given on 26 occasions when then recorded blood pressure exceeded 120/80 mm Hg. The medication was signed as held on 29 occasions when the recorded blood pressure was lower than 120/80 mm Hg. The medication was given incorrectly 55 of the 62 opportunities to pass the medication. The back page of the MAR noted: 03/01/12 7 AM "[MEDICATION NAME] 2.5 mg held b/p 111/72" 03/10/12 7 AM "held [MEDICATION NAME] 2.5 mg b/p 108/71" 03/14/12 7 AM "held [MEDICATION NAME] 2.5 mg b/p 99/71 per orders" 03/15/12 7 AM "held [MEDICATION NAME] 2.5 mg per orders b/p 109/71" 03/19/12 7 AM "held [MEDICATION NAME] 2.5 mg per orders b/p 115/76" 03/20/12 7 AM "held [MEDICATION NAME] 2.5 mg per orders b/p 111/78" 03/21/12 7 AM "held [MEDICATION NAME] 2.5 mg per orders b/p 109/71" 03/27/12 7 AM "med held [MEDICATION NAME] 2.5 po pt b/p 101/58" Review of Resident # 17's MAR dated April 2012 reflected "[MEDICATION NAME] 2.5 mg tab po bid, BP reading before giving [MEDICATION NAME] BID, hold [MEDICATION NAME] if BP is 120/80 or > (greater than)." This medication was signed as given on 11 occasions when the recorded blood pressure exceeded 120/80 mm Hg from 04/01/12-04/12/12. The medication was signed as held on 11 occasions when the recorded blood pressure was lower than 120/80 mm Hg. One medication pass on 04/09/12 has no information recorded on the MAR. The medication was given incorrectly 22 of the 24 opportunities to pass the medication. Continued review of Resident #17's April 2012 MAR reflected the physician's orders [REDACTED]. An additional note was added to the description of the medication "If pt passes out. Put her in bed, lower head & raise legs - Do not rush pt out to ER." From 04/13/12-04/30/12 the medication was signed as given on 20 occasions when then recorded blood pressure exceeded 120/80 mm Hg and was then signed as held on 32 occasions when the recorded blood pressure was lower than 120/80 mm Hg. The medication was given incorrectly 52 of the 54 opportunities to pass the medication. There are no nurse's notes on the reverse side of the MAR to document why the medication was given outside of the physician ordered parameters. Review of Resident # 17's MAR dated May 2012 reflected "[MEDICATION NAME] 2.5 mg tab po tid, check BP TID and hold [MEDICATION NAME] if BP is 120/80 or > (greater than)." The MAR did not include a space to record the 7 AM blood pressure. This medication was signed as given on 26 occasions when then recorded blood pressure exceeded 120/80 mm Hg. The medication was signed as held on 31 occasions when the recorded blood pressure was lower than 120/80 mm Hg. The medication was given incorrectly 57 of the 62 opportunities to pass the medication during the 11:00 AM and 3:00 PM medication passes. No blood pressures were recorded for 3 of the passes. Documentation on the reverse side of the MAR noted the medication was incorrectly held on at least 12 occasions for blood pressures less than 120/80mm Hg during the 7:00 AM medication pass. Review of Resident #17's June and July 2012 MAR reflected recorded blood pressures and medications signed as held and as given however there were no times associated with the blood pressures to show which medication pass they belong to. Review of Resident #17's August 2012 MAR reflected "[MEDICATION NAME] 2.5 mg tab po tid, check BP TID and hold [MEDICATION NAME] if BP is 120/80 or >" and "greater than" was hand written beside the medication information. On 08/01/12 Resident #17 received a 7:00 AM dose of the medication with a blood pressure of 160/87 mm Hg. The remaining two doses were not given as the resident was in the hospital. On 08/02/12 the 11:00 AM dose was given with a blood pressure of 134/82 mm Hg. On 08/03/12 the 7:00 AM dose was given with a blood pressure of 148/93 mm Hg. B) Review of the Face Sheet reflected Resident # 40 was admitted on [DATE] and readmitted on [DATE] with the [DIAGNOSES REDACTED]. " Review of the Medication Administration Record (MAR) dated April, May, June, and July 2012 for Resident # 40 reflected that he was receiving the medication [MEDICATION NAME] ([MEDICATION NAME]) 5mg three times a day (TID) with no documented blood pressure (BP). Review of the MAR, revised after the IJ was identified, dated August 2012 reflected for [MEDICATION NAME] to hold medication if BP was more then 160/100. Also on the row for [MEDICATION NAME] were rows to document the systolic and diastolic of the blood pressure, with the times 9:00 AM, 5:00 PM and 9:00 PM. Review of the admission orders [REDACTED]. Review of the Telephone Orders dated 7/23/12 reflected that Resident #40 had a clarification order for [MEDICATION NAME] 5mg to hold the [MEDICATION NAME] if BP > 160/100. In an interview on 08/04/12 at 10:45 AM the Administrator stated that the ADON has been frustrated by physician order [REDACTED]. She stated that the previous person responsible for medical records had multiple transcription issues and did not correct medication orders to reflect resident movement within the facility. The Administrator stated that the hallways were split into two medication pass times so that all the medications were not due at the same time. When residents would change hallways the medication orders would not get updated to reflect the change in times for those hallways. She stated that she believed this was a portion of the problem for issues with medication timing. Review of [MEDICATION NAME] Dosage and Administration reflected: Dosing should take place during the daytime hours when the patient needs to be upright, pursuing the activities of daily life. A suggested dosing schedule of approximately 4-hour intervals is as follows: shortly before or upon arising in the morning, midday, and late afternoon (not later than 6 P.M.). <http://www.drugs.com/pro/[MEDICATION NAME].html> Review of facility policy and procedure titled 7.1 'GENERAL GUIDELINES' dated 09/10 reflected the following: POLICY Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after the have familiarized themselves with the medication. PROCEDURES Medication Preparation:... Medication Administration: 1. Medications are administered in accordance with written orders of the prescriber. If a dose seems excessive considering the resident's age and condition, or a medication order seems to be unrelated to the resident's current [DIAGNOSES REDACTED]. If necessary, the nurse contacts the prescriber for clarification. This interaction with the pharmacy and the resulting order clarification are documented in the nursing notes and elsewhere in the medical record as appropriate. 2. Obtain and record any vital signs as necessary prior to medication administration. 14. Medications are administered within 60 minutes of scheduled time, except before or after meal orders, which are administered, based on meal times. Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the nursing care center. The facility's Administrator, interim DON, ADON and Vice President of Operations were informed that an IJ existed on 8/3/12 at 6:20 PM due to the facility's failure to ensure that Resident #17 and Resident #40 who received [MEDICATION NAME] for Hypotention were free from significant medication errors. The facility provided the following plan of removal on 8/4/12 at 12:05 PM and accepted on 8/4/12 at 1:15 PM. Plan of Removal Resident #17 has an order for [REDACTED]. The order requires that the medication be held if the blood pressure is greater than 120/80 but medication was given when blood pressure was over 120/80. This medication is for the treatment of [REDACTED]. This resident was re-assessed by a Registered Nurse (RN) on 8/3/2012 and the attending physician was updated with the re-assessment findings. The MD gave new order for parameters and times of dose for [MEDICATION NAME]. The care plan was updated 8/3/2012 to reflect approaches to prevent falls related to [MEDICAL CONDITION]. The re-assessment was documented and care plans updated by the RN on 8/3/2012. A list of residents on blood pressure medications was reviewed by the Director of Nurses (DON) or designee on 8/4/2012 to determine other residents on blood pressure medications requiring parameters to be monitored. The number of residents in the facility receiving blood pressure medications totaled 58. The 2 residents specifically identified with MD orders for [MEDICATION NAME] have been re-assessed by RNs on 8/3/2012 to update the plan of care. Medication Order Review Audits to clarify orders were started on 8/2/2012 by visiting DON on 8/3/2012. The re-education by DON of nurses and medication aides was started on 8/2/2012 on Medication Administration, Following MD orders and Med Pass procedures with copies of policies and procedures given to the employees. Med Pass observations by DON were started with nurses and med aides. Med Pass observations by Pharmacist were conducted on 8/3/12 with 5 nurses and medication aides and individual re-education was done during that med pass regarding identified concerns. The Pharmacist identified one med aide that needed further training and she will be individually re-educated by the Nurse Consultant from pharmacy on 8/4/12. Re-education by Nurse Consultant for pharmacy was started on 8/3/12 and will continue thru 8/4/12 with nurses and med aides on medication administration, following MD orders, MD orders with parameters including blood pressure medications, medication error reporting and adverse drug reaction prevention and detection and notification of MD when MD orders including parameters are not followed with copies of inservice, policies and procedures given to the employee. The Nurse Consultant for pharmacy will complete med pass observations and re-education individually based on results of observations with nurses and medication aides starting on 8/3/12 thru 8/4/12. Ongoing, Med Pass observations and individual re-education based on results of observation will be completed three times per week covering each shift by DON or designee with facility nurses and medication aides. The med pass observations with nurses and medication aides will randomly include but not be limited to oral medications, injections, tube feedings, eye drops, nasal sprays or any other MD order that is included on the MAR (Medication Administration Record). MARs audits for in-house residents will be conducted weekly by DON or designee to include MD orders listed on each residents' MARs in order to identify potential medication errors. The MAR audits will compare the MD orders noted on the MAR to the administration recorded by nurses or med aides to verify parameters of medications have been followed per MD order. A Quality Assurance (QA) meeting was held on 8/4/12 at 12:45 AM to review and approve the corrective action taken with no policy changes identified. The Medical Director was notified on 8/4/12 at 12:15 AM of the IJ regarding the resident's medication orders and parameters with no further recommendations were made. The DON is responsible for ongoing compliance through review of corrective actions taken and reporting results of review to QA team for any needed revision. Continuing QA will include review of corrective actions for further interventions monthly for three months. Staff were inserviced on medication errors and physician ordered medication with parameters on 8/3/12 and 8/4/12. The Consultant Pharmacy Manager began observation medication passes on 8/3/12. The DON conducted an observation/teaching medication pass on 8/3/12. MARs audit was conducted by the DON to identify medication orders with parameters. Observation on 8/4/12 at 1:30 revealed Resident # 17 and # 40 MARS had a spot to put the systolic and dystolic blood pressure reading. The [MEDICATION NAME] was moved from the Medication Aid giving the medication to the Licensed Vocational Nurse giving the medication. Both MARS reflected the medication given or held at the specified time, within the appropriate parameters specified by the physician. B) 1.) Review of the Facesheet reflected Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED]. Review of the current Care Plan dated 5/31/12 reflected Resident #7 was at risk for aspiration due to Dysphagia. The onset date was 9/12/11. Approaches listed were as follows: *Staff Note: Resident has dysphagia - trouble swallowing. *Diet order: NAS (no added salt), Mechanically soft with nectar thick liquids/ NO STRAWS Texture: Ground Meat *Feed in upright position and maintain upright position for one (1) hour after eating when possible to reduce risk of aspiration/choking. Review of the current, consolidated Physician order [REDACTED]. Texture: Ground Meat, Liquids: Nectar, with additional [DIAGNOSES REDACTED]. Review of the Diet Order Form dated 3/8/12 reflected Resident #7 was to be assisted while eating. He was to receive a mechanical diet with ground meat (dysphasia) and nectar thickened liquids. Review of the Comprehensive Nutritional assessment dated [DATE] reflected Resident #7 had [DIAGNOSES REDACTED]. Under the Oral Condition section it reflected that Resident #7 had difficulty swallowing. Observation of meal service on 7/30/12 at 12:15 PM revealed that Resident #7 was the fourth resident to be served. Resident #7 received large chunks of sliced tomatoes in juice and pulled apart, stringy turkey on his plate. In a separate bowl, Resident #7 was served slices of canned pears. The red colored drink in front of Resident #7 had ice in it. The resident had a special spoon and was attempting to put whole pieces of tomato and large bites of turkey in his mouth. Review of Resident #7's Diet card, located on the table next to his plate, on 7/30/12 at 12:15 PM reflected Resident #7 was to have a mechanical soft, NAS, nectar liquids and fortified food diet with no straws. Resident #7's menu on the card reflected the following: Ground Roast Turkey, scalloped tomatoes, sage bread dressing, dinner roll/bread, Margarine, applesauce and pureed nectar orange. Observation on 7/30/12 at 12:30 PM revealed Resident #7 coughing with his eyes watering, and his nose running, CNA Q walked to Resident #7's table after being alerted by the RN Surveyor. CNA Q stated, "looks like you need more napkins." Resident #7 had large amounts of food in his lap. LVN A walked over and looked at Resident #7. She then encouraged him to drink and take another bite, and walked away from the Resident #7. Observation in the dining room on 7/30/12 at 5:30 PM, before he had received his evening meal, revealed CNA W serve a glass of unthickened cranberry juice with ice in it to Resident #7. Observation on 7/30/12 at 5:40 PM revealed Resident #7 was served the following meal: an egg salad sandwich cut in half, a pickle spear, vegetable medley/"Creamy Ranch Medley" (chopped carrots, peas, corn, and lima beans and green beans mixed with ranch dressing), and ice cream. Resident was taking bites of the sandwich without swallowing or chewing, large portions falling out of his mouth onto his chin and lap. Resident #7 picked up the pickle spear and bit the end off, attempted to chew/swallow, causing him to cough with his eyes watering. There was no staff member near by monitoring Resident #7 while eating. A test tray was received on 7/30/12 at 5:50 PM. The vegetables in the vegetable medley were raw; stiff, hard and crunchy. In an interview on 7/30/12 at 6:45 PM the Registered Dietician (RD) stated that for a resident who was on a mechanically soft diet, a pickle spear, should not be on their meal tray. She further stated that generally raw vegetables would not be given with a mechanical soft diet, and that staff should always refer to the menu that says what those residents could have. Review of the 24 Hour Report dated 7/30/12 reflected that the choking incident of Resident #7 was not documented on the report. In an interview on 8/01/12 LVN X stated that she heard about Resident #7's choking incident yesterday on 7/31/12. She further stated that she was never notified on 7/30/12 of the choking incident. LVN X went on to state that she was assigned to Resident #7's hall the day that he choked in the dining room, but nobody told her about it. In an interview on 7/30/12 at 8:30 PM LVN C, who was assigned to Resident #7's hall, stated that nothing had been reported to him about an incident in the dining room regarding Resident #7. He further stated that during shift change they walk the halls with the preceding shift and give report of any changes with the residents. LVN C did not go assess Resident #7 at that time but went to the staff break room. In an interview on 7/30/12 at 8:45 PM the Assistant Director of Nursing (ADON) stated that she was told lunch hadn't gone well. She stated that a CNA told her that residents in the dining room had received chopped meat when they should have received ground meat. The ADON further stated that Resident #7 had a problem swollowing and that he may have choked on some of his food. She stated that the nurse from Resident #7's hall (LVN C) checked him out but he was fine. She further stated that Resident #7 did cough his food up at times. The ADON stated that if the nurse finds a resident choking they should make sure the resident was breathing and coughing, and that the nurse should listen to breath sounds and assess the resident's mouth to make sure everything was out. She further stated, "that's why we have a nurse in the dining room" in case there are any problems. The ADON stated, "we do have several residents that cough during meals." The ADON stated that coughing while eating could cause aspiration. When asked what the nurses role in the dining room was, she stated that the nurse should check the resident's diet card and make sure it matches what is on the resident's plate. When asked what the definition of aspiration was, she stated you would hear wet sounds in the lungs, possibly gurgly sounds, and that when someone does choke in the dining room that they would get an x-ray ordered and notify the physician. She further stated that the nurse who assessed the resident should chart in the residents chart, put it on the 24 hour report, and notify the oncoming nurse on rounds. The ADON stated that LVN A should have listened to Resident #7's breath sounds and taken his Oxygen saturation level. She further stated that the resident should then be monitored closely for 24 hours. In an interview on 7/30/12 at 9:05 PM the Administrator stated she was told that Resident #7 choked a little in the dining room during lunch, she further stated that they would be getting a chest x-ray in the morning. In an interview on 7/31/12 at 2:45 PM the Speech Language Pathologist (SLP) stated that she looked at Resident #7 during breakfast and lunch. He was eating large bites and eating very quickly. She further stated that his tray was not delivered until 12:45 PM so she figured he was pretty hungry. She stated that Resident #7 should be kept upright for at least 20 minutes after eating. She further stated that Resident #7 went to the hospital in March 2012 for Pneumonia. She stated that she gave the diet change to the kitchen and that his meat should be "very ground." The SLP further stated that "chopped" means that the chops should be no bigger than a ? in

Based on observation, interview, and record review the facility failed to provide adequate supervision and assistance to prevent choking and possible aspirations for 1 of 5 residents (Resident #7) in the facility's dining room that was at risk for aspiration. 1.) Resident #7 had a [DIAGNOSES REDACTED]. He had a Physicians Order for a mechanical soft diet. At the noon meal on 7/30/12, Resident #7 received large chunks of sliced tomatoes in juice; pulled apart, stringy turkey; and slices of canned pears. While eating, Resident #7 began coughing, his eyes were watering and his nose was running. This resulted in an Immediate Jeopardy (IJ) on 7/30/12. While the IJ was lowered on 7/31/12, the facility remained out of compliance at a severity level of potential for more than minimal harm that is not an IJ at a scope of a pattern because the facility had not had time to implement, monitor and evaluate the effectiveness of their Plan of Removal. This deficient practice placed 22 residents receiving mechanical diets at risk for choking and aspiration. Findings include: 1.) Review of the Face Sheet reflected Resident #7 was admitted on [DATE] and readmitted on [DATE] with the Diagnoses: [REDACTED]. Review of the Care Plan dated 8/2012 reflected Resident #7 had a problem onset dated 9/12/11 for Aspiration, risk for complications due to Dysphagia. Approaches were listed as: *Staff Note: Resident has Dysphagia - trouble swallowing. *Diet order - NAS (no added salt), Mechanically soft with nectar thick liquids/NO STRAWS Texture Ground Meat *Feed in upright position and maintain upright position for one (1) hour after eating when possible to reduce risk of aspiration/choking. Review of the Physician order [REDACTED]. Texture: Ground Meat, Liquids: Nectar, with additional [DIAGNOSES REDACTED]. Review of the Diet Order Form dated 3/8/12 reflected Resident #7 was to be assisted while eating, with ground meat (dysphasia) with nectar thickened liquids. Review of the Comprehensive Nutritional assessment dated [DATE] reflected Resident #7 had [DIAGNOSES REDACTED]. Diet order NAS, Mechanically Soft with nectar thick liquids, no straws. Under the Oral Condition section it reflected that the Resident had poor condition or difficulty swallowing. Review of the Diet Card for lunch on 7/30/12 at 12:15 PM revealed Resident #7 to have a diet of Mechanically soft, NAS, nectar liquids, fortified food, no straws, Ground Roast Turkey - 3 ounces (oz), scalloped tomatoes - ? cup, sage bread dressing - ? cup, dinner roll/bread 1 each, Margarine 1 each, applesauce - ? cup, pureed nectar orange - 8 oz. Observation of Resident #7's meal tray on 7/30/12 at 12:15 PM revealed large chunks of sliced tomatoes in juice and pulled apart, stringy turkey. In a bowl were slices of pears (no applesauce). The drink on the table was not thickened and had ice in it. The Resident had a special spoon and was attempting to put whole pieces of tomato and turkey into his mouth. The Resident was not sitting at a table with supervision from a staff person. All staff in the dining room were busy delivering meal trays and Resident #7 out of their line of sight. Observation on 7/30/12 at 12:30 PM revealed Resident #7 coughing with his eyes watering, nose running, Certified Nurse Aid (CNA) Q came over to resident and stated, " Looks like you need more napkins because of the mess in his lap". A few minutes later Licensed Vocation Nurse (LVN) A walked up to the Residents table and encouraged him to drink, and take another bite of food. LVN A then walked away from the Resident. Observation on 7/30/12 at 1:00 PM revealed Resident #7 in his room laying flat on his bed without supervision. Observation on 7/30/12 at 5:30 PM in the dining room revealed CNA W brought Resident #7 a glass of cranberry juice unthickened with ice in it. Observation on 7/30/12 at 5:40 PM revealed the tray delivered to Resident #7 contained the following: egg salad sandwich, pickle spear, vegetable medley (chopped carrots, peas, corn, green beans and lima beans mixed with ranch), and ice cream. Resident was taking bites of the sandwich without swallowing or chewing with large portions falling out of his mouth onto his chin and lap. Resident #7 picked up the pickle spear and bit the end off, attempted to chew/swallow the pickle causing him to cough with his eyes watering. There were no staff members present to monitor the Resident while coughing and eating. Review of the Menu Guide Report dated 7/30/12 reflected the Dinner menu as Cream of Mushroom Soup, Saltine Crackers, Egg Salad Sandwich, Creamy Vegetable Salad, Ice Cream, and Milk. In an interview on 7/30/12 at 6:45 PM Registered Dietician (RD) stated that for a resident with a mechanically soft diet a pickle spear should not be on his tray. She further stated that generally with a mechanically soft diet raw vegetables are not eaten, and that staff should always refer to the menu that says what they (the resident) can have to eat. Review of the 24 Hour Report dated 7/30/12 reflected that the choking incident of Resident #7 was not put on the report. In an interview on 7/30/12 at 8:30 PM LVN C stated that nothing had been reported to him about an incident in the dining room. He further stated that during shift change they walk the halls with the preceding shift and give report of any changes with the residents. When done with the interview LVN C walked back into the break room and did not check on the Resident. In an interview on 7/30/12 at 8:45 PM the Assistant Director of Nursing (ADON) stated that she was told lunch wasn't going well. She stated that a CNA told her that residents in the dining room were receiving chopped meat when they were supposed to be getting ground. The ADON further stated that Resident #7 had a problem and that he may have choked on some of his food. She stated that the nurse from hall one(1) checked him out but he was fine. She further stated that Resident #7 coughs his food up sometimes. The ADON stated that if the nurse finds a resident choking they should make sure he was coughing and still breathing, and that the nurse should listen to breath sounds and asses the mouth and make sure everything is out. She further stated that is "Why we have a nurse in the dining room in case there are problems". The ADON stated, "We do have several residents that cough during meals". Which she further stated that coughing while eating could cause aspiration. When asked what the nurses' role in the dining room was, she stated that the nurse should check the diet card and make sure it matches what is on the plate. When asked what the definition of aspiration was, she stated you would hear wet sounds in the lungs, possibly gurgled sounds, and that when someone does choke in the dining room that they would get an x-ray ordered and notify the physician. She further stated that the nurse who assessed the resident should chart in the residents chart, put it on the 24 hour report, and notify the oncoming nurse on rounds. The ADON stated that LVN A should have listened to Resident #7's breath sounds and taken his Oxygen saturation level. In an interview on 7/30/12 at 9:05 PM the Administrator stated she was told that Resident #7 choked a little in the dining room during lunch, she further stated that they would be getting an x-ray in the morning. The facility's Administrator and ADON were informed that an IJ existed on 7/30/12 at 9:07 PM due to the facility's failure to adequately monitor and supervise residents at risk for aspiration. In an interview on 7/31/12 at 2:45 PM the Speech Language Pathologist (SLP) stated that she looked at Resident #7 during breakfast and lunch. He was eating large bites and eating very quickly. She further stated that his tray was not delivered until 12:45 PM so she figured he was pretty hungry. She stated that the Resident should be kept up at least 20 minutes after eating. She further stated that the Resident went to the hospital in March for pneumonia and that he had fallen. She stated that she gave the diet change to the kitchen and that his meat should be very ground. The SLP further stated that chopped means that the chops should be no bigger than a ? inch. She stated that the vegetables should be very tender, no raw vegetables at all and that even green beans should be cut up smaller. The SLP further stated that on a Nectar thickened diet that the resident should not have any ice in a glass, no jello, and no ice cream. In an interview on 7/31/12 at 5:23 PM LVN A stated that while in the dining room on 7/30/12 during lunch, a CNA came up to her and said someone may be choking. Resident #7 coughed a few times, she believed him to be ok. She further stated that she gave report to LVN H. LVN A stated that its normal for Resident #7 to have a runny nose and his eyes watering. She further stated that LVN H took over for her in the dining room at 12:30 to 12:45 PM, and that LVN X was assigned to Resident # 7's hall. LVN A stated that she did not report the choking incident to LVN X. When asked what the sign and symptoms of aspiration were LVN A stated that a person would have watery eyes and not be breathing. She further stated that she was responsible for checking residents trays to make sure that they received the appropriate diet ordered for them. She further stated that the way the turkey was at lunch on 7/30/12 was what the kitchen was calling ground. When asked what the turkey looked like to her, she stated that it looked chopped. Observation on 8/1/12 at 12:50 PM revealed Resident #7 sitting in the dining room, using his butter knife to scoop food out of bowl with pureed sugar cookie in it. Food was dripping off of his chin and liquid draining out of the right side of his mouth, observed to be coughing off and on during the meal. Observation on 8/1/12 at 1:00 PM the SLP walked over and sat next to Resident #7 and stated she was going to try and set him up for a swallow study. Review of the undated Diet Accuracy policy reflected that * Tray card are to be used on the tray line for service and checked prior to leaving the kitchen for accuracy. * Prior to serving the tray, the nurse aide must check the tray card to assure that the correct tray is being served to the resident. If there is doubt, the charge nurse should be notified and the chart checked for the current physician's order [REDACTED]. Review of the undated Signs and Symptoms policy reflected signs and symptoms of aspiration will likely include choking, wheezing, coughing, and trouble breathing. Some other signs of accidental aspiration include watery eyes and nose, throat clearing and a wet or gurgling voice. (http://www.ehow.com/info_ 92_aspiration-precautions-signs.html#ixzz22Em84NIH <http://www.ehow.com/info_ 92_aspiration-precautions-signs.html>) Review of the undated Signs and Symptoms of Aspiration reflected * Aspiration: the entry of food or liquid into the airway below the true vocal folds; food or liquid " going down the wrong pipe " . * Silent Aspiration: when a patient does not cough in response to aspiration and may appear to swallow safely. ? Coughing during and/or after meals ? Choking ? Throat clearing ? Wet/gurgling voice after swallowing ? Fever ? Chills ? Respiratory changes or chest congestion ? Leakage of food or saliva from mouth ? Excess secretions ? Shortness of breath (<http://www.uwhealth.org/healthfacts/B_EXTRANET_HEALTH_INFORMATION-FlexMember-Show_Public_HFFY_ 805.html>) Review of the Food and Nutrition Services Department In-Service dated 7/30/12 reflected the following: *Meats are ground to ground meat consistency *Gravies, Broths, Sauces used to keep meat moist , tender *Fruits/Vegetables - served soft, diced, or chopped or shredded *Omit Nuts, Potato chips, coconut *CHECK MENU EXTENSIONS Resident may be restricted further upon speech therapy review Mechanical Soft Diet The mechanical soft diet is designed to minimize the amount of chewing necessary to ingest food and to increase the ease of swallowing. The diet is used for those individuals with chewing and swallowing problems due to irritation of the mouth, lack of teeth, surgery, therapy or Dysphagia. Under the category MECHANICAL SOFT DIET FOOD GROUP RECOMMENDATIONS row of SOUPS, STEWS AND CASSEROLES lists all should have soft cooked, chopped vegetables and rice/noodles, If meat present it should be ground. Under Foods to Limit - Whole meats, large pieces of vegetables/starch. The facility provided the following final plan of removal on 7/31/12 at 6:00 PM and accepted on 7/31/12 at 6:20 PM. Plan of Removal "Resident #7 was assessed on 7/30/12 by Respiratory Therapist (RT) and Licensed Vocational Nurse (LVN) at 8:30 PM and by the Assistant Director of Nurses (ADON), RN (Registered Nurse) at 9:45 PM for lung sounds, O2 (oxygen) saturation, vital signs and skin color changes. The MD was called at 9:30 PM and return call was received from another MD, the on call physician at 9:45 PM. A physician order [REDACTED]. Resident was sent out by EMS at 10:58 PM. Resident returned to the facility with no new orders at 2:20 AM. Per report of ER nurse, chest x-ray and all lab work done at ER "came back fine". The facility received the written results of the x-ray at 10:15 AM which reported "the lungs are well aerated. No evidence of active intrathoracic disease seen". ADON audited facility residents (See Attachment #1) to determine those at high risk for aspiration/choking (See Attachment #2) based on altered diets,tracheotomy and tube feeding orders. Nursing Administration team members including Medical Records Clerk, LVN (Licensed Vocational Nurse); Staff Development Coordinator, LVN; Treatment Nurse, LVN; and Nurse Supervisor, LVN assessed residents with potential high risk for aspiration starting on 7/30/12 at 11:15 PM to include vital signs, lung sounds, change in skin color and O2 saturation. Residents identified as potential high risk for aspiration will be evaluated by ST and/or RT beginning on 7/30/12 to be completed on 7/31/12. Care plans to be updated by MDS (Minimum Data Set) nurse, RN as appropriate based on assessment results on 7/31/12 which included updates to care plans for one of the following:potential for aspiration, tracheotomy, tube feedings or altered diets. Re-education started on 7/30/12 with dietary staff including Dietary Manager, cooks, and dietary aides regarding altered diets at approximately 1:30 PM by Registered Dietitian. Re-education was started 7/30/12 at approximately 10:00 PM by Staff Development Coordinator, LVN on notification of any potential aspiration/choking incidents, signs & symptoms of aspiration (University of Wisconsin Hospitals and Clinicals Authority), monitoring for 72 hours following incident, notification of physician and responsible party (RP) as practicable following incident and physician diet order and tray card reconciliation by dietary manager at least monthly and with new order changes. Evaluation of the training will be done by completing skills assessments with nurses for appropriate follow up for potential aspirations including vital signs, skin color changes, O2 saturation and lung sounds as well as RP and MD notification to determine effectiveness of education. These skills assessments will be initiated on 7/31/12 and ongoing by the Staff Development Coordinator, LVN with facility nurses. Staff re-education on 7/31/12 to include education of care plan approaches for those identified at high risk of aspiration such as time frames of staying up after meals. Dietary tray cards will be reconciled with the meal plated prior to serving resident meal by dietary staff preparing tray and nursing/CNA (Certified Nurse Aide) staff receiving tray from kitchen. Physician diet orders and dietary tray card reconciliation was completed on 7/30/12 by the Registered Dietitian and Dietary Manager. Meal observations by nursing administration and department heads to include Nurse Supervisor, Treatment Nurse, Social Services, Staff Development Coordinator, Medical Records Clerk, RN Supervisor, DON and Administrator will be initiated on 7/31/12. Meal Observations will be completed three times a day for two weeks and then at minimum once daily thereafter. A Quality Assurance (QA) meeting was held on 7/31/12 at 2 AM to review and approve the corrective actions taken with no policy changes identified. The Medical Director was notified on 7/30/12 at 10:15 PM of the corrective actions being implemented were with no recommendations made. The DON is responsible for ongoing compliance through review of corrective actions taken and reporting results of review to QA team for any needed revision. Continuing Quality Assurance will include review of corrective actions for further interventions monthly for three months." Review of inservices reflected the facility began inservicing all staff about Signs and Symptoms of Aspiration, Policy and Procedure for Choking, Diet Accuracy, Mechanical Soft Diets and Physician Notification on 7/30/12. The facility began a chart audit to identify any residents at risk for aspiration/choking on 7/30/12. Forty three residents were identified by the facility as potentially high risk for aspiration. During an interview on 7/31/12 at 3:00 PM, CNA R stated that she attended the mandatory staff in-service on choking and aspiration. She described signs and symptoms of choking and aspiration as runny nose, watery eyes, cough, and difficulty breathing. When asked what she would do if she saw a resident with these signs and symptoms, she stated she would pull the call light in a room for help, put the head of the bed up, or go for a nurse for assistance. She also stated she would see if she could remove what is in the resident ' s mouth. During an interview 07/31/12 at 3:20 PM, Medication Aid (MA) S stated that she had attended the mandatory staff in-service on choking and aspiration. MA S described the signs and symptoms of choking and aspiration as red face, change in demeanor, drooling, and nasal drainage. When asked what she would do if she saw a resident with these signs and symptoms, she stated she would call for a nurse and attempt to remove food or an object out of the resident ' s mouth. During an interview 07/31/12 at 3:35 PM, Restorative Nurses Aide (RNA) T stated that she had attended the mandatory staff in-service on choking and aspiration. RNA T described the signs and symptoms of choking and aspiration as runny nose and coughing. When asked what she would do if she saw a resident with these signs and symptoms she stated she would call for a nurse would not give the resident anything else to eat. During an interview on 7/31/12 at 3:40 PM, CNA U stated that she attended the mandatory staff in-service on choking and aspiration. CNA U described signs and symptoms of choking and aspiration as runny nose, red watery eyes, coughing, gurgle or hoarse voice. When asked what she would do if she saw a resident with these signs and symptoms, she stated she would call for the nurse, keep the resident away from the food and attempt to remove the food. During an interview on 7/31/12 at 3:45 PM, CNA V stated that she attended the mandatory staff in-service on choking and aspiration. CNA V described signs and symptoms as hand to throat, red face, coughing, labored breathing and drooling. When asked what she would do if she saw a resident with these signs and symptoms, she stated she would call for a nurse and attempt to remove the food or object from the resident's mouth. While the IJ was removed on 7/31/12 at 6:20 PM the facility out of compliance at a severity level of potential for more than minimal harm that is not an IJ at a scope of a pattern. The facility had not had time to implement, monitor and evaluate the effectiveness of their Plan of Removal. The facility provided a list of 22 residents with physician's orders [REDACTED].