Every finding on record at Garden Terrace Healthcare Center of Fort Worth

Based on interviews and record reviews, the resident has a right to personal privacy and confidentiality of his or her personal and medical records for 3 (Resident #1, Resident #2, and Resident #3) of 3 residents reviewed. The facility failed to obtain resident consent before identifiable health information was sent out via email by the SW to nonresidents. This failure placed residents at risk of personal health Information exposed. Findings include:Record review of Resident #1's face sheet revealed he was admitted on [DATE] and was diagnosed with cognitive communication deficit (a condition where cognitive impairments disrupt person's ability to communicate effectively, despite intact language or speech abilities) and mild cognitive impairment of uncertain or unknown etiology (measurable cognitive decline that does not yet meet criteria for Dementia and lacks a clearly identified cause. Resident#1 was his own responsible party.Record reviews of Resident #1's medical records revealed no authorization for release of information form on file that would allow for the release of medical information. Record review of SW list of emails that she sent out had nonresident name listed as the receiver for Resident #1's information. Record review of Resident #2's revealed she was initially admitted on [DATE] and readmitted on [DATE]. Resident #2 was an [AGE] year-old female and was diagnosed with cognitive communication delict, personal history of transient ischemic attack (TIA) and cerebral infraction without residual deficits. Resident#2 was her own responsible party.Record reviews of Resident #2's medical records revealed no authorization for release of information form on file that would allow for the release of medical information.Record review of SW list of emails that she sent out recipients had nonresident name listed as the receiver for Resident #2's information. Record review of Resident# 3's revealed he was admitted on [DATE]. Resident #3 was a [AGE] year-old female and was diagnosed with Hemiplegia (complete paralysis) and Hemiparesis (partial weakness) following cerebral infraction affecting right dominant side. Resident#3 was his own responsible party.Record reviews of Resident #3's medical records revealed no authorization for release of information form that would allow for the release of medical information. Record review of SW list of emails that she sent out had nonresident name listed as the receiver for Resident # 3's information. During an interview and record review on 05/04/26 at 8:57am SW stated she sends out a welcome letter within three days and sent out 7 days clinical unless a specific date was determined for information to be sent. The SW stated residents under managed care received an outcome prediction which the facility received from the insurance company and current orders are sent to email on file. The SW stated she did not encrypt the messages because some families had a challenging time opening the email and it was a hassle. The SW stated if she typed in the incorrect email address the system would kick it back. The SW stated she asked family and residents if they would like the information emailed and confirmed the email addressed. The SW stated she was not aware of family and/or resident signing a health release form. The surveyor asked the SW to send a sample email with information that was included. The surveyor observed in email: welcome letter, advance directive handout, notice of nondiscrimination, your rights in a nursing facility, current orders, and the home and community care transition prediction outcome which included patient evaluation information, care needs at the NF/SNF, and anticipated discharge information. The social worker stated she was not able to send the surveyor a list of all the residents whose clinics had been sent out over the last 60 days. The social worker was able to gather some of the emails sent out in the last 30 days. During an interview on 05/04/26 at 9:28 am the MRD stated an authorization for release of information had to be completed before resident personal information could be released. MRD stated he was responsible for the consent forms. The MRD stated family members and/or residents could put in a request for the form. The MRD stated the doctor's office would provide they're on form to fill out and a resident lawyer did not need to complete a consent form. The MRD stated he was not aware that the SW was sending medical record information. The MRD stated residents' personal information needed to be protected.Attempted to interview Resident #2 on 05/04/26 at 11:52 am and she was not able to answer questions about email.Attempted to interview Resident #3 on 05/04/26 at 11:55 am and he was not able to answer questions about email.During an interview on 05/04/25 at 12:00 pm the surveyor attempted to interview Resident#1, and he was not able to answer questions about email. Resident#1 family member stated that she does not receive the emails, but another family member had her email set-up to receive them, and she kept up with the information from the facility. During an interview on 05/04/26 at 12:10 pm the AD stated mediation orders and outcome predications are considered medical records. The AD stated emails are sent out to the email on the resident's face sheets. The AD stated she was not responsible for sending out medical records by email. During an interview on 05/04/26 at 12:30 pm the EDHIM specialist stated the MRD was responsible for sending out the consent form to be signed by resident and/or representative. The EDHIM stated the facility shared an encrypted file and residents' information was protected. The EDHIM specialist stated she was not aware that the SW sent out medical record information. During an interview on 05/04/26 at 12:40 pm the DON stated the SW will assist with sending out the current orders and outcome predictions after the teams had gone over baseline care plans. The DON stated the family members are incredibly involved and some are ill and cannot come to the facility. The DON stated that is why the facility keeps family updated with emails. During an interview and record review on 05/04/26 at 12:45 pm the ED stated she believed the emails are sent securely.Record review of facility policy titled, Disclosure of Protected Health Information (PHI)- Release of Information, revised 04/16/26 reflected .Eash resident has the right to access his or her protected health information contained in the medical record. The resident is assured confidential treatment of his or her medical records and may approve or refuse their release to an individual outside the facility.procedure . 2. When a request is made by a current resident or another party to view or copy the medical records, those request should be directed to the Health Information Management Director/Privacy official.Review of authorization for Release of Information.4.Copies of authorization are kept as a permanent part of the residents medical records

Based on interviews and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 5 residents (Resident #1 and Resident #2) reviewed for care plans. The facility failed to develop a care plan to address Resident #1's and Resident #2's inability to use a call light. This failure could have placed residents at risk of not having their needs identified and met. The findings were: Resident #1Record review of Resident #1's face sheet reflected a [AGE] year old female resident with an admission date of 4/27/2023 with diagnoses that included: unspecified dementia (disease affecting memory, thinking, and the ability to perform daily activities), generalized muscle weakness, heart failure, schizoaffective disorder (mental disorder characterized by psychosis and mood disorder), and anxiety disorder.Record review of Resident #1's Quarterly MDS dated [DATE] reflected Resident #1 was not assessed for a BIMS score because she was rarely/never understood. The BIMS reflected she had short-term and long-term memory problems. Her cognitive skills for daily decision making were reflected as moderately impaired with decisions poor and cues/supervision required. Her cognitive assessment reflected inattention and altered level of consciousness (vigilant, lethargic, stuporous, and/or comatose). The MDS reflected Resident #1 was dependent on staff for all self-care functional abilities. The MDS reflected Resident #1 was dependent on staff for all mobility functional abilities except for toileting transfers and walking 10 feet which were not applicable.Record review of the care plan dated 12-29-2025 reflected Resident #1 had an activity of daily living self-care performance deficit and an intervention included to encourage the resident to use the call light for assistance. The care plan did not reflect Resident #1's inability to use the call light and provide alternatives. Resident #2Record review of Resident #2's face sheet reflected a [AGE] year old female last admitted to the facility on [DATE] with diagnoses that included: hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (partial weakness and complete paralysis following a stroke), generalized muscle weakness, acute kidney failure, other lack of coordination, cognitive communication deficit (affects a person's ability to communicate effectively), memory deficit following cerebral infarction (stroke), and unspecified dementia (disease affecting memory, thinking, and the ability to perform daily activities).Record review of Resident #2's Significant Change MDS assessment dated [DATE], reflected a BIMS assessment was not conducted as resident was rarely/never understood. The MDS reflected Resident #2 had functional limitation in range of motion in an upper extremity on one side. The MDS reflected Resident #2 was dependent on staff to do all of the effort for oral hygiene, toileting hygiene, showering/bathing, upper and lower body dressing, putting on/taking off footwear, and personal hygiene. The MDS reflected Resident #2 required substantial/maximal assistance for eating. The MDS reflected Resident #2 required substantial/maximal assistance for the following activities: roll left and right, sit to lying, lying to sitting on side of the bed, moving from sitting to standing, and transferring from chair/bed-to-bed transfer. The MDS reflected she was completely dependent on staff for tub/shower transfers and that toilet transfers and walking 10 feet were not applicable.Record review of Resident #2's care plan initiated 8-28-2025 reflected Resident #2 was at risk for falls and an intervention included that her call light should be within reach. Her care plan did not reflect her inability to use a call light and did not provide alternative interventions for the use of the call light.In an interview on 02/11/2026 at 08:05 a.m., RN A stated that Resident #1 could not press her call light due to her cognitive status. He stated that she was unable to remember and unable to know that she had to use the call light. He stated that Resident #1 was at risk of falls and not getting her immediate needs met if she was unable to use a call light and did not have alternatives in place.In an interview on 02/11/2026 at 08:13 a.m., CNA B stated that Resident #1 was not able to use her call light and did not yell or call out for assistance, but that Resident #1 typically had a sitter at the bedside from around noon to 6 p.m. each day. CNA B stated that Resident #1 could not use her call light because of her mental status. She stated that Resident #1 would not be at risk if she could not use a call light or have planned alternatives because staff were aware of her inability to use the call light and were monitoring her frequently.In an observation on 02/11/2026 at 08:22 a.m., Resident #2 was observed in bed awake. She was observed as nonverbal, and she appeared confused and unable to follow commands. She did not respond when asked about where her call light was.In an interview on 02/11/2026 at 08:30 a.m., LVN C stated that Resident #2 had used her call light before she experienced a decline and was placed on hospice (date unknown), but that since that time she had not been able to use the call light. She stated that the aides know they have to check on Resident #2 because she cannot remember to use the call light. She stated that if Resident #2 could not use a call light and did not have an alternative, she would be at risk for falls.In an interview on 02/11/2026 at 08:40 a.m., CNA D stated that Resident #2 had never pushed the call light in the past month that she had worked at the facility. CNA D stated she did not think Resident #2 was able to understand using the call light. She stated staff made frequent rounds and left Resident #2's door open because they were aware she could not use her call light. She stated that if a resident could not use a call light and there were no alternative interventions, the resident could potentially fall and if they choked, they could not call for help.In an interview on 02/12/2026 at 12:45 p.m., the DON stated that Resident #1 had not been able to use her call light since she had begun working at the facility in 2023. She stated that Resident #1 typically had a sitter in her room from approximately 10 a.m. until 7 p.m. The DON stated that Resident #1 had not had any falls or injuries in the past year that she was aware of. The DON stated that Resident #2 had not been able to use her call light since her admission in 2024 due to her advanced dementia. She stated that Resident #2 had not had any falls or injuries in the past year that she was aware of. The DON stated that if a resident could not use a call light the facility should put a different intervention in the care plan, such as leaving the resident's door open or performing more frequent rounding. She stated that all nurses, the DON, and the MDS nurse were responsible for updating the care plan. She stated that if the care plan was not updated to reflect a resident's inability to use a call light it would be, a safety concern to the resident.In an interview on 02/12/2026 at 01:15 p.m., the ADM stated that Resident #1 and Resident #2 were unable to use their call lights. She stated that the facility policy stated that if a resident could not use the call light, alternatives including things such as leaving the doors open, moving the resident closer to the nurse's station, or more frequent monitoring could be used. She stated that the MDS coordinator was responsible for updating the care plan with alternative interventions. She stated that updating the care plan with these alternative interventions was important so that staff were aware of what they needed to follow for the patients.Review of the facility policy titled, Resident Call System with reviewed date of 12/23/2025 stated, The call light should be positioned within reach of the resident. Return demonstration may be used when educating the resident about call light use. If the resident is unable to demonstrate appropriate call light use, the nurse must be notified to determine an adequate alternative.Review of the facility policy titled, Comprehensive Care Plans and Revisions with reviewed date of 08/29/2025 stated, the facility should monitor the resident over time to help identify changes in the resident condition that may warrant an update to the person-centered plan of care.

Based on observation, interview, and record review, the facility failed to currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for storage of drugs and biologicals under proper temperature controls, and provide separately locked, permanently affixed compartments for storage of medications for 2 (med rooms A and B) of 2 reviewed for medication storage. 1. The facility failed to ensure medication rooms A and B were clean and well-lit. 2. The facility failed to ensure the fridge/freezer was at an appropriate temperature, which caused medications to freeze over in medication room A. This deficient practice could affect residents prescribed medications in the facility and place them at risk of receiving compromised or contaminated medications. Findings included: Observation on [DATE] at 08:07 AM of med room A with the Regional Nurse revealed a refrigerator with temperature of the fridge was 30 degrees Fahrenheit with no narcotics in the fridge. The Regional Nurse stated that they did not use the sink and that they would have to go across the hallway to wash hands in case of spills. She stated they also did not mix any medications in the med rooms. An interview and observation on [DATE] at 08:20 AM with the Regional Nurse of med room B revealed lightning was dark, which made it difficult to see the inside the refrigerator. The refrigerator contained no narcotics. The IV medication for Resident #81 had visible ice particles in both bags. Insulin and vaccine vials were stored in the bottom of the refrigerator in standing water and were wet. The temperature on the door of the refrigerator was observed to be 30 degrees Fahrenheit. The Regional Nurse stated the medication was cool. The Regional Nurse stated that the risk to residents who had medications with ice particles in them was improper dosage and potency of medication. She stated the nursing staff was responsible for cleaning the med rooms and for reporting non-working refrigerators and lighting. In a phone Interview on [DATE] at 01:08 PM the ADON stated all nursing staff were responsible for making sure medication rooms were clean, and medications were not expired. If the meds are frozen or sitting in water, that was not good. She stated freezing could change the structure and make it lose effectiveness. Interview on [DATE] at 3:15 PM with LVN I, she stated when she gave Resident #81 her antibiotics on Monday ([DATE]), the meds were not frozen. She stated if they were, she would have called the pharmacy. She stated, You can't let it thaw and use it. She stated the process would have been to call pharmacy for a new one because residents need it, and she would not want the resident to miss her dose. LVN I stated she would not give meds that were compromised because it was not in the purest form anymore, with ice particles and water, the medicine could be diluted. She stated she believed the night staff were responsible for cleaning the med rooms. She stated she was not sure if they were also responsible for the refrigerators, but any nurse was permitted to discard old things. LVN I stated she felt there was enough lighting but recently, a light did go out and they replaced it. She stated when it went out, they called the maintenance man, and he came to do things when they ask him. She stated she was here on Monday and did not see the light out until this morning, so it might have gone out Tuesday. She told the maintenance man this morning. She told his assistant. She has never used [work order system], she just requested of him verbally. In an Interview on [DATE] at 4:11 PM with the DON all the nurses were responsible for the med rooms, to make sure things were working properly. She stated staff checked temps each shift in the fridge. The DON stated if the fridge was frozen, they would have to defrost it. The DON stated she thought maybe they did not wait for them to defrost fully. She stated medication that was frozen was not good as it might change the quality of the medication. She stated they called housekeeping when a nurse was there for them to clean it. The DON stated she saw the sink in med room B and they had a housekeeper clean it today. She stated nurses did not mix meds in the med rooms. They did not use the sinks. She stated they have done in-services on med rooms. She stated all staff should know how to use [work order system] to report broken items as the administrator had sent out an email to everyone. DON stated housekeepers clean the nourishment fridge. Review of facility policy titled Storage and Expiration, dating of medication, Biological, revision dated [DATE] reflected .reflected in part 3.4. Facility should ensure that infusion therapy products and supplies are stored separately from other medications and biologicals, under appropriate temperatures and sterility conditions, according to the manufacturers or suppliers' recommendations .4. Facility should ensure that medication and biological that: (1) have an expired date on the label;(2) have been retained longer than recommended by the manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier. 5. Once any medication or biological package is open, the Facility should follow manufacturer/supplier guidelines with respect to expiration date for opened medications. Facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when medication has a shortened expiration date once opened or opened.5.3. If a multi-dose vial of an injectable medication has been opened or accessed (e.g., needle punctured) the vial should be dated with dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial.11. Facility should monitor refrigerator storage for evidence of moisture and condensation (humidity) and may consult with the pharmacy regarding medication integrity .

Based on observation, interview, and record review the facility failed to establish and maintain an Infection Prevention and Control Program designed to help prevent the standard and transmission-based precautions to be followed to prevent the spread of infections or diseases for 4 of ten (Resident #15, #18, and #25) reviewed for infection control. 1. LVN F failed to ensure PPE was worn for residents on EBP (Residents #15 and #25). 2. CNA J failed to perform hand hygiene during breakfast in A hall dining room and after assisting Resident #18. The failures could place residents that require assistance with personal care at risk for healthcare associated cross-contamination and infections. Findings included : Review of Resident #15's face sheet, dated 11/07/24, revealed a [AGE] year-old male, admitted to the facility on [DATE], with the diagnoses of esophageal obstruction (a blockage or narrowing of the esophagus), cancer of esophagus, Gastrostomy status (this is a feeding tube that is placed through the abdominal cavity area into the stomach for nutritional purpose and medication for individual who have a difficulty swallowing), and chronic kidney diseases . Review of Resident #15's care plan, dated 11/06/24, revealed the resident was on enhanced barrier precautions due to dysphagia (difficulty swallowing) which required tube feeding and esophageal cancer. The goal indicated Resident#15 to remain free of complications with tube-feeding. Interventions included: Administer peg tube feedings as ordered and provide local care to J-tube site as ordered. Review of Resident #15's physician's orders, dated 11/06/24, did not reflect dressing change and monitoring. Review of Resident #18's face sheet, dated 11/05/24, reflected he was a [AGE] year-old male, admitted to the facility on [DATE], and having diagnoses of heart disease with heart failure, acute and chronic respiratory failure, and chronic obstructive pulmonary disease (a condition which makes breathing difficult). Review of Resident #18's quarterly MDS Assessment, dated 10/14/24, revealed Resident #18 had a BIMS score of 14, which indicated the resident was cognitively intact. Resident was dependent on toileting, required substantial assistance in bathing, and dressing. Resident #18 had an active diagnosis of respiratory failure and chronic obstructive pulmonary disease, and was on oxygen therapy. Review of Resident #25's face sheet, dated 11/06/24, revealed the resident was a [AGE] year-old male , admitted on [DATE], with the following diagnoses of acute respiratory failure with hypoxia, heart failure, and COVID-19. Review of Resident #25's quarterly MDS assessment, dated 10/02/24, revealed the resident had a BIMS score of 15, which indicated the resident was cognitively intact. The resident required extensive assistance in bathing and dressing. Review of Resident #25's physician's orders, dated 11/06/24, revealed the following Open area to Left heel everyday shift for Open area clean area with wound cleanser, pat dry, apply anasept (antiseptic) with collagen powder. cover with Gauze Island with boarder dressing apply once daily for 30 days. Order active on 11/05/24. Open area to Right HEEL everyday shift for Open area to right heel clean area with wound cleanser, pat dry, apply anasept with collagen powder. Cover with Gauze Island w/ bdr apply once daily for 30 day. Review of Resident #25's care plan, dated 11/06/24, revealed the resident was on enhanced barrier precautions due to stage 3 pressure wounds ulcer to Left Heel and Right Heel and is at a Stage IV (wound that extends below subcutaneous fat into deep tissues, including ligaments and tendons) pressure ulcer development related to dehydration, Immobility Date Initiated: 08/23/2024. The goal was that the resident's pressure ulcer would show signs of healing and remain free from infection by/through review date. The interventions indicated to administer treatments as ordered and Enhanced barrier precautions. Review of Resident #21's face sheet, dated 11,07/24, revealed the resident was an [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses were colon cancer, perforated intestine due to pulps (diverticulosis), shingles without complication and high blood pressure. Review of Resident #81's face sheet, dated 11/05/24, revealed the resident was a [AGE] year-old female, admitted on [DATE], with the diagnoses of cervical region spondylosis with myelopathy (this is a condition that occurs when the spinal code in the neck deteriorated due to aging, Escherichia coli (a type of infection), and bacteremia, and Alzheimer's disease with late onset (this is a brain condition that progressively destroys memory and other important mental functions ). Review of Resident #81's MDS admission assessment, dated 10/30/24, revealed no pertinent information on her IV. Review of Resident #81's physician's orders, dated 11/05/24, did not reflect dressing change and monitoring for her IV. Review of Resident #81's care plan, dated 11/05/24, revealed the resident had dehydration or potential fluid deficit due to E. coli Bacteremia Infection and is on IV medication. The goal was Resident #81 would be free of symptoms of dehydration and maintain moist mucous membranes and good skin turgor. The resident is also on enhanced barrier precautions due to IV medications (Ceftriaxone) for Bacteremia and E. coli. The goal was for the resident to be free of complications from IV therapy. Interventions included: IV dressing: Observe every shift and change dressing and record observation of site as ordered. Observe signs and symptoms of infection at the site of the IV such as drainage, inflammation, swelling, redness, and warmth. Observation and interview on 11/06/24 at 10:17 AM, revealed Resident #15 in his room. The door sign read STOP Enhanced Barrier Precautions. Everyone must clean their hands before entering the room and when leaving the room. Providers and staff must wear gloves and gown for the following: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use such as; central lines, urinary catheter, feeding tube, tracheostomy. Wound care: any skin opening requiring dressing. LVN F washed her hands upon entry to go into Resident #15's room, she wore gloves on her hands, but she did not wear a gown as she accessed Resident #15's port that was located on his right upper chest area and dressing was clean, intact, and undated. LVN F stated she forgot to wear a gown before accessing Resident #15's port. She stated the purpose of Enhanced barrier precautions was to keep infection from the residents. Observation and interview with LVN F on 11/06/24 10:56 AM, revealed Resident #25 in his wheelchair, pain assessed to which the resident replied it was 2.78% LVN F stated she was going to do wound care on both his feet. The bedside table was cleaned. Wax paper used for contamination. LVN F completed wound care without wearing a gown during wound care. H and hygiene was completed afterward. LVN F assessed Resident #25 again for pain before cleaning and sanitizing the bedside table. Hand hygiene was completed . LVN F stated she forgot to wear her gown. She stated she had been trained on EBP and a resident with wounds was put on EBP for infection control. She stated the gown was worn not to spread infection to the resident and others. Observation on 11/07/24 at 07:59 AM revealed CNA J coming from Resident #21's room after asking her for one of the straws. Resident #21 asked, Why are you taking my straw? CNA J stated, You have so many. I will not take them all. CNA J did not perform hand hygiene after leaving Resident #21's room, before going to the dining room, or before removing the wrapper from the straw for Resident #18. CNA J placed the straw in Resident #18 's drink. CNA J then went to pick up a tray without performing hand hygiene and placed it on the cart before entering Resident #25's room to open a sugar packet to pour onto Resident #25's food . CNA J mixed the food with the sugar before giving the resident a bite while standing over him. Then CNA J went to pick up another tray before finally performing hand hygiene complete. Interview on 11/07/2024- 8:45 AM with CNA J revealed he got a straw from a resident's room and took it to another resident. He stated he put the straw in the drawer and then realized they had no straws left for Resident#18, who needed to sip his drink. CNA J stated Resident #18 couldn't drink without a straw. CNA J stated he did not go to the kitchen to get a clean one, because he knew where he could grab one. He stated it was not appropriate to get things from one resident's room for another resident. CNA J stated when he took a meal tray, he realized he had to sanitized his hands but when he discovered Resident #25 couldn't help himself, and he had not been eating well. He went to go assist him and failed to sanitize his hands along the way. CNA J stated he did not know what happened to him today and was not able to explain why he did not follow infection control protocol. In a phone interview on 11/07/24 at 01:08 PM with the ADON, revealed Resident #15 admitted with the g-tube and she was aware he had a chemo port. The ADON did not think she was unsure whether it was dated. She stated she had in-serviced staff on enhanced barrier precautions. She stated if someone was accessing a midline or port, they have to use PPE and for wound care, as well. The ADON stated It was an extra layer of protection between staff and the patient, and for anyone who had any type of opening (such as a catheter). She stated they have to gown-up to make beds, touch the patient, and any direct care with the resident. The ADON stated she had done multiple in-services on EBP. The ADON stated getting a straw from another resident and having no hand hygiene during meal services was not acceptable. She stated that was an example of bad hand hygiene. She stated she did a [competency] checkoff, had signs up, and monitored staff. The ADON stated if staff took something out of a resident's room and take it to another, that was already the start of a bad situation. They have been in-services on hand washing and staff would sing the happy birthday song in front of her to show competency. The ADON stated her checkoffs and in-services were in binders. The ADON stated the risk was cross contamination from the moment that person took the straw from one resident to the other, that was already cross contamination. Interview on 11/07/24 at 4:11 PM with the DON revealed CNA J at mealtime with straw should have been doing infection control, with hand hygiene. The straw was infection control, and she would expect him to get the straw from the med cart or the boxes they had. The DON stated when accessing the port or midline, the nurse should have followed EBP for infection control. The DON stated she did not know when the port dressing for Resident #15 was done. Review of the facility's in-service dated 06/14/24, enhanced barrier precaution by the ADON revealed, LVN F and RN G had completed training. Review of the facility's Midline Catheter Dressing Change policy, revised 06/2024, revealed, .sterile dressing change using transparent dressing is performed .at least weekly .label dressing with date, time and nurses' initials . Review of the facility's Enhanced Barrier Precautions policy, revised 03/21/24, revealed, .EBP are indicated for residents with any of the following: 1. Infection or colonization with a CDC-targeted MDRO .Wounds and/or indwelling medical devices even if a resident is not known to be infected or colonized with a MDRO .post signage .high-contact resident care activities requiring gown and glove use . Review of the facility's policy dated November 9, 2022, and titled Standard Precautions revealed .Standard precautions are used in the care of all residents regardless of their diagnoses, or suspected or confirmed infection status .hand hygiene is performed with soap (anti-microbial or non-antimicrobial) or alcohol-based hand rub before and after contact with the resident .

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food safety in the facility's only kitchen. 1. The facility failed to ensure kitchen staff had a hair net on while in the kitchen. 2. The facility failed to ensure food items in the dry storage were dated, labeled, and securely stored. 3. The facility failed to ensure two cans of canned goods were free from dents. 4. The facility failed to ensure food items in the walk-in freezer were labeled, dated, and secured. 5. The facility failed to ensure a metal container of melted fat held on the gas stove was properly covered and dated. 6. The facility failed to ensure cleaning equipment was not placed against clean dishes. 7. The facility failed to ensure nourishment refrigerators were free from cross-contamination? 8. The facility failed to prevent a fan from severing and blowing towards the food area . These failures could place residents at risk for food-borne illnesses. Findings include: Observation on [DATE] at 08:13 AM upon entry to the kitchen, revealed a staff member Dietary aide D was observed with a fast-food bag and a drink in the kitchen area without a hairnet on . Another staff member [NAME] B was observed with a white hat worn backwards, and another staff member the Dietary manager was observed without a hair net on either. Of the four staff in the kitchen, only Dietary aide C had a hair net on. Observation and interview on [DATE] at 08:15 AM of the dry storage with the Dietary Manager revealed the following: One bag of nacho chips tied up with what appeared to be plastic wrap dated ,d+[DATE]. The Dietary Manager stated the nachos were used last week and lasted up to 7 days after opening. She was unsure if the labeled date was from when the nacho chips were delivered or used. One can of marinara sauce and one cream of celery soup were dented. The Dietary Manager stated if canned goods were dented or not safe for consumption, they were not accepted at delivery. Observation on [DATE] at 08:20 AM of the walk-in freezer with the Dietary Manager revealed the following: One package of sausage had a use by date of 8/X/2024. The month and year were visible, but day was not. One bag of opened frozen hush puppies, with no date, and not properly packaged for storage (bag was open in freezer). Observation on [DATE] at 08:30 AM of the kitchen revealed the following: A metal container of [NAME] sitting on the gas stove top shelf. The container was 75% covered with aluminum foil, exposing the [NAME] to air. The mop handle without a head was leaning up against clean bowls. Interview on [DATE] at 08:32 AM with the Dietary Manager revealed the mop head and the attachment should be in the storage room. Observation and interview on [DATE] 07:53 AM of the kitchen fan close to entry inside the kitchen on blowing and severing towards the steam table, food lids were open. Dietary aide C stated she did not know who turned it on. Dietary aide C stated she always wore a hairnet when before she entered the kitchen to prevent hair from falling into the food and it was a requirement. She stated [NAME] B and Dietary aide D did not come to work today. Interview on [DATE] at 2:04 PM with the Dietary Manager revealed she was not aware of the staff food in the preparation area. She stated there was a locker where staff normally stored their food. The Dietary Manager stated staff knew their items did not go out on her floor (the kitchen areas where food was prepared and stored.) She stated it was not allowed because she was preparing residents' meals, and that was a policy she upheld. She stated it could cause cross-contamination. The Dietary Manager stated when she saw Dietary Aide D with the food, she was coming out of the right area with it, so she probably put it in there when she saw the State. She stated they were not supposed to have the fan swerving, and it was supposed to blow directly toward the dish area. She stated she was not aware that a second fan was also going. She stated they would not want that, because it was blowing whatever is in the air, and it could change the temperature of the food. The Dietary Manager stated the aide, and cooks were responsible for dating and labeling when they stored things. She stated she had a new aide and a new cook. She had a label and date sheet to show them the time frames things were supposed to be dated with, and she was constantly telling them to use it. The Dietary Manager stated she had in-serviced everyone on that. She stated the fat on the stove was butter and it was not supposed to be stored with foil. It was a daily-use item, and they took a block of butter out each day and used it throughout the day. Cooks were supposed to discard it at the end of the day. She stated the night cook was supposed to discard it. The Dietary Manager stated the freezer had sausage links that were dated wrong, and she has her order form to show that. She stated the hushpuppies were also dated wrong, and she knew who did it and had already done an in-service with them. She stated when she talked to that employee, and asked her why, the employee said she did not know they were not supposed to put the date they used the food on it. The Dietary Manager stated if they cooked something and it had (was good for) three days, they put three days on it. She stated she had a cook who went through and made sure expired foods were not in there, but he was usually pretty good with it. She did not know what happened this time. She stated he had a log he marked off when he did it. The Dietary Manager stated the stove was a gas stove, and the problem with the exposed container of fat over was that it could cause a fire. Whoever was working on the day they got a truck that was responsible removing the dented cans, and she knew Dietary Aide D put the dented cans there. The Dietary Manager stated Dietary Aide D told her that the can only had a little dent, so she in-serviced her and told her about the harm a little dent could cause. The Dietary Manager stated the risk was that the aluminum could get into the product. She stated that there was a risk for food poisoning from even a small dent. The Dietary Manager stated the risk of cleaning equipment being against clean dishes could cause contamination. She was very nervous, she said. The Dietary Manager revealed the risk of cleaning equipment being against clean dishes could cause contamination . When asked about the staff not wearing hair nets, she said she had just stepped into the area and normally did not answer the door without her hair net, but she barely had a chance to put her things down before the surveyor knocked on the door. She said the other two staff were written up for not wearing [NAME], because one of them was an established employee and knew better, and the newer employee had been counseled about it already, and told to put a hair net on under her hat. She said the problem with not wearing them was also the risk of contamination. Interview on [DATE] at 5:31 PM with the Administrator revealed his expectation was for the kitchen to remain clean, food items dated/labeled and safe as it could lead to contamination and unsanitary conditions. Review of the facility's Food Safety policy, revised [DATE], revealed, .pre-packaged food is placed in a leak-proof, pest-proof, non-absorbent, sanitary .container with a tight-fitting lid .container is labeled with the name of the contents and date (when item is transferred to a new container). 'Use by Date' is noted on the label or product when available .dented, leaky, rusted and swelling cans that could affect food safety are returned to the vendor but stored in a designated area away from other food . Review of the U.S. Public Health Service Food Code, dated 2017, reflected: XXX,d+[DATE].18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A food specified in ,d+[DATE].17(A) or (B) shall be discarded if it: . (2) Is in a container or package that does not bear a date or day; (3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section; or ,d+[DATE].17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when packaging food using a reduced oxygen packaging method as specified under S ,d+[DATE].12, and except as specified in (E) and (F) of this section, refrigerated, ready-to eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5 C (41 F ) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1 . Review of the U.S. Public Health Service Food Code, dated 2017, reflected: XXX,d+[DATE].15 Package Integrity. Food packages shall be in good condition and protect the integrity of the contents so that the food is not exposed to adulteration or potential contaminants .

Based on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice, for three (Residents #18, #25, and #133) of ten residents reviewed for oxygen: The facility failed to ensure the humidifier water was changed according to the facility policy for Residents #18, #25 , and #133 and failed to ensure oxygen tubing was changed weekly per facility policy for Residents #18 and #25. This deficient practice could affect residents who received oxygen therapy by causing them to receive incorrect or inadequate oxygen support and could expose them increased infection risk, resulting in infections and a decline in health. Findings included : 1. Review of Resident #18's face sheet, dated 11/05/24, reflected he was a [AGE] year-old male, admitted to the facility on [DATE], and having diagnoses of heart disease with heart failure, acute and chronic respiratory failure, and chronic obstructive pulmonary disease (a condition which makes breathing difficult ). Review of Resident #18's quarterly MDS Assessment, dated 10/14/24, revealed Resident #18 had a BIMS score of 14, which indicated the resident was cognitively intact. Resident was dependent on toileting, required substantial assistance in bathing, and dressing. Resident #18 had an active diagnosis of respiratory failure and chronic obstructive pulmonary disease, and was on oxygen therapy. Review of Resident #18's care plan, dated 11/06/2024, revealed the resident was at risk for shortness of breath due to a diagnosis of COPD. The goal indicated the resident would have no complications related to shortness of breath. Interventions included: Administer oxygen as ordered, maintain clear airway by encouraging resident to clear own secretions with effective coughing. If secretions cannot be cleared, suction as needed to clear secretions. Review of Resident #18's order summary, dated 11/05/24, reflected: - Change oxygen tubing and nebulizer circuit every night shift every Sun With an order date of 05/28/2024 and a start date of 06/02/2024. - Clean oxygen concentrator filter with soap and water weekly every Sun With an order date of 05/28/2024 and a start date of 06/02/2024. - Oxygen at _2-5_ liters/minute per nasal cannula as needed With an order date of 05/28/2024 and a start date of 05/28/24. - Oxygen at 2_5 liters/minute continuously per nasal cannula. Document every shift With an order date of 05/28/2024 and a start date of 05/28/24. - Oxygen sat rates every shift With an order date of 05/28/2024 and a start date of 05/28/24. - Oxygen sat rates every shift may titrate to keep above_96__% With an order date of 05/28/2024 and a start date of 05/28/24. - There was no order mentioned replacing the humidifier water. Observation on 11/05/24 at 10:00 AM with Resident #18 revealed the resident was asleep. Observation of Resident#18's oxygen concentrator revealed 5 L of compressed air attached to him, the humidifier water was dated 10/27 on one side and 11/03 on the other side. The oxygen tubing dated 08/24. 2. Review of Resident #25's face sheet, dated 11/06/24, revealed the resident was a [AGE] year-old male, admitted on [DATE], with the following diagnoses of acute respiratory failure with hypoxia (low levels of oxygen in body tissue), heart failure, and COVID-19 . Review of Resident #25's care plan, dated 11/06/24, revealed the resident had shortness of breath due to history of PNA and respiratory failure. The goal indicated Resident #25 would have no complications related to shortness of breath. Interventions included: Administer oxygen as ordered, encourage sustained deep breaths .using incentive spirometer. Review of Resident #25's quarterly MDS assessment, dated 10/02/24, revealed the resident had a BIMS score of 15, which indicated the resident was cognitively intact. The resident required extensive assistance in bathing and dressing. Review of Resident #25's physician orders, dated 11/06/24, revealed the following: Change oxygen tubing and nebulizer circuit every night shift every Sunday, start date 08/14/24. Change oxygen tubing as needed, start date 08/12/24. Clean oxygen concentrator filter with soap and water weekly every Sunday, start date 08/18/24. Observation on 11/05/24 at 10:26 AM with Resident #25 revealed his oxygen tubing was dated 08/24 on an orange label attached to his oxygen tubing. The family stated Resident #25 had been wearing oxygen since he was diagnosed with pneumonia. 3. Review of Resident #133's face sheet, dated 11/06/24, revealed the resident was a [AGE] year-old female, admitted on [DATE], with the following diagnoses of acute and chronic respiratory failure with hypoxia, obstructive sleep apnea, and moderate persistent asthma. Review of Resident #133's MDS assessment, dated 10/29/24, revealed the resident had a BIMS score of 14, which indicated the resident was cognitively intact. The resident was dependent on toileting and hygiene and required extensive assistance with bathing and dressing. Resident #133 was diagnosed with respiratory failure and asthma. Resident #133 was on oxygen therapy. Review of Resident #133's care plan, dated 10/25/24, revealed the resident had shortness of breath due to asthma. The goal indicated Resident #133 would be free of complications from asthma. Interventions included: Administer oxygen as ordered, give medications as ordered, and observe for signs and symptoms of impending asthma attack. Review of Resident #133's order summary, dated 11/07/24, reflected: - Change oxygen tubing and nebulizer circuit every night shift every Sun with an order date of 10/29/2024 and a start date of 11/03/2024. - Oxygen at _2-5__ liters/minute continuously per nasal cannula with an order date of 10/29/2024 and a start date of 10/29/2024. - Oxygen at 2-5_ liters/minute per nasal cannula as needed with an order date of 10/29/2024 and a start date of 10/29/2024. - Oxygen sat rates every shift with an order date of 10/29/2024 and a start date of 10/29/2024. - Oxygen sat rates every shift may titrate to keep above __95_% with an order date of 10/29/2024 and a start date of 10/29/2024. Observation on 11/05/24 at 10:30 AM with Resident #133 revealed the resident seated in her recliner chair drinking coffee. Her oxygen was attached to a compressor, then to her nose. Resident #133's oxygen concentrator revealed 3 L of compressed air, and the humidifier water was dated 10/27 on one side and 11/03 on the other side. The tubing was dated 11/03. Resident stated she was watching her favorite TV show and did not want to interview. In an interview on 11/05/24 at 2:30 PM with LVN F, she stated she knew how to change the oxygen tubing and the humidifier water. She stated that the facility did not have a respiratory therapist, and the nurses were responsible for changing the tubing every Sunday. She stated the humidifier water was only changed when it ran out. She stated the risk to not changing tubing was infection due to residents breathing in the germs. Interview on 11/07/24 at 3:15 PM with LVN I, revealed she had some residents on oxygen in the secured unit and named them. She stated she knew how to change the tubing and filter water, and it was done every Sunday, usually it was the night shift that changed them. She stated when she arrived on Monday morning and it was not changed, she made sure it was changed. LVN I stated she has seen staff scratch the date off the humified water and she has told them to re-do it because she had no way of knowing if they changed the date or not. She was reticent to see who she had told. She stated she wanted to make sure residents get enough oxygen, because if tubing was old, kinks and bacteria could grow in the humidified water. In an observation and interview with DON on 11/05/24 at 3:20 PM, revealed she went around to Resident #25's room and took the old tubing out. She then went into Resident #133 and into Resident #18's rooms and stated that the tubing and humified water were expected to be changed every Sunday and as needed if the humidified water ran out. She stated it was unacceptable for a nurse to cross off a date and write a new date on the humidification bottle. She stated the whole bottle should be changed and a new date written on it. She stated nursing staff were responsible for monitoring the oxygen and she was also responsible for making sure nursing staff was following policy. Humidification on O2 was changed every Sunday night, every 7 days. The nurse on duty did it. It is not ok to cross out a date and write a new date. They change it weekly. They change it weekly because everything goes back to infection control. That is the risk. Review of the facility's Oxygen Administration (Safety, Storage, and Maintenance), revised 10/11/24, revealed, .Change oxygen supplies weekly and when visibly soiled. Equipment should be labeled with patient name and dated when setup or changed out .Humidifier/Aerosol bottles should be dated and replaced every 7 days regardless of H2O level .

Based on observation, interviews, and record review the facility failed to ensure residents received parenteral fluids administered consistent with professional standards of practice and in accordance with physician orders for 2 (Residents #15 and #81) of 2 residents reviewed for peripheral intravenous care. 1.The facility failed to attach Resident #81's needleless connector (connects to the end of a catheter to delivery IV therapy) to the IV every seven days as indicated in the physician's orders. (A midline is a long flexible tube that is inserted into the vein in the upper arm to administer medication or fluids intravenously) and failed to date the IV dressing. 2.RN G failed to disinfect the midline catheter prior to securing the needleless connector on the IV for Resident #81. 3.The facility failed to date Resident #15's chemo port dressing (this is a small implantable device that allows for easy access to veins for medical treatments) and failed to date Resident #81's intravenous midline dressings. 4.LVN F failed to wear appropriate PPE when accessing Resident #15's chemo port. The failures placed residents at risk of developing an infection. Findings included: 1. Review of Resident #81's face sheet, dated 11/05/24, revealed the resident was a [AGE] year-old female, admitted on [DATE], with diagnoses of cervical region spondylosis with myelopathy (this is a condition that occurs when the spinal code in the neck deteriorated due to aging, Escherichia coli (a type of infection), and bacteremia, and Alzheimer's disease with late onset (this is a brain condition that progressively destroys memory and other important mental functions ). Review of Resident #81's physician orders, dated 11/05/24, revealed the following: - IV: Midline Catheter - Change needleless connector every day shift every 7 day(s) AND as needed and with blood draws or transfusions with start date of 11/06/24 Review of Resident #81's care plan, dated 11/05/24, revealed the resident had dehydration or potential fluid deficit due to E. coli Bacteremia Infection and is on IV medication. The goal was Resident #81 would be free of symptoms of dehydration and maintain moist mucous membranes and good skin turgor. The resident is also on enhanced barrier precautions due to IV medications (Ceftriaxone) for Bacteremia and E. coli. The goal was for the resident to be free of complications from IV therapy. Interventions included: IV dressing: Observe every shift and change dressing and record observation of site as ordered. Observe signs and symptoms of infection at the site of the IV such as drainage, inflammation, swelling, redness, and warmth. Review of Resident #81's MDS admission assessment, dated 10/30/24, revealed no pertinent information related to the resident's IV. Review of Resident #81's MAR for November 2024, revealed the needleless catheter was last changed on 11/06/24, the date surveyor made the observation and again on 11/07/24. Observation and interview on 11/05/24 at 01:19 PM, with RN G revealed Resident #81 with a single IV catheter tube in her left upper arm. The dressing around the IV catheter was undated and the IV catheter tube had no needleless connector (connects to the end of a catheter to delivery IV therapy) to it. RN G stated Resident #81 had a midline with a single lumen (central venous catheter with a single distal port for drug infusion, blood drawing, etc .). He stated he did not know what happened to the needless connector and he did not know when the dressing was changed. He stated he would put the cap back on the midline. RN G wheeled Resident #81 out of her room and put on gloves and put a green cap at the end of IV catheter tube without the needless connector. The needless connector was still missing from the end of the IV catheter tube. RN G did not disinfect the midline catheter before securing the green cap to it. Resident #81 was non interviewable about the midline. She smiled and said hello. Observation and interview on 11/06/24 at 8:01 AM of Resident #81 with RN G revealed Resident #81 was attached to the IV pole with antibiotics done. Resident #81's midline IV dressing had been changed and dated 11/05/24. The needless connector was attached at the end of IV catheter tube. RN G stated the needless connector was used for filtration and to keep infection out of the midline. He stated he did not know who had removed it yesterday. He stated when he had administered Resident #81's antibiotics on 11/05/24 at 1:00 PM the needless connector was there. RN G stated he should have cleaned the IV catheter before putting on the green cap and he should have secured another needleless connector to the midline IV catheter. He stated it might have fallen off during the night shift. RN G was asked if he noticed it missing during the morning IV medication administration to which he responded he was not aware the needless connector was missing. 2. Review of Resident #15's face sheet, dated 11/07/24, revealed a [AGE] year-old male, admitted to the facility on [DATE], with the diagnoses of esophageal obstruction (a blockage or narrowing of the esophagus), cancer of esophagus, Gastrostomy status (this is a feeding tube that is placed through the abdominal cavity area into the stomach for nutritional purpose and medication for individual who have a difficulty swallowing), and chronic kidney diseases . Review of Resident #15's physician's orders, dated 11/07/24, revealed Saline flush solution. Use 10 ml intravenous every 3 months starting on the 28th for 10 days for port to implanted port-valved when not accessed. The physician's orders did not reflect dressing changes and monitoring. Review of Resident #15's Care Plan initiated 10/22/24 revealed Resident #15's care plan did not reflect a chemo port and interventions. Observation and interview on 11/06/24 at 10:17 AM, revealed Resident #15 was in his room. The door sign reflected STOP Enhanced Barrier Precautions. Everyone must clean their hands before entering the room and when leaving the room. Providers and staff must wear gloves and gown for the following: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use such as; central lines, urinary catheter, feeding tube, tracheostomy (surgical procedure that involves creating an opening in the neck to access the trachea). Wound care: any skin opening requiring dressing. LVN F washed her hands upon entry to go into Resident #15's room. She wore gloves on her hands, but she did not wear a gown as she accessed Resident #15's port that was located on his right upper chest area. The dressing was clean, intact, and undated. LVN F opened the port and flushed it with 10 ml of saline. Resident #15 stated the port was put in when he was doing chemo and radiation for his cancer. He stated it had not been used since he was at the facility. LVN F stated that she had to flush the chemo port per physician's order with saline. LVN F stated she forgot to wear a gown before accessing Resident #15's port. She stated the purpose of enhanced barrier precautions was to keep infection from the residents. Phone Interview on 11/07/24 at 01:08 PM with the ADON, she stated she had done an in-service on IVs; it was about tubing, dressing changes, and IV administration. That was the most recent and it had been within the last week. The ADON stated midline dressings, the clear one, was changed weekly. LVN I stated it should be dated. She stated it should have a needleless connector on it. The ADON stated if the needleless connector was not on, there was a risk for infection. She stated the nurse who administered medications through the IV would have been the first person to make sure it was attached, and the floor nurse would monitor the IV. The ADON stated if she saw that the resident did not have the connector, she would have assess the resident and ensured Resident #81 had the connector and attached it, and before she put it back on, she would clean the site first. She stated she would clean the site with alcohol. The ADON stated they had plenty of supplies for dressing changes, and had extra supplies stored. The dressing change was a sterile one. The needleless connector was treated as sterile. The ADON stated the port access should be done according to physician's orders and infection control precautions should be followed accordingly. She stated she was unaware that Resident #15 had a port. Interview on 11/07/24 at 3:15 PM with LVN I revealed she administered antibiotics to Resident #81 via IV on 11/04/24, Monday. She stated she did not remember what the little part that was connected to the IV was (needleless connector). LVN I stated the dressing was dated when she changed it, and it had the twist part that connected, but she could not remember the name. She stated it was to allow fluids to flow through and she would close it up to protect the tubing from bacteria. The surveyor showed LVN I a picture of the dressing that was undated as of 11/05/24. LVN I stated Resident #81 would pull off the dressing and that someone must have replaced it since she did not know why it was not dated. She stated the dressing was sterile for infection control. LVN I stated last month she thought they did EBP training, and they did it for IV, and she did a whole course on it about a month and a half ago. She stated there was no in-service the past week though. LVN I stated she was an IP nurse, so she had to do training on IV. She stated the ADON does most of it, but LVN I stated she stepped up when the ADON was out of the facility. She stated she was mainly on the floor. She stated EBP was for any resident with wounds, catheters, IV . there were a lot of different ones that were required to be on EBP. She would expect the staff to wear PPE to provide care for a midline or port. The purpose was to protect staff and the resident from spreading bacteria. LVN I stated it was a precaution. LVN I revealed that residents admitted with a chemo port doctor's orders were followed regarding the care of the chemo port site. She stated they would document the chemo port on admission, the dressing, how it looked and what it was, and whatever the orders were. If there was no order for dressing or anything, she would reach out to the physician. LVN I stated the admitting nurse would be responsible for verifying the orders with the physician and on their daily rounds with the DON and the IDT. She stated they would confirm and double check those orders. LVN I stated she was not sure about whether they were allowed to change the dressing and would have to look at the policy. LVN I stated she had never dealt with a chemo port nor had she done anything with it. She stated if the chemo port had a dressing that needed to be changed or cleaned, they would do that, but there would have to be orders in place to even do that. She stated the NP would get with the doctor who would deal with the port. LVN I stated sometimes they got orders from physicians that they see outside the facility. LVN I stated she has never changed a dressing on a chemo port, nor does she know how. LVN I stated if someone had an undated dressing on a port, she would not touch it. She stated she would get someone who knew how and would find out what she was even allowed to do with the chemo port. LVN I stated she would reach out to DON first, then the physician. She stated she would not touch it without doing that first. LVN I stated she would not want to do anything without asking, because it would be outside of her scope as she was not an RN. LVN I stated she would want a date on the dressing because they need to know if it was clean and how long the dressing had been on. She stated if the dressing had been on for 10 days there were probably a lot of germs under it. Interview on 11/07/24 at 4:11 PM with the DON revealed her expectations of IV dressings was to make sure they were dated all the time. She stated she had a conversation with the Pharmacist because when they placed the midline, they came in without a date, and nurses had to check for that. The DON stated the blue cap (needless connector), the green cap, and the date were missing in the photo of the midline for Resident #81. She stated the blue cap (needless connector) was placed so residents do not have infection, because the line was direct from the vein, and it was exposed. The DON stated the nurses were responsible for ensuring the cap was on there. She stated the nurse should not have placed the green cap directly without the blue part (needless connector) on the line. She stated they did training with the nurses and even had someone from outside come in and train the nurses. The DON stated the RNs already had IV certification, so it was the LVNs who needed training. The DON revealed when a resident had a port, like a chemo port, the expectation was that nurses do not touch the chemo port. She stated there was an order for the port, which needed to be flushed every three months with heparin (anticoagulant, to help prevent clots in the port) by the provider. The DON stated if the hospital gave them orders to flush it, they would do it. She stated she has never flushed the chemo port, and her staff do not change the dressing. The DON stated if the dressing was not dated, she would call the provider and ask them to come and change the dressing. She stated they usually come within two days. She was aware of the port, and stated she saw the provider when he came, because she spoke to his case manager when he came. The DON stated she spoke to the provider regarding the port, and they were not required to do anything with it. She stated she did not tell them it was undated. The DON stated she had a lot of conversations and could not remember if she talked to them about the dating. She stated she did not remember if LVNs were allowed to access the port, or flush it and would have to look at the policy After reviewing the orders, the DON stated she looked at the order, and it did say flush with saline, however, there was no order for the dressing. The DON stated it was important to ensure dressings were done in order to monitor the port and dressing for signs of infection, and because he was on chemo he was susceptible to infection. The DON stated when accessing the port, the nurse should have followed EBP for infection control. The DON stated she did not know when the port dressing for Resident #15 was done. She stated the order should have been to flush [NAME] every 3 months instead of saline. She stated the facility was not allowed to change the port dressing and orders should have been put in to reflect that. Review of the facility's in-service dated 06/14/24, enhanced barrier precaution by the ADON revealed, LVN F and RN G had completed training. Review of facility's competency check off for IV revealed the checks were completed by LVN F and RN G on 11/05/24. Review of the facility's Midline Catheter Dressing Change policy, revised 06/2024, revealed, .sterile dressing change using transparent dressing is performed .at least weekly .label dressing with date, time and nurses' initials . Review of the facility's Enhanced Barrier Precautions policy, revised 03/21/24, revealed, .EBP are indicated for residents with any of the following: 1. Infection or colonization with a CDC-targeted MDRO .Wounds and/or indwelling medical devices even if a resident is not known to be infected or colonized with a MDRO .post signage .high-contact resident care activities requiring gown and glove use . There was no facility policy on needleless connectors. Internet search What Is A Needleless Connector?, dated 02/23/21, revealed, .Needleless connectors (NCs) are devices connected at the end of vascular catheters. Once connected to the vascular catheter, two critical clinical activities could be done: (1) infusion can be done through it, or (2) aspiration can be performed . prevent the unnecessary entry of disease-causing microorganisms while infusion or aspiration is occurring

Based on observation, interview, and record review, the facility failed to provide Food that accommodates resident allergies, intolerances, and preferences for one (Resident #131) of 3 residents reviewed for food preferences. The facility provided Resident #131 a lunch meal that contained meat in it, which did not match her vegetarian preferences. This failure could affect residents who ate meals from the facility's only kitchen by placing them at risk of not having their choices and food preferences accommodated, possible weight loss, and a diminished quality of life. Findings included: Review of Resident #131's face sheet, dated 11/06/24, revealed the resident was a [AGE] year-old female, admitted on [DATE], with the diagnoses of anemia, major depressive disorder, and hypertension (high-blood pressure ). Review of Resident #131's initial MDS assessment, dated 11/01/24, revealed no pertinent information. Review of Resident #131's care plan, dated 11/05/24, revealed she was at risk for weight fluctuation due to current health status. The goal was to maintain Resident #131's current weight. Resident #131's diet was listed as regular. No documentation of the residents' dietary preferences was found. Interview on 11/05/24 at 09:19 AM with Resident #131 revealed she was recently admitted and that she generally did not eat much. Resident #131 stated she was a vegetarian and liked salad. Observation and interview on 11/06/24 at 11:46 AM with Resident #131 in her room revealed that she did not like the taste of the pasta because there was meat in it. She stated she did not eat meat. Resident #131 stated the person who brought her food took out the bigger chunks of meat but there was still meat on the pasta. She stated that was, however, the first time that she had been served anything with meat since she was admitted . Observation of Resident #131's meal revealed chunks of meat in the gravy and the pasta. Review of Resident #131's meal ticket revealed, Reg Texture, Thin, Veg .no meat . In an interview on 11/06/24 at 11:50 AM with the Dietitian revealed Resident #131 was a vegetarian. The Dietitian offered a grilled cheese sandwich to Resident #131. She stated the procedure was to check the plates to ensure accuracy of the resident's meal preferences. The Dietitian stated it was important to honor preferences. The Dietitian stated she talked to Resident #131 regarding her meal preference and about getting yogurt. Interview on 11/06/24 at 11:56 AM with CNA E revealed she took the lunch tray to Resident #131 and did not open it to look at the meal. She stated she was aware the resident was vegetarian. CNA E stated Resident #131's preference was on the meal slip and the resident herself had told her. CNA E stated she would have told Resident #131 to give her a second and get her a different tray had she had known. CNA E stated residents that did not eat meat should not be given meat. Interview and observation on 11/06/2024 at 12:07PM with [NAME] A and the Dietitian revealed that [NAME] A stated the gravy used in Resident #131's lunch meal was beef flavored gravy with no actual meat. Observation of the gravy mix revealed it was [Brand Name] gravy mix and contained ingredients of chicken fat and gelatin. [NAME] A stated that she cooked the meat and gravy separately. The Dietitian stated the chunks on Resident #131's pasta could have been the noodles or gravy mix. The Dietitian stated that she had an extensive length talk with Resident #131 yesterday, 11/05/2024, about her dietary preferences. She discussed that Resident #131 didn't like the flavor of meat and was offered options as an alternative to what was being served each day. She stated cottage cheese was ordered for Resident #131. [NAME] A and the Dietitian confirmed that Resident #131's meal card instructions reflected her dietary preference was vegetarian. Phone Interview on 11/07/24 at 01:08 PM with the ADON revealed the facility conducted training with the staff on the meal tickets and on reading it, if residents had a like or dislike. The facility would also, during orientation, ask new patients to tell them what they disliked, and if they had a special diet. She expected the staff to do the set-up of the plate for meals, which was a part of the meal service. The ADON stated they were to open the plate up, make sure residents had all of their items. She stated that was part of the dining experience. The ADON stated it was a problem when staff didn't notice when the meal did not match food preferences. She stated the aide would normally notify the kitchen, let the nurse know, and get the resident a substitute. The nurse would review the dietary slip so they could solve the problem. The ADON stated it was a problem because it was Resident #131's right to have food she could eat, and the resident could get upset. She stated if the resident did not get food she wanted, she would not eat. Interview on 11/07/24 at 2:04 PM with the Dietary Manager revealed [NAME] A cooked all the gravies the kitchen used such as chicken, beef, and turkey, and the only one Resident # 131 was supposed to have was the brown gravy, because each of the other gravies had meat in them. The Dietary Manager stated [NAME] A gave her beef gravy instead of brown gravy. The Dietary Manager confirmed Resident #131's lunch meal had chunks of meat in the gravy and pasta. She stated normally the meat was cooked separately, cooked first, and when it was done, it was combined with the gravy. She stated the staff knew Resident #131 was vegetarian and did not have any problems with that before. The Dietary Manager stated she reviewed all the different diets with the kitchen staff, and they had a chart they can read about any special diet, celiac (immune reaction to gluten), anything. She stated she watched facility staff to ensure they were abiding by resident preferences. The Dietary Manager stated when she was not in the kitchen, she would hope staff would do the right thing, and she was not right there when Resident #131 was served a meal with meat in it. She stated it was the right of the residents to get served food that met their preferences. Interview on 11/07/24 at 3:15 PM with LVN F revealed if a resident was vegetarian or had an allergy she knew where to look for it. She stated if the resident was vegetarian, she would check to see if there was anything on the meal tray that was not vegetarian such as any meat or anything their diet stated they were not supposed to have. LVN F stated that could affect the resident as they may not know what kind of reaction the resident would have. LVN F stated she talked to the CNAs about checking trays. She stated the nurses check the plates before the CNAs deliver them. She stated it was important to check trays to make sure everyone had the right texture, first off, because she doesn't want anyone to choke. Interview on 11/07/24 at 4:11 PM with the DON revealed she looked at the photo of the noodles with gravy with meat chunks on them for Resident #131's lunch meal and stated that she would take the tray back to the kitchen. She stated staff should let the nurse know if they see the meal did not match the meal ticket and take the tray back to get another preference. The DON stated the nurses check the trays before the CNAs deliver them. She stated that was protocol for both halls, not just the secured unit. She stated checking trays was in place to prevent choking and making sure people have the right diet. Interview on 11/07/24 at 5:31 PM with the Administrator revealed honoring food preferences for residents was a resident's right. The Administrator stated the risk of not honoring food preferences could be allergic reactions, could cause mental stress, and GI issues. Review of the facility's Resident Satisfaction with Food and Dining policy, revised 04/25/23, revealed, Facility will have a process in place to monitor the quality of food and beverages delivered to the residents .

Based on observation, interview and record review, the facility failed to provide pharmaceutical services including procedures to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs to meet the needs of each resident for 1 of 3 Residents reviewed for pharmaceutical services for 2 (med rooms A and B) of 2 reviewed for medication storage 1. The facility failed to dispose of expired medications. This failure could place residents at risk of not receiving the intended therapeutic benefit of the medications. Findings included: Observation on 11/07/24 at 08:07 AM of med room A with the Regional Nurse revealed expired TB vaccine dated 9/27 on one side and 10/13 on the other side. There was no year. The Regional Nurse stated that vaccines were good for 30 days. She said that the vaccine potency was the risk for expired vaccines. In a phone Interview on 11/07/24 at 01:08 PM the ADON stated all nursing staff were responsible for ensuring meds were not expired. She stated the pharmacist checks monthly for expired meds. If the meds are frozen or sitting in water, that is not good. She stated freezing can change the structure and make it lose effectiveness. Review of facility policy titled Storage and Expiration, dating of medication, Biological, revision dated 08/07/23 reflected .reflected in part .Once any medication or biological package is open, the Facility should follow manufacturer/supplier guidelines with respect to expiration date for opened medications. Facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when medication has a shortened expiration date once opened or opened.5.3. If a multi-dose vial of an injectable medication has been opened or accessed (e.g., needle punctured) the vial should be dated with dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial.11. Facility should monitor refrigerator storage for evidence of moisture and condensation (humidity) and may consult with the pharmacy regarding medication integrity .

Based on observation, interview, and record review the facility failed to ensure that each resident received adequate supervision and assistance to prevent accidents for one (Resident #3) of four residents who are perscribed medication reviewed for accidents and supervision. The facility failed to ensure RN A and CNA B provided Resident #3 adequate supervision after leaving syringes in the trash can of the resident's room, exposed and within reach of confused residents. This failure could place resident at risk for accidents and injury. Findings included: Review of Resident #3's electronic admissions report undated reflected a [AGE] year-old-female admitted to the facility on [DATE]. Primary diagnosis SUBLUXATION OF C4/C5 CERVICAL VERTEBRAE , SUBSEQUENT ENCOUNTER (associated with an increase in facet joint gap/distraction), UNSPECIFIED DEMENTIA, UNSPECIFIED SEVERITY, WITH OTHER BEHAVIORAL DISTURBANCE Review of Resident #3's care plan revised on [DATE] reflectedFocus: The resident/is has potential to be verbally aggressive r/t Dementia, ineffective coping skills, poor impulse control. Goals: The resident will demonstrate effective coping skills. Intervention: Administer medications as ordered. Review of Resident #3's MDS Resident Assessment and Care Screening dated [DATE] reflected; Section C- Cognitive Patterns- Should Brief Interview for Mental Status be Conducted. 0- No, resdient is rarely/never understood. Review of Resident #3's doctors orders dated [DATE] reflected; ABH Gel (Ativan, Benadryl, Haldol) Gel apply to wrist topically every 4 hours for Anxiety Observation/Interview on [DATE] at 11:11 a.m. revealed; in the secure unit's common area (area where a group of residents share the space not owned by a specific resident) observation of 10 residents and CNA B, Resident #3 seated in a recliner with footrest up in a reclining postion. Resident #3s eyes were closed. Resdient #5 aroused and used her right hand to move the [NAME] and lower the footrest placing her in a sitted postion. CNA B assisted Resident #3 to her wheelchair. Once Resident #3 was moved to a table with other residents , observation of the within reach enviorment revealed trashcan A with a clear plasic trashliner. In trashcan A, there were two red neddleless syringes. Continued enviormental observation of the common area revealed trashcan B (located by the exit door) with various items of trash on top of a visiable red syringe type item. Interview with CNA B reflected the red syringe is used to apply gel on the residents wrist to calm them down. He stated the nurse is the person that applied the medication. Interview and observation on [DATE] at 11:17 am with RN A revealed; the syringes are used to apply the bio gel to residents for anxiety. RN A stated he did not know who was responsible for disposing the items in the trash. RN A immedialy removed the trash liners from each trashcan and stated that it should not be placed in the trashcan. RN A stated the risk to the resdents was they could pick it up and eat it. Interview on [DATE] at 2:19 pm with MDS Coodinator reflected; the risk to the residents was the residents could get the syringe out of the trash. She stated that the expecation was once used they are placed in the [NAME] container. Review of policy Disposal/Destruction of Expired or Discontinued Medication revised date [DATE] refected; Facility staff should destroy and dispose of medications in accordance with Facility policy and Applicable Law, and applicable enviormental regulations.

Based on observation, interview and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 2 of 10 residents (#1, #2) observed for dignity during lunch service: RN A and CNA B stood up to feed Residents #1 and #2 during lunch. This deficient practice could affect 10 residents that reside in memory care. The findings included: Review of Resident #1's Admission Record undated revealed he was admitted to the facility on [DATE] with principal diagnoses of CENTRAL DISLOCATION OF RIGHT HIP, SUBSEQUENT ENCOUNTER; DEMENTIA IN OTHER DISEASES CLASSIFIED ELSEWHERE, UNSPECIFIED SEVERITY, WITHOUT BEHAVIORAL DISTURBANCE, PSYCHOTIC DISTURBANCE (severe mental health conditions that cause abnormal thinking and perceptions), MOOD DISTURBANCE (mental health conditions affecting mood), AND ANXIETY and ALZHEIMER'S DISEASE, UNSPECIFIED. Review of Resident #2's Admission Record undated revealed [AGE] year-old male admitted on [DATE] with a primary diagnoses of METABOLIC ENCEPHALOPATHY (condition where brain function is disturbed due to different diseases); ALZHEIMER'S DISEASE WITH LATE ONSET. Review of Resident #1's Care Plan dated 07/09/2024 revealed; ADL 's Mobility; Goal: Resident will be able to: (Specify); Interventions *EATING; The resident will be able to (Specify) Review of Resident #2's Care Plan dated 02/29/2024 revealed; ADL Goal; Intervention: EATING: The resident requires (Supervision-limited assistance) by (X1) staff to eat. Review of Resident #1's Resident Assessment and Care Screening dated 07/14/2024 revealed; No BIMS score entered for Resident #1. Section GG- Functional Abilities and Goals; Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident. Resident admission performance: 03 Partial/Moderate assistance- Helper does LESS THAN HALF the effort. Observation on 07/18/2024 at 11:42 am, in the memory care day room revealed RN A assisting Resident #1 with lunch. He stood next to him holding the eating utensil for Resident #1 offering him food. Observation on 07/18/2024 at 11:56 am, in the memory care day room revealed CNA B assisting Resident #2 with his lunch. He walked over to Resident #2 encouraged him to eat then picked up the eating utensil and offered Resident #2 his food. Interview on 07/18/2024 at 1:53 pm with CNA B reflected, he was standing when feeding Resident #2 in order to go back and forth between residents for assistance. He stated that you sit next to the resident to be on the same level and watch how they eat. Interview on 07/18/2024 at 1:57 pm with RN A reflected, he was standing to feed the resident because the residents in memory care were lit (not calm) and he needed to stand to be able to move around the area if he was needed. He stated that he knew he was supposed to sit down when assisting residents with meals. Review of facility policy and procedure on Feeding a Resident dated revised 08/24/2023 revealed Procedure .3. Sit to assist resident with eating.

Based on observation, interview, and record review the facility failed to properly secure medications in a locked compartment for 2 of 2 medication carts (secured unit and general population hall) reviewed for drug storage. LVN V and unidentified staff left 2 medication carts (secured unit and general population hall) unlocked and unattended for an unknown amount of time. These failures placed residents at risk for unauthorized access to the medication cart and consumption of harmful medications. Findings include: Observation on 03/30/24 at 6:15 AM revealed the general population medication cart was unlocked in front of the nursing station. Observation of the general population medication cart revealed the drawers facing outward and key mechanism popped out with a display of a red mark. Observed staff down the other end of the hallway. Observation on 03/30/24 at 6:30 AM revealed, the secure unit medication cart was unlocked on the secure unit. Observation of the secure unit medication cart revealed the drawers facing outward and key mechanism popped out with a display of a red mark. Observed no staff in sight of the medication cart. Interview on 04/01/24 at 6:35 AM with LVN V revealed, this was his medication cart and he was taking a resident's blood pressure and coming back to the cart. LVN L revealed the medication cart should always be locked. LVN V revealed residents could get into the medication cart and take medication not prescribed to that resident. Observation on 03/30/24 at 6:45 AM with Medical Records Director revealed, she locked the medication cart when she walked by the medication cart located in the general population. Interview on 03/30/24 at 6:47 AM with The Medical Records Director revealed, she noticed the medication cart was unlocked and locked it. The medical Records Director revealed she did not know the facility policy on administration of medication. Interview on 03/30/24 at 7:00 AM with LVN L revealed the medication cart should be locked when not in use. LVN L revealed residents could get into the cart and self-medicate. Observation on 03/30/24 at 7:04 AM revealed prescription medications and over the counter medications were in the medication cart. Interview on 03/30/24 at 7:48 AM with the DON revealed, nurses are responsible for the medication cart, and it should be locked to prevent residents from going into it. The DON was asked about the medication cart in general population and who was responsible for the medication cart. The DON did not reveal the staff that worked on the medication cart in general population. Interview on 04/01/24 at 7:15 PM with LVN E revealed, the medication cart was always locked to protect residents from taking prescribed medications out of the cart. Interview on 04/01/24 at 8:45 PM with Administrator revealed nursing staff are expected to follow facility policy and keep the medication carts locked and secured. Record review of facility policy titled, Medication Administration Guide revised 06/2023 reflected, It is the designated staff member's responsibility to maintain the possession of the keys and security of the medication cart. The medication cart always needed to be securely locked when it is out of the nurses visual.

Based on interview and record review, the facility failed to implement written policies and procedures that prohibit and prevent the neglect of residents for one (Resident #1) of five residents reviewed for injury of origin. The Administrator and DON failed to implement the facility's written policies and procedures on 03/28/24 that prohibit and prevent neglect of residents. Resident #1 was found on the floor in her room by a family member on 03/28/24 and subsequently had a serious injury, bleeding on the brain. The Administrator and DON failed to thoroughly investigate the injury of origin of Resident #1. The Administrator failed to report the injury of origin for Resident #1 to the State agency within the given time frame. These failures could place residents at risk for not having allegations of injury of origin investigated. Findings included: Record Review of face sheet dated 03/30/24 revealed Resident #1 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included: spinal stenosis-cervical region (narrowing of the spinal canal in the neck), muscle weakness, dysphagia-oropharyngeal phase (swallowing disorder sucking, chewing, and moving food or liquid into the throat), cognitive communication deficit, encephalopathy (a disease that affects brain structure or function that causes altered mental status and confusion), and Bell's palsy (facial palsy). Record review of Resident #1 MDS dated [DATE] revealed Resident #1 had no BIMS score noted. Record review of Resident's #1's care plan dated 03/28/24 reflected: Resident has limited physical mobility related to weakness. Goal: Resident will remain free of complications through next review date. Interventions: .Staff to assist with all transfers and ambulation as needed .Focus: Resident is at risk for falls related to weakness Goal: Resident will not sustain serious injury requiring hospitalization through the review date. Interventions: assist with ADLs .Call light within reach and complete fall risk assessment . Record review of the NRSG: Fall Risk Evaluation completed by LVN L dated 03/29/24, revealed the resident scored a 16. Scores between 16-20 represented starting the fall protocol, with the resident being at high likelihood of a fall occurring. Record review of Resident #1's progress notes dated 03/28/24 reflected Resident #1 had an unwitnessed fall, resident found on the floor by family, upon entering the room resident was laying on her left side, bilateral [both] lower extremities extended, Bump noted on the left forehead, no loss of consciousness, v/s obtained, 151/90, HR 87, SPO2 100, TEMP 98.0, resident able to move all extremities without any difficulties, neuro checks initiated per facility protocol and are WNL. resident assisted back to the bed with three person assist, nurse sent resident to the ER for further evaluation, Resident last checked 10 min prior to fall notification, resident behaviors, refused medication, refused dinner , alert .she refused her HS meds, system review, resident has history of unsteady gait, resident recently admitted to the facility, call light within reach, resident weak with poor appetite, DON and NP notified. Record review of Resident #1 neuro checks, dated 03/28/24 revealed, her vitals were checked twice at 8:00 PM and 8:15 PM. Record review of neuro checks revealed: BP 151/90 (High), HR 87, SPO2 100, TEMP 98.0 at 8:00 PM. Record review of neuro checks at 8:15 PM revealed: BP 168/90 (high), HR87, SP02 100, TEMP 97.0 Interview on 03/30/24 at 7:00 AM with LVN L revealed, Resident #1 was found on the floor by her family member and had a knot on her forehead. LVN L completed assessment and on Resident #1. LVN L revealed Resident #1 was not able to tell what occurred. LVN L revealed Resident #1 was sent out to the hospital. Interview on 03/30/24 at 12:15 PM with the DON revealed Resident #1's unwitnessed fall was not a reportable event. The DON revealed Resident#01 did not sustain injury and was not in pain. The DON revealed, facility policy was followed and completed. The DON revealed the Administrator was the Abuse Coordinator. The DON revealed she called the hospital and checked on Resident #1 and no concerns were reported. Observation and interview on 04/01/24 at 4:30 PM at the hospital with Resident #1 revealed she knew she had a fall, but she did not remember what happened. Interview and record review on 04/01/24 at 5:03 PM with the Hospital Nurse revealed, Resident #1 was admitted because of a fall. Hospital Nurse revealed Resident #1's MRI revealed new bleeding on the brain that came from the fall. Interview on 04/01/24 at 7:10 PM with the DON revealed she did not believe this was a reportable event because the resident did not have serious injury such as a laceration. The DON revealed by a reportable event not being reported can cause the residents to be abused. Interview on 04/01/24 at 8:45 PM with the Administrator revealed she did not think Resident #1's accident on 03/28/24 was a reportable event because the resident was not seriously injured. The Administrator revealed the facility did not report the incident because it did not meet the criteria for reporting since the resident did not have a serious injury. Record review of the facility's Incident and Reportable Event Management policy, dated 09/14/23, reflected: 1) Ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source .are reported immediately, but no later than 2 hours . 4) Report the results of all investigations to the Executive Director or his or her designee and to other officials in accordance with State law, including the State Survey Agency within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. The agency policy goes on to define injuries of unknown source as Any injury should be classified as an injury of unknown source when both of the following conditions are met: - The source of injury was not observed by any person, or the source of the injury could not be explained by the patient. .not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the state survey agency .

Based on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care was provided with such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 5 of 5 residents (Resident #1, #3, #5, #7, #9) reviewed for respiratory care. The facility failed to ensure Resident #1, #3, #5, #7, and #9's oxygen tubing was labeled and dated. The facility failed to ensure Resident #1, #3, and #9's CPAP tubing were dated and properly stored when they weren't in use. These failures could place residents at risk of not receiving proper delivery of oxygen, cross contamination, respiratory compromise and/or infection and residents not having their respiratory needs met. Findings Included: Review of Resident #1's Face Sheet, dated 01/31/24, revealed he was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included Bilateral primary osteoarthritis primary most common form of arthritis affecting both knees), Chronic obstructive pulmonary disease (progressive lung disease), Chronic respiratory failure (respiratory failure inadequate gas exchange), and morbid obesity (severe weight gain). Review of Resident #1's Quarterly MDS, dated [DATE], revealed a BIMS of 15 indicating memory intact, functions Partial/moderate assistance: helper provided less than half the effort. Assist with mobility and ADLs as needed. oxygen use under treatment Section O. Record review of Resident #1's physician orders revealed the following: Change oxygen tubing and nebulizer circuit every night shift every Sunday dated 2/4/24 .Oxygen sat rates every shift .Oxygen at 2-5 liters/minute per nasal cannula as needed .Oxygen at 2-5_ liters/minute continuously per nasal cannula. Document every shift .dated 01/30/24. Resident #1 An observation on 01/30/24 at 11:25 AM, revealed Resident #1 was lying in bed with oxygen tubing nasal cannula in his nose, oxygen concentrator operating. The oxygen tubing and bottle were not dated. Resident #1 stated that he was fine and the air from the oxygen was fine. He stated it was changed on yesterday, but they no longer date. Resident said no discomfort with oxygen. An interview with Resident #1 on 01/30/24 at 11:25 AM revealed the tubing was changed regularly and he could not recall the date. He said nursing changes normally on Mondays. He said that dates were used in the past when changed, however, he has not observed this practice lately. A second observation on 02/01/24 at 12:10 PM, reflected a date of 01/29/24 on Resident #1's nasal cannula tubing. Resident #3 Review of Resident #3's Face Sheet, dated 01/30/24, revealed face sheet reflected an [AGE] year-old male admitted on [DATE] with diagnoses personal history of transient ischemic attack (TIA) (mini stroke), and Cerebral infarction (stroke). Review of Resident #3's Quarterly MDS, dated [DATE] reflected BIMS of 13 indicating his memory was intact, required extensive assistance and used oxygen. Record review of Resident #3's comprehensive care plan dated 1/30/24 reflected The resident has oxygen therapy r/t Ineffective gas exchange .Increased heart rate (Tachycardia), Restlessness, Diaphoresis, Headaches, Lethargy, Confusion, Atelectasis, Hemoptysis, Cough, Pleuritic pain, Accessory muscle usage, Skin color. Record review of Resident #3's physician orders revealed the following: Change oxygen tubing and nebulizer circuit every night shifts every Sunday .Oxygen at 2-5liters/minute per nasal cannula as needed Oxygen at 2-5 liters/minute continuously per nasal cannula. Document every shift. An observation and interview with Resident #3 on 01/31/24 at 11:35 AM, revealed resident lying in bed with his nasal cannula in his nose, oxygen concentrator operating, and tubing undated. CPAP tubing lying on night stand undated and unbagged, while not in use. Resident #3 was interviewed, and he did not know when the tubing was changed and if staff dated the tubing. Resident #5 Review of Resident #5's Face Sheet dated 01/30/24 revealed a [AGE] year-old female admitted on [DATE] with diagnoses description: Pneumonia (inflammation of the lungs), Heart and Chronic Kidney Disease with Heart Failure Stage 1 through Stage 4 chronic kidney disease (kidney disease that caused decrease in heart function). Record review of quarterly MDS dated [DATE], indicated Resident #5 had a BIMS of 11 which indicated moderate cognitive impairment .Resident requires a 2-person transfer Staff assist with transfers and ambulation as needed, supportive care assistance and oxygen use. Record review of Resident #5's comprehensive care plan dated 12/11/23 reflected oxygen therapy resident has Congestive Heart Failure. Check breath sounds and observe for labored breathing. Observe for use of accessory muscles while breathing .Give cardiac medications as ordered . Observe and report PRN any s/sx of Congestive Heart Failure: SOB upon exertion, weakness, weight gain unrelated to intake, crackles and wheezes upon auscultation (listening to lungs) of the lungs, weakness and/or fatigue, increased heart rate (Tachycardia) lethargy and disorientation. Resident #5 has oxygen therapy r/t dx of Chronic Respiratory Failure with Hypoxia .will have no s/sx of poor oxygen absorption through the review date .Administer O2 as ordered .Give medications as ordered by physician .Observe for s/sx of respiratory distress and report to MD PRN: Respirations, Pulse oximetry, Increased heart rate (Tachycardia), Restlessness, Diaphoresis, Headaches, Lethargy, Confusion, Atelectasis, Hemoptysis, Cough, Pleuritic pain, Accessory muscle usage, Skin color .Promote lung expansion and improve air exchange by positioning with proper body alignment. If tolerated, head of bed elevated. Record review of Resident #5's active MD orders dated 10/10/23 reflected clean oxygen concentrator filter with soap and water weekly every Sundays. Change oxygen tubing and nebulizer circuit every night shifts every Sun. Oxygen sat rates every shift Oxygen sat rates every shift may titrate to keep above 96% .Oxygen at2 -5 liters/minute per nasal cannula as needed Oxygen at 2-5liters/minute continuously per nasal cannula. Document every shift. An observation on 01/31/24 at 11:50 AM, revealed Resident #5 lying in bed with nasal cannula in 1 nostril and other pointed outward and unlabeled and dated. An interview with Resident #5 revealed she did not know if the tubing was dated when changed. She does not know when the tubing was last changed. Resident #7 Record review of Resident #7's face sheet dated 01/30/245 reflected an [AGE] year-old male admitted on [DATE] with diagnoses Chronic Respiratory Failure with Hypoxia (respiratory failure affecting oxygen) Chronic Combined Systolic (caused by another cardiovascular condition that weakens the hear), Heart Failure obstructive Sleep Apnea (condition affecting cardiovascular disease in adults). Record review of Resident #7's quarterly MDS dated [DATE], BIMS score of 11 indicating Moderate cognitive impairment. Resident #7 requires Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs. Oxygen treatment and use in section O. Record review of Resident #7's Comprehensive care plan dated 01/31/24 reflected Resident #7 Resident #7is at risk for altered respiratory status/difficulty breathing r/t dx of OSA and uses CPAP at HS .Resident #7 will have no complications related to SOB though the review date .Administer medication/puffers as ordered .Administer O2 as ordered .Encourage sustained deep breaths by: Using demonstration (emphasizing slow inhalation, holding end inspiration for a few seconds, and passive exhalation); Using incentive spirometer (place close for convenient resident use); Asking resident to yawn .Maintain a clear airway by encouraging resident to clear own secretions with effective coughing. If secretions cannot be cleared, suction as ordered/required to clear secretions .Observe for changes in orientation, increased restlessness, anxiety, and air hunger .Observe for s/sx of respiratory distress and report to MD PRN: Increased Respirations; Decreased Pulse oximetry; Increased heart rate (Tachycardia); Restlessness; Headaches; Confusion; Cough; Pleuritic pain; Accessory muscle usage; Skin color changes to blue/grey .Observe/report abnormal breathing patterns to MD: increased rate, decreased rate, periods of apnea, prolonged inhalation, prolonged exhalation, prolonged shallow breathing, prolonged deep breathing, use of accessory muscles, pursed-lip breathing, nasal flaring .Obtain BIPAP/CPAP as ordered. Record review of Resident #7's active MD orders dated 10/10/23 reflected clean oxygen concentrator filter with soap and water weekly every Sundays. Change oxygen tubing and nebulizer circuit every night shifts every Sun. Oxygen sat rates every shift Oxygen sat rates every shift may titrate to keep above 96% .Oxygen at2 -5 liters/minute per nasal cannula as needed Oxygen at 2-5liters/minute continuously per nasal cannula. Document every shift. Record review of Resident #7's electronic TAR from January 2024 reflected Clean oxygen concentrator filter with soap and water weekly every Sunday. The TAR dates reflected cleanings for the following dates: 01/07/24, 01/14/24, 01/21/24, and 01/28/24. This contradicts the date on the tubing of 1/16/24. An observation Resident #7 on 02/01/24 at 10:00 AM revealed resident lying in bed on his back with his nasal cannula in his nose properly positioned and CPAP tubing unbagged, undated, and labeled. Nasal Cannula tubing was dated 01/16/24.An interview with Resident #7 revealed he did not know when his tubing was last changed. the tubing was changed however he thought it was dated. He said staff are changing tubing regularly. Resident #9 Record review of Resident #9's face sheet dated 01/30/24 reflected an [AGE] year-old male with diagnoses of Acute Chronic Diastolic (Congestive) Heart Failure Coronary Atherosclerosis (hardening of the arteries) Due to Calcified (plaque) Coronary Lesion pneumonia (inflamed lungs affecting small air sacs). Record review of Resident #9's Quarterly MDS dated [DATE] with a BIMS score of 15, indicating he was cognitively intact. Resident #9 requires Partial/moderate assistance for ADL care .oxygen use documented on section O. Record review of Resident #9's Comprehensive care plan dated 01/24/24 reflected Resident was at risk for shortness of breath (SOB) r/t dx of COPD .will have no complications related to SOB though the review date .Administer Oxygen as ordered .Maintain a clear airway by encouraging resident to clear own secretions with effective coughing. If secretions cannot be cleared, suction as needed to clear secretions. Observe for breathing patterns. Report abnormalities to MD: Nasal flaring, Respiratory depth changes, altered chest excursion, Use of accessory muscles, Pursed lip breathing or prolonged expiratory phase, Increased anteroposterior chest diameter. Observe for changes in orientation, increased restlessness, anxiety, and air hunger .Observe/Report breathing abnormalities to MD . Resident with proper body alignment for optimal breathing pattern .clean oxygen concentrator filter with soap and water weekly every Sundays. Change oxygen tubing and nebulizer circuit. every night shifts every Sundays .Oxygen sat rates every shift .Oxygen sat rates every shift may titrate to keep above 96% .Oxygen at 2-5 liters/minute per nasal cannula as needed .Oxygen at 2-5 liters/minute continuously per nasal cannula. Document every shift. Record review of Resident #9's MD orders dated 10/15/23 reflected clean oxygen concentrator filter with soap and water weekly every Sundays. Change oxygen tubing and nebulizer circuit every night shifts every Sundays. Oxygen sat rates every shift Oxygen sat rates every shift may titrate to keep above 96% .Oxygen at 2 -5 liters/minute per nasal cannula as needed Oxygen at 2-5liters/minute continuously per nasal cannula. Document every shift. Review record of Resident #9's treatment records for January 2024 reflected changing oxygen tubing and nebulizer circuit every night shifts every Sunday Clean oxygen concentrator filter with soap and water weekly every Sunday. The TAR dates reflected tubing change and filter cleaning on 1/7/24, 1/14/24, 1/21/24, and 1/28/24, water same dates the date on Resident #9's concentrator was 1/29/24 on 02/01/24. In an interview with Resident #9 on 01/30/24 at 11:40 AM , he stated that he uses his oxygen continuously and could not remember when his tubing was changed, however staff are changing regularly. An observation of Resident #9's oxygen concentrator on 01/30/24 reflected nasal cannula tubing undated and unlabeled while in resident nose. In an interview with RN K on 01/30/24 at 1:52 PM, revealed that night shift was responsible for changing resident respiratory tubing every Sunday. RN K said she checked resident tubing, oxygen levels, every 2 hours, and she was pretty sure she observed dates on Resident's #1, #3, #5, #7, and #9's tubing. She stated that she changed Resident #1's water bottle today. RN K said it was important to change and date resident tubing to prevent overuse that can lead to infections. RN K said all nurses are responsible for checking dates on tubing, oxygen flow, and respiratory percentage during each shift. In an interview with the DON on 02/01/24 at 11:50 AM, revealed that all nursing staff were in-serviced on 1/30/24 and 1/31/24 on changing, auditing, and monitoring resident tubing and storage while not in use. The DON said all equipment supplies should be dated to prevent overuse and communicate with the tubing was last changing. She expects nursing to change overnight weekly on Sundays, nursing assesses during rounds and check for dates, as well as change and date if undated. The DON was responsible for rounding to audit and monitor tubing change and dates daily. She said failing to change tubing or dating could lead to infections. In an interview with the ADM on 02/01/24 at 2:30 PM, revealed she expects nursing staff to monitor care and equipment according to the policy. Record review of Facility Inservice completed by the DON dated 1/30/24 at 3:30 PM addressing CPAP, oxygen support, Administration Safety, Storage, and Maintenance of Resident on oxygen. All tubing should be dated at the time of change. Nursing staff should be checking tubing during rounds. Record review of facility policy dated 9/26/23 and titled Oxygen administration/safety/storage/maintenance reflected oxygen will be administered in accordance with physician orders and current standard practice. Procedure .This facility will utilize the following [NAME], while incorporating the other elements outlined below.1. Change oxygen supplies weekly and when visibly soiled. Equipment should be dated when setup or changed out .2. Humidifier/ Aerosol bottles should be dated and replaced every 7 days regardless of H20 level .a. Prefilled humidifiers are recommended. If re-usable humidifier is used, refill, using sterile water only. Water is to be emptied and replaced daily. Re-usable humidifiers should also be replaced every 7 days. 3. Store oxygen and respiratory supplies in bag labeled with resident's name when not in use. 4. Clean exterior of concentrators weekly with an EPA registered hospital disinfectant. a. The concentrator must be stationed where there is free air movement. B. External filter should be checked daily, and all dust should be removed. Filters should be washed with soap and water once each week and PRN. Dry with a towel and reinsert. Discard and replace when damaged. 5. If oxygen is discontinued, discard all disposable pieces including filters (replace with new). 6. If oxygen is continued post discharge of isolation precautions, dispose of all disposable a. equipment, clean all non-disposable equipment with an EPA registered hospital.

Based on observation, interview and record review, the facility failed to ensure residents had the right to be free from neglect and failed to develop and implement written policies and procedures that prohibit and prevent neglect for 1 of 37 residents (Resident # 1) reviewed for neglect. RN K failed to report and assess Resident #1's fall to the facility when the family alleged the resident was dropped during transfer. The facility was unaware the resident had fractured ribs and sternum until Resident #1 was sent to the hospital due to unrelated concern of low blood pressure, three days after the incident. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 12/14/23. While the IJ was removed on 12/15/23, the facility remained out of compliance at a severity of actual harm with a scope identified as isolated. The facility was continuing to monitor for safe resident transfers as well as education to staff. This failure placed residents at risk for neglect due to a delay in treatment, and a worsening of their condition or could result in death. Findings include: Record review of Resident #1's face sheet dated 12/15/23 revealed Resident #1 was an [AGE] year-old female admitted on [DATE] with the following diagnoses: Muscle weakness, end stage renal disease, acute respiratory failure (body's inability to deliver oxygen properly), heart failure(heart doesn't pump blood like it should), hypertension (high blood pressure), and difficulty in walking. Review of Resident #1's MDS Quarterly Assessment, dated 12/04/23, reflected the resident's functional status: the resident required substantial/maximal assistance to go from lying to sitting on the side of the bed, sitting to stand, and to transfer from wheelchair to bed and from bed to wheelchair. An interview on 12/14/23 at 9:40 a.m. with the Admin, revealed Resident #1 came back from the hospital with multiple fractures but never had a fall at the facility. The Administrator then stated they interviewed everyone such as dialysis, transportation, and EMS and none of them stated anything happened to the resident that resulted in fractured ribs and sternum so the investigation was inconclusive. Review of Resident #1's hospital record, dated 11/27/23, revealed, .Final diagnosis as of 11/27/23 2327 .Rib fractures .Sternal fracture .Dyspnea .Pleura effusion . In an interview and observation on 12/14/23 at 10:50 a.m., Resident #1 stated [the facility staff] took her out of the car van from dialysis and they were working together to put her in the bed when they dropped her on the floor. Resident #1 was observed lying in bed and was small and frail but alert and oriented to surroundings. In an interview on 12/14/23 at 10:51 a.m. with Resident #1's family member A revealed another family member reported it the day it happened to the nurse (RN K) when she visited Resident #1. The following Monday 11/27/23 Resident #1's blood pressure dropped during dialysis and she was taken to the hospital. The hospital reported she had multiple fractured ribs and a fractured sternum. In an interview on 12/14/23 at 10:58 a.m. with Resident #1's family member B revealed she came to visit Resident #1 on 11/24/23. She stated she signed in around 4:10PM-4:15pm and Resident #1 had not been back for too long but realized Resident #1 was agitated. Resident #1 then told family member B that when [facility staff] were getting her back to her bed and out of the wheelchair, they dropped her. Family member B stated Resident #1 could not sit up well, was pointing to her ribs and told family member B she was hurting. Family member B spoke to RN K and told her the resident stated she had been dropped and was hurting. Family member B asked if there was something that could be given to Resident #1 for pain. RN K told family member B that she was in the vicinity when Resident #1 was transferred in her room and that the fall probably happened at the dialysis center. Family member B then revealed RN K bringing her some Tylenol in for Resident #1 since family member B stated she was in pain. In an interview with RN K at 12/14/23 at 11:30 a.m. revealed family member B came to her and stated the resident was dropped during transfer. RN K stated she was there at the facility when the resident returned from dialysis on 11/24/23. When Resident #1 first returned to the facility, she was exhausted and that was when Resident #1 stated to RN K she was dropped by an old man and a nurse, but RN K stated she thought Resident #1 was just having a dream. RN K also stated Resident #1 was not complaining of any pain at that time. RN K then revealed that it did not occur to her that the fall could have happened. RN K stated after she was notified by family member B, RN K did not take Resident #1's clothes off to do a full body assessment. She revealed she did give Resident #1 Tylenol since family member B stated she was in pain. RN K also stated she was by Resident #1's door when the transfer occurred while she was helping pass out dinner trays, however, she did not directly see the transfer. RN K stated if something like a resident was dropped during transfer were to occur, she was supposed to report it to the doctor, the DON, and Admin, but she just assumed the fall did not occur, and she did not notify the physician. RN K also stated even the next day the resident did not complain of pain. She then revealed she had been in serviced on falls and what to do. She stated she was supposed to do a head-to-toe assessment, obtain vitals, notify the DON and the physician. In an interview with Admin on 12/14/23 at 11:50 a.m. revealed she was unaware family member B reported to RN K that the Resident #1 had fallen during transfer. The Admin revealed in RN K's witness statement all she wrote was that a fall did not occur at the facility for Resident #1. In an interview with the physician on 12/14/23 at 2:09 p.m. revealed he was not aware Resident #1 fell , but he stated he was there when she went to the hospital on 11/27/23. He stated the x-rays that were taken did not specify if the rib and sternum fracture was a new or old injury. He stated she had a lot of fluid drained from her chest and that could have been why she was in pain. The physician stated the resident was admitted for fluid overload. The physician specified since this was a change of condition, he should have been notified by the nurse who was RN K at the time. In an interview with the transportation manager on 12/14/23 at 2:26 p.m., he revealed Transportation driver R was the one who transported Resident #1 back to the facility on [DATE]. He stated once they arrived, they usually let staff know the resident is back at the facility. He stated transportation driver R told him he helped her in bed and then went to get help to reposition her into the bed by asking a facility staff member. There was no fall. On 12/24/23 at 2:29 p.m. attempted to call transportation driver R with no answer. In an interview with CNA E on 12/14/23 at 2:40 p.m. revealed she was working that day Resident #1 came back from dialysis on 11/24/23 but she was working the opposite hall of Resident #1. The transportation Driver R called CNA E to come help him transfer her back to the bed and to let RN K know Resident #1 was back at the facility from dialysis. CNA E then revealed she usually worked nights but was helping the dayshift that day. She stated Resident #1 was in her wheelchair when CNA E walked in the room to help transfer her back to the bed with transportation driver R. She stated she was on one side and transportation driver R was on the other and they got Resident #1 out of the wheelchair and pivoted toward the bed. The resident never fell . In an interview with dialysis nurse on 12/15/23 at 12:23PM revealed she was the nurse taking care of Resident #1 on 11/27/23. Resident #1 was having a hard time breathing, her oxygen was low and she was having pain in her rib cage. That was when Resident #1 revealed to the dialysis nurse that someone dropped her from the facility. Resident #1 then stated she wanted to go to the hospital and EMS was called on 11/27/23. The dialysis nurse stated Resident #1 comes to dialysis every Monday, Wednesday and Friday. She revealed the facility called and stated the resident fell at dialysis and the dialysis nurse stated no, Resident #1 told me she fell at the facility. In an interview with Admin on 12/15/23 at 3:22p.m. she stated staff training and ongoing training will occur with asking residents if they have any accidents of abuse or neglect that has not been reported or need to be reported. She then revealed she would be asking nursing staff questions about incidents as rounds are conducted. The Admin then stated 10 residents a day for 60 days will have assessments and may be extended if any issues occur. Record review of the facility's Abuse - Inservice Training policy, dated 07/18/2023, revealed, .Facility procedures and Federal and State requirements for reporting abuse, neglect, exploitation, and misappropriation of resident property, including injuries of unknown sources, timeframes for reporting, and to whom staff and others must report their knowledge related to any alleged violation without fear of retaliation . On 12/14/23 at 4:40 p.m. the Admin was informed of an Immediate Jeopardy existed and a copy of the IJ template was provided. The following Plan of Removal was accepted on 12/15/23 at 11:39 a.m. Plan of Remediation: [Facility Name] Re: IJ 12/14/2023 F580 Notification of physician Failure: The facility failure resulted in a delay in resident receiving timely x-rays and treatment, which could lead to serious harm/impairment/death. Corrective Action for those found to have been affected by the deficient practice: Identified Resident remains in the facility with no adverse residual effects. The Identified Licensed Nurse will be suspended (possibly terminated with HR approval) and Nurse License will be reported to the Board of Nursing. Resident Head to toe competencies will be completed by all licensed nurses by end of day 12/15/2023. The following in-services will be completed by 12/15/2023, by the following Administrative Nursing Staff to include, MDS, [MDS Coordinator], Infection Prevention/Staff Development Coordinator, [Infection Preventionist/Staff Development Coordinator], Senior Regional Director of Clinical Services, [Senior Regional Director of Clinical Services]. Head to toe assessments-How and When to complete the assessments Significant Change in status-When a resident has a change who to report to Incidents and Accidents and how to report and complete Reporting to the Physician-Reporting any significant changes or incident that occurs with a resident and in a timely manner. Reporting to the Administrative Staff-Any significant changes or incident that has been reported, observed or noted. Abuse and Neglect-Who to report to, types of Abuse, prevention strategies Fall Management-Interventions to put in place and what to do when a fall occur Identification of other residents having the potential to be affected: Fall assessments were completed on 12/14/2023 by Sr. Regional Director of Clinical Services, MDS Coordinator RN, and Infection Preventionist/Staff Development Coordinator, to determine which residents would be potentially affected. Residents who are identified to be at risk for falls will be care planned appropriately by Sr. Regional Director of Clinical Services, MDS Coordinator RN, and Infection Preventionist/Staff Development Coordinator. Current and past falls for the last 30 days reviewed for compliance to ensure that regulatory guidelines have been met. These were reviewed, by [Senior Regional Director of Clinical Services], for the last 30 days to ensure that regulatory guidelines have been met. Measures/Systemic Changes to ensure the deficient practice does not recur: Competency Assessments for completing and documenting head to toe will be completed by all licensed nursing staff prior to them working their next shift. They will not be allowed to work until these are completed. These Competencies will be conducted by Admin Nursing Staff to include, MDS, [MDS Coordinator], Infection Prevention/Staff Development Coordinator, [Infection Preventionist/Staff Development Coordinator], Senior Regional Director of Clinical Services, [Senior Regional Director of Clinical Services]. These will be completed by end of day 12/15/2023. In-services and education for all licensed nursing staff will be completed by 12/15/2023 by Admin Nursing Staff to include, MDS, [MDS Coordinator], Infection Prevention/Staff Development Coordinator, [Infection Prevention/Staff Development Coordinator], Senior Regional Director of Clinical Services, [Senior Regional Director of Clinical Services]. In-service topics will include the following: Head to toe assessments-How and When to complete the assessments Significant Change in status-When a resident has a change who to report to Incidents and Accidents and how to report and complete Reporting to the Physician-Reporting any significant changes or incident that occurs with a resident and in a timely manner. Reporting to the Administrative Staff-Any significant changes or incident that has been reported, observed or noted. Abuse and Neglect-Who to report to, types of Abuse, prevention strategies Fall Management-Interventions to put in place and what to do when a fall occurs. Ongoing Monitoring: Interviews with staff and residents will be completed during morning grand rounds and throughout the day to identify if they have had any injuries or falls that have not been reported. This will continue weekly for 60 days. Administrative staff will make facility rounds daily, until compliance is achieved. All components of this plan of correction will be submitted to the facility QAPI committee meeting and additional recommendations will be made until substantial compliance has been achieved. The Medical Director was notified and agrees with the plan of correction. The Admin Nursing Staff to include, MDS, [MDS Coordinator], Infection Prevention/Staff Development Coordinator [Infection Prevention/Staff Development Coordinator], Senior Regional Director of Clinical Services, [Senior Regional Director of Clinical Services], DON, [DON], Executive Director, [Administrator], are responsible for the corrections and continued monitoring. Completion date: By 5pm 12/15/2023 - Review of in-services dated 12/15/23 were completed and interviews with staff confirmed by verbalizing expectations. - Interviews on 12/15/2023 between 8:00am and 1:00PM with multiple staff on various shifts revealed confirmatory knowledge of in-services dated 12/15/2023 Observation on 12/15/23 at 9:41am revealed CNA G and CNA H using the Hoyer lift to transfer a resident with the wheelchair at the head of the bed. No problems or concerns with transfer 2-person transfer. During interviews on from 8:00 a.m. to 1:00 p.m. with facility staff revealed they had been trained on head-to-toe assessments, significant change in status, incidents and accidents, reporting to the physician, reporting to the administration staff, abuse and neglect, fall management and suspected injury or witness fall. All staff interviewed were able to verbalize the new training instructions back. The staff interviewed consisted of the following: LVN D, LVN E, LVN F, CNA G, and CNA H. While the IJ was removed on 12/15/23, the facility remained out of compliance at a severity of actual harm with a scope of isolated due to the need for the facility to monitor it corrective action for effectiveness.

Based on observation, interview, and record review, the facility failed to immediately consult with the resident's physician and notify the resident's representative when there was a significant change in the resident's physical, mental, or psychosocial status (deterioration in health in either life-threatening condition) for 1 (Resident #1) of 37 residents reviewed for physician notification. The facility failed to ensure the physician was notified after Resident #1 was alleged to have been dropped mid-transfer. After being taking to the hospital during dialysis on 11/27/23 the resident was reported to have multiple fractured ribs and a sternum fracture. On 11/24/23 resident family member reported to the nurse that the resident told her she was dropped, and her chest was hurting. RN K gave pain medication but failed to do a full body assessment nor did she report it to the physician. This failure placed residents at risk of a delay in treatment, and a worsening of their condition or could result in death. An Immediate Jeopardy (IJ) was identified on 12/14/23. The IJ template was provided to the facility on [DATE] at 4:30 pm. While the IJ was removed on 12/15/23, the facility remained out of compliance at a severity of actual harm with a scope identified as isolated. The facility was continuing to monitor for safe resident transfers as well as education to staff. Findings included: Record review of Resident #1's face sheet dated 12/15/23 revealed Resident #1 was an [AGE] year-old female admitted on [DATE] with the following diagnoses: Muscle weakness, end stage renal disease, acute respiratory failure (body's inability to deliver oxygen properly), heart failure(heart doesn't pump blood like it should), hypertension (high blood pressure), and difficulty in walking. Review of Resident #1's MDS Quarterly Assessment, dated 12/04/23, reflected the resident's functional status: the resident required substantial/maximal assistance to go from lying to sitting on the side of the bed, sitting to stand, and to transfer from wheelchair to bed and from bed to wheelchair. An interview on 12/14/23 at 9:40 a.m. with the Admin, revealed Resident #1 came back from the hospital with multiple fractures but never had a fall at the facility. The Administrator then stated they interviewed everyone such as dialysis, transportation, and EMS and none of them stated anything happened to the resident that resulted in fractured ribs and sternum so the investigation was inconclusive. Review of Resident #1's hospital record, dated 11/27/23, revealed, .Final diagnosis as of 11/27/23 2327 .Rib fractures .Sternal fracture .Dyspnea .Pleura effusion . In an interview and observation on 12/14/23 at 10:50 a.m., Resident #1 stated [the facility staff] took her out of the car van from dialysis and they were working together to put her in the bed when they dropped her on the floor. Resident #1 was observed lying in bed and was small and frail but alert and oriented to surroundings. In an interview on 12/14/23 at 10:51 a.m. with Resident #1's family member A revealed another family member B reported it the day it happened to the nurse (RN K) when she visited Resident #1. The following Monday 11/27/23 Resident #1's blood pressure dropped during dialysis, and she was taken to the hospital. The hospital reported she had multiple fractured ribs and a fractured sternum. In an interview on 12/14/23 at 10:58 a.m. with Resident #1's family member B revealed she came to visit Resident #1 on 11/24/23. She stated she signed in around 4:10PM-4:15pm and Resident #1 had not been back for too long but realized Resident #1 was agitated. Resident #1 then told family member B that when [facility staff ] were getting her back to her bed and out of the wheelchair, they dropped her. Family member B stated Resident #1 could not sit up well, was pointing to her ribs and told family member B she was hurting. Family member B spoke to RN K and told her the resident stated she had been dropped and was hurting. Family member B asked if there was something that could be given to Resident #1 for pain. RN K told family member B that she was in the vicinity when Resident #1 was transferred in her room and that the fall probably happened at the dialysis center. Family member B then revealed RN K bringing her some Tylenol in for Resident #1 since family member B stated she was in pain. In an interview with RN K at 12/14/23 at 11:30 a.m. revealed family member B came to her and stated the resident was dropped during transfer. RN K stated she was there at the facility when the resident returned from dialysis on 11/24/23. When Resident #1 first returned to the facility, she was exhausted and that was when Resident #1 stated to RN K she was dropped by an old man and a nurse, but RN K stated she thought Resident #1 was just having a dream. RN K also stated Resident #1 was not complaining of any pain at that time. RN K then revealed that it did not occur to her that the fall could have happened. RN K stated after she was notified by family member B, RN K did not take Resident #1's clothes off to do a full body assessment. She revealed she did give Resident #1 Tylenol since family member B stated she was in pain. RN K also stated she was by Resident #1's door when the transfer occurred while she was helping pass out dinner trays, however, she did not directly see the transfer. RN K stated if something like a resident was dropped during transfer were to occur, she was supposed to report it to the doctor, the DON, and Admin, but she just assumed the fall did not occur, and she did not notify the physician. RN K also stated even the next day the resident did not complain of pain. She then revealed she had been in serviced on falls and what to do. She stated she was supposed to do a head-to-toe assessment, obtain vitals, notify the DON and the physician. In an interview with Admin on 12/14/23 at 11:50 a.m. revealed she was unaware family member B reported to RN K that the Resident #1 had fallen during transfer. The Admin revealed in RN K's witness statement all she wrote was that a fall did not occur at the facility for Resident #1. In an interview with the physician on 12/14/23 at 2:09 p.m. revealed he was not aware Resident #1 fell , but he stated he was there when she went to the hospital on 11/27/23. He stated the x-rays that were taken did not specify if the rib and sternum fracture was a new or old injury. He stated she had a lot of fluid drained from her chest and that could have been why she was in pain. The physician specified since this was a change of condition, he should have been notified by the nurse who was RN K at the time. An interview with Admin on 12/15/23 at 3:22 p.m. she stated staff training and ongoing training will occur with asking residents if they have any accidents of abuse or neglect that has not been reported or need to be reported. She then revealed she would be asking nursing staff questions about incidents as rounds are conducted. The admin then stated 10 residents a day for 60 days will have assessments and may be extended if any issues occur. Record review of the facility's Changes in Resident Condition or Status policy, dated 11/26/2018, revealed, .This facility will notify the resident, his/her primary care provider, and resident/resident representative of changes in the resident's condition or status. In the case of death of a resident, the resident's physician will be notified immediately by facility staff in accordance with State law . On 12/14/23 at 4:40 p.m. the Admin was informed an Immediate Jeopardy existed and a copy of the IJ template was provided. The following Plan of Removal was accepted on 12/15/23 at 11:39 a.m. Plan of Remediation: [Facility Name] Re: IJ 12/14/2023 F580 Notification of physician Failure: The facility failure resulted in a delay in resident receiving timely x-rays and treatment, which could lead to serious harm/impairment/death. Corrective Action for those found to have been affected by the deficient practice: Identified Resident remains in the facility with no adverse residual effects. The Identified Licensed Nurse will be suspended (possibly terminated with HR approval) and Nurse License will be reported to the Board of Nursing. Resident Head to toe competencies will be completed by all licensed nurses by end of day 12/15/2023. The following in-services will be completed by 12/15/2023, by the following Administrative Nursing Staff to include, MDS, [MDS Coordinator], Infection Prevention/Staff Development Coordinator, [Infection Preventionist/Staff Development Coordinator], Senior Regional Director of Clinical Services, [Senior Regional Director of Clinical Services]. Head to toe assessments-How and When to complete the assessments Significant Change in status-When a resident has a change who to report to Incidents and Accidents and how to report and complete Reporting to the Physician-Reporting any significant changes or incident that occurs with a resident and in a timely manner. Reporting to the Administrative Staff-Any significant changes or incident that has been reported, observed or noted. Abuse and Neglect-Who to report to, types of Abuse, prevention strategies Fall Management-Interventions to put in place and what to do when a fall occur Identification of other residents having the potential to be affected: Fall assessments were completed on 12/14/2023 by Sr. Regional Director of Clinical Services, MDS Coordinator RN, and Infection Preventionist/Staff Development Coordinator, to determine which residents would be potentially affected. Residents who are identified to be at risk for falls will be care planned appropriately by Sr. Regional Director of Clinical Services, MDS Coordinator RN, and Infection Preventionist/Staff Development Coordinator. Current and past falls for the last 30 days reviewed for compliance to ensure that regulatory guidelines have been met. These were reviewed, by [Senior Regional Director of Clinical Services], for the last 30 days to ensure that regulatory guidelines have been met. Measures/Systemic Changes to ensure the deficient practice does not recur: Competency Assessments for completing and documenting head to toe will be completed by all licensed nursing staff prior to them working their next shift. They will not be allowed to work until these are completed. These Competencies will be conducted by Admin Nursing Staff to include, MDS, [MDS Coordinator], Infection Prevention/Staff Development Coordinator, [Infection Preventionist/Staff Development Coordinator], Senior Regional Director of Clinical Services, [Senior Regional Director of Clinical Services]. These will be completed by end of day 12/15/2023. In-services and education for all licensed nursing staff will be completed by 12/15/2023 by Admin Nursing Staff to include, MDS, [MDS Coordinator], Infection Prevention/Staff Development Coordinator, [Infection Prevention/Staff Development Coordinator], Senior Regional Director of Clinical Services, [Senior Regional Director of Clinical Services]. In-service topics will include the following: Head to toe assessments-How and When to complete the assessments Significant Change in status-When a resident has a change who to report to Incidents and Accidents and how to report and complete Reporting to the Physician-Reporting any significant changes or incident that occurs with a resident and in a timely manner. Reporting to the Administrative Staff-Any significant changes or incident that has been reported, observed or noted. Abuse and Neglect-Who to report to, types of Abuse, prevention strategies Fall Management-Interventions to put in place and what to do when a fall occurs. Ongoing Monitoring: Interviews with staff and residents will be completed during morning grand rounds and throughout the day to identify if they have had any injuries or falls that have not been reported. This will continue weekly for 60 days. Administrative staff will make facility rounds daily, until compliance is achieved. All components of this plan of correction will be submitted to the facility QAPI committee meeting and additional recommendations will be made until substantial compliance has been achieved. The Medical Director was notified and agrees with the plan of correction. The Admin Nursing Staff to include, MDS, [MDS Coordinator], Infection Prevention/Staff Development Coordinator [Infection Prevention/Staff Development Coordinator], Senior Regional Director of Clinical Services, [Senior Regional Director of Clinical Services], DON, [DON], Executive Director, [Administrator], are responsible for the corrections and continued monitoring. Completion date: By 5pm 12/15/2023 Monitoring included: - Review of in-services dated 12/15/23 were completed and interviews with staff confirmed by verbalizing expectations. - Interviews on 12/15/2023 between 8:00am and 1:00PM with multiple staff on various shifts revealed confirmatory knowledge of in-services dated 12/15/2023 Observation on 12/15/23 at 9:41am revealed CNA G and CNA H using the Hoyer lift to transfer a resident with the wheelchair at the head of the bed. No problems or concerns with transfer 2-person transfer. During interviews on 12/15/23 from 8:00 a.m. to 1:00 p.m. with facility staff revealed they had been trained on head-to-toe assessments, significant change in status, incidents and accidents, reporting to the physician, reporting to the administration staff, abuse and neglect, fall management and suspected injury or witness fall. All staff interviewed were able to verbalize the new training instructions back. The staff interviewed consisted of the following: LVN D, LVN E, LVN F, CNA G, and CNA H. While the IJ was removed on 12/15/23 the facility remained out of compliance at a severity of actual harm and scope level of isolated due to the need for the facility to monitor it corrective action for effectiveness.

Based on observation, interview and record review the facility failed to ensure the residents' environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 1 Resident # 1 of 37 residents (Resident#1) reviewed for adequate supervision accident and hazards. RN K failed to report Resident #1's fall to the facility and failed to assess Resident #1 when the family alleged the resident was dropped during transfer. The facility was unaware the resident had fractured ribs and sternum until Resident #1 was sent to the hospital due to unrelated concern of low blood pressure, three days after the incident. This resulted in the residents at risk for delay in assessment in treatment, placing them at risk for further harm, injury, or death. An Immediate Jeopardy (IJ) was identified on 12/14/23. The IJ template was provided to the facility on [DATE] at 4:30pm. While the IJ was removed on 12/15/23, the facility remained out of compliance at a severity of actual harm with a scope identified as isolated. The facility was continuing to monitor for safe resident transfers as well as education to staff. Findings include: Record review of Resident #1 face sheet dated 12/15/23 revealed Resident #1 was a [AGE] year old female admitted on [DATE] with the following diagnoses: Muscle weakness, end stage renal disease, acute respiratory failure (body inability to deliver oxygen properly), heart failure(heart doesn't pump blood like it should), hypertension (high blood pressure), and difficulty in walking. Review of Resident #1's MDS Quarterly Assessment, dated 12/04/23, reflected the resident's functional status: Lying to sitting on side of bed: Substantial/maximal assistance, sitting to stand: Substantial/maximal assistance, chair to bed-to chair transfer: Substantial/maximal assistance. An interview on 12/14/23 at 9:40 a.m. with the Admin, revealed Resident #1 came back from the hospital with multiple fractures but never had a fall at the facility. The Administrator then stated they interviewed everyone such as dialysis, transportation, and EMS and neither one of them stated anything happened to the resident that resulted in fractured ribs and sternum so the investigation was inconclusive. Review of Resident #1's hospital record, dated 11/27/23, revealed, .Final diagnosis as of 11/27/23 2327 .Rib fractures .Sternal fracture .Dyspnea .Pleura effusion . In an interview and observation on 12/14/23 at 10:50 a.m., Resident #1 stated [the facility staff] took her out of the car van from dialysis and they were working together to put her in the bed when they dropped her on the floor. Resident #1 was observed lying in bed and was small and frail but alert and oriented to surroundings. In an interview on 12/14/23 at 10:51 a.m. with Resident #1's family member A revealed the family member's sister-in-law reported it the day it happened to the nurse (RN K) when she visited Resident #1. The following Monday,11/27/23 Resident #1's blood pressure dropped during dialysis and she was taken to the hospital. The hospital reported she had multiple fractured ribs and a fractured sternum. In an interview on 12/14/23 at 10:58 a.m. with Resident #1's family member B revealed she came to visit Resident #1 on 11/24/23. She stated she signed in around 4:10PM-4:15pm and Resident #1 hadn't been back for too long but realized Resident #1 was agitated. Resident #1 then told family member B that when [facility staff] were getting her back to her bed and out of the wheelchair, they dropped her. Family member B stated Resident #1 couldn't sit up well, was pointing to her ribs and told family member B she was hurting. Family member B spoke to RN K and told her the resident stated she had been dropped and was hurting. Family member B asked if there was something that could be given to Resident #1 for pain. RN K told family member B that she was in the vicinity when Resident #1 was transferred in her room and that the fall probably happened at the dialysis center. Family member B then revealed RN K bringing her some Tylenol in for Resident #1 since family member B stated she was in pain. In an interview with RN K at 12/14/23 at 11:30 a.m. revealed family member B came to her and stated the resident was dropped during transfer. RN K stated she was there at the facility when the resident returned from dialysis on 11/24/23. When Resident #1 first returned to the facility, she was exhausted and that's when Resident #1 stated to RN K she was dropped by an old man and a nurse, but RN K stated she thought Resident #1 was just having a dream. RN K also stated Resident #1 wasn't complaining of any pain at that time. RN K then revealed that it didn't occur to her that the fall could have happened. RN K stated after she was notified by family member B, RN K did not take her clothes off to do a full body assessment. She revealed she did give Resident #1 Tylenol since family member B stated she was in pain. RN K also stated she was by Resident #1's door when the transfer occurred while she was helping pass out dinner trays, however, she did not directly see the transfer. RN K stated if something like a resident was dropped during transfer were to occur, she was supposed to report it to the doctor, the DON, and Admin, but she just assumed the fall didn't occur, she didn't notify. RN K also stated even the next day the resident didn't complain of pain. She then revealed she had been in serviced on falls and what to do. She stated she was supposed to do a head-to-toe assessment, obtain vitals, notify the DON and the physician. In an interview with Admin on 12/14/23 at 11:50 a.m. revealed she was unaware family member B reported to RN K that the Resident #1 had fallen during transfer. The Admin revealed in RN K's witness statement all she wrote was that a fall did not occur at the facility for Resident #1. In an interview with the physician on 12/14/23 at 2:09 p.m. revealed he was not aware Resident #1 fell , but he stated he was there when she went to the hospital on 11/27/23. He stated the x-rays that were taken didn't specify if the rib and sternum fracture was a new or old injury. He stated she had a lot oof fluid drained from her chest and that could have been why she was in pain. The physician specified since this was a change of condition, he should have been notified by the nurse who was RN K at the time. In an interview with the transportation manager on 12/14/23 at 2:26 p.m., he revealed Transportation driver R was the one who transported Resident #1 back to the facility on [DATE]. He stated once they arrived, they usually let staff know the resident is back at the facility. He stated transportation driver R told him he helped her in bed and then went to get help to reposition her into the bed by asking a facility staff member. He stated transportation driver R was prn but was a really good worker and he had no issues regarding him. There was no fall. On 12/24/23 at 2:29 p.m. attempted to call transportation driver R with no answer. In an interview with CNA E on 12/14/23 at 2:40 p.m. revealed she was working that day Resident #1 came back from dialysis on 11/24/23, but she was working the opposite side of Resident #1. The transportation Driver R called CNA E to come help him transfer her back to the bed and to let RN K know Resident #1 was back at the facility from dialysis. CNA E then revealed she usually worked nights but was helping the dayshift that day. She stated Resident #1 was in her wheelchair when CNA E walked in the room to help transfer her back to the bed with transportation driver R. She stated she was on one side and transportation driver R was on the other and they got Resident #1 out of the wheelchair and pivoted toward the bed. The resident never fell . In an interview with dialysis nurse on 12/15/23 at 12:23PM revealed she was the nurse taking care of Resident #1 on 11/27/23. Resident #1 was having a hard time breathing, her oxygen was low and she was having pain in her rib cage. That was when Resident #1 revealed to the dialysis nurse that someone dropped her from the facility. Resident #1 then stated she wanted to go to the hospital and EMS was called on 11/27/23. The dialysis nurse stated Resident #1 comes to dialysis every Monday, Wednesday and Friday. She revealed the facility called and stated the resident fell at dialysis and the dialysis nurse stated no, Resident #1 told me she fell at the facility. In an interview with Admin on 12/15/ at 3:22 revealed this was a IJ because protocol was not followed and potential to resident harm. She stated staff training and ongoing training will occur with asking residents if they have any accidents of abuse or neglect that has not been reported or need to be reported. She then revealed she would be asking nursing staff questions about incidents as rounds are conducted. The Admin then stated 10 residents a day for 60 days will have assessments and may be extended if any issues occur. Record review of the facility's fall management policy, dated 12/04/23, revealed, .To promote patient safety and reduce patient falls by proactively, identifying, care planning, and monitoring patients fall indicators .The facility will assess the resident upon admission/readmission, quarterly with change in condition, and with fall event for any fall risk ad will identify appropriate interventions to minimize the risk of injury to falls . On 12/14/23 at 4:40 p.m. the Admin was informed of an Immediate Jeopardy existed and a copy of the IJ template was provided. The following Plan of Removal was accepted on 12/15/23 at 11:39 a.m. Plan of Remediation: [Facility Name] Re: IJ 12/14/2023 F 689 Accidents/Hazards Failure: The facility failure resulted in a delay in resident receiving timely x-rays and treatment, which could lead to serious harm/impairment/death. Corrective Action for those found to have been affected by the deficient practice: Identified Resident remains in the facility with no adverse residual effects. The Identified Licensed Nurse will be suspended (possibly terminated with HR approval) and Nurse License will be reported to the Board of Nursing. Resident Head to toe competencies will be completed by all licensed nurses by end of day 12/15/2023. The following in-services will be completed by 12/15/2023, by the following Administrative Nursing Staff to include, MDS, [MDS Coordinator], Infection Prevention/Staff Development Coordinator, [Infection Preventionist/Staff Development Coordinator], Senior Regional Director of Clinical Services, [Senior Regional Director of Clinical Services]. Head to toe assessments-How and When to complete the assessments Significant Change in status-When a resident has a change who to report to Incidents and Accidents and how to report and complete Reporting to the Physician-Reporting any significant changes or incident that occurs with a resident and in a timely manner. Reporting to the Administrative Staff-Any significant changes or incident that has been reported, observed or noted. Abuse and Neglect-Who to report to, types of Abuse, prevention strategies Fall Management-Interventions to put in place and what to do when a fall occur Identification of other residents having the potential to be affected: Fall assessments were completed on 12/14/2023 by Sr. Regional Director of Clinical Services, MDS Coordinator RN, and Infection Preventionist/Staff Development Coordinator, to determine which residents would be potentially affected. Residents who are identified to be at risk for falls will be care planned appropriately by Sr. Regional Director of Clinical Services, MDS Coordinator RN, and Infection Preventionist/Staff Development Coordinator. Current and past falls for the last 30 days reviewed for compliance to ensure that regulatory guidelines have been met. These were reviewed, by [Senior Regional Director of Clinical Services], for the last 30 days to ensure that regulatory guidelines have been met. Measures/Systemic Changes to ensure the deficient practice does not recur: Competency Assessments for completing and documenting head to toe will be completed by all licensed nursing staff prior to them working their next shift. They will not be allowed to work until these are completed. These Competencies will be conducted by Admin Nursing Staff to include, MDS, [MDS Coordinator], Infection Prevention/Staff Development Coordinator, [Infection Preventionist/Staff Development Coordinator], Senior Regional Director of Clinical Services, [Senior Regional Director of Clinical Services]. These will be completed by end of day 12/15/2023. In-services and education for all licensed nursing staff will be completed by 12/15/2023 by Admin Nursing Staff to include, MDS, [MDS Coordinator], Infection Prevention/Staff Development Coordinator, [Infection Prevention/Staff Development Coordinator], Senior Regional Director of Clinical Services, [Senior Regional Director of Clinical Services]. In-service topics will include the following: Head to toe assessments-How and When to complete the assessments Significant Change in status-When a resident has a change who to report to Incidents and Accidents and how to report and complete Reporting to the Physician-Reporting any significant changes or incident that occurs with a resident and in a timely manner. Reporting to the Administrative Staff-Any significant changes or incident that has been reported, observed or noted. Abuse and Neglect-Who to report to, types of Abuse, prevention strategies Fall Management-Interventions to put in place and what to do when a fall occurs. Ongoing Monitoring: Interviews with staff and residents will be completed during morning grand rounds and throughout the day to identify if they have had any injuries or falls that have not been reported. This will continue weekly for 60 days. Administrative staff will make facility rounds daily, until compliance is achieved. All components of this plan of correction will be submitted to the facility QAPI committee meeting and additional recommendations will be made until substantial compliance has been achieved. The Medical Director was notified and agrees with the plan of correction. The Admin Nursing Staff to include, MDS, [MDS Coordinator], Infection Prevention/Staff Development Coordinator [Infection Prevention/Staff Development Coordinator], Senior Regional Director of Clinical Services, [Senior Regional Director of Clinical Services], DON, [DON], Executive Director, [Administrator], are responsible for the corrections and continued monitoring. Completion date: By 5pm 12/15/2023 - Review of in-services dated 12/15/23 were completed and interviews with staff confirmed by verbalizing expectations. - Interviews on 12/15/2023 between 8:00am and 1:00PM with multiple staff on various shifts revealed confirmatory knowledge of in-services dated 11/15/2023 Observation on 12/15/23 at 9:20am Revealed Resident #1 sitting at the dining table in her wheelchair ready to go to dialysis. Observation on 12/15/23 at 9:41am revealed CNA G and CNA H using the Hoyer lift to transfer a resident with the wheelchair at the head of the bed. No problems or concerns with transfer 2-person transfer. During interviews on from 8:00 a.m. to 1:00 p.m. with facility staff revealed they had been trained on head-to-toe assessments, significant change in status, incidents and accidents, reporting to the physician, reporting to the administration staff, abuse and neglect, fall management and suspected injury or witness fall. All staff interviewed were able to verbalize the new training instructions back. The staff interviewed consisted of the following: LVN D, LVN E, LVN F, CNA G, and CNA H. While the IJ was removed on 12/15/23 the facility remained out of compliance at a severity of actual harm and scope of isolated due to the need for the facility to monitor it corrective action for effectiveness.

Based on interview, observation, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 4 medication carts (Southeast nurse's cart) and 2 (Residents #2 and #7) of 8 residents reviewed for pharmacy services. 1. The facility did not ensure RN K, counted the home narcotic drugs (narcotics that were brought in from the family) every shift change. On 11/30/2023 charge nurse A and RN B counted their meds at the beginning of shift change and there was a discrepancy of 10 tablets. 2. The facility failed to ensure RN M administered the correct medication dosage to Resident #7. These failures could result in an inaccurate narcotic medication count, drug diversion, and decreased therapeutic effects from medications. Findings included: Review of the facility's Provider Investigation Report, dated 12/06/23, revealed on 11/30/23, a discrepancy was revealed during shift change, with 10 tablets of Hydromorphone 4 mg missing for Resident #2. The police were contacted. During a record review of the narcotics log, the bottle of Hydromorphone 4mg for Resident #2 on 11/28/23 was signed off as 120 tablets and on 11/30/23 during the morning count revealed 105 tablets, the narcotic sheet was 115 tablet, which revealed 10 missing tablets . RN K counted the tablets at 120 on 11/28/23. RN A and LVN B counted the tablets at 105 on 11/30/23. During an interview with the Admin on 12/14/2023 at 10:30am revealed the two nurses listed on the self-report regarding the missing narcotics were RN A and LVN B. The Admin stated they were the nurses that caught the medication error from the day before 11/30/2023. After further review of the narcotics book it was determined that RN K did not follow protocol for receiving home narcotics. The protocol was for a nurse, along with another nurse, to count the medications together and not go by what was on the bottle to ensure accuracy. During an observation on 12/15/2023 at 11:00am during medication pass with LVN C (Southeast Nurse's Cart) revealed after she verified the resident (Resident #3) she was giving medication to (Cefuroxime 500mg tablet, Dexamethasone 2mg tablet, Escitalopram Oxal 10mg Tablet, Mucinex 400mg, BP HIGH 116/70 Metoprolol Succ ER 100mg, and Nifedipine OC 30mg), LVN C pulled out the narcotics book. After she popped out the pill she signed it out in the book underneath the resident's name. She stated that was done to keep an accurate count of the narcotics. She stated that in the morning when she came to work she counted the medication with the receiving nurse. Observation of the narcotic book revealed what she counted was accurate with the amount she received. During an interview on 12/14/2023 at 11:25am with RN I revealed if a family member brought in medication for a resident, before receiving it, MDS Nurse L stated she would bring in another nurse in front of the family, count the medications 1 by 1, and sign off on it as well as the family member to ensure that all the counts are the same. RN I stated they were always supposed count medications brought in by the family and never take the word of what was on the bottle. She stated this failure could potentially cause a drug diversion. During a phone interview with RN K on 12/15/2023 at 9:20 am, revealed she was not aware that the medication had to be counted in front of another nurse as well as the family member. She stated when she looked at the bottle she just assumed that the count on the label was accurate and that it was a new prescription. RN K stated that if she would have known that it was to be counted and in front of another nurse and a family member she would have made sure it was done. She stated going forward she knows now because this could have been avoided. She stated this failure could potentially cause a drug diversion and it made it look bad because now they did not have an accurate count. Review of the facility's policy, Management of Controlled Substances, dated 08/29/23, revealed, .the facility will ensure that the incoming qualified individual and outgoing qualified individual count all controlled substances and other medications with a risk of abuse or diversion at the change of each shift and whenever control of the controlled substances changes from one qualified individual to another . 2. Review of Resident #7's face sheet, dated 12/14/2023, revealed that the resident was a 69- year-old female admitted into the facility on [DATE]. Admission diagnosis included spinal stenosis (A condition where spinal column narrows and compresses the spinal cord), essential hypertension, lower back pain, and edema. Record Review of facility's Provider Investigation Report, dated, 12/04/23, revealed, .o Date/Time you first learned of incident: 11/27/2023 o Date/Time the incident occurred: 11/26/2023 o Brief narrative summary of the reportable incident: two Norco 10-325mg were punched by the nurse into the medication cup. The [family member] was at the resident's bedside. The nurse turned towards the resident to take the blood pressure, when she turned back around to give the medications, 1 narcotic was missing from the medication cup . During an interview on 12/14/23 at 10:30 a.m. with RN M, stated she set the medication down on the bedside table to get the resident settled in bed because she was sitting far down in the bed. The family member picked up the cover of the tray and blocked the view of the breakfast tray. She intervened by telling her to stop and she then noticed the pill was missing. At some point of time, she admitted that she lost sight of the medication due to the family member covering the medication with the cover of the breakfast tray. She then said the family member moved. RN R demonstrated what happened in the room on 11/26/2023. She stated that she was sure that there were two Narcotics in the pill cup. She stated that she did not 100% have her eye on the medication but as a nurse she was aware of her surroundings. RN M stated that the risk of having Norco unattended was the potential to be taken away by someone. All it would take is a second. Phone interview at 12:29pm on 12/14/2023 with Resident #7's family member revealed that she was in the room and the nurse, RN M, was bringing Resident #7 the medication. The nurse was checking Resident #7's blood pressure and stated that the nurse set the medication down and then turned around and said that a pill was missing. Resident #7's family member asked the RN M if she took the medication . She stated the nurse stated that her cart was short of the medication (Norco 10-325 mg). She stated that the nurse stated that she knows that she pulled it. The family member stated that the nurse only gave Resident #7 the 1 pill instead of both. Resident #7's family member stated that the pain medication was missing, and the nurse made a mistake. At that time, she stated that she came daily to visit Resident #7 and she stated that it has never been a problem. Resident #7's family member stated that there had not been any other issues in regard to her Resident #7's care. She stated that even when Resident #7 took her own medication she took it outside. She stated that there as normally a lot of pills in the cup BP, WATER, POTASSIUM, PAIN MEDS so she did not pay attention to the cup actually. Review of Resident #7's MAR for December 2023 revealed it was documented by RN M that both pills of the Norco 10-325 mg) were given instead of just one. During an interview with the Administrator on 12/14/2023 at 10:00 a.m. the Admin said that the incident happened on 11/26/23 but was not reported to the Admin until 11/27/23. The admin reported to HHSC within 2 hrs of being made aware of the incident. The Admin stated the nurse failed to report it to her within the two hour limit that the facility required. During record review of policy Medication brought to facility by the resident/family/physician/prescriber dated 01/01/2022 revealed, . 1.3. In States where the facility must use medications brought into the facility by a resident, a resident's Responsible Party, or a resident's Physician/Prescriber, facility staff should 1.3.1 Acquire an order to use the medications from the Physician/Prescriber . 1.3.2 Verify the medication and strength in the container with a pharmacist, on-line pill identifier, or by using the drug information tab on Omnicare Omniview .1.3.3 Verify the directions on the label with current orders .

Based on observation, interview and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for one (Resident #7) of 8 residents reviewed for medication storage. The facility failed to ensure medications were monitored during medication pass, leaving medications exposed on the medication cart when RN M turned away. This failure could place all residents at risk of not receiving the therapeutic benefit of medications, adverse reactions to medications and drug diversion. Findings included: Review of Resident #7's face sheet, dated 12/14/2023, revealed that the resident was a 69- year-old female admitted into the facility on [DATE]. Admission diagnosis included spinal stenosis (A condition where spinal column narrows and compresses the spinal cord), essential hypertension, lower back pain, and edema. Review of the facility's Provider Investigation Report, dated 12/04/23, revealed on 11/26/23, the nurse (RN M) removed two pills of Norco 10-325 mg to administer to the resident (Resident #7), placed the pill in a medication down, turned away to take the resident's blood pressure, and found that one pill was missing. The police were contacted. During an interview on 12/14/23 at 10:30 a.m. with RN M, stated she set the medication down on the bedside table to get the resident settled in bed because she was sitting far down in the bed. The family member picked up the cover of the tray and blocked the view of the breakfast tray. She intervened by telling her to stop and she then noticed the pill was missing. At some point of time, she admitted that she lost sight of the medication due to the family member covering the medication with the cover of the breakfast tray. She then said the family member moved. RN R demonstrated what happened in the room on 11/26/2023. She stated that she was sure that there were two Narcotics in the pill cup. She stated that she did not 100% have her eye on the medication but as a nurse she was aware of her surroundings. RN M stated that the risk of having Norco unattended was the potential to be taken away by someone. All it would take is a second. During an interview on 12/14/23 at 11:25 a.m. with RN I - Stated she does not take her eyes off the medication, no matter what the circumstances were even if it were regular medications, especially if someone else is in the room. Phone interview at 12:29pm on 12/14/2023 with Resident #7's family member revealed that she was in the room and the nurse, RN M, was bringing Resident #7 the medication. The nurse was checking Resident #7's blood pressure and stated that the nurse set the medication down and then turned around and said that a pill was missing. Resident #7's family member asked the RN M if she took the medication . She stated the nurse stated that her cart was short of the medication (Norco 10-325 mg). She stated that the nurse stated that she knows that she pulled it. The family member stated that the nurse only gave Resident #7 the 1 pill instead of both. Resident #7's family member stated that the pain medication was missing, and the nurse made a mistake. At that time, she stated that she came daily to visit Resident #7 and she stated that it has never been a problem. Resident #7's family member stated that there had not been any other issues in regard to her Resident #7's care. She stated that even when Resident #7 took her own medication she took it outside. She stated that there as normally a lot of pills in the cup BP, WATER, POTASSIUM, PAIN MEDS so she did not pay attention to the cup actually. During an interview with the Administrator on 12/14/2023 at 10:00 a.m. the Admin said that the incident happened on 11/26/23 but was not reported to the Admin until 11/27/23. The admin reported to HHSC within 2 hrs of being made aware of the incident. The Admin stated the nurse failed to report it to her within the two hour limit that the facility required. Review of facility's Drug Diversion Prevention Program, training, undated revealed, .Nurses have a professional responsibility to store, administer, and dispose of controlled substances appropriately, guarding against abuse while ensuring that residents have medication available when needed

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for kitchen sanitation in the facility's only kitchen observed for kitchen sanitation. 1. The facility failed to ensure kitchen staff wore appropriate hair and beard restraints. 2. The facility failed to ensure food items in the refrigerator were dated, labeled and sealed appropriately. These failures could affect residents by placing them at risk for food-borne illness. Findings included: 1. In an observation and interview on 10/10/2023, at 9:15 AM, revealed Activity Assistant A was not wearing a hairnet. Activity Assistant A stated that she thought she had one on and it must have come off her head. Activity Assistant A stated the importance of wearing a hairnet to prevent foodborne illness and put one on immediately. Review of the facility's Food Safety Policy titled Chapter 9 - Food and Nutrition Services that was not dated, stated: All associates should have their hair covered with hair restraints. No bangs should be hanging out . . 6. The staff is utilizing proper hair restraints, covering exposed hair . 17. Infection Control Several guidelines are important in preventing the spread of infection . Also, proper usage of hairnets is essential. These must be properly sanitized to prevent disease transmittal among residents and associates. Review of the U.S. Public Health Service Food Code, dated 2022, reflected: 2-402.11 Effectiveness. (Hair Restraints) 1. Code of Federal Regulations, Title 21, Sections 110.10 Personnel. indicated (1) Wearing outer garments suitable to the operation (6) Wearing, where appropriate, in an effective manner, hair nets, head bands, caps, beard covers, or other effective hair restraints. 2. In an observation and interview on 10/10/2023, at 9:20 AM, with Cook C reflected a food tray containing cooked sausage, hard shelled eggs, and butter were stored in the refrigerator without being labeled or dated. The tray was covered in cellophane plastic. Cook C stated it was important to label and date foods stored in the refrigerator to prevent serving foods past their expiration date to prevent foodborne illness. Cook C stated she just forgot to put the date on the tray as she was in a hurry and was the only one working at the time. Review of the U.S. Public Health Service Food Code, dated 2022, reflected: 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day1. Review of the facility's Food Safety in Receiving and Storage policy, that was not dated, titled Chapter 9 - Food and Nutrition Services, revealed, Any food not in its original container must be labeled with the date and contents and must be securely covered. Temperatures are to run 34 to 38 F. 3. In an interview on 10/11/2023, at 11:25 AM with the Dietician, revealed the Dietary Manager was out on sick leave and she was filling in as Dietary Manager until the Dietary Manager returns. The Dietician stated she normally only worked on Wednesdays and was contracted with the facility. The Dietician indicated the importance of wearing hair restraints and dating foods put in the refrigerator was to prevent food borne illnesses.

Based on interview and record review the facility failed to ensure personnel provided basic life support, which included CPR (Cardio- Pulmonary Resuscitation), to a resident who required such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directive for 1 of 5 residents (Resident #1) reviewed for CPR. PTA A failed to initiate CPR for a resident who was unresponsive with a code status of Full Code. The resident expired in the facility. This noncompliance was identified as Past Noncompliance (PNC). The noncompliance began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the survey began. This failure could place residents who could need CPR at risk of death. The findings include: Record review of Resident #1's face sheet, dated [DATE], revealed he was an [AGE] year-old male who was admitted to the facility on [DATE]. He had diagnoses which included difficulty swallowing caused by stroke, communication deficit caused by stroke. The face sheet revealed, There were no Advance Directives selected for this resident and his Code Status was Full Code. Record review of Resident #1's admission MDS assessment, dated [DATE], BIMS was not completed as the resident was rarely/never understood. He required extensive assistance for activities of daily living. Record review of Resident #1's physician progress note, dated [DATE], revealed continue supportive care, but now with decline .monitor, if cognition and/or oral nutrition not improved, will need to discuss need for peg tube or hospice evaluation. Record Review of Resident #1's progress note, dated [DATE], LVN B documented, she was alerted by CNA C to check on Resident #1. Resident #1 was in the hallway with PTA A. LVN B observed PTA A at Resident #1's side with blood pressure cuff to the wrist. LVN B's assessment of Resident #1 revealed he was non-responsive to voice command, LVN B was not able to feel a pulse in Resident #1's neck. CNA C checked the chart for code status and reported Resident #1 was a full code. LVN B paged the code blue, dialed 911, retrieved the crash cart CPR was initiated at approximately 11:25 AM. Resident #1 was pronounced deceased at 11:43 AM. Record review of the Provider Investigation Report (PIR) dated [DATE] revealed on [DATE] between 11:00 - 11:05 AM PTA A picked up Resident #1 from the day room transported him to the therapy gym; between 11:12 - 11:20 AM PTA A attempted to arouse Resident #1 using a loud voice, shaking shoulders and performing a sternal rub, no response was observed. PTA A attempted to obtain a O2 saturation and blood pressure without success. PTA A transported Resident #1 to a hallway near the nurses station to a walled blood pressure cuff and attempted to obtain a O2 sat and BP, without success. 11:22 AM- 11:23 AM, PTA A stopped CNA C in the halllway, CNA C observed Resident #1 and quickly informed LVN B, she needed to check Resident #1. Code blue was called 11:25 AM, CPR was initiated 11:26 AM. EMS arrived and took over CPR at 11:33 AM, Resident #1 was pronounced dead at 11:43 AM in the facility. The PIR included a written statement (1st statement) by PTA A, dated [DATE], stated: upon entry to the activity room Resident #1 was seated in his WC with his back facing PTA A. PTA A approached Resident #1 from behind, leaned over his shoulder as she tapped on it and introduced herself. PTA A observed the left side of Resident #1's face and noted his eyes were closed. Resident #1 did not respond to PTA A's verbal stimuli. PTA A wheeled Resident #1 out of the activity room into the hallway and spoke to Resident #1, he did not respond to the verbal stimuli. PTA A reported his eyes were closed, his head fully upright in neutral position. PTA A wrote she thought Resident #1 was sleeping as she wheeled him into the occupational therapy gym. PTA A applied lotion to Resident #1's legs and performed ROM exercises. PTA A observed no response from Resident #1 to verbal or tactile stimuli, PTA A performed a sternal rub (a painful stimulus used to elicit a response in an unconscious person) Resident #1 did not respond. PTA A used a wrist blood pressure cuff to check Resident #1 blood pressure it read error; the O2 saturation probe read no pulse detected PTA A attempted to feel for a pulse on the left wrist of Resident #1 and reported I am having difficult feeling a pulse. PTA A wrote she placed her hand on the chest of Resident #1 to feel for chest rise and fall, but could not determine if it was just so shallow that I couldn't detect it or if there was no breath. PTA A thought equipment failure and wheeled Resident #1 to a wall blood pressure cuff located near the nurses station, applied the blood pressure cuff attempted to get blood pressure reading, it read error. PTA A attempted to get a second blood pressure, as CNA C walked by PTA A told CNA C I cannot get vitals on him and do not think he is alive, to tell the nurse. In an interview on [DATE] at 11:55 AM the Adm stated while the facility completed the investigation it could not be determined at what point Resident #1 passed away. Adm would expect that if therapy found a resident who was unresponsive, they would immediately report to the nurse. On [DATE] PTA A submitted her resignation via email. In an interview on [DATE] at 12:34 PM, COTA D stated Resident #1 had declined during the past week, described him as less engaged, tired and frequently falling asleep in his WC. COTA D stated on [DATE] around 11:10 AM she walked into the therapy gym to grab something and noted PTA A with Resident #1 he was in his WC sitting upright with his head down, with his chin on his chest. In an interview on [DATE] at 2:11 PM, LVN H stated she overheard PTA A explain to the police she did not check BP, HR or O2 sat at the beginning of the therapy session. In an interview on [DATE] at 2:22 PM, the DOR stated she expected the therapy staff to elicit a response from a resident prior to transport off the unit. If the resident could not be aroused, the therapist should check-in with the nurse and report findings. The DOR believed the application of lotion to the legs of Resident #1 was an attempt to wake him not part of the treatment. In an interview on [DATE] at 3:31 PM, PTA A stated Resident #1 was in his WC, with his back to her. PTA A leaned over the left shoulder of Resident #1, visulized the left side of his face, eyes were closed, Resident #1 did not respond to her greeting, she believed it was because of the noise in the room. PTA A pushed Resident #1 in his WC to the therapy gym and continued talking to him, without a response from Resident #1. PTA A stated she was seen pushing Resident #1 in his WC by OT D, LVN B, and CNA C and no person indicated she needed to stop or something was wrong. PTA A stated she no longer felt comfortable talking about the situation and declined to provide additional information. The noncompliance began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance on [DATE] before the survey began. The facility took the following actions to correct the non-compliance: 1. PTA A was suspended [DATE] pending investigation. 2. [DATE] education provided to all staff entittled Changes in Residents condition or status Code Status CPR Guidelines 3. [DATE] education provided therapy staff entitled Updated best practice for therapy prior to leaving nursing unit with patient Therapy response when patient becomes unresponsive during treatment session 4. Conducted mock codes with nursing and therapy staff 5. Implentation of new procedure - prior to removing a resident from the unit for therapy, staff was required to check blood pressure, HR, O2 sat and report to nurse. 6. Therapy staff was required to document Blood pressure, HR, and O2 sat residents's EHR. In an interview on [DATE] at 12:16 PM, PTA E stated prior to taking a resident to the therapy, they were to check and record BP, HR and O2 sat and inform the nurse. If a resident had an emergency during treatment, get help immediately. The code status of the resident had been added to their daily schedules. In an interview on [DATE] at 12:34 PM, PTA D stated prior to beginning therapy she was to check BP, HR, and O2sat, results were recorded in the EHR and discussed with the nurse. The code status was added to the therapist schedule for the day. If a residenet had an emergency during treatment, get help immediately. In an interview on [DATE] at 12:46 PM, ST F stated prior to starting therapy they were to check BP, O2 sat and report findings to the nurse and document in the EHR. If there was an emergency they were told to get help immediately. In an interview on [DATE] at 1:19 PM, OT G stated therapists were now required to take BP, HR and O2 sats before moving a resident from their room. Findings were to be documented and reported to the nurse. In the case of an emergency, get help immediately. Record Review of the facility policy Changes in Residents's condition or status, review date [DATE], revealed This facility will notify the resident, his/her primary care provider, and resident/resident representative of changes in the resident condition or status. In the case of death of a resident, the resident's physician will be notified immediately by facility staff in accordance with State law. Record review of the facility policy Cardiopulmonary Resusscitation (CPR) Guidelines, review date [DATE], revealed to ensure that each facility is able to and does provide emergency basic life support immediately when needed, included CPR to any resident requiring such care prior to the arrival of emergency medical personnel in accordance with related physician orders, such as DNRs, and the resident advance directives.

Based on interview and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 5 residents (Resident #1) reviewed for quality of care. PTA A failed to initiate CPR for a resident who was unresponsive with a code status of Full Code. The resident expired in the facility. This noncompliance was identified as Past Noncompliance (PNC). The noncompliance began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the survey began. This failure could place residents who could need CPR at risk of death. The findings include: Record review of Resident #1's face sheet, dated [DATE], revealed he was an [AGE] year-old male who was admitted to the facility on [DATE]. He had diagnoses which included difficulty swallowing caused by stroke, communication deficit caused by stroke. The face sheet revealed, There were no Advance Directives selected for this resident and his Code Status was Full Code. Record review of Resident #1's admission MDS assessment, dated [DATE], BIMS was not completed as the resident was rarely/never understood. He required extensive assistance for activities of daily living. Record review of Resident #1's physician progress note, dated [DATE], revealed continue supportive care, but now with decline .monitor, if cognition and/or oral nutrition not improved, will need to discuss need for peg tube or hospice evaluation. Record Review of Resident #1's progress note, dated [DATE], LVN B documented, she was alerted by CNA C to check on Resident #1. Resident #1 was in the hallway with PTA A. LVN B observed PTA A at Resident #1's side with blood pressure cuff to the wrist. LVN B's assessment of Resident #1 revealed he was non-responsive to voice command, LVN B was not able to feel a pulse in Resident #1's neck. CNA C checked the chart for code status and reported Resident #1 was a full code. LVN B paged the code blue, dialed 911, retrieved the crash cart CPR was initiated at approximately 11:25 AM. Resident #1 was pronounced deceased at 11:43 AM. Record review of the Provider Investigation Report (PIR) dated [DATE] revealed on [DATE] between 11:00 - 11:05 AM PTA A picked up Resident #1 from the day room transported him to the therapy gym; between 11:12 - 11:20 AM PTA A attempted to arouse Resident #1 using a loud voice, shaking shoulders and performing a sternal rub, no response was observed. PTA A attempted to obtain a O2 saturation and blood pressure without success. PTA A transported Resident #1 to a hallway near the nurses station to a walled blood pressure cuff and attempted to obtain a O2 sat and BP, without success. 11:22 AM- 11:23 AM, PTA A stopped CNA C in the halllway, CNA C observed Resident #1 and quickly informed LVN B, she needed to check Resident #1. Code blue was called 11:25 AM, CPR was initiated 11:26 AM. EMS arrived and took over CPR at 11:33 AM, Resident #1 was pronounced dead at 11:43 AM in the facility. The PIR included a written statement (1st statement) by PTA A, dated [DATE], stated: upon entry to the activity room Resident #1 was seated in his WC with his back facing PTA A. PTA A approached Resident #1 from behind, leaned over his shoulder as she tapped on it and introduced herself. PTA A observed the left side of Resident #1's face and noted his eyes were closed. Resident #1 did not respond to PTA A's verbal stimuli. PTA A wheeled Resident #1 out of the activity room into the hallway and spoke to Resident #1, he did not respond to the verbal stimuli. PTA A reported his eyes were closed, his head fully upright in neutral position. PTA A wrote she thought Resident #1 was sleeping as she wheeled him into the occupational therapy gym. PTA A applied lotion to Resident #1's legs and performed ROM exercises. PTA A observed no response from Resident #1 to verbal or tactile stimuli, PTA A performed a sternal rub (a painful stimulus used to elicit a response in an unconscious person) Resident #1 did not respond. PTA A used a wrist blood pressure cuff to check Resident #1 blood pressure it read error; the O2 saturation probe read no pulse detected PTA A attempted to feel for a pulse on the left wrist of Resident #1 and reported I am having difficult feeling a pulse. PTA A wrote she placed her hand on the chest of Resident #1 to feel for chest rise and fall, but could not determine if it was just so shallow that I couldn't detect it or if there was no breath. PTA A thought equipment failure and wheeled Resident #1 to a wall blood pressure cuff located near the nurses station, applied the blood pressure cuff attempted to get blood pressure reading, it read error. PTA A attempted to get a second blood pressure, as CNA C walked by PTA A told CNA C I cannot get vitals on him and do not think he is alive, to tell the nurse. In an interview on [DATE] at 11:55 AM the Adm stated while the facility completed the investigation it could not be determined at what point Resident #1 passed away. Adm would expect that if therapy found a resident who was unresponsive, they would immediately report to the nurse. On [DATE] PTA A submitted her resignation via email. In an interview on [DATE] at 12:34 PM, COTA D stated Resident #1 had declined during the past week, described him as less engaged, tired and frequently falling asleep in his WC. COTA D stated on [DATE] around 11:10 AM she walked into the therapy gym to grab something and noted PTA A with Resident #1 he was in his WC sitting upright with his head down, with his chin on his chest. In an interview on [DATE] at 2:11 PM, LVN H stated she overheard PTA A explain to the police she did not check BP, HR or O2 sat at the beginning of the therapy session. In an interview on [DATE] at 2:22 PM, the DOR stated she expected the therapy staff to elicit a response from a resident prior to transport off the unit. If the resident could not be aroused, the therapist should check-in with the nurse and report findings. The DOR believed the application of lotion to the legs of Resident #1 was an attempt to wake him not part of the treatment. In an interview on [DATE] at 3:31 PM, PTA A stated Resident #1 was in his WC, with his back to her. PTA A leaned over the left shoulder of Resident #1, visulized the left side of his face, eyes were closed, Resident #1 did not respond to her greeting, she believed it was because of the noise in the room. PTA A pushed Resident #1 in his WC to the therapy gym and continued talking to him, without a response from Resident #1. PTA A stated she was seen pushing Resident #1 in his WC by OT D, LVN B, and CNA C and no person indicated she needed to stop or something was wrong. PTA A stated she no longer felt comfortable talking about the situation and declined to provide additional information. The noncompliance began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance on [DATE] before the survey began. The facility took the following actions to correct the non-compliance: 1. PTA A was suspended [DATE] pending investigation. 2. [DATE] education provided to all staff entittled Changes in Residents condition or status Code Status CPR Guidelines 3. [DATE] education provided therapy staff entitled Updated best practice for therapy prior to leaving nursing unit with patient Therapy response when patient becomes unresponsive during treatment session 4. Conducted mock codes with nursing and therapy staff 5. Implentation of new procedure - prior to removing a resident from the unit for therapy, staff was required to check blood pressure, HR, O2 sat and report to nurse. 6. Therapy staff was required to document Blood pressure, HR, and O2 sat residents's EHR. In an interview on [DATE] at 12:16 PM, PTA E stated prior to taking a resident to the therapy, they were to check and record BP, HR and O2 sat and inform the nurse. If a resident had an emergency during treatment, get help immediately. The code status of the resident had been added to their daily schedules. In an interview on [DATE] at 12:34 PM, PTA D stated prior to beginning therapy she was to check BP, HR, and O2sat, results were recorded in the EHR and discussed with the nurse. The code status was added to the therapist schedule for the day. If a residenet had an emergency during treatment, get help immediately. In an interview on [DATE] at 12:46 PM, ST F stated prior to starting therapy they were to check BP, O2 sat and report findings to the nurse and document in the EHR. If there was an emergency they were told to get help immediately. In an interview on [DATE] at 1:19 PM, OT G stated therapists were now required to take BP, HR and O2 sats before moving a resident from their room. Findings were to be documented and reported to the nurse. In the case of an emergency, get help immediately. Record Review of the facility policy Changes in Residents's condition or status, review date [DATE], revealed This facility will notify the resident, his/her primary care provider, and resident/resident representative of changes in the resident condition or status. In the case of death of a resident, the resident's physician will be notified immediately by facility staff in accordance with State law. Record review of the facility policy Cardiopulmonary Resusscitation (CPR) Guidelines, review date [DATE], revealed to ensure that each facility is able to and does provide emergency basic life support immediately when needed, included CPR to any resident requiring such care prior to the arrival of emergency medical personnel in accordance with related physician orders, such as DNRs, and the resident advance directives.

Based on observation, interview and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 10 staff reviewed (CNA E , CNA F and CNA G) for infection. 1. The facility failed to protect residents from exposure to COVID-19 when they allowed CNA E to work in the facility after she stated she had symptoms of COVID-19. Two to three days later 7(Resident #1, #2, #3, #4, #5, #6, and #7) residents and 2(CNA H and LVN T)2 staff members tested positive for COVID-19. 2. The facility failed to appropriately screen employees for signs, symptoms and exposure to COVID -19. An Immediate Jeopardy (IJ) situation was identified on 12/14/2021. While the IJ was removed on 12/15/2021, the facility remained out of compliance at a scope of a pattern with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems . This failure could place residents at risk for exposure to COVID-19, health complications, and death. Findings include : Record review of Resident #1 face sheet dated 12/07/21 revealed the resident was admitted to the facility on [DATE]. She was an [AGE] year old female, her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She tested positive for COVID on 12/07/21. She was discharged to the local hospital on 12/07/21 following the positive result. Record review of Resident # 2 face sheet dated 12/07/21 reveaeled the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident tested positive for COVID-19 on 12/07/21. The resident was discharged from the facility on 12/07/21 to a hospital Record review of Resident # 3 face sheet dated 12/07/21 reveaeled the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident tested positive for COVID-19 on 12/07/21. The resident was discharged from the facility on 12/07/21 to his home. Record review of Resident # 4 face sheet dated 12/07/21 reveaeled the resident was a [AGE] year-old female admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident tested positive for COVID-19 on 12/07/21. The resident was discharged from the facility on 12/07/21 to another that accepted resident with positive COVID test results. Record review of Resident # 5 face sheet dated 12/07/21 reveaeled the resident was a [AGE] year-old female admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident tested positive for COVID-19 on 12/07/21. The resident was discharged from the facility on 12/07/21 to another that accepted resident with positive COVID test results. Record review of Resident # 6 face sheet dated 12/09/21 reveaeled the resident was a [AGE] year-old female admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident tested positive for COVID-19 on 12/09/21. The resident was discharged from the facility on 12/09/21 to the local hospital. Record review of Resident # 6 face sheet dated 12/09/21 reveaeled the resident was a [AGE] year-old female admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident tested positive for COVID-19 on 12/09/21. The resident was discharged from the facility on 12/09/21 to the local hospital. Record review of the facility's investigation reported, dated 12/07/21, revealed 7( (Resident #1, #2, #3, #4, #5, #6, and #7) residents tested positive for COVID-19 on 12/07/21. Resident # 1One of the residents wwent out of the facility for [CONDITION(S)] treatment and tested positive while at the center. The resident was transferred to the hospital. All residents who tested positive were transferred to the hospital or another nursing facility. Three staff members tested positive and were all asked to not return to work and quarantine. Record review revealed thResident #1, #2, #3, #4, #5, #6, and #7 resident e residents who tested who tested positive for COVID-19 were all located on the facility's B wing . Record review of the screening form for CNA F and CNA G revealed they had not missed any days of reporting signs and symptoms. Record review of the screening form completed for CNA E, dated 12/05/21, revealed she reported no signs and symptoms of COVID-19. CNA E did not report a fever or high temperature. She had not completed any international travel . Record review of the timecard for CNA E, on 12/05/21, revealed she worked at 10:10 p.m. to 6:28 a.m. During an interview on 12/14/21 at 11:15 a.m., CNA E revealed she last worked at the facility on 12/05/21. Her shift at the facility was 10 p.m. to 6 a.m. She stated while she worked on the shift on 12/05/21 into 12/06/21, she began to feel ill. She informed RN A she had symptoms of COVID-19 to include body aches, fatigue and headache. She continued to work the rest of her shift and completed a COVID-19 test and the results were negative. She was not aware 7 residents and 2 staff members had tested positive starting on 12/07/21. She was assigned to the B wing on 12/05/21 into 12/06/21. She had not been vaccinated for COVID-19. An interview with RN A on 12/14/21 at 11:44 a.m. revealed she worked the night of 12/05/21 into 12/06/21. She was assigned to the facility B wing. She stated CNA E did inform her she felt ill during the shift. The aide told her she had body ache (back pain) and she had a headache. She did not inform the DON or Administration staff because the aide always complained of back pain. The aide was allowed to continue to work and finish the shift. The aide was tested for COVID-19, that morning, and tested negative . An interview with the ED on 12/14/21 at 12:45 p.m. revealed she was not aware CNA E had symptoms of COVID-19. RN A had not reported any of CNA E symptoms . The expectation, if any of the staff members felt ill, they must not continue to work. They must be tested and removed from working until the symptoms no longer existed. During an observation and interview on 12/14/21 at 2:20 p.m. revealed CNA F at the nurses station, sitting with the pervious aide . She revealed she entered through the back door at 2 p.m. She did not screen to determine if she had signs and symptoms of COVID-19. After state surveyor inquiry, CNA F left the unit and get screened . Observation and interview on 12/14/21 at 2:25 p.m. revealed CNA G worked on the facility's locked unit. She stated she began work at 2 p.m. She revealed she entered through the facility's back door and had not been screened for signs and symptoms of COVID-19 before working. She stated it was common for staff to enter through the back door. After state surveyor inquiry she went to the front of the building and was screened and returned to work . An interview with the ED on 12/14/21 at 2:44 p.m. revealed she was not aware staff were entering the facility through the back entrance . She started her expectations were for the staff to enter the facility through the main entrance and are screened prior to beginning their shifts . An interview with the DON on 12/14/21 at 3:32 pm revealed she was not aware CNA E had symptoms while working at the facility. She expected RN A to have sent the aide home after she reported symptoms. Even though she tested negative for COVID on 12/06/21, the staff should not have been allowed to work with residents. Record review of the facility's Coronavirus- COVID-19 policy, revised 11/29/21, revealed Associates (HCP/Staff) will be actively screened at the beginning of their work day and shift in accordance with current guidance from CDC, CMS and local and state health departments. The policy also revealed Any associate who develops signs or symptoms of a respiratory infection or COVID-19 while on the job should, immediately stop work, keep facemask/face covering on, inform the facilities infection preventionist. The associate should be tested and held out of work until the results are received from test. This was determined to be an Immediate Jeopardy (IJ) on 12/14/21 at 4:26 p.m. The Administrator was notified. The Administrator was provided with the IJ template on 12/14/21 at 4:28 p.m. The following Plan of Removal submitted by the facility was accepted on 12/15/2021 at 3:15 p.m.: Interventions: 100% of associates/ staff on-site were interviewed to determine if they were experiencing any signs and/or symptoms of [CONDITION(S)]-COV-2. There were no other associates identified. Education was provided by the Director of Nurses and ED on 12/14/21 and will be completed by 12/15/21 to all staff on-site regarding: o Requirement to report symptoms of [CONDITION(S)]-COV-2 immediately upon onset if in the facility, before or after and to immediately stop work and keep a facemask in place o Associate should be tested and out of work until results received o Requirement to report onset of symptoms while not in the facility and to avoid reporting to work if symptoms are present o Avoiding work with symptoms o What to do if an associate reports symptom during their shift o Entering through only one designated entrance in the facility to be screened Additional associates will receive education via telephone and COVR. (COVR is an electronic secure text system that sends out messages to staff and family members- No HIPPA information is discussed) Remaining associates will receive education prior to working their next scheduled shift. PRN and agency staff will be in-serviced and competency tested prior to them coming onto shift. Entrance to the facility has been restricted to one entrance. A sign was posted at the back entrance to advise associates to enter only through the front entrance. In addition, the access code to the other door was changed, with only the Executive Director (ED) and the Maintenance Director with a code. All other doors were checked to ensure signage was posted and associates did not have access to them . The codes to enter the door were changed, with only the maintenance director and ADM knowing the access codes. Education was provided to all staff on-site regarding the requirement to enter through the designated front entrance. Additional associates will receive education via telephone and COVR. Remaining associates will receive education prior to working their next scheduled shift. PRN and agency staff will be in-serviced and competency tested prior to them coming on shift. Competency testing will be completed for associates regarding the education provided and will require 100% pass rate, this will be completed on 12/15/21 or prior to the staff working an assigned shift Monitoring will be completed by the ED and DON for all shifts until compliance is achieved. Monitoring will include observation of sign in sheets, entering through one designated area of the facility and observing staff for any signs and symptoms of COVID symptoms. Monitoring will also include random training and in-services as indicated. The facility Medical Director was called on 12/14/21 to notify of the Immediate Jeopardy. He agreed with the plan for removal of the Immediate Jeopardy. A Quality Assurance Performance Improvement (QAPI) team meeting was held to review the plan for removal on 12/14/21. Monitoring of the POR included: Observation on 12/15/21 at 2:12 p.m. revealed a signage DO NOT ENTER, ENTER ONLY THROUGH FONT DOOR TO SCREEN PRIOR TO BEGINNING OF SHIFT. NO EXCEPTIONS posted on the back door. Staff were observed entering through the front door for screening . The door was locked . Record review and observation revealed all staff present at the facility at 2:25 p.m. on 12/15/21 had been screened and did not indicate having any symptoms of COVID-19. 5 aides, 2 nurses and 2 therapy staff LVNs (on all shifts - 6 a.m.- 2 p.m., 2 p.m.- 10 p.m., 10 p.m.- 6 a.m. all shifts 6 a.m.- 6 p.m., 2 p.m.- 10 p.m., 10 p.m.-6 a.m.), said they received training regarding infection control , staff must enter through the front of the facility to be screened prior to beginning of their shift , CDC recommendations for quarantine post exposure to COVID-19. All staff said if they were exposed to COVID-19 they would immediately report the exposure to their charge nurse, DON and Administrator. The DON and Administrator said they had educated their staff regarding the proper procedure for staff screening. They stated the staff had completed competency tests and all scored 100 percent. Staff were informed of the different symptoms of COVID-19. Symptoms must be reported to the charge nurse or DON if they have symptoms before, during and after working at the facility. The Administrator was informed the Immediate Jeopardy was removed on 12/15/21 at 3:15 p.m. The facility remained out of compliance at a severity level of the potential for more than minimal harm and a scope of a pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview, and record review, the facility failed to maintain an Infection Control Program designed to help prevent the transmission of disease and infection; maintain a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, and visitors; follow accepted national standards; follow a system of surveillance designed to identify possible communicable diseases or infections before they could spread to other persons in the facility; follow standard and transmission-based precautions to prevent spread of infections for 8 residents (Residents #65, #121, #22, #119, #269, #31, #49, and #30) of 69 residents reviewed for infection. 1. The facility failed to appropriately identify, track, and trend symptoms of spreading nausea, vomiting, and/or diarrhea symptoms to prevent further infection amongst residents. The first resident showed symptoms on 02/11/19. 2. The facility failed to contact the Health Department and follow CDC guidelines including placing residents in contact isolation, wearing appropriate PPE, performing hand hygiene, and cleaning/disinfecting surfaces with bleach cleansers after residents developed nausea, vomiting, and diarrhea that spread throughout the facility. As a result, the facility experienced a spread of nausea, vomiting, and/or diarrhea symptoms requiring medical intervention beginning on 02/11/19 that affected 26 residents and eight staff as of 02/23/19. An Immediate Jeopardy (IJ) was identified on 02/20/19. While the Immediate Jeopardy was removed on 02/22/19, the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy, and at a scope of pattern because the facility was still monitoring the Plan of Removal. These failures placed the residents residing in the facility at risk for the development of nausea, vomiting, and/or diarrhea symptoms and related complications including dehydration. Findings included: 1. Interview and observation on 02/20/19 at 9:40 AM of the A Hall secured unit revealed facility staff held open the door to allow entrance and an isolation personal protective equipment (PPE) cart was observed just inside the door on the right side of the hall. The Maintenance Assistant said the PPE was there for visitors who had cold symptoms to use when they entered the unit. Continued observation of A Hall secured unit revealed many residents were in the television room watching television as a group and no resident appeared to be ill or in any physical distress. A housekeeper was observed wearing gloves and a facemask. CNA Q was also observed wearing a face mask. Charge nurse LVN A was not wearing PPE, but the Activity Director was wearing a facemask. Interview with the DON and Infection Control Nurse on 02/20/18 at 9:53 AM related to A Hall isolation and PPE revealed the DON said the wing had a GI bug. She said all residents on A Hall were sick, and B Hall had three residents sick. She said G Hall also had one resident who was sick. The DON said they called the resident's Physicians and the Medical Director, and his PA. Orders were received to treat residents with symptoms of nausea, vomiting and diarrhea. She said the first resident became sick on 02/11/19. The Infection Control Nurse said she believed the illness was at the tail end, meaning the illness and spread was coming to an end. The DON said they did not call the Health Department because it was not indicated according to their guidelines. (A copy of the guidelines was requested but not provided.) The Infection Control Nurse said the Corporate Team was at the facility and had given them verbal guidance to control the infection. Interviews with B Hall LVN D on 02/22/19 at 1:18 PM revealed: CNA FF had reported Resident #47 was having symptoms on 02/13/19. The last day Resident #47 sick was 02/15/19. She exhibited nausea and vomiting, and a little later in the day, diarrhea. CNA FF reported to her that Resident #49 was ill and had at least three vomiting episodes and about four episodes of diarrhea. She said she also notified the Physician and received new orders for [MEDICATION NAME] for nausea and to monitor the resident. Resident #269 told her he was nauseated before becoming ill and vomiting after lunch on 02/15/19. He had an order for [REDACTED]. He had a roommate at the time of the nausea, but the roommate went home 02/15/19 before the vomiting began. He had at least two to three episodes of vomiting. He was medicated with [MEDICATION NAME]. It was reported to the DON and Physician. Resident #31 was ill on 02/14/19 thru 02/17/19. She said during walking rounds she noticed the resident was not doing well and Resident #31 said she had not been feeling well. Later, on Friday 02/15/19, Resident #31 vomited. The resident had two vomiting episodes and four diarrhea episodes during LVN D's shift. [MEDICATION NAME] PRN was given and a new order for [MEDICATION NAME] was received. The DON was notified and Resident #31 remained in her room, by herself. Interview with A Hall LVN F on 02/22/19 at 2:17 PM revealed Resident #31 was sick the previous week with nausea and vomiting but no diarrhea. LVN F said she believed the resident had two symptomatic episodes on her shift. The resident was given [MEDICATION NAME], PRN. LVN F informed the 6 PM - 2 PM nurse, LVN A, and followed up to ensure the resident's Physician was notified. Observation and interview on 02/20/19 at 9:50 AM of LVN R, Wound Care Nurse, at the nurse's station wearing a face mask and gloves revealed he said he was wearing PPE because the facility had a GI bug which infected four to five residents last week (02/10/19 - 02/16/19). He said the DON or Infection Control Nurse would know for sure who had been infected. Observation of a sign on the exit door on A Hall on 02/20/19 at 9:52 AM revealed: Visitation due to Identified Stomach Illness. Please Sanitize your Hands Upon Entering and Exiting. Please Use Universal Precautions During Your Visit. CDC Guidelines recommended contact isolation precautions, not universal precautions. PPE needed for contact isolation included gown, gloves, foot covers, and a face mask if splash or splatter was a risk. Observation on 02/20/19 at 12:00 PM of A Hall staff LVN A (charge nurse), CNA S, CNA Q, and the Activity Director revealed none of the staff were wearing any PPE. Two visitors were also observed wearing face masks only. Housekeeper P was also not wearing any PPE while on A Hall. Observation of Housekeeper P on 02/20/19 at 12:18 PM revealed she was not wearing any PPE and was exiting the A Hall. She stopped at the isolation cart, and with her bare hands, picked up and discarded the PPE trash by tying a knot in the plastic bag and placing the bag into the regular trash container. She then left the unit without performing hand hygiene. Observation of the Infection Control Nurse on 02/21/19 at 7:45 AM revealed she was picking glasses up from the top lip with bare hands and delivering them to residents, while also touching trays, and helping to feed residents. She did not perform hand hygiene procedures in-between residents. Interview with the Maintenance Director/Laundry Director on 02/20/19 at 1:45 PM revealed the staff had received in-servicing on the use of PPE prior to 02/20/19. 2. Review of Resident #65's MDS Assessment, dated 01/29/19, reflected he was a 71- year-old male, admitted to the facility on [DATE] with diagnoses which included [MEDICAL CONDITION] and [MEDICAL CONDITION] liver disease. Review of the facility's 24-Hour Report dated 02/11/19 - 02/20/19, reflected: 02/11/19 Resident #65 had nausea and vomiting. Resident #65 was the first resident to become ill. Review of the Infectious Disease Report, dated 02/11/19, reflected Resident #65's condition was GI Upset. Interview with the Infection Control Nurse on 02/20/19 at 9:00 AM revealed on 02/11/19, Resident #65 was the first resident that became sick with vomiting and diarrhea, and then soon after the infection spread to other residents. On 02/13/19 after the identified infection had spread to other residents and to facility staff, the facility checked the temperature of the water in the kitchen to make sure it was hot enough to disinfect the dishes, and it was. The facility put isolation carts in place outside of A Hall and just inside the entrance to A Hall. She said they told everyone to wear PPE upon entering the A Hall - shoe covers, gowns, gloves and face mask. They were told to perform hand sanitation after removing PPE for A Hall only. The Physicians were called, and the Medical Director's PA came in on 02/13/19 and wrote standing orders to treat symptoms for all residents on A Hall with [MEDICATION NAME] for nausea and vomiting, and [MEDICATION NAME] for diarrhea when they identified the infection was spreading. No [DIAGNOSES REDACTED]. Housekeeping was to clean with a general disinfectant room spray. The Infection Control Nurse said they did not check the CDC's guidelines related to the infection. A Hall residents were quarantined to the hall and all services were provided by staff in the resident's room. If a resident had to leave the hall, they had to wear a face mask. 3. Review of Resident #124's MDS Assessment, dated 11/28/18, reflected she was an [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included Non-Alzheimer's Dementia. Review of the facility's 24-Hour Report dated 02/11/19 - 02/20/19, reflected: 02/12/19 - Resident #124 vomited three times and had loose stools three times. 02/13/19 - Resident #124 had diarrhea five times and required PRN [MEDICATION NAME], Pepto-Bismol, and IV fluids. Resident #124 was the second resident to become ill. Review of the Infectious Disease Report, dated 02/12/19, reflected Resident #124 had GI Upset. Review of Resident #124's telephone physician orders, dated 02/13/19, reflected to start Peripheral IV. Give normal saline 75mL per hour. An order dated 02/13/19 was given for [MEDICATION NAME] 4mg for nausea and vomiting for fourteen days. 4. Review of Resident 119's MDS Assessment, dated 02/15/19, reflected she was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included [MEDICAL CONDITION]. Review of the facility's 24-Hour Report dated 2/11/19-2/20/19 reflected: 02/12/19 - Resident #119 vomited four times, had diarrhea, and required [MEDICATION NAME]. 02/13/19 - Resident # 119 had nausea requiring [MEDICATION NAME]. 02/14/09 - Resident # 119 vomited twice and required [MEDICATION NAME]. 02/15/19 - Resident # 119 vomited seven times and required IV fluids, [MEDICATION NAME] rectal suppository, and [MEDICATION NAME]. Resident #119 was the third resident to become ill and the facility should have contacted the health department per CDC guidelines. Review of Resident #119's Physician orders, dated 02/12/19, reflected [MEDICATION NAME] 4mg orally as needed as every four hours and [MEDICATION NAME] 2mg orally. 5. Review of Resident #22's MDS Assessment, dated 01/22/19, reflected she was an [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included [MEDICAL CONDITION] and [MEDICAL CONDITION]. Resident #22's Care Plan dated 07/18/14 reflected a focused area identifying her at risk for dehydration related to use of diuretic. Goals - Will have no signs or symptoms of dehydration through next review. Approaches included: Encourage fluids during and between meals. Monitor for signs and symptoms of dehydration and repot abnormal finding to physician. Review of the facility's 24-Hour Report dated 2/11/19-2/20/19 reflected: 02/12/19 - Resident #22 had six episodes of diarrhea and nausea. 02/13/19 - Resident #22 required IV fluids and [MEDICATION NAME] Review of Resident #22's Physician telephone orders, dated 02/13/19, reflected: insert a peripheral IV and administer ½ Normal Saline at 75 cc/hr. for 24 hours. Hold [MEDICATION NAME] for three days. [MEDICATION NAME] 4 mg PRN and Pepto PRN nausea. Review of Infectious Disease Report dated 02/12/19 reflected on 02/12/19 Resident #22 had onset of GI Upset. 6. Review of Resident #64's MDS Assessment, dated 01/29/19, reflected he was a [AGE] year-old male, admitted to the facility on -7/30/18 with diagnoses which included depression and spinal stenosis. Review of the facility's 24-Hour Report dated 2/11/19-2/20/19 reflected: Friday (missing date and wing) A Hall. Resident #64 had diarrhea, was placed on contact precautions, and an order for [REDACTED].>Review of the Infectious Disease Report, dated 02/13/19, reflected Resident #64 had GI Upset. 7. Review of Resident #30's MDS Assessment, dated 01/22/19, reflected she was an [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included [MEDICAL CONDITION] and diabetes. Review of Resident #30's Care Plan, dated 02/21/19, reflected the resident had a bowel elimination problem as evidenced by diarrhea related to other contact isolation pre-protocol. The approaches for this problem included: contact isolation, report changes to physician, and observe the resident for bowel movement status and dehydration. Review of the facility's 24-Hour Report dated 2/11/19-2/20/19 reflected: 02/20/19 - Resident #30 placed in isolation for diarrhea and received a new order to have a stool culture collected. Review of Resident #30's Physician telephone orders, dated 02/20/19, reflected to place the resident on isolation, hold orders for stool softeners or laxatives for four days, and start Pepto Bismol. An order to obtain a stool culture with white blood cell count dated 02/20/19 was also made. Review of Resident #30's progress notes, dated 02/21/19, reflected a late entry was made from 02/20/19 on the 2:00 PM to 10:00 PM shift that the resident was transferred to a different room for contact isolation due to loose stools. A new order was received to collect a stool culture. The stool culture was collected and refrigerated for the lab to pick it up. Observation on 02/20/19 at 12:00 PM revealed Resident #30 in her room on E Hall. She was non-interviewable and was receiving tube feeding. The room smelled of feces. Interview with the DON on 02/19/19 at 3:15 PM revealed she was told Resident #30 on E Hall was identified with diarrhea on 02/19/19. Observation of RN N coming out of Resident #30's room on E Hall on 02/21/19 at 11:30 AM revealed the RN exited the resident's room with booties still covering her shoes. RN N walked down the hallway to the dining room without removing the booties. Interview with the DON on 02/20/19 at 3:15 PM revealed one resident, Resident #30, on E Hall was identified with symptoms that afternoon (02/20/19). One resident on the male secured unit was also identified that morning. Interview with E Hall nurse, RN N, on 02/23/19 at 10:03 AM revealed there was one resident on isolation at that time. Resident #30 became sick on 02/20/19; she had loose stools. The CNA had reported the loose stools. The resident had one episode of diarrhea on my RN N's shift around 1:00 p.m. Resident #30 was in her room, on a feeding pump. The resident was in bed and her linens and clothing were soiled. RN N spoke to the PA who told her to place the resident on contact isolation precautions. The PA told RN N to hold Resident #30's stool softener, give her Pepto, and [MEDICATION NAME] if vomiting. The resident never vomited. RN N said she did not give the resident any Pepto. She said she did not medicate the resident at all Wednesday 02/20/19 for her symptoms. She said the PA did not give her orders to give the resident extra water. She said the staff monitored the resident closely. The 2:00 PM - 10:00 PM shift collected the resident's stool and got lab work done. RN N said she documented the lab collection on the 24-hour report. She said she could not remember what she had documented in the progress notes for the resident. 8. Review of Resident #121's MDS Assessment, dated 02/16/19, reflected he was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses which included hypertension and [MEDICATION NAME] degeneration. Review of Resident #121's care plan, dated 02/21/19, reflected the resident had a bowel elimination problem as evidences by diarrhea relating to other contact isolation per protocol. The intervention for the problem included: contact isolation per protocol, report changes to physician, and observe bowel movements and signs of dehydration. Review of Resident #121's Physician orders, dated 02/20/19, reflected the resident was to be on contact isolation and have a stool culture with white blood cell count. Review of Resident #121's progress notes, dated 02/16/19, reflected the resident said he had loose stools and nausea during the night shift. Progress notes dated 02/20/19 for Resident #121 reflected new orders to collect a stool sample for a stool culture and the resident remained on contact isolation due to diarrhea. Progress note dated 02/21/19 for Resident #121 reflected the resident was assessed for GI upset and the resident stated on 02/19/19 he had some light diarrhea. Observation on 02/20/19 at 9:45 AM revealed Resident #121 in his room, lying in bed. The resident said the facility failed to provide appropriate care and treatment for [REDACTED]. He said women were coming into his room to use the bathroom because the facility failed to clean the diarrhea from other resident's rooms. He said he had no idea why they were coming into his room to use his bathroom. 9. Review of Resident #51's MDS Assessment, dated 01/11/19, reflected he was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses which included [MEDICAL CONDITION] and depression. Review of Resident #51's care plan, dated 02/21/19, reflected the resident had a bowel elimination problem as evidenced by diarrhea relating to nausea and vomiting and contact isolation. The intervention for this problem was contact isolation per protocol, notify physician, and observe bowel movement status and dehydration. Review of the facility's 24-Hour Report dated 2/11/19-2/20/19 reflected: 02/20/19 - Resident #51 had vomiting. Review of Resident #51's telephone physician orders, dated 02/20/19, reflected contact isolation. Review of Resident #51's progress notes, dated 02/20/19, reflected new orders to place the resident on contact isolation for stomach infection. New orders for lab stool culture and hold [MEDICATION NAME] and laxatives for four days. Give [MEDICATION NAME] 12.5mg as needed for nausea and vomiting. Interview with the Infection control nurse on 02/20/19 at 1:20 PM revealed she had just received a report that Resident #51 had vomited at that time and PPE was placed outside of the resident's room. Observation on 02/21/19 at 7:28 AM revealed Resident #51 was sitting in the doorway of the room. There was no sign posted for contact isolation. CNA GG asked the resident to go back in the room and pushed the resident's wheelchair back. She did not wash her hands or use any personal sanitizer after handling the resident's wheelchair. A few minutes later at 7:33 AM, the resident wheeled to the nurses' station by his room and grabbed a tissue from a communal box. At that time, CNA GG came back and told him he could not be out of his room and pushed him back in his room. She did not use any PPE before she touched his wheelchair. CNA GG did not wash her hands after she touched the wheelchair. Observation on 02/21/19 at 7:42 AM revealed CNA GG put on PPE equipment and went into Resident #51's room to give them their meal tray. When she left the room, she did not wash or sanitize her hands as there was no sanitizer on the isolation cart. She proceeded to go and help serve breakfast in the dining area with residents who were not sick without completing hand hygiene procedures. A telephone interview with Resident #51's responsible party on 02/21/19 at 1:22 PM revealed she was told by the facility that Resident #51 had a stomach bug, but she was not told more residents in the facility had become symptomatic or that families should take precautions when visiting. She said she was going visit the facility on Tuesday (02/19/19), but she was glad she had not. She said she would not visit the facility for a few days until the symptoms were gone. She said she was not told needed to wear gloves or mask when came to facility. 10. Interview with the PA for the Medical Director on 2/20/19 at 4:08 PM revealed she was contacted by the facility and notified of the spread of resident symptoms after approximately 10 residents became ill. She believed the illness was a rapidly spreading virus because the symptoms resolved quickly, and the infection was contained to A Hall. She said she considered the origin may have been from food, but because the infection was contained to A Hall, that was ruled out. Review of the Facility's 24-hour reports revealed the infection was not isolated to the A Hall. 11. Interview with LVN A on 02/20/19 at 12:10 PM revealed she became ill with GI symptoms on Tuesday, 02/12/19 and went home sick. She said she was sick through Friday 02/15/19 and she returned to work on Monday (02/18/19) without receiving clearance to return to work. Interview with CNA S on 02/20/19 at 12:13 PM revealed she got sick with GI symptoms on unknown date and the infection spread to her family. Interview with CNA Q on 02/20/19 at 12:15 PM revealed she had been sick with nausea, vomiting and diarrhea, and the infection spread to her family. Interview with A Hall CNA S on 02/22/19 at 9:23 AM revealed she got sick at the end of the shift on 02/13/19 with symptoms of nausea and diarrhea. None of her family got sick. She said she had worked with Resident #17 prior to getting sick and had to provide incontinence care for the resident multiple times. On 02/13/19, CNA S said she had to assist Resident #17 with incontinence care several times because the resident had diarrhea. The CNA said she notified the nurse and wore PPE when changing the resident. CNA S said the Charge Nurse told her several residents had diarrhea and some were vomiting. They did not tell her how the bug was spread. The CNA said the staff were provided in-services saying they were supposed to wear gloves, masks, gowns, and booties, take the gown and gloves and booties off before walking out the door and wash hands, then take mask off and put it in the trash on the way out the door prior to 02/20/19. Interview with A Hall CNA DD on 02/22/19 at 9:36 AM revealed she called in on 02/13/19 because her daughter was vomiting, and she thought it came from school. She said the staff were serving everyone meals in their rooms and on plastic flatware. Trays were being left in the hallways. CNA DD said she did not use hand sanitizer gel because she had an allergy to it. She said she washed her hands in and out of the room. CNA DD said staff had received in-services prior to 02/20/19 that included: when entering a contact isolation room staff were supposed to use gowns, mask, gloves, and shoe covers. She said when exiting the room, she took off the gown first, then mask, then gloves. Interview with PT CC on 02/22/19 at 9:10 AM revealed she had gotten sick on 02/14/19. Her signs and symptoms were nausea and vomiting and stomach cramps. She was off 02/15/19, 02/16/19, and 02/20/19. She did not get medical clearance prior to returning to work. Interview with A Hall LVN A on 02/22/19 at 10:04 AM revealed she said first had symptoms of nausea and vomiting on 02/14/19. She was sick on 02/14/19 and 02/15/19. Then, around 3:00 PM on 02/15/19 was the last time she had a symptomatic episode. No one in her family got ill. Interview with the Activity Director on 02/22/19 at 10:23AM revealed she got sick on Valentine's day in the afternoon. She went home on 02/14/19 with symptoms of vomiting and diarrhea. She stayed home 02/15/19, 02/16/19 and 02/20/19. She denied she had fever. Nobody in her family got sick. She said she worked on A Hall on 02/13/19 and 02/14/19 and there were quite a few residents out of their rooms doing activities, mostly in the TV room. On 02/14/19 in the morning, the Activity Director said she was told they were not to take residents from B Hall to A Hall. At that time, she had four residents in day room doing exercises and playing trivia. Most of the sick residents were sleeping. She said she was going to have activity in the afternoon on Valentine's Day, but she cancelled it. About 2:30 PM she had a grumble in her stomach and went home around 3:30 PM. Interview with on 02/22/19 at 11:17 AM with PTA EE revealed he started having symptoms Thursday 02/14/19. He said he was told to stay home. He said he had diarrhea on 02/14/19, 02/15/19, and 02/16/19. Interview with OT BB on 02/22/19 at 10:46 AM revealed she got sick on 02/14/19. That was the only that night she was sick and she stayed home 02/15/19. Her symptoms were nausea, diarrhea and fatigue. Interview with E Hall LVN X on 02/22/19 at 10:31 AM revealed the day shift nurse, LVN I, had been vomiting at 10:31 AM that day and called off. She was off the day prior as well (02/21/19). Interview with the DON and Infection Control Nurse on 02/22/19 at 10:44 AM revealed LVN I went out (left work) on 02/20/19 with similar symptoms to the residents. She said she was not put on the list of staff that had become infected. Staff who had signs/symptoms of nausea, vomiting and/or diarrhea did not receive a diagnosis. The Infection Control Nurse said the facility's policy was, if a staff member was out for more than three days due to illness they were supposed to have medical clearance to come back to work. There was no evidence to indicate staff waited for at least 2 days (48 hours) after symptoms stopped before returning to work per CDC guidelines. 12. Interview with the Epidemiologist from the Public Health Department on 02/21/19 at 4:53 PM revealed she said she was off work 02/20/19 but she did have missed phone calls from the facility on 02/20/19. She spoke with the facility on 02/21/19 and gave the facility the main number and her direct number when she returned their call. She said the facility should have called the Health Department when they identified the problem, which should be when there are three cases of an unusual disease. She said she explained that information to the DON and the corporate nurse. She said the facility had about an 80% infection rate on the locked unit and about a 15% infection rate on other units. The Epidemiologist said when the spread of an infection starts, the facility should start contacting family, and they should follow isolation precautions. She said they should be [MEDICATION NAME] handwashing and they should not be visiting with other staff. She said they did not require an order to do testing, but that the facility should let the Medical Director know the Health Department visited so he would understand what the process was. The Epidemiologist recommended the facility clean resident rooms twice a day, every high touch surface, hand rails, and light switches. She said bleach was fine to use and was great for Norovirus, but the facility had been using Lysol instead of bleach. She recommended to maintain contact isolation when the bathroom was not at the front door, and staff and visitors could remove PPE and wash their hands in the restroom in resident's rooms. She said the facility should keep an isolation bin at the doorway for paper towels used for drying hands and opening the door. She also said they needed to have hand sanitizer at the door or immediately at the PPE cart. She asked the facility to check the PPE carts every shift as she did not want them to go into the room and find they were missing items. They were supposed to sign off that they were checked. Dining was also to be done with disposable flatware and additional fluids should be at the bedside. She suggested residents who were symptomatic stay in rooms and get electrolyte replacement. The Epidemiologist said the facility should have a contact isolation sign on the door instead of see nurses' station and activities should not be done until she could meet with the facility the following Monday (02/25/19). The facility did not stop their activities program when symptoms were identified and were taking residents from B hall to A hall activities. The Epidemiologist said if the facility went 72 hours with no new onset of symptoms, then there could be a discussion of resuming activities. She said she would suggest not admitting anyone new to the secured units and to cohort staff with the units. She said the plan going forward was to have a conversation the next day (02/22/19) and Monday (02/25/19). On 02/22/19, they would learn about the next 12 hours. They also needed to run stool test and were supposed to notify the Epidemiologist when they had a sample. Review of the Health Department line listing (A line listing allows information about time, person, and place to be organized and reviewed quickly during an outbreak investigation) for residents reflected: 02/11/19 - Resident #65 developed nausea and vomiting 02/12/19 - Resident #124 developed nausea, vomiting, and diarrhea 02/12/19 - Resident #119 developed nausea and vomiting 02/12/18 - Resident #22 developed vomiting 02/13/19 - Resident #64 developed nausea and vomiting 02/13/19 - Resident #47 developed vomiting 02/14/19 - Resident #269 developed nausea and vomiting 02/14/19 - Resident #31 developed nausea and vomiting 02/15/19 - Resident #49 developed nausea, vomiting, and diarrhea 02/19/19 - Resident #30 developed diarrhea 02/20/19 - Resident #121 developed diarrhea 02/20/19 - Resident #51 developed vomiting Review of the local Public Health Department's policy Control Measures for Facilities Experiencing an Increased Number of Patients with Gastrointestinal (GI) Illness, undated, reflected: .All disease in unusual numbers is required to be reported to a local health department immediately Cancel group activities until 48 hours after the last person illness has stopped by no longer exhibit diarrhea and vomiting. Meal should be eaten in patients' rooms and not the dining room until 48 hours after the last person illness has stopped by no longer exhibit diarrhea and vomiting. Disposable plates, cups, and utensils should be provided for meals. Encourage ill resident movement to respective room until 48 hours after symptoms have ended Post a sign on the front door alerting people to the symptom's patients are experiencing. Where possible separate staff who are caring for ill residents versus those caring for non-ill residents Housekeeping staff cleaning after ill patients should use contact precautions including gloves, gowns, and face masks The CDC Guideline for Norovirus, updated 06/01/18 and retrieved on 03/05/19, reflected the following from https://www.cdc.gov/norovirus/: People with norovirus illness can shed billions of norovirus particles. And only a few virus particles can make other people sick. You can get norovirus from having person, consuming contaminated food or water or touching contaminated surfaces and putting you unwashed hands in your mouth. Norovirus Symptoms The most common symptoms include nausea, vomiting, diarrhea and stomach pain. Wash your hands thoroughly with soap and water, especially after using the toilet or changing diapers, always before eating, preparing, or handling food, and before giving yourself or someone else medicine. Norovirus can be found in your vomit or poop even before you start feeling sick. [MEDICAL CONDITION] can stay in your poop for 2 weeks or more after you feel better. It is important to continue washing your hands often during this time. You can use alcohol-based hand sanitizers in addition to hand washing. But, you should not us

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 needs of each resident for one (Resident #169) of 17 residents reviewed pharmacy services. 1. Nursing staff failed to ensure Resident #169 did not run out of her Xarelto (blood thinner), and did not ensure it was reordered and received timely once it was noticed to be out. 2. LVN HH and LVN II failed to contact the physician when Resident #169 ran out of her Xarelto (blood thinner) from [DATE] through [DATE], per facility policy. As a result, Resident #169 was transported to the hospital on [DATE] due to a change in condition. The resident was in [MEDICAL CONDITION] and was diagnosed with [REDACTED]. Resident #169 expired on [DATE]. An Immediate Jeopardy (IJ) was identified to have occurred from [DATE] to [DATE]. This was determined to be past Immediate Jeopardy due to the facility having implemented action that lowered the immediacy to potential for harm at a pattern of isolated prior to the investigation. These failures placed residents at risk for not receiving the necessary medications to treat their specific condition or diagnoses. Findings included: Review of Resident #169's MDS assessment dated [DATE], revealed the resident was an [AGE] year-old female admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Review of Resident #169's care plan dated [DATE] reflected the resident was at risk for abnormal bleeding or hemorrhage because of anticoagulation usage related to Xarelto. Approaches included to administer medications, labs, and treatments as ordered. Review of Resident #169's undated monthly physician orders [REDACTED]. Review of Resident #169's (MONTH) (YEAR) MAR revealed she was taking Xarelto 15mg tablet by mouth daily as ordered until [DATE]. The MAR further reflected the Xarelto was not administered on [DATE] and [DATE] through [DATE]. The remarks on the back of the MAR dated [DATE] and initialed by LVN HH reflected the following, 8AM Xarelto not available. Review of Resident #169's progress notes dated [DATE] at 11:18 PM revealed the following: .Res (resident) eyes fixed to the right showing right sided weakness and unable to answer question. This nurse assisted in preparing to sent (sic) res out to EMS for evaluation and treatment. Review of Resident #169's hospital records dated [DATE] revealed the following: .Assessment and Plan Acute right middle cerebral artery stroke Acute occlusion of the M1 segment of the right middle cerebral artery [MEDICAL CONDITION] Fibrillation -Etiology is cardioembolic due to being off anticoagulation x4 days prior to presentation . Review of information on embolic [MEDICAL CONDITION], obtained on [DATE] from https://www.hopkinsmedicine.org/healthlibrary/conditions/nervous_system_disorders/types_of_stroke_85,p reflected, Embolic [MEDICAL CONDITION] are usually caused by a blood clot that forms elsewhere in the body ([MEDICAL CONDITION]) and travels through the bloodstream to the brain. Embolic [MEDICAL CONDITION] often result from [MEDICAL CONDITION] or heart surgery and occur rapidly and without any warning signs. About 15% of embolic [MEDICAL CONDITION] occur in people with [MEDICAL CONDITION], a type of abnormal heart rhythm in which the upper chambers of the heart do not beat effectively. Interview on [DATE] at 3:47 PM with LVN II revealed Resident #169 did not have Xarelto on [DATE] so she called the pharmacy Friday and Saturday ([DATE] and [DATE]) to refill the medication but it never arrived. LVN BB also stated she did not contact anyone, including the physician, to let them know Resident #169 had run out of Xarelto, stating she did not know she was supposed to. Interview on [DATE] at 10:05 AM with LVN HH revealed the protocol regarding a resident running out of medication included checking the E-kit first to see if the medication is available, calling the family to see if they have the medication at home, and call the DON and the physician. LVN HH further stated she did not recall details of Resident #169 running out of medications. Interview on [DATE] at 2:41 PM with the DON revealed she was called about Resident #169 being sent to the hospital due to having stroke like symptoms. She then went through the resident's clinical record and she came across the resident's MAR and noticed there were some missed doses of Xarelto. The DON interviewed LVN HH, who said Resident #169 did not have any on [DATE], therefore it was not given. LVN HH said she found the medication the next day, [DATE], and it was administered then. She then interviewed LVN II who stated Resident #169 did not have Xarelto on Friday, [DATE], and said she had called the pharmacy both Friday and Saturday ([DATE] and [DATE]), but the medication never arrived. The DON further stated she began a medication audit to make sure all medications were in the building and accounted for. Both LVN HH and LVN II received write-ups and in-services as a result of the missed medications. Interview on [DATE] at 3:02 PM with a Pharmacy Manager revealed the facility received a Xarelto prescription for Resident #169 on [DATE] at 9:55 PM and the refill only contained 15 pills. He did not have documentation in their system of the facility calling in for more refills. Interview with Physician JJ on [DATE] at 3:57 PM revealed Resident #169 had many comorbidities and was a high-risk patient. He stated the resident missing Xarelto doses possibly contributed to the stroke she had. He went on to say Xarelto was a high-risk medication and very important, and someone should have reached out to him when Resident #169 ran out due to its significance. Interview on [DATE] at 1:00 PM with Resident #169's family member revealed the resident was sent to the hospital from the facility due to a change in condition. Once the family member was at the hospital, they were told the hospital had not found any traces of blood thinner in the resident's system. The family then called the facility and spoke with the DON who said the resident had gone four days without the blood thinner, and they were currently doing a medication audit to try and fix the problem. Resident #169 was put on hospice services and died on [DATE]. Review of in-service records revealed nursing staff had received in-service training on [DATE] regarding unavailable medications/extended refusals or holds and notification of physician due to unavailable or missed medications. The in-service further reflected LVN HH was present and signed the in-service sheet. Review of the website www.xarelto-us.com, for healthcare professionals, accessed on [DATE], reflected: Increased risk of blood clots if you stop taking Xarelto .People with [MEDICAL CONDITION] (an irregular heart beat) that is not caused by a heart valve problem (nonvalvular) are at an increased risk of forming a blood clot in the heart, which can travel to the brain, causing a stroke, or to other parts of the body. .Premature discontinuation of any oral anticoagulant, including Xarelto, increases the risk of [MEDICAL CONDITION] events. If anticoagulation with Xarelto is discontinued for a reason other than pathological bleeding or completion of a course of therapy, consider coverage with another anticoagulant. Review of the facility's current policy for medication administration revised (MONTH) 2004 reflected the following: Standard All medications are administered safely and appropriately to help residents overcome illness, relieve/prevent symptoms, and help in [DIAGNOSES REDACTED]. If medication is ordered but not present: a. Check other resident drawers to see if it was placed in the wrong drawer b. call the pharmacy or supervisor to obtain the medication .Other documentation may include: Notification of physician. Review of the facility's current policy titled Anticoagulation/[MEDICATION NAME] Drug Meeting dated [DATE] reflected the following: Policy Residents receiving anticoagulation therapy are reviewed to ensure correct dosage and adequate monitoring. .4. Review the MAR for the previous day's anticoagulant order to ensure the anticoagulant was administered or held per physician order. The facility took the following actions to correct the non-compliance prior to the investigation: Review of in-services records revealed both LVN HH and LVN II received one on one education on [DATE] regarding abuse/neglect, resident rights, anticoagulant use, medication ordering procedures, medication administration; and on [DATE] they were in-serviced on notification of physician for refusal of, or unavailable medications. Further review of the in-services reflected all nursing staff were trained on [DATE] on holding medications due to medication not being available and notification of the physician for refusal of/or unavailability of medication on [DATE]. Review of a medication review skills check off from [DATE] through [DATE] reflected all nursing staff had been cleared on [DATE].

Based on observation, interview and record review, the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's condition or a need to alter treatment significantly for one (Resident #169) of 17 residents reviewed for physician consultation. 1. Nursing staff failed to ensure Resident #169 did not run out of her Xarelto (blood thinner), and did not ensure it was reordered and received timely once it was noticed to be out. 2. LVN HH and LVN II failed to contact the physician when Resident #169 ran out of her Xarelto (blood thinner) from [DATE] through [DATE], per facility policy. As a result, Resident #169 was transported to the hospital on [DATE] due to a change in condition. The resident was in [MEDICAL CONDITION] and was diagnosed with [REDACTED]. Resident #169 expired on [DATE]. An Immediate Jeopardy (IJ) was identified to have occurred from [DATE] to [DATE]. This was determined to be past Immediate Jeopardy due to the facility having implemented action that lowered the immediacy to potential for harm at a pattern of isolated prior to the investigation. These failures placed residents at risk for not receiving the necessary medications to treat their specific condition or diagnoses. Findings included: Review of Resident #169's MDS assessment dated [DATE], revealed the resident was an [AGE] year-old female admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Review of Resident #169's care plan dated [DATE] reflected the resident was at risk for abnormal bleeding or hemorrhage because of anticoagulation usage related to Xarelto. Approaches included to administer medications, labs, and treatments as ordered. Review of Resident #169's undated monthly physician orders [REDACTED]. Review of Resident #169's (MONTH) (YEAR) MAR revealed she was taking Xarelto 15mg tablet by mouth daily as ordered until [DATE]. The MAR further reflected the Xarelto was not administered on [DATE] and [DATE] through [DATE]. The remarks on the back of the MAR dated [DATE] and initialed by LVN HH reflected the following, 8AM Xarelto not available. Review of Resident #169's progress notes dated [DATE] at 11:18 PM revealed the following: .Res (resident) eyes fixed to the right showing right sided weakness and unable to answer question. This nurse assisted in preparing to sent (sic) res out to EMS for evaluation and treatment. Review of Resident #169's hospital records dated [DATE] revealed the following: .Assessment and Plan Acute right middle cerebral artery stroke Acute occlusion of the M1 segment of the right middle cerebral artery [MEDICAL CONDITION] Fibrillation -Etiology is cardioembolic due to being off anticoagulation x4 days prior to presentation . Review of information on embolic [MEDICAL CONDITION], obtained on [DATE] from https://www.hopkinsmedicine.org/healthlibrary/conditions/nervous_system_disorders/types_of_stroke_85,p reflected, Embolic [MEDICAL CONDITION] are usually caused by a blood clot that forms elsewhere in the body ([MEDICAL CONDITION]) and travels through the bloodstream to the brain. Embolic [MEDICAL CONDITION] often result from [MEDICAL CONDITION] or heart surgery and occur rapidly and without any warning signs. About 15% of embolic [MEDICAL CONDITION] occur in people with [MEDICAL CONDITION], a type of abnormal heart rhythm in which the upper chambers of the heart do not beat effectively. Interview on [DATE] at 3:47 PM with LVN II revealed Resident #169 did not have Xarelto on [DATE] so she called the pharmacy Friday and Saturday ([DATE] and [DATE]) to refill the medication but it never arrived. LVN BB also stated she did not contact anyone, including the physician, to let them know Resident #169 had run out of Xarelto, stating she did not know she was supposed to. Interview on [DATE] at 10:05 AM with LVN HH revealed the protocol regarding a resident running out of medication included checking the E-kit first to see if the medication is available, calling the family to see if they have the medication at home, and call the DON and the physician. LVN HH further stated she did not recall details of Resident #169 running out of medications. Interview on [DATE] at 2:41 PM with the DON revealed she was called about Resident #169 being sent to the hospital due to having stroke like symptoms. She then went through the resident's clinical record and she came across the resident's MAR and noticed there were some missed doses of Xarelto. The DON interviewed LVN HH, who said Resident #169 did not have any on [DATE], therefore it was not given. LVN HH said she found the medication the next day, [DATE], and it was administered then. She then interviewed LVN II who stated Resident #169 did not have Xarelto on Friday, [DATE], and said she had called the pharmacy both Friday and Saturday ([DATE] and [DATE]), but the medication never arrived. The DON further stated she began a medication audit to make sure all medications were in the building and accounted for. Both LVN HH and LVN II received write-ups and in-services as a result of the missed medications. Interview on [DATE] at 3:02 PM with a Pharmacy Manager revealed the facility received a Xarelto prescription for Resident #169 on [DATE] at 9:55 PM and the refill only contained 15 pills. He did not have documentation in their system of the facility calling in for more refills. Interview with Physician JJ on [DATE] at 3:57 PM revealed Resident #169 had many comorbidities and was a high-risk patient. He stated the resident missing Xarelto doses possibly contributed to the stroke she had. He went on to say Xarelto was a high-risk medication and very important, and someone should have reached out to him when Resident #169 ran out due to its significance. Interview on [DATE] at 1:00 PM with Resident #169's family member revealed the resident was sent to the hospital from the facility due to a change in condition. Once the family member was at the hospital, they were told the hospital had not found any traces of blood thinner in the resident's system. The family then called the facility and spoke with the DON who said the resident had gone four days without the blood thinner, and they were currently doing a medication audit to try and fix the problem. Resident #169 was put on hospice services and died on [DATE]. Review of in-service records revealed nursing staff had received in-service training on [DATE] regarding unavailable medications/extended refusals or holds and notification of physician due to unavailable or missed medications. The in-service further reflected LVN HH was present and signed the in-service sheet. Review of the website www.xarelto-us.com, for healthcare professionals, accessed on [DATE], reflected: Increased risk of blood clots if you stop taking Xarelto .People with [MEDICAL CONDITION] (an irregular heart beat) that is not caused by a heart valve problem (nonvalvular) are at an increased risk of forming a blood clot in the heart, which can travel to the brain, causing a stroke, or to other parts of the body. .Premature discontinuation of any oral anticoagulant, including Xarelto, increases the risk of [MEDICAL CONDITION] events. If anticoagulation with Xarelto is discontinued for a reason other than pathological bleeding or completion of a course of therapy, consider coverage with another anticoagulant. Review of the facility's current policy for medication administration revised (MONTH) 2004 reflected the following: Standard All medications are administered safely and appropriately to help residents overcome illness, relieve/prevent symptoms, and help in [DIAGNOSES REDACTED]. If medication is ordered but not present: a. Check other resident drawers to see if it was placed in the wrong drawer b. call the pharmacy or supervisor to obtain the medication .Other documentation may include: Notification of physician. Review of the facility's current policy titled Anticoagulation/[MEDICATION NAME] Drug Meeting dated [DATE] reflected the following: Policy Residents receiving anticoagulation therapy are reviewed to ensure correct dosage and adequate monitoring. .4. Review the MAR for the previous day's anticoagulant order to ensure the anticoagulant was administered or held per physician order. The facility took the following actions to correct the non-compliance prior to the investigation: Review of in-services records revealed both LVN HH and LVN II received one on one education on [DATE] regarding abuse/neglect, resident rights, anticoagulant use, medication ordering procedures, medication administration; and on [DATE] they were in-serviced on notification of physician for refusal of, or unavailable medications. Further review of the in-services reflected all nursing staff were trained on [DATE] on holding medications due to medication not being available and notification of the physician for refusal of/or unavailability of medication on [DATE]. Review of a medication review skills check off from [DATE] through [DATE] reflected all nursing staff had been cleared on [DATE].

Based on observation, interview, and record review, the facility failed ensure residents were free of any significant medication errors for one (Resident #169) of 17 residents reviewed for medications. 1. Nursing staff failed to ensure Resident #169 did not run out of her Xarelto (blood thinner), and did not ensure it was reordered and received timely once it was noticed to be out. 2. LVN HH and LVN II failed to contact the physician when Resident #169 ran out of her Xarelto (blood thinner) from [DATE] through [DATE], per facility policy. As a result, Resident #169 was transported to the hospital on [DATE] due to a change in condition. The resident was in [MEDICAL CONDITION] and was diagnosed with [REDACTED]. Resident #169 expired on [DATE]. An Immediate Jeopardy (IJ) was identified to have occurred from [DATE] to [DATE]. This was determined to be past Immediate Jeopardy due to the facility having implemented action that lowered the immediacy to potential for harm at a pattern of isolated prior to the investigation. These failures placed residents at risk for not receiving the necessary medications to treat their specific condition or diagnoses. Findings included: Review of Resident #169's MDS assessment dated [DATE], revealed the resident was an [AGE] year-old female admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Review of Resident #169's care plan dated [DATE] reflected the resident was at risk for abnormal bleeding or hemorrhage because of anticoagulation usage related to Xarelto. Approaches included to administer medications, labs, and treatments as ordered. Review of Resident #169's undated monthly physician orders [REDACTED]. Review of Resident #169's (MONTH) (YEAR) MAR revealed she was taking Xarelto 15mg tablet by mouth daily as ordered until [DATE]. The MAR further reflected the Xarelto was not administered on [DATE] and [DATE] through [DATE]. The remarks on the back of the MAR dated [DATE] and initialed by LVN HH reflected the following, 8AM Xarelto not available. Review of Resident #169's progress notes dated [DATE] at 11:18 PM revealed the following: .Res (resident) eyes fixed to the right showing right sided weakness and unable to answer question. This nurse assisted in preparing to sent (sic) res out to EMS for evaluation and treatment. Review of Resident #169's hospital records dated [DATE] revealed the following: .Assessment and Plan Acute right middle cerebral artery stroke Acute occlusion of the M1 segment of the right middle cerebral artery [MEDICAL CONDITION] Fibrillation -Etiology is cardioembolic due to being off anticoagulation x4 days prior to presentation . Review of information on embolic [MEDICAL CONDITION], obtained on [DATE] from https://www.hopkinsmedicine.org/healthlibrary/conditions/nervous_system_disorders/types_of_stroke_85,p reflected, Embolic [MEDICAL CONDITION] are usually caused by a blood clot that forms elsewhere in the body ([MEDICAL CONDITION]) and travels through the bloodstream to the brain. Embolic [MEDICAL CONDITION] often result from [MEDICAL CONDITION] or heart surgery and occur rapidly and without any warning signs. About 15% of embolic [MEDICAL CONDITION] occur in people with [MEDICAL CONDITION], a type of abnormal heart rhythm in which the upper chambers of the heart do not beat effectively. Interview on [DATE] at 3:47 PM with LVN II revealed Resident #169 did not have Xarelto on [DATE] so she called the pharmacy Friday and Saturday ([DATE] and [DATE]) to refill the medication but it never arrived. LVN BB also stated she did not contact anyone, including the physician, to let them know Resident #169 had run out of Xarelto, stating she did not know she was supposed to. Interview on [DATE] at 10:05 AM with LVN HH revealed the protocol regarding a resident running out of medication included checking the E-kit first to see if the medication is available, calling the family to see if they have the medication at home, and call the DON and the physician. LVN HH further stated she did not recall details of Resident #169 running out of medications. Interview on [DATE] at 2:41 PM with the DON revealed she was called about Resident #169 being sent to the hospital due to having stroke like symptoms. She then went through the resident's clinical record and she came across the resident's MAR and noticed there were some missed doses of Xarelto. The DON interviewed LVN HH, who said Resident #169 did not have any on [DATE], therefore it was not given. LVN HH said she found the medication the next day, [DATE], and it was administered then. She then interviewed LVN II who stated Resident #169 did not have Xarelto on Friday, [DATE], and said she had called the pharmacy both Friday and Saturday ([DATE] and [DATE]), but the medication never arrived. The DON further stated she began a medication audit to make sure all medications were in the building and accounted for. Both LVN HH and LVN II received write-ups and in-services as a result of the missed medications. Interview on [DATE] at 3:02 PM with a Pharmacy Manager revealed the facility received a Xarelto prescription for Resident #169 on [DATE] at 9:55 PM and the refill only contained 15 pills. He did not have documentation in their system of the facility calling in for more refills. Interview with Physician JJ on [DATE] at 3:57 PM revealed Resident #169 had many comorbidities and was a high-risk patient. He stated the resident missing Xarelto doses possibly contributed to the stroke she had. He went on to say Xarelto was a high-risk medication and very important, and someone should have reached out to him when Resident #169 ran out due to its significance. Interview on [DATE] at 1:00 PM with Resident #169's family member revealed the resident was sent to the hospital from the facility due to a change in condition. Once the family member was at the hospital, they were told the hospital had not found any traces of blood thinner in the resident's system. The family then called the facility and spoke with the DON who said the resident had gone four days without the blood thinner, and they were currently doing a medication audit to try and fix the problem. Resident #169 was put on hospice services and died on [DATE]. Review of in-service records revealed nursing staff had received in-service training on [DATE] regarding unavailable medications/extended refusals or holds and notification of physician due to unavailable or missed medications. The in-service further reflected LVN HH was present and signed the in-service sheet. Review of the website www.xarelto-us.com, for healthcare professionals, accessed on [DATE], reflected: Increased risk of blood clots if you stop taking Xarelto .People with [MEDICAL CONDITION] (an irregular heart beat) that is not caused by a heart valve problem (nonvalvular) are at an increased risk of forming a blood clot in the heart, which can travel to the brain, causing a stroke, or to other parts of the body. .Premature discontinuation of any oral anticoagulant, including Xarelto, increases the risk of [MEDICAL CONDITION] events. If anticoagulation with Xarelto is discontinued for a reason other than pathological bleeding or completion of a course of therapy, consider coverage with another anticoagulant. Review of the facility's current policy for medication administration revised (MONTH) 2004 reflected the following: Standard All medications are administered safely and appropriately to help residents overcome illness, relieve/prevent symptoms, and help in [DIAGNOSES REDACTED]. If medication is ordered but not present: a. Check other resident drawers to see if it was placed in the wrong drawer b. call the pharmacy or supervisor to obtain the medication .Other documentation may include: Notification of physician. Review of the facility's current policy titled Anticoagulation/[MEDICATION NAME] Drug Meeting dated [DATE] reflected the following: Policy Residents receiving anticoagulation therapy are reviewed to ensure correct dosage and adequate monitoring. .4. Review the MAR for the previous day's anticoagulant order to ensure the anticoagulant was administered or held per physician order. The facility took the following actions to correct the non-compliance prior to the investigation: Review of in-services records revealed both LVN HH and LVN II received one on one education on [DATE] regarding abuse/neglect, resident rights, anticoagulant use, medication ordering procedures, medication administration; and on [DATE] they were in-serviced on notification of physician for refusal of, or unavailable medications. Further review of the in-services reflected all nursing staff were trained on [DATE] on holding medications due to medication not being available and notification of the physician for refusal of/or unavailability of medication on [DATE]. Review of a medication review skills check off from [DATE] through [DATE] reflected all nursing staff had been cleared on [DATE].

Based on observation, interview and record review, it was determined the facility failed to ensure one (Resident #10) of one resident with an ostomy received proper treatment and care. The facility failed to ensure there were physician orders specifying the proper size ostomy bag and wafer for Resident #10, who had an [MEDICAL CONDITION]. The facility failed to have ostomy supplies available to meet Resident #10's needs. As a result, Resident #10's [MEDICAL CONDITION] leaked stool onto her skin causing pain, redness, and irritation to the stoma site and surrounding area on her abdomen. Resident #10 was transferred to the hospital on [DATE] due to the pain and irritation. This failure resulted in the facility's only resident with an ostomy, Resident #10, experiencing significant pain, redness, and skin irritation. Findings included: Resident #10's MDS assessment, dated 03/24/15, reflected she was an [AGE] year-old female, who was admitted to the facility on [DATE]. The resident had an [MEDICAL CONDITION] along with [DIAGNOSES REDACTED]. The resident required extensive assistance with personal hygiene, bed mobility, and toilet use. The resident had moderately impaired cognitive skills and was able to understand others and be understood by others. The 2015 Merriam Webster Medical Dictionary defines an [MEDICAL CONDITION] as: "surgical formation of an artificial anus by connecting the ileum (last section of the small intestine) to an opening in the abdominal wall." Resident #10's Care Plan, dated 03/17/15, reflected the resident had a care plan for her [MEDICAL CONDITION]. The care planned approaches to address the [MEDICAL CONDITION] included: - checking for elimination each shift and as needed to appropriate fit, leakage, and need for emptying; - monitoring for signs and symptoms of complications to include resident complaints of pain; - assessing the skin around the stoma site for signs of irritation and breakdown; and - report signs and symptoms of complications to the physician. Resident #10's Progress Notes written by LVN F, dated 03/18/15, reflected: "3/17/15 Late Entry, Resident arrived...from Hospital...hx (history) of Colovesical Fistula, Ilestomy (sic) to right side, stoma Pink, Green liquid stool via [MEDICAL CONDITION] bag...." Resident #10's Physician admission orders [REDACTED]. There was no order regarding the size of the ostomy bag or the wafer (skin barrier) for Resident #10's [MEDICAL CONDITION]. Review of Resident #10's Physician Telephone Orders from her date of admission, 03/17/15, through 04/16/15 revealed no physician orders specifying the type or size of bag and wafer that were needed for Resident #10. Resident #10's physician progress notes [REDACTED].#10 was seen per family request due to increased irritation to the resident's stoma site. PA L noted that the irritation to the stoma site might be caused by stool, and she discussed keeping the site clean with one of the resident's nurses. An interview on 04/15/15 at 11:52 a.m. with Resident #10 revealed her [MEDICAL CONDITION] overflowed at times. Resident #10 stated she usually alerted staff when her [MEDICAL CONDITION] bag was getting full. The resident stated staff did not routinely check the [MEDICAL CONDITION], but the staff had to change the bag. An interview on 04/15/15 at 12:28 p.m. with LVN F, a charge nurse on the 6:00 a.m. to 2:00 p.m. shift, revealed staff checked and emptied Resident #10's [MEDICAL CONDITION] bag/pouch whenever the resident called them. Also, staff checked the resident's bag/pouch at least two times per shift. Resident #10's Progress Notes written by LVN N, dated 04/15/15 3:03 p.m., reflected: "Resident alert and responsive, seen by PA (PA L) on 4/14/15 s/p (status [REDACTED]." An interview on 04/16/15 at 8:10 a.m. with Resident #10 revealed there was a problem with her [MEDICAL CONDITION] last night. Resident #10 explained that the facility ran out of ostomy bags; however, LVN F was able to piece one together this morning. An interview on 04/16/15 at 10:55 a.m. with CNA H revealed she checked and emptied Resident #10's [MEDICAL CONDITION] bag each morning, then after lunch, and other times if needed. An interview on 04/16/15 at 12:20 p.m. with LVN F revealed Resident #10's [MEDICAL CONDITION] bag had come off. At that time upon entering Resident #10's room, she was observed sitting on the toilet. The resident did not have an ostomy bag in place. Resident #10 explained that earlier while sitting in her wheelchair she felt her pants getting wet. She stated she discovered that her ostomy bag had fallen off, and there was stool on her pants. The resident stated she had been sitting on toilet for 30 minutes, and she was feeling uncomfortable. The resident made a facial grimace like she was experiencing pain, and she had generalized trembling. She also waved her hands in the air anxiously. Resident #10 then activated her call light to request assistance. LVN F arrived within three minutes at 12:26 a.m. LVN F stated NP E was on her way to see the resident. Resident #10 then stated she felt faint and asked for a wash cloth. The resident continued to tremble and have facial grimacing like she was experiencing pain or discomfort. LVN F assisted Resident #10 off the toilet and into her wheelchair. CNA H brought the resident a face cloth and towel. The resident pressed the wet wash cloth over her face, and she continues to moan and tremble. The towel was placed beneath the ostomy to protect the resident's abdominal skin from further drainage. LVN F stated she was unsure if the bag she put on this morning was the same size as Resident #10's previous ostomy bag. LVN F explained they had run out of bags last night, and she had nothing to check to determine the correct size of bag for Resident #10. An observation of Resident #10's ostomy site at this time revealed it was extremely red. The skin below the resident's ostomy and on her upper right leg had patches of extreme redness. The area of redness on the resident's abdomen by the ostomy site was approximately 4 inches by 4 inches. The area of redness on the resident's upper leg was approximately 2 inches by 1 inch. Resident #10 complained of pain, and she stated her ostomy site was burning since the site was cleaned. Resident #10 moaned, waved her hands in the air, and had increased trembling. Whenever the reddened area on the resident's abdomen was touched near the ostomy site, she displayed pain by taking in a deep breath. LVN F leaves the room and asks CNA H to remain with Resident. At 12:38 p.m. on 04/16/15, ADON A entered Resident #10's room. The resident stated her pain was a 10 on a scale of 0-10 with zero being no pain and ten being the worst pain she could possibly imagine. At 12:42 p.m. on 04/16/15, LVN F returned to room, and she stated the resident's ostomy sight was not previously red. She stated the area looked "puffier." LVN F then applied skin prep to the area, and she explained it would help the ostomy wafer adhere. Next, LVN F applied a 4 inch x 4 inch dressing to the ostomy site to catch stool drainage. A small amount of stool was oozing from site. At 12:49 p.m. on 04/16/15, ADON A returned to Resident #10's room, and she gave the resident one tablet of Tylenol 500 mg. LVN F then applied a wafer to the resident's ostomy site. Resident #10 displayed increased pain when she was touch lightly by LVN F. LVN F attempted to attach an ostomy bag ([MEDICATION NAME] 57 mm 2 1/4 inch) to the wafer, but she stopped when the resident exhibited signs of severe pain. At 1:03 p.m. on 04/16/15, NP E evaluated Resident #10. NP E lightly touched Resident #10's abdomen, and the resident sucked in her breath sharply showing signs of pain. NP E then told Resident #10 she needed to go to the hospital for evaluation because the facility did not have pain medications strong enough to help with the resident's pain. At that time, the resident was then placed in bed. The nursing staff then left the room. Resident #10 was asked about her pain, and she stated her pain was a 6 on a scale from 0-10. Resident #10's physician progress notes [REDACTED]." this AM (morning) pt reports pain started and has progressed slowly x 1 day..." NP E documented distention to the right abdominal area near the [MEDICAL CONDITION] site along with a rash on that area. She noted that Resident #10 was guarding the area and the area was tender to palpitation. At 1:30 p.m. on 04/16/15, LVN F returned with a larger size bag/wafer (70 mm 2 ¾ inches). She did not measure the ostomy area to determine what size was actually needed. At 2:00 p.m. on 04/16/15, Resident #10 was transferred to the hospital ER. An interview on 04/16/15 at 3:00 p.m. with LVN F revealed the 10:00 p.m. to 6:00 a.m. charge nurse normally changed Resident #10's [MEDICAL CONDITION] bag and wafer each night. LVN F stated the bag occasionally needed to be changed on the day shift. LVN F explained that LVN K, who was the 10:00 p.m. to 6:00 a.m. charge nurse, advised her in report this morning that the resident's ostomy bag was not staying in place. LVN K also told her they had run out of the ostomy bags. She instructed LVN F to change the bag and wafer this morning. LVN F stated spoke with Central Supply Assistant I, and she requested ostomy bags. LVN F stated she usually contacted Central Supply to get more ostomy bags when there were only three to four ostomy bags in treatment cart. She stated she would either contact Central Supply to re-order the bags or she would write a request in the Central Supply binder located at the nurses' station. Resident #10's Progress Notes written by LVN F, dated 04/16/15 at 5:48 p.m., reflected: "...illestomy (sic) bag changed liquid stool, stoma pink, excoriated around stoma area, alert and oriented, makes needs known...1210 pm Noted swelling above stoma area with (sic, resident) states (it) hurts when touched, Ilestomy (sic) bag changed 1245 pm tylenol 500mg for pain of 10/10 to area above stoma, 110 (NP E) here to see resident (gave) orders to transfer (resident) to (hospital) to treat and evaluate 150 pm ilestomy (sic) changed again tolerated well pain better...320 pm (resident) transported to (hospital) by (ambulance service)...." A telephone interview on 04/17/15 at 8:30 a.m. with LVN K, a 10:00 p.m. to 6:00 a.m. shift charge nurse, revealed she worked 04/13/15 through 04/15/15. She stated during her shift on 04/16/15 she cleaned stool from Resident #10's ostomy site as a result of the stool flowing out of ostomy bag and beneath the wafer. LVN K stated she noticed the skin around the resident's ostomy site was reddened. She explained that she usually had to completely change out the resident's ostomy wafer and bag each shift because the bag kept popping open and away from the wafer thus spilling stool. LVN K stated she usually ordered ostomy supplies when there were only three or four ostomy bags left on the cart. She stated she thought someone else may have ordered supplies so she did not request more. A review of the Central Supply binder on 04/16/15 at 3:15 p.m. revealed no written request for ostomy supplies. An interview on 04/16/15 4:00 p.m. with ADON A revealed when Resident #10 was admitted to facility, she brought her own ostomy supplies. When the resident's personal supplies were depleted, Central Supply Aide I checked the size information on resident's supplies, and she gave the information to Central Supply Assistant J, who ordered the supplies. An interview on 04/16/15 4:24 p.m. with Central Supply Assistant J revealed he had invoices for the ostomy supplies. Review of the invoices revealed the ostomy supplies for Resident #10 were requested on 04/15/15 by Central Supply Assistant I. The request to order was approved by the Administrator on 04/16/15 at 12:02 p.m. A prior request reflected the order was approved on 04/09/15 and ordered on [DATE]. Central Supply Assistant J stated orders were placed Monday and Thursday. He stated one box of wafers (flange with microporous adhesive) contained five wafers, and one box of bags (drain pouches) contained ten bags. An interview on 04/17/15 at 9:44 a.m. with Central Supply Assistant I revealed supply requests were supposed to be written and placed in the Central Supply Requisition Binder that was available at each nurses' station. She stated each morning she gathered the requests and ordered the supplies. The nurse was supposed to indicate what size ostomy supplies were needed on the written request forms. Central Supply Assistant I stated she has not received any written requests for ostomy supplies for Resident #10 since her admission to the facility on [DATE]. She stated she received a text message on 04/16/15 at 6:55 a.m. from LVN F requesting ostomy supplies for Resident #10. Central Supply Assistant I stated she just happened to have come in early that morning so she brought the supplies to the unit. She stated she knew what size to bring because Resident #10 was the only resident in the facility with an ostomy. She stated the nurses checked the resident's personal ostomy supplies and advised her of the size needed. Review of the hospital Emergency Department records for Resident #10, dated 04/16/15, revealed she was evaluated for worsening redness and irritation around the [MEDICAL CONDITION] site. The [MEDICAL CONDITION] site was noted to have a rash with nickel-sized abrasions. The hospital evaluation reflected the site was not infected, and the resident did not have to be treated for [REDACTED]. Resident #10's Progress Notes written by LVN O, dated 04/17/15 at 12:36 a.m., reflected that Resident #10 returned from the hospital on [DATE] at 11:50 p.m. An observation on 04/17/15 8:10 a.m. revealed Resident #10 sitting in her wheelchair. She stated she felt much better and explained that her skin blistered and burned when stool came into contact with it. Resident #10's Physician Telephone Orders, dated 04/17/15, reflected an order for [REDACTED]." An interview on 04/17/15 at 12:55 p.m. with NP E revealed Resident #10's complaint of abdominal pain prompted her to send the resident to the hospital. She explained that the resident had a history of [REDACTED]. An interview on 04/17/15 at 1:36 p.m. with ADON A revealed she was responsible for overseeing wound care and general skin issues in the facility. She explained that the unit nurses performed the routine wound evaluations and updated the skin assessments when there were any changes in skin condition. They were also responsible for notifying the physician of changes. ADON A stated this information would also go in the 24-hour report book. Review of the 24-hour report book revealed there was no documentation regarding skin changes for Resident #10 from 04/14/15 through 04/17/15. An interview with on 04/17/15 at 1:59 p.m. with ADON B revealed the facility had not conducted any recent in-service training regarding ostomy care. The Resident Census and Conditions of Residents Form CMS-672, signed and dated by the MDS Coordinator on 04/15/15, reflected one resident had an ostomy.

Based on interview and record review, it was determined the facility failed to implement policies and procedures that prohibit neglect for two (Residents #1 and #2) of 15 residents reviewed for neglect as evidenced by the following: A) Resident #2 sustained a fracture while being given a shower in the shower room. Resident #2 slid off the shower chair during the shower and fractured her ankle. She was transported to the emergency room and required a stabilizer for her ankle. B) Resident #1 experienced six falls while residing in the facility. There was a chair alarm observed on the resident's wheelchair, but it was not connected to his clothing and did not alarm when Resident #1 fell from his wheelchair. This failure resulted in Resident #1 having another fall and being at risk for injury. These failures to implement new interventions to prevent the potential for falls could affect the facility's nine residents identified with falls including Resident #1, and placed them all at risk for continuing to fall, sustaining injuries, which could be life-threatening and result in loss of cognition, the need for further medical treatment, and hospitalization . In addition, these failures could affect the facility's 23 residents who required total assistance with activities of daily living including Residents #1 and #2 and placed them at risk for neglect by the facility's failure to provide adequate care and supervision. Findings included: 1) Review of Resident #2's electronic clinical record revealed she was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #2's most current MDS assessment dated [DATE] reflected the following Diagnoses: [REDACTED]. Resident #2's assessment indicated she was rarely/never understood, and had both short-term and long-term memory deficits. Resident #2's cognitive skills for daily decision making indicated she was severely impaired. Resident #2's functional status was reflected as having "total dependence" with bed mobility, transfers, locomotion, dressing, eating, toileting and personal hygiene. Resident #2 's functional limitation in range of motion was marked as "no impairment" in either upper or lower extremities. It was indicated that Resident #2 was "always incontinent of both bowel and bladder." The assessment further reflected that Resident #2 did not have any falls within the look back period. 2) During initial rounds with LVN D on 03/26/14 at approximately 10:00 AM, Resident #2 was observed to be in a Geri-chair reclined back with her legs elevated. LVN D reported the resident was totally dependent on staff and had behaviors which included crying out, would repeatedly ask if she "was dead" or did she "die last night?" LVN D stated Resident #2 had a fall which resulted in a [MEDICAL CONDITION] ankle. The resident was a Hoyer-lift due to her inability to bear weight on her lower extremities. Resident #2 was not interviewable and had communication problems. 3) Resident #2's Nurse's Notes for Friday 01/24/14 reflected the following entries: 01/24/14 at 2:30 PM, "Nurse was called to shower room on D-wing by CNA, upon entering the room, resident was on her back on the floor, assessed from head to toe, left ankle noted to be twisted from opposite side, resident lifted by hoyler (sic) lift to bed, family member notified and PA (Physician's Assistant) called, resident sent to (hospital) ER to be evaluated and for treatment. " 01/24/14 at 8:08 PM, "Pt readmitted from hosp(sic) on gurney with son in attendance/ Dx (sic) non displaced tibia/fibula fx boot in place toes warm to touch/ minimal swelling of toes noted/ will keep elevated/ if swelling will ice pack and loosen boot ...will continue to monitor. " 4) Review of the "Radiology Report" for Resident #2 dated 01/24/14, revealed the following: "Findings: ...views of the left tibia and fibula are submitted. Slightly offset [MEDICAL CONDITION] fibular shaft and an oblique minimally laterally offset [MEDICAL CONDITION] tibial shaft is seen. Bones appear demineralized. Impression: Minimally offset fractures of the distal tibial and fibular shafts." 5) Review of the incident report regarding Resident #2's fall revealed the following: "Incident Date: 01/24/14. Summary of Investigative Facts: CNA was showering resident in a shower chair. Resident begun to have a BM (bowel movement) and start (sic) squirming. As she was squirming she slid out of the shower chair. She fx (sic) her left ankle." 6) Review of LVN E's written statement revealed the following: "Called to shower room on D-wing by CNA upon entering room, resident was on the shower floor on her back, hoyer lift was used to transfer resident off the shower floor, assessed from head to toe. Left foot twisted from opposite side, resident sent to ER (emergency room ) for evaluation." 7) Review of CNA F's written statement revealed the following: "...She lift her legs up fighting out to have a bowel movement, and she slip from the chair in the shower so I rushed out to call the nurse ...The water was running and it was slippery...." 8) An interview with CNA F on 03/26/14 at 2:55 PM revealed that on the day of the incident, she used the Hoyer lift and independently transferred Resident #2 to the shower chair. She stated she "could not find anybody to help transfer the resident" to the shower chair, so she transferred the resident with the Hoyer lift by herself. CNA F stated she got the resident into the shower chair and locked the wheels of the chair. She began cleaning the resident when Resident #2 started "screaming and wiggling around" in the chair. The resident lifted her legs up, and moved her body and fell to the floor, landing on her ankle. CNA F stated she called for help, and LVN E and another CNA assisted with moving the resident. CNA F stated she knew two staff members should operate the Hoyer lift. 9) An interview with the Corporate RN on 03/27/14 at 2:00 PM revealed they determined what happened that lead to the fall. The Corporate RN revealed that he felt the injury was not based on neglect or abuse. The Corporate RN revealed he did not know that CNA F used the Hoyer lift independently at the time of the incident, as it was not reported. 10) Review of the facility's undated "Incident Management Process Policy & Procedures Manual" revealed the following: "Incident Management-Intent: The facility identifies residents at risk for incident and adequately plans care and implements procedures designed to reduce incident risk and minimize the potential for occurrence." " Policy: Each resident receives adequate assistance and oversight as defined in an individualized plan of care that reduces the risks for incidents. If a resident has had an accident or fall, the facility investigates and provides focused review to minimize the potential for recurrence. " " Procedure: Develop an organized method to define, monitor, and reduce risks associated with incidents and falls that can compromise a resident's lifestyle and quality of life. Define an ' accident ' as an unexpected, unintended event that can result in bodily injury, but does not include adverse outcomes associated as a direct consequence of treatment or care ...Provide timely investigation of incidents and utilize RAP triggers including: cognitive loss/dementia, physical restraints, and [MEDICAL CONDITION] drug use to assess causal factors and/or trends and implement reasonable and appropriate action plans reducing the risk of recurrence. Provide timely investigation of accidents/falls to determine if the incident is reportable to local agencies per regulations. Provide a method for further investigation of reportable accidents and a means to identify potential trends. Develop and implement action plans in response to conclusions that reduce the potential for recurrence. Develop a communication system that ensures staff providing care to residents are notified of accident/fall interventions as it relates to the residents for which they are caring." " Procedural Steps: Define all areas considered to be accidents/incidents including but not limited to: ...falls, ...other accidents resulting in injury." "Incidents that result from alleged physical and/or verbal abuse, elopement, or incidents that result in physical injury that require medical treatment outside the facility will be immediately reported to the director of nursing and/or designee and the executive director. All incident reports will be reviewed by the director of nursing and/or designee to rule out the possibility of willful abuse or neglect. Reportable incidents will be called to appropriate agencies per State guidelines. The need for further incident investigation is determined by the executive director, director of nursing, and/or designee. Falls, reportable incidents, incidents with injury, repeated incidents, or injuries of unknown origin are examples of incidents that require additional investigation. Subsequent investigation should include assessment of possible contributing clinical and environmental factors. For example a post-fall investigation should include: review of medications, patterns of the fall, behaviors, pain, constipation, and restraints. If the incident is determined to be reportable, the incident must be called to State officials promptly. Written results of the investigation must be reported to the administrator and other officials in accordance with State law. (Federal law requires you to report the incident within five (5) working days of the incident." 11) Review of the facility's "Protection of Residents: Reducing the Threat of Abuse and Neglect, Chapter 2 " revised 02/09, reflected "The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with state law. The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in process. The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with the state law within five working days of the incident, and if the alleged violation is verified, appropriate corrective action must be taken. " 12) The MDS assessment dated [DATE] reflected Resident #1 was an [AGE] year-old male admitted to the facility on [DATE] with a readmission date of [DATE]. The MDS assessment reflected [DIAGNOSES REDACTED]. Review of Resident #1's Care Plan dated 06/28/13 and updated 03/27/13 revealed he was at risk for falls. The facility's Incident/Accident Log reflected the following falls from August 2013 through March 2014 for Resident #1: 08/21/13, 12/20/13, 02/25/14, 02/28/14, 03/04/14 and 03/27/14. 13) Observation during the morning tour on 03/27/14 at 7:55 AM in the Bluebonnet Neighborhood revealed Resident #1 was sitting in his wheelchair with multiple other residents in the common area/dining area. The surveyor was standing at the Nurses Medication cart near-by when an unidentified staff member began calling for assistance. Resident #1 was observed to be on the floor lying on his left side, his wheelchair was behind him.There was a chair alarm which was attached to Resident #1's wheelchair, but had not been attached to his clothing and did not sound the alarm when he fell . Resident #1 was rolled to his back and he was assessed by the ADON and Corporate RN. 14) An interview with the ADON on 03/27/14 at 8:10 AM, revealed that Resident #1's chair alarm was not attached to him or his clothing and did not sound when he tried to stand up. The ADON was aware that the clip to the chair alarm was on the alarm itself, therefore would not sound if the resident tried to stand, as it was not attached to him. The ADON tested the alarm and it was working properly when the pin was pulled. 15) Observation on 03/28/14 accompanied by LVN Q at 2:00PM revealed Resident #1 was seeping in his bed; no bed alarm or chair alarm were found for Resdent #1. 16) An interview on 03/27/14 at 10:40 AM with CNA O revealed when asked who was responsible to ensure the alarms were applied correctly for residents who have chair alarms and bed alarms; CNA Q replied "it would be the CNA." 17) An interview on 03/27/14 at 10:43 AM with CNA P revealed when asked who was responsible to ensure chair and bed alarms were properly placed, she stated it would be the CNA who was transferring the resident to chair or bed to make sure the alarm was put on correctly. 18) An Interview with LVN N on 03/27/14 at 11:20 AM revealed when asked what the process was in determining which residents would have bed and chair alarms. She stated it was part of the nursing assessment; if there was a fall it would be an automatic intervention to have both chair and bed alarms. When asked who would be responsible for checking to make sure the device was functioning properly, she stated when anyone assisted a resident to a chair or I bed that person must make sure it was functioning properly. When asked if alarms required a physician's orders [REDACTED]. 19) An interview on 03/27/14 at 12:20 PM with the Corporate RN related to Bed and Chair Alarms revealed the facility did not have a Policy and Procedure for alarms. He stated bed and chair alarms were seen as a nursing intervention for falls. 20) An interview with LVN Q on 03/28/14 at 2:00 PM related to Resident #1's missing chair and bed alarms revealed she would folllow up and put both alarms in place and in working order. 21) Record review of the facility's Incident/Accident Data Entry Questionnaire Witness Statement revealed no staff had witnessed Resident #1's fall. 22) The facility's Resident Census and Conditions of Residents Form, CMS-672 completed by the Corporate RN on 03/26/14 reflected the facility had a census of 65 residents.

Based on interview and record review, it was determined the facility failed to implement its written policies and procedures that prohibit mistreatment, neglect and abuse for two (Residents #1 and #2) of 15 residents reviewed for neglect. A) The facility failed to investigate and report an incident involving Resident #2 when she sustained a fracture while in the shower room. Resident #2 slid off the shower chair during a shower and fractured her ankle. She was transported to the emergency room and needed a stabilizer for her ankle. B) B) Resident #1 experienced six falls while residing in the facility. There was a chair alarm observed on the resident's wheelchair, but it was not connected to his clothing and did not alarm when Resident #1 fell from his wheelchair. This failure resulted in Resident #1 having another fall and being at risk for injury. These failures to implement new interventions to prevent the potential for falls could affect the facility's nine residents identified with falls including Resident #1, and placed them all at risk for continuing to fall, sustaining injuries, which could be life-threatening and result in loss of cognition, the need for further medical treatment, and hospitalization . In addition, these failures could affect the facility's 23 residents who required total assistance with activities of daily living including Residents #1 and #2 and placed them at risk for neglect by the facility's failure to provide adequate care and supervision. Findings included: 1) Review of the facility's "Protection of Residents: Reducing the Threat of Abuse and Neglect, Chapter 2 " revised 02/09, revealed "The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with state law. The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in process. The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with the state law within five working days of the incident, and if the alleged violation is verified, appropriate corrective action must be taken." 2) Review of the facility's undated "Incident Management Process Policy & Procedures Manual" revealed the following: "Incident Management- Intent: The facility identifies residents at risk for incident and adequately plans care and implements procedures designed to reduce incident risk and minimize the potential for occurrence." "Policy: Each resident receives adequate assistance and oversight as defined in an individualized plan of care that reduces the risks for incidents. If a resident has had an accident or fall, the facility investigates and provides focused review to minimize the potential for recurrence." "Procedure: Develop an organized method to define, monitor, and reduce risks associated with incidents and falls that can compromise a resident's lifestyle and quality of life. Define an 'accident' as an unexpected, unintended event that can result in bodily injury, but does not include adverse outcomes associated as a direct consequence of treatment or care ...Provide timely investigation of incidents and utilize RAP triggers including: cognitive loss/dementia, physical restraints, and [MEDICAL CONDITION] drug use to assess causal factors and/or trends and implement reasonable and appropriate action plans reducing the risk of recurrence. Provide timely investigation of accidents/falls to determine if the incident is reportable to local agencies per regulations. Provide a method for further investigation of reportable accidents and a means to identify potential trends. Develop and implement action plans in response to conclusions that reduce the potential for recurrence. Develop a communication system that ensures staff providing care to residents are notified of accident/fall interventions as it relates to the residents for which they are caring." "Procedural Steps: Define all areas considered to be accidents/incidents including but not limited to: ...falls, ...other accidents resulting in injury. " " Incidents that result from alleged physical and/or verbal abuse, elopement, or incidents that result in physical injury that require medical treatment outside the facility will be immediately reported to the director of nursing and/or designee and the executive director. All incident reports will be reviewed by the director of nursing and/or designee to rule out the possibility of willful abuse or neglect. Reportable incidents will be called to appropriate agencies per State guidelines. The need for further incident investigation is determined by the executive director, director of nursing, and/or designee. Falls, reportable incidents, incidents with injury, repeated incidents, or injuries of unknown origin are examples of incidents that require additional investigation. Subsequent investigation should include assessment of possible contributing clinical and environmental factors. For example a post-fall investigation should include: review of medications, patterns of the fall, behaviors, pain, constipation, and restraints. If the incident is determined to be reportable, the incident must be called to State officials promptly. Written results of the investigation must be reported to the administrator and other officials in accordance with State law. (Federal law requires you to report the incident within five (5) working days of the incident." 3) Review of Resident #2's electronic clinical record revealed she was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #2's most current MDS assessment dated [DATE] reflected the following Diagnoses: [REDACTED]. Resident #2's assessment indicated she was rarely/never understood, and had both short-term and long-term memory deficits. Resident #2's cognitive skills for daily decision making indicated she was severely impaired. Resident #2's functional status was reflected as having "total dependence" with bed mobility, transfers, locomotion, dressing, eating, toileting and personal hygiene. Resident #2 's functional limitation in range of motion was marked as "no impairment" in either upper or lower extremities. It was indicated that Resident #2 was "always incontinent of both bowel and bladder." The assessment further reflected that Resident #2 did not have any falls within the look back period. 4) During initial rounds with LVN D on 03/26/14 at approximately 10:00 AM, Resident #2 was observed to be in a Geri-chair reclined back with her legs elevated. LVN D reported the resident was totally dependent on staff and had behaviors which included crying out, and would repeatedly ask if she "was dead" or did she "die last night?" LVN D stated Resident #2 had a fall which resulted in a [MEDICAL CONDITION] ankle. The resident was a Hoyer-lift due to her inability to bear weight on her lower extremities. Resident #2 was not interviewable and had communication problems. 5) Resident #2's Nurses' Notes for Friday 01/24/14 reflected the following entries: 01/24/14 at 2:30 PM, "Nurse was called to shower room on D-wing by CNA, upon entering the room, resident was on her back on the floor, assessed from head to toe, left ankle noted to be twisted from opposite side, resident lifted by hoyler (sic) lift to bed, family member notified and PA (Physician's Assistant) called, resident sent to (hospital) ER to be evaluated and for treatment." 01/24/14 at 8:08 PM, "Pt readmitted from hosp(sic) on gurney with son in attendance/ Dx (sic) non displaced tibia/fibula fx boot in place toes warm to touch/minimal swelling of toes noted/ will keep elevated/ if swelling will ice pack and loosen boot ...will continue to monitor." 6) Review of the "Radiology Report " for Resident #2 dated 01/24/14, revealed the following: "Findings: ...views of the left tibia and fibula are submitted. Slightly offset [MEDICAL CONDITION] fibular shaft and an oblique minimally laterally offset [MEDICAL CONDITION] tibial shaft is seen. Bones appear demineralized. Impression: Minimally offset fractures of the distal tibial and fibular shafts." 7) Review of the incident report regarding Resident #2's fall revealed the following: "Incident Date: 01/24/14. Summary of Investigative Facts: CNA was showering resident in a shower chair. Resident begun to have a BM (bowel movement) and start (sic) squirming. As she was squirming she slid out of the shower chair. She fx (sic) her left ankle." 8) Review of LVN E's written statement revealed the following: "Called to shower room on D-wing by CNA upon entering room, resident was on the shower floor on her back, hoyer lift was used to transfer resident off the shower floor, assessed from head to toe. Left foot twisted from opposite side, resident sent to ER (emergency room ) for evaluation." 9) Review of CNA F's written statement revealed the following: "...She lift her legs up fighting out to have a bowel movement, and she slip from the chair in the shower so I rushed out to call the nurse ...The water was running and it was slippery ...." 10) Interview with the Administrator on 03/26/14 at 2:45 PM revealed the incident was not reported to DADS state office because it "did not meet the criteria for reporting." He stated he followed "Dads Reporting Guidelines form"to determine what is reportable or not reportable. The Administrator revealed he did not have any reportable incidents or accidents since October 2013. In addition, the Administrator stated they were currently without a DON (Director of Nurses) and had been since the end of February. 11) Interview with CNA F on 03/26/14 at 2:55 PM revealed that on the day of the incident, she used the Hoyer lift and independently transferred Resident #2 to the shower chair. She stated she "could not find anybody to help transfer the resident" to the shower chair, so she transferred the resident with the Hoyer lift by herself. CNA F stated she got the resident into the shower chair and locked the wheels of the chair. She began cleaning the resident when Resident #2 started "screaming and wiggling around " in the chair. The resident lifted her legs up, and moved her body and fell to the floor, landing on her ankle. CNA F stated she called for help and LVN E and another CNA assisted with moving the resident. CNA F stated she knew two staff members should operate the Hoyer lift. 12) An interview with the Corporate RN on 03/27/14 at 2:00 PM revealed they determined what happened that lead to the fall, therefore it was not reported to DADS. He stated they could not determine that it was abuse or neglect resulting in the fall with injury. The Corporate RN revealed the form was "not clear in what was reportable or not," but felt the injury was not based on neglect or abuse. The Corporate RN revealed he did not know that CNA F used the Hoyer lift independently at the time of the incident, as it was not reported. 13) The MDS assessment dated [DATE] reflected Resident #1 was an [AGE] year-old male admitted to the facility on [DATE] with a readmission date of [DATE]. The MDS assessment reflected [DIAGNOSES REDACTED]. Review of Resident #1's Care Plan dated 06/28/13 and updated 03/27/13 revealed he was at risk for falls. The facility's Incident/Accident Log reflected the following falls from August 2013 through March 2014 for Resident #1: 08/21/13, 12/20/13, 02/25/14, 02/28/14, 03/04/14 and 03/27/14. 14) Observation during the morning tour on 03/27/14 at 7:55 AM in the Bluebonnet Neighborhood revealed Resident #1 was sitting in his wheelchair with multiple other residents in the common area/dining area. The surveyor was standing at the Nurses Medication cart near-by when an unidentified staff member began calling for assistance. Resident #1 was observed to be on the floor lying on his left side, his wheelchair was behind him.There was a chair alarm which was attached to Resident #1's wheelchair, but had not been attached to his clothing and did not sound the alarm when he fell . Resident #1 was rolled to his back and he was assessed by the ADON and Corporate RN. 15) An interview with the ADON on 03/27/14 at 8:10 AM, revealed that Resident #1's chair alarm was not attached to him or his clothing and did not sound when he tried to stand up. The ADON was aware that the clip to the chair alarm was on the alarm itself, therefore would not sound if the resident tried to stand, as it was not attached to him. The ADON tested the alarm and it was working properly when the pin was pulled. 16) Observation on 03/28/14 accompanied by LVN Q at 2:00PM revealed Resident #1 was seeping in his bed; no bed alarm or chair alarm were found for Resdent #1. 17) An interview on 03/27/14 at 10:40 AM with CNA O revealed when asked who was responsible to ensure the alarms were applied correctly for residents who have chair alarms and bed alarms; CNA Q replied "it would be the CNA." 18) An interview on 03/27/14 at 10:43 AM with CNA P revealed when asked who was responsible to ensure chair and bed alarms were properly placed, she stated it would be the CNA who was transferring the resident to chair or bed to make sure the alarm was put on correctly. 19) An Interview with LVN N on 03/27/14 at 11:20 AM revealed when asked what the process was in determining which residents would have bed and chair alarms. She stated it was part of the nursing assessment; if there was a fall it would be an automatic intervention to have both chair and bed alarms. When asked who would be responsible for checking to make sure the device was functioning properly, she stated when anyone assisted a resident to a chair or I bed that person must make sure it was functioning properly. When asked if alarms required a physician's orders [REDACTED]. 20) An interview on 03/27/14 at 12:20 PM with the Corporate RN related to Bed and Chair Alarms revealed the facility did not have a Policy and Procedure for alarms. He stated bed and chair alarms were seen as a nursing intervention for falls. 21) An interview with LVN Q on 03/28/14 at 2:00 PM related to Resident #1's missing chair and bed alarms revealed she would folllow up and put both alarms in place and in working order. 22) Record review of the facility's Incident/Accident Data Entry Questionnaire Witness Statement revealed no staff had witnessed Resident #1's fall. 23) The facility's Resident Census and Conditions of Residents Form, CMS-672 completed by the Corporate RN on 03/26/14 reflected the facility had a census of 65 residents.

Based on observation, interview, and record review, it was determined that the facility failed to ensure two (Resident #1and Resident #2) of 15 residents reviewed for accidents received adequate supervision and assistance devices to prevent accidents. A) Resident #2 sustained a fracture while being given a shower in the shower room. Resident #2 slid off the shower chair during the shower and fractured her ankle. She was transported to the emergency room and required a stabilizer for her ankle. B) Resident #1 experienced six falls while residing in the facility. There was a chair alarm observed on the resident's wheelchair, but it was not connected to his clothing and did not alarm when Resident #1 fell from his wheelchair. This failure resulted in Resident #1 having another fall and being at risk for injury. These failures to implement new interventions to prevent the potential for falls could affect the facility's nine residents identified with falls, as well as Resident #1, and placed them all at risk for continuing to fall, sustaining injuries, which could be life-threatening and result in loss of cognition, the need for further medical treatment, and hospitalization . In addition, these failures could affect the facility's 23 residents who required total assistance with activities of daily living including Residents #1 and #2 and placed them at risk for accidents by the facility's failure to provide adequate care and supervision. Findings included: 1) Review of Resident #2's electronic clinical record revealed she was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #2's most current MDS assessment dated [DATE] reflected the following Diagnoses: [REDACTED]. Resident #2's assessment indicated she was rarely/never understood, and had both short-term and long-term memory deficits. Resident #2's cognitive skills for daily decision making indicated she was severely impaired. Resident #2's functional status was reflected as having "total dependence" with bed mobility, transfers, locomotion, dressing, eating, toileting and personal hygiene. Resident #2's functional limitation in range of motion was marked as "no impairment" in either upper or lower extremities. It was indicated that Resident #2 was "always incontinent of both bowel and bladder." The assessment further reflected that Resident #2 did not have any falls within the look back period. 2) During initial rounds with LVN D on 03/26/14 at approximately 10:00 AM, Resident #2 was observed to be in a Geri-chair reclined back with her legs elevated. LVN D reported the resident was totally dependent on staff and had behaviors which included crying out, would repeatedly ask if she "was dead" or did she "die last night?" LVN D stated Resident #2 had a fall which resulted in a fracture of the left ankle. The resident was a Hoyer-lift due to her inability to bear weight on her lower extremities. Resident #2 was not interviewable and had communication problems. 3) Resident #2's Nurses' Notes for Friday 01/24/14 reflected the following entries: 01/24/14 at 2:30 PM, "Nurse was called to shower room on D-wing by CNA, upon entering the room, resident was on her back on the floor, assessed from head to toe, left ankle noted to be twisted from opposite side, resident lifted by hoyler (sic) lift to bed, family member notified and PA (Physician's Assistant) called, resident sent to (hospital) ER to be evaluated and for treatment. " 01/24/14 at 8:08 PM, "Pt readmitted from hosp(sic) on gurney with son in attendance/ Dx (sic) non displaced tibia/fibula fx boot in place toes warm to touch/ minimal swelling of toes noted/ will keep elevated/ if swelling will ice pack and loosen boot ...will continue to monitor. " 4) Review of the "Radiology Report" for Resident #2 dated 01/24/14, revealed the following: "Findings: ...views of the left tibia and fibula are submitted. Slightly offset fracture of the distal fibular shaft and an oblique minimally laterally offset fracture of the distal tibial shaft is seen. Bones appear demineralized. Impression: Minimally offset fractures of the distal tibial and fibular shafts." 5) Review of the incident report regarding Resident #2's fall revealed the following: "Incident Date: 01/24/14. Summary of Investigative Facts: CNA was showering resident in a shower chair. Resident begun to have a BM (bowel movement) and start (sic) squirming. As she was squirming she slid out of the shower chair. She fx (sic) her left ankle." 6) Review of LVN E's written statement revealed the following: "Called to shower room on D-wing by CNA upon entering room, resident was on the shower floor on her back, hoyer lift was used to transfer resident off the shower floor, assessed from head to toe. Left foot twisted from opposite side, resident sent to ER (emergency room ) for evaluation." 7) Review of CNA F's written statement revealed the following: "...She lift her legs up fighting out to have a bowel movement, and she slip from the chair in the shower so I rushed out to call the nurse ...The water was running and it was slippery...." 8) An interview with CNA F on 03/26/14 at 2:55 PM revealed that on the day of the incident, she used the Hoyer lift and independently transferred Resident #2 to the shower chair. She stated she "could not find anybody to help transfer the resident" to the shower chair, so she transferred the resident with the Hoyer lift by herself. CNA F stated she got the resident into the shower chair and locked the wheels of the chair. She began cleaning the resident when Resident #2 started "screaming and wiggling around" in the chair. The resident lifted her legs up, and moved her body and fell to the floor, landing on her ankle. CNA F stated she called for help, and LVN E and another CNA assisted with moving the resident. CNA F stated she knew two staff members should operate the Hoyer lift. 9) An interview with the Corporate RN on 03/27/14 at 2:00 PM revealed they determined what happened that lead to the fall. The Corporate RN revealed that he felt the injury was not based on neglect or abuse. The Corporate RN revealed he did not know that CNA F used the Hoyer lift independently at the time of the incident, as it was not reported. 10) Review of the facility's undated "Incident Management Process Policy & Procedures Manual" revealed the following: "Incident Management-Intent: The facility identifies residents at risk for incident and adequately plans care and implements procedures designed to reduce incident risk and minimize the potential for occurrence." " Policy: Each resident receives adequate assistance and oversight as defined in an individualized plan of care that reduces the risks for incidents. If a resident has had an accident or fall, the facility investigates and provides focused review to minimize the potential for recurrence." "Procedure: Develop an organized method to define, monitor, and reduce risks associated with incidents and falls that can compromise a resident's lifestyle and quality of life. Define an 'accident' as an unexpected, unintended event that can result in bodily injury, but does not include adverse outcomes associated as a direct consequence of treatment or care ...Provide timely investigation of incidents and utilize RAP triggers including: cognitive loss/dementia, physical restraints, and psychotropic drug use to assess causal factors and/or trends and implement reasonable and appropriate action plans reducing the risk of recurrence. Provide timely investigation of accidents/falls to determine if the incident is reportable to local agencies per regulations. Provide a method for further investigation of reportable accidents and a means to identify potential trends. Develop and implement action plans in response to conclusions that reduce the potential for recurrence. Develop a communication system that ensures staff providing care to residents are notified of accident/fall interventions as it relates to the residents for which they are caring." Procedural Steps: Define all areas considered to be accidents/incidents including but not limited to: ...falls, ...other accidents resulting in injury." "Incidents that result from alleged physical and/or verbal abuse, elopement, or incidents that result in physical injury that require medical treatment outside the facility will be immediately reported to the director of nursing and/or designee and the executive director. All incident reports will be reviewed by the director of nursing and/or designee to rule out the possibility of willful abuse or neglect. Reportable incidents will be called to appropriate agencies per State guidelines. The need for further incident investigation is determined by the executive director, director of nursing, and/or designee. Falls, reportable incidents, incidents with injury, repeated incidents, or injuries of unknown origin are examples of incidents that require additional investigation. Subsequent investigation should include assessment of possible contributing clinical and environmental factors. For example a post-fall investigation should include: review of medications, patterns of the fall, behaviors, pain, constipation, and restraints. If the incident is determined to be reportable, the incident must be called to State officials promptly. Written results of the investigation must be reported to the administrator and other officials in accordance with State law. (Federal law requires you to report the incident within five (5) working days of the incident)." 11) Review of the facility's "Protection of Residents: Reducing the Threat of Abuse and Neglect, Chapter 2 " revised 02/09, reflected "The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with state law. The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in process. The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with the state law within five working days of the incident, and if the alleged violation is verified, appropriate corrective action must be taken." 12) The MDS assessment dated [DATE] reflected Resident #1 was an [AGE] year-old male admitted to the facility on [DATE] with a readmission date of [DATE]. The MDS assessment reflected [DIAGNOSES REDACTED]. Review of Resident #1's Care Plan dated 06/28/13 and updated 03/27/13 revealed he was at risk for falls. The facility's Incident/Accident Log reflected the following falls from August 2013 through March 2014 for Resident #1: 08/21/13, 12/20/13, 02/25/14, 02/28/14, 03/04/14 and 03/27/14. 13) Observation during the morning tour on 03/27/14 at 7:55 AM in the Bluebonnet Neighborhood revealed Resident #1 was sitting in his wheelchair with multiple other residents in the common area/dining area. The surveyor was standing at the Nurses Medication cart near-by when an unidentified staff member began calling for assistance. Resident #1 was observed to be on the floor lying on his left side, his wheelchair was behind him.There was a chair alarm which was attached to Resident #1's wheelchair, but had not been attached to his clothing and did not sound the alarm when he fell . Resident #1 was rolled to his back and he was assessed by the ADON and Corporate RN. 14) An interview with the ADON on 03/27/14 at 8:10 AM, revealed that Resident #1's chair alarm was not attached to him or his clothing and did not sound when he tried to stand up. The ADON was aware that the clip to the chair alarm was on the alarm itself, therefore would not sound if the resident tried to stand, as it was not attached to him. The ADON tested the alarm and it was working properly when the pin was pulled. 15) Observation on 03/28/14 accompanied by LVN Q at 2:00PM revealed Resident #1 was seeping in his bed; no bed alarm or chair alarm were found for Resdent #1. 16) An interview on 03/27/14 at 10:40 AM with CNA O revealed when asked who was responsible to ensure the alarms were applied correctly for residents who have chair alarms and bed alarms; CNA Q replied "it would be the CNA." 17) An interview on 03/27/14 at 10:43 AM with CNA P revealed when asked who was responsible to ensure chair and bed alarms were properly placed, she stated it would be the CNA who was transferring the resident to chair or bed to make sure the alarm was put on correctly. 18) An Interview with LVN N on 03/27/14 at 11:20 AM revealed when asked what the process was in determining which residents would have bed and chair alarms. She stated it was part of the nursing assessment; if there was a fall it would be an automatic intervention to have both chair and bed alarms. When asked who would be responsible for checking to make sure the device was functioning properly, she stated when anyone assisted a resident to a chair or I bed that person must make sure it was functioning properly. When asked if alarms required a physician's orders [REDACTED]. 19) An interview on 03/27/14 at 12:20 PM with the Corporate RN related to Bed and Chair Alarms revealed the facility did not have a Policy and Procedure for alarms. He stated bed and chair alarms were seen as a nursing intervention for falls. 20) An interview with LVN Q on 03/28/14 at 2:00 PM related to Resident #1's missing chair and bed alarms revealed she would folllow up and put both alarms in place and in working order. 21) Record review of the facility's Incident/Accident Data Entry Questionnaire Witness Statement revealed no staff had witnessed Resident #1's fall. 22) The facility's Resident Census and Conditions of Residents Form, CMS-672 completed by the Corporate RN on 03/26/14 reflected the facility had a census of 65 residents.