Every finding on record at Gilmer Nursing & Rehabilitation

Based on interview and record review the facility failed to collaborate with hospice representatives and coordinating LTC facility staff participation in the hospice care planning process for those residents receiving hospice services for 3 of 6 residents (Resident #10, Resident #12, and Resident #27) reviewed for hospice services. 1.The facility failed to obtain and ensure Resident #10's most current Hospice Plan of Care/ Interdisciplinary Group Reports, Medication Report, Physician Orders, Nurse Visit Notes, Aide Visit Notes, Chaplain Visit Notes, and Social Worker Visit Notes were part of the current clinical record. 2. The facility failed to obtain Resident #27's most current interdisciplinary group notes. 3.The facility failed to obtain Resident #12's most current Hospice Certification of Terminal Illness and Hospice Plan of Care. These deficient practices could place residents at risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs.Findings included: 1. Record review of Resident #10's face sheet, dated 3/13/2026, indicated Resident #10 was a 90- year- old female who was initially admitted to the facility on [DATE]. Resident #10 had diagnoses which included Alzheimer's disease (progressive disease that destroys memory and other important mental functions), generalized anxiety disorder (severe, ongoing anxiety that interferes with daily activities), and memory deficit following other cerebrovascular disease (a group of conditions that affect the blood flow and the blood vessels in the brain). Record review of Resident #10's Quarterly MDS assessment, dated 12/12/2025, indicated Resident #10 was usually understood by others and usually understood others. Resident #10 had a BIMS score of 99, which indicated she was unable to complete the interview. Resident #10 received hospice services while a resident at the facility. Record review of Resident #10's Order Summary Report, dated 3/13/2026, indicated she admitted to hospice services with a diagnosis of Alzheimer's disease with a start date of 4/08/2024. Record review of Resident #10's care plan, revised on 1/17/2026, indicated she had a terminal prognosis and was receiving hospice services with interventions for coping strategies, respecting resident wishes, encouraging support systems of family and friends, and working with nursing staff to provide maximum comfort of the resident. Record review of Resident #10's hospice binder indicated: Plan of care/ Interdisciplinary Group Reports, dated 1/30/2026- 2/12/2026 Medication Report, dated 1/30/2026- 2/12/2026 Physician Orders, dated 1/30/2026- 2/12/2026 Nurse Visit Notes, dated 1/30/2026- 2/12/2026 Aide Visit Notes, dated 1/30/2026- 2/12/2026 Chaplain Visit Notes, dated 1/30/2026- 2/12/2026 Social Worker Visit Notes, dated 1/30/2026- 2/12/2026 During an interview on 3/12/2026 at 3:07 PM, the Hospice Agency Executive Director stated the Community Education Representative was responsible for bringing the updated information and placing it into the binders. the Hospice Agency Executive Director stated the Community Education Representative was out on extended leave and the Executive Director had not remembered the binders were not being updated. The Executive Director stated it was important to keep the binders updated to ensure any changes or new orders were communicated. It was important for the best care of the resident. During an interview on 3/13/2026 at 1:10 PM, the Facility Administrator stated she expected the hospice agency to keep the hospice binders up to date. Administrator stated there was no one currently designated to ensure the hospice binders were current. The Facility Administrator stated keeping the hospice binders up to date was important for continuity of care and to guarantee the resident's needs were met. During an interview on 3/13/2026 at 2:45 PM, the DON stated Medical Records was responsible for ensuring the hospice binders were updated. The DON stated the facility did not currently have the Medical Records position filled. The DON stated until the Medical Records position was filled, she and the ADON were responsible for keeping the binders updated. The DON stated it was important to maintain updated hospice records for the continuity of care for the resident. 2. Record review of Resident #27's face sheet, dated 03/11/2026, indicated a [AGE] year-old female who was re-admitted to the facility on [DATE]. Resident #27 had diagnoses which included dementia (loss of memory, language, and thinking abilities that are severe enough to interfere with daily life), frontal lobe and executive function deficit (damage or dysfunction to the brain's prefrontal cortex), myocardial infarction (heart attack caused by cessation of blood flow to the heart), and high blood pressure. Record review of Resident #27's quarterly MDS assessment, dated 02/10/2026, indicated she usually understood others and could usually make others understand her. Resident #27 had a BIMS score of 0, which indicated her cognition was severely impaired. Resident #12 received hospice services while a resident at the facility. Record review of Resident #27's comprehensive care plan, dated 11/7/2025, indicated she required hospice as evidenced by a terminal illness with hospice staff to assist with resident care. Record review of Resident #27's hospice binder indicated: Interdisciplinary Group Meeting was dated 02/11/2026. Record review of Resident #27's Order Summary Report, dated 03/11/2026, indicated admit to hospice services with diagnosis of Cerebral ischemia (critical medical condition in which the blood flow deprives brain tissue of oxygenand nutrients, leading to cell death) with a start date of 11/10/2025. 3. Record review of a face sheet dated 03/11/2026 indicated Resident #12 was an [AGE] year-old female initially admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease (progressive disease that destroys memory and other important mental functions) and dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life). Record review of Resident #12's Quarterly MDS assessment dated [DATE] indicated Resident #12 was sometimes understood by others and sometimes understood others. The MDS assessment indicated Resident #12 had a BIMS score of 0, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #12 received hospice services while a resident at the facility. Record review of Resident #12's Order Summary Report dated 03/11/2026 indicated admit to hospice services with diagnosis of Alzheimer's disease with a start date of 09/11/2025. Record review of Resident #12's care plan reviewed 12/21/2025 indicated she had a terminal prognosis and was receiving hospice services to work cooperatively with the hospice team to ensure the resident's spiritual, emotional, intellectual, physical, and social needs were met. Record review of Resident #12's hospice binder indicated: Hospice Certification of Terminal Illness was dated 08/27/2025-10/25/2025. There was no current Hospice Certification of Terminal Illness. Hospice Plan of Care with a certification period of 10/26/2025-12/24/2025. There was no current hospice plan of care. During an interview on 03/11/2026 at 2:49 PM, the Hospice Patient Care Coordinator said the hospice aide took the hospice records to the facility. She said the hospice records such as the certification of terminal illness, interdisciplinary team meetings, notes from the hospice aide, chaplain, nurse, and social worker were taken to the facility every other week after their interdisciplinary team meetings. The Hospice Patient Care Coordinator said she was not aware Resident #12's hospice records were not up to date at the facility. She said it was important for the facility to have the most current hospice documents so they knew what was going on with the resident and so they could see if there were any changes made to the residents' plan of care. During an interview on 03/11/2026 at 3:22 PM, LVN L said she was not aware Resident #12 did not have the most current hospice documents. LVN L said the ADON or DON were responsible for ensuring the hospice documents were available in the facility. LVN L said it was important for the facility to have the hospice documents, so they knew what care to provide for the residents. During an interview on 03/13/2026 at 1:16 PM, the DON said she did not know who was supposed to ensure the residents' hospice documents were available in the facility. The DON said she knew it was not the nursing department's responsibility. The DON said it was important to have the residents' hospice documents so they could see what the residents' plans of care were and for coordination of care. During an interview on 03/13/2026 at 1:33 PM, the Administrator said she expected the residents' hospice records to be available in the facility. The Administrator said the charge nurse should be reviewing the hospice documents and notifying the nurse managers of missing documentation for them to obtain it from the hospice. The Administrator said it was important to have the residents' hospice documentation for continuity of care and to meet the residents' needs for their hospice services. Record review of the facility's undated policy titled, Hospice Services, indicated, The DON or designee will be responsible for ensuring that documentation is a part of the current clinical record. At a minimum, the documentation will include: The current and past Texas Medicaid Hospice Recipient Election/Cancellation Form (#3071) Texas Medicaid Hospice-Nursing Facility Assessment Form (#3073) Physician Certification of Terminal Illness (#3074) Medicare Election Statement (if dual eligible) Verification that the recipient does not have Medicare Part A Hospice Plan of Care Current interdisciplinary notes to include nurses notes/summaries, physician orders and progress notes, and medications and treatment sheets during the hospice certification period.

Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and provide care in a manner that promotes maintenance or enhancement of his or her quality of life for 3 of 3 residents (Resident #9, Resident #12, and Resident #31) reviewed for resident rights. The facility failed to ensure CNA K did not stand over Resident #9 and Resident #31 while assisting them to eat on 03/11/2026. The facility failed to ensure CNA K was not on her personal cell phone when assisting Resident #9 with eating and while sitting with Resident #12 on 03/11/2026. These failures could place residents at risk of decreased self-worth, loss of dignity, and a diminished quality of life.Findings included: 1. Record review of a face sheet dated 03/11/2026 indicated Resident #9 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease (progressive disease that destroys memory and other important mental functions) and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (paralysis/weakness affecting the left side of the body after a stroke). Record review of Resident #9's Quarterly MDS assessment dated [DATE] indicated he was sometimes understood and sometimes understood others. The MDS assessment indicated Resident #9's BIMS score was 0, which indicated his cognition was severely impaired. Record review of Resident #9's care plan revised 01/23/2026 indicated he required assistance of one staff member with eating. During an observation on 03/11/2026 at 9:30 AM, CNA K assisted Resident #9 with eating his pudding snack. CNA K was standing up next to Resident #9 and started giving him the pudding snack by pressing the spoon against his lips. After a couple seconds Resident #9 realized, she was trying to give him the pudding and he opened his mouth and started eating. While she was assisting Resident #9 with his pudding, she pulled her cell phone out of her pocket, looked at it, and then returned it to her pocket. 2. Record review of a face sheet dated 03/11/2026 indicated Resident #12 was an [AGE] year-old female initially admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease (progressive disease that destroys memory and other important mental functions) and dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life). Record review of Resident #12's Quarterly MDS assessment dated [DATE] indicated Resident #12 was sometimes understood by others and sometimes understood others. The MDS assessment indicated Resident #12 had a BIMS score of 0, which indicated her cognition was severely impaired. Record review of Resident #12's care plan reviewed 12/21/2025 indicated she had a communication problem to anticipate and meet her needs and provide a safe environment. During an observation on 03/11/2026 at 11:55 AM, Resident #12 was sitting at a table in the secure unit's dining area with CNA K. CNA K was utilizing her cell phone while she was sitting at the table with Resident #12. 3. Record review of a face sheet dated 03/11/2026 indicated Resident #31 was an [AGE] year-old male initially admitted to the facility on [DATE] with diagnoses which included chronic systolic congestive heart failure (heart is unable to pump enough force to push enough blood into circulation) and dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life). Record review of Resident #31's Quarterly MDS assessment dated [DATE] indicated Resident #31 was sometimes understood by others and sometimes understood others. The MDS assessment indicated Resident #31's BIMS score was 4, which indicated his cognition was severely impaired. Resident #31's MDS assessment indicated he required partial/moderate assistance with eating. Record review of Resident #31's care plan revised 01/04/2026 indicated he had an ADL self-care performance deficit and required supervision with eating as needed. During an observation on 03/11/2026 at 12:28 PM, CNA K was standing over Resident #31 while assisting him to eat his lunch. During an interview on 03/11/2026 at 3:24 PM, LVN L said when they were assisting residents with their meals they should sit down next to the residents because if they were standing up it was demeaning to the residents. LVN L said she was responsible for ensuring the CNAs were doing this. LVN L said she noticed CNA K was standing when assisting residents with their meals, but it didn't click in her mind or she would have told her something. LVN L said when assisting residents with their meals the CNAs should explain to them what they were doing, so the residents would not get scared. LVN L said she noticed CNA K was on her phone while with the residents, and she should not be doing this. LVN L said if CNA K was on her phone she was not providing correct care and not giving the residents the correct attention. LVN L said this could make the residents feel like they did not care about them. During an interview on 03/11/2026 at 3:39 PM, CNA K said when she assisted residents with their meals she should be sitting down next to them. CNA K said when she was assisting the residents she should explain to them what she was doing. CNA K said she should not be on her phone when she was with the residents. CNA K said it did not cross her mind to sit down next to Resident # 9 and Resident #31 when assisting them to eat. CNA K said she was messaging a family member when she was sitting at the table with Resident #12, and she should have stepped away from the resident to use her cell phone. CNA K said using her cell phone in front of the residents could make them feel like she was not paying attention. CNA K said it was important to sit next to the residents to assist them with their meals and explain what she was doing so they would not choke or get irritable. During an interview on 03/13/2026 at 1:10 PM, the DON said the CNAs should be sitting next to the residents while assisting them with their meals so they could have eye contact with them. The DON said when assisting the residents the CNAs should explain what they were doing and direct them face to face. The DON said this was important so the staff could be one on one with the residents, so the residents would not be scared, and so the residents did not have to look up at the staff while they were eating. The DON said the staff should never have cell phones in patient care areas. The DON said the staff should not have their cell phones while assisting the residents with their meals so they could ensure the residents did not choke and to provide direct care to the residents. The DON said the staff having their cell phones in patient care areas could make the residents feel like they were not paying attention to them, and they could get more agitated because the staff were not focused on assisting them with completing their tasks. The DON said the charge nurses were responsible for monitoring the CNAs. During an interview on 03/13/2026 at 1:25 PM, the Administrator said she expected the CNAs to sit in a chair at the residents' level, when they were assisting them with their meals. The Administrator said the charge nurses, DON, DON designee, and herself provided monitoring. The Administrator said she had not noticed the CNAs standing over the residents while assisting them with their meals. The Administrator said it was important to sit at the residents' level, so they did not feel intimidated. The Administrator said she expected the staff to get in the residents' line of sight, introduce themselves, and explain what they were going to do. The Administrator said this was important so the residents understood what was happening with their care and they could participate to the best of their abilities. The Administrator said she expected the staff to engage in resident care and activities and remain off their cell phones when with the residents. The Administrator said the staff having their cell phones when with the residents could make them feel unseen and like they were not getting the attention they needed. Record review of the facility's undated policy titled, Resident Rights, indicated, A facility must 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. The facility must protect and promote the rights of the resident. Respect and dignity - The resident has a right to be treated with respect and dignity, including: 3. The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food and nutrition services. The facility did not ensure:1. Food items were labeled and dated.2. Hair restraints were worn. 3. Personal items were properly stored. 4. The dome covers, bowls, and trays were not stacked with water pooled between them. 5. The pureed mixer top was free from food debris. These failures could place residents at risk for foodborne illness.Findings included: During the initial tour observation and interview with the Dietary Manager on 03/10/26 beginning at 9:28 a.m., revealed the following: 1. Four boxes of 3 lb. cream cheese were undated in the refrigerator. 2. A green thick substance was noted on the pureed mixer top. 3. The dome covers, bowls, and trays were stacked and remained wet with water pooled in between. 4. A cell phone, and personal drink mug were on the tray rack where food could be stored. 5. A work bag observed under the serving table. During an observation on 03/10/26 at 9:30 a.m., Dietary Aide D and the Dietary Manager's hairnets were not covering their entire head. There was loose hair sticking out. During an interview on 03/11/26 at 3:56 p.m., [NAME] B stated all staff were responsible for dating food products. [NAME] B stated hair nets should always be worn while in the kitchen and covered the entire head without loose hair sticking out. [NAME] B stated personal items should be stored out of sight away from the work area. [NAME] B stated these failures could potentially put residents at risk for foodborne illness and cross contamination. During a telephone interview on 03/12/26 at 11:42 a.m., the Dietitian stated whoever put the food items up was responsible for dating the food products. The Dietician stated hair nets should always be worn while in the kitchen and covered the entire head without loose hair sticking out. The Dietician stated the dome covers, bowls, and trays should be air dried first before stacking. The Dietician stated personal items should be away from the workstation wherever the designated area was located. The Dietician stated she monitored by monthly observations. The Dietician stated these failures could potentially put residents at risk for foodborne illness and cross contamination. During an interview on 03/12/26 at 2:04 p.m., Dietary Aide D stated all staff were responsible for dating food products. Dietary Aide D stated the aides were responsible for ensuring the pureed mixer was cleaned after each use. Dietary Aide D stated hair nets should always be worn while in the kitchen and covered the entire head without loose hair sticking out. Dietary Aide D stated her cell phone, work bag and drink mug should have been stored away from the work area. Dietary Aide D stated the cook was responsible for ensuring the mixer was properly cleaned prior to placing it back on the mixer. Dietary Aide D stated the dome covers, bowls, and trays should be air dried first before stacking. Dietary Aide D stated these failures could potentially put residents at risk for foodborne illness and cross contamination. During a telephone interview on 03/12/26 at 2:17 p.m., Dietary Aide E stated she had only been washing dishes for a couple of days. Dietary Aide E stated she was trained by Dietary Aide D to let the dishes air dry first before stacking. Dietary Aide E stated she was rushing trying to get all the dishes washed, that was why the dome covers, bowls, and trays were stacked wet. Dietary Aide E stated these failures could potentially put residents at risk for foodborne illness and cross contamination. During an interview on 03/12/26 at 2:21 p.m., the Dietary Manager stated cleanliness was important in the kitchen, so her staff were not spreading germs or contaminating anything. The Dietary Manager stated she was responsible for making sure the kitchen was cleaned appropriately. The Dietary Manager stated all food should be dated by the date received. The Dietary Manager stated hair nets should be worn while in the kitchen and covering the entire head without loose hair sticking out. The Dietary Manager stated the pureed mixer top should be free from food debris. The Dietary Manager stated the dome covers, bowls, and trays should be air dried first before stacking. The Dietary Manager stated personal items should not be in the work area and should be stored in the bins in the restroom. The Dietary Manager stated she was responsible for monitoring and overseeing by weekly checkoffs, visual observations, and in serviced staff. The Dietary Manager stated these failures could potentially put residents at risk for cross contamination and food borne illness. During an interview on 03/12/26 at 3:48 p.m., the Administrator stated she expected food to be dated, hair nets covering the entire head without loose hair sticking out, personal items stored in the designated area away from the workstation. The Administrator stated dome covers, bowls, and trays should be air dried first before stacking. The Administrator stated the pureed mixer top should be cleaned prior to placing it back on the mixer. The Administrator stated the Dietary Manager was responsible for monitoring and overseeing. The Administrator stated these failures could potentially put residents at risk for cross contamination, and food borne illness. Record review of the facility's policy titled, Dietary Food Service Personnel Policy and Procedures 2012 reflected .Work Conduct: 3. All personal belongings (cell phones, and purses.) must be kept out of the food preparation area.Sanitation and Food Handling: 2. Hair nets or hat covering the hairline are worn at all times. 9. All utensils, pots, and pans must be properly washed and sanitized after use.Dishwashing Preparation and Dishwashing. f. Towel drying of dishes and utensils is not permitted. They must be air dried.Dry Storage and Supplies. the policy did not address dating food products. Record review of FDA 2-402.11, dated 2022, revealed FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE_SERVICE and SINGLE-USE ARTICLES.

Based on observation, interview and record review the facility failed to ensure menus met the nutritional needs of residents in accordance with established guidelines were followed for 1 of 1 meal (the lunch meal) reviewed for nutritional adequacy. The facility did not ensure 2 fish tacos were given to residents on 03/10/26. This failure could place residents at risk of a decrease in resident choices, diminished interest in meals, and weight loss. Findings include:. Record review of the undated, extended week four menu reflected 2 crispy fish tacos. During an observation and interview during the lunch meal on 03/10/2026 starting at 12:30 PM, seven residents in the secure unit dining room received one fish taco instead of two fish tacos. LVN C stated she did not notice the residents' meal tickets indicated they should have received two fish tacos. LVN C stated she did not check the trays because they were checked by the nurses in the main dining room, LVN A and the Treatment Nurse, and if they checked them, she did not. LVN C stated it was important for the residents to receive their meals as specified on their meal tickets to ensure they received the proper nutrition and protein intake. During an observation of the lunch meal on 03/10/26 starting at 12:38 p.m., seven residents in the main dining room received one fish taco instead of two fish tacos. During an interview on 03/11/26 at 3:56 p.m., [NAME] B stated she was responsible for ensuring the correct portions sizes were served. [NAME] B stated she knew the correct serving size, but the residents did not like this meal, so she only gave them one. [NAME] B stated the residents knew they could ask for more. [NAME] B stated it was important to follow the menu to ensure the residents received the correct calorie count. During a telephone interview on 03/12/26 at 11:42 p.m., the Dietician stated she expected [NAME] B to follow the menu. The Dietician stated the cooks should be reviewing the tray card to ensure it matched the menu and the correct portion size. The Dietician stated the nurses should be checking the tray at the door to ensure all items were available prior to serving residents. The Dietician stated she monitored by checking the test trays monthly for portion sizes and verbally speaking with the Dietary Manager and residents. The Dietician stated it was important menus were followed to meet the residents' needs. During an interview on 03/12/26 at 1:40 p.m., LVN A stated she was responsible for checking the lunch tray ticket to ensure the plate matched the ticket. LVN A stated she was focused on the diet instead of the amount of food. LVN A stated it was important menus were followed to prevent weight loss. During an interview on 03/12/26 at 1:45 p.m., the Treatment Nurse stated she was responsible for checking the tickets to ensure it was the correct portion size prior to serving the residents. The Treatment Nurse stated she was focused on ensuring the residents received the correct diet than the amount. The Treatment Nurse stated it was important menus were followed to prevent weight loss. During an interview on 03/12/26 at 2:21 p.m., the Dietary Manager stated the cook was responsible for the serving of the meal. The Dietary Manager stated [NAME] B should have had the extended menu visible while preparing the trays even if she felt the residents did not like the meal. The Dietary Manager stated the nurses should have reviewed the tray card prior to serving the residents to ensure the tray was accurate. The Dietary Manager stated she monitored by visual observation of meal service and in service staff. The Dietary Manager stated it was important menus were followed to prevent weight loss. During an interview on 03/12/26 at 3:18 p.m., the DON stated she expected the menu to be followed. The DON stated she expected the nurses to check the trays prior to serving the resident. The DON stated her and the ADON were responsible for monitoring and overseeing by observation of meal service. The DON stated it was important menus were followed to ensure the residents received the proper diet. During an interview on 03/12/26 at 3:48 p.m., the Administrator stated [NAME] B should have reviewed the lunch tray card as prepared the trays and as the nurse checked the tray card and diet consistency they would have been mindful of portion size. The Administrator stated the Dietary Manager was responsible for monitoring and overseeing. The Administrator stated it was important menus were followed to prevent weight loss and malnutrition. Record review of the facility's policy titled Standardized Portions, 2012, reflected . We will strive to assure the resident's nutritional needs are provided based on the RDA. The standard menu will ensure nutritional adequacy of all diets, offer a variety of food in adequate amounts at each meal, and standardize food production.4. If any meal served varies from the planned menu, the change and reason for the change shall be noted on the substitution log. 5. The menus will be prepared as written using standardized recipes. The Dietary Service Manager and cooks are trained in and responsible for the preparation and service of therapeutic diets as prescribed.

Based on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment, for 3 of 6 residents (Resident's #52, #1 and #39) reviewed for care plans.1.The facility failed to ensure Resident #52 and Resident #1 were care planned for use of Eliquis (a prescription anticoagulant (blood thinner) used to reduce stroke risk in nonvalvular atrial fibrillation (fast, uneven heartbeat), to treat or prevent deep vein thrombosis (a serious condition where a blood clot forms in a deep vein, usually in the legs, causing symptoms like swelling, pain, warmth, and redness), and pulmonary embolism (blockage in a lung artery). 2.The facility failed to ensure Resident #39 was care planned for the use of Refresh Tears Ophthalmic Solution (quickly alleviates dryness, irritation, and discomfort by replenishing moisture to the eyes.)These failures could place residents at risk of not receiving appropriate interventions to meet their current needs.Findings included:1. Record review of Resident #52's face sheet, dated 03/16/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #52 had diagnoses which included Atrial fibrillation also known as AFib (is an irregular and often very rapid heart rhythm), stroke, diabetes (high blood sugar), and high blood pressure.Record review of Resident #52's quarterly MDS assessment, dated 12/31/25, reflected Resident #52 sometimes made herself understood and was usually understood by others. Resident #52's BIMS score was 05, which indicated her cognition was severely impaired. Resident #52 used anticoagulant during the 7-day look back period.Record review of Resident #52 's physician orders, dated 04/04/25 reflected, Eliquis Oral Tablet 5 milligram (Apixaban) Give 1 tablet by mouth two times a day related to atrial fibrillation.Record review of Resident #52's care plan, last review date of 01/07/26, did not reflect she had an anticoagulant care plan. 2. Record review of Resident #1's face sheet, dated 03/16/26, reflected an [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #1 had diagnoses which included pneumonia (an infection that inflames the air sacs in one or both lungs), dementia (loss of memory), Dysphagia (problem swallowing), and high blood pressure.Record review of Resident #1's admission 5-day MDS assessment, dated 02/27/26, reflected Resident #1 sometimes made himself understood and was sometimes understood by others. Resident #1's BIMS score was 04, which indicated his cognition was severely impaired. Resident #1 used anticoagulants during the 7-day look back period.Record review of Resident #1's physician orders, dated 02/13/26, reflected Eliquis Oral Tablet 5 MG (Apixaban) Give 1 tablet by mouth two times a day related to prevention.Record review of Resident #1's care plan, dated 02/13/26, did not reflect he had an anticoagulant care plan.3. Record review of Resident #39's face sheet, dated 03/16/26, reflected Resident #39 was an [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #39 had diagnoses which included detachment of the retina of the left eye (a serious eye condition that affects your vision), and macula of the left eye (a small, central area of the retina responsible for sharp, detailed, and color central vision, essential for reading and driving).Record review of Resident #39's quarterly MDS assessment, dated 01/26/26, reflected Resident #39 understood and was understood by others. Resident #39 had a BIMS score of 15, which indicated he was cognitively intact. The MDS assessment did not reflect Resident #39 had received eye medication within the last 7 days of the look-back period. Record review of Resident #39's care plan, last reviewed on 12/12/25, did not reflect a care plan for his dry eyes. Record review of Resident #39's physician order, dated 12/18/25, reflected Refresh Tears Ophthalmic Solution 0.5 % (Carboxymethylcellulose Sodium). Instill 1 drop in both eyes two times a day for dry eyes.During an interview on 03/13/26 at 11:01 a.m., the MDS Nurse said she was responsible for long term care residents care plans. She looked at Resident #52, and Resident #1's care plan and said she did not see the medication of Eliquis for anticoagulant or eye drops for Resident #39 on his care plan. She said those medications and interventions should have been added to their care plan when she did their MDS assessment. She said it must have been an oversight. She said care plans reflected the care of the residents, what problems they might have and what staff should be doing to monitor their care. She said the risk of not having medications on their care plan was they could potentially have interventions missed.During an interview on 03/13/26 at 12:13 p.m., the DON looked and verified Resident #52 and Resident #1 did not have a care plan for the medication of Eliquis nor did Resident #39 have a care plan for his eye drops. She said the IDT was responsible for ensuring all care plans were started and/or updated as needed during their weekly meetings. She said she did random checks in their weekly meetings to make sure the care plans were done. She said if care plans were not done, it could place residents at risk of not being properly cared for and nurses not knowing their needs. During an interview on 03/13/26 at 1:04 p.m., the Administrator said the MDS nurse was responsible for care plans. She said care plans were done to paint a picture of the resident care. She said if the care plans were not done the nurses would not know about the residents' care or what they would need to monitor.Record review of the facility's, undated, policy titled, Comprehensive Care Planning, from the Nursing Policy & Procedure Manual, reflected, The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. A comprehensive care plan will be- Developed within 7 days after completion of the comprehensive assessment. The resident's care plan will be reviewed after each Admission, Quarterly, Annual and/or Significant Change MDS assessment, and revised based on changing goals, preferences, and needs of the resident and in response to current interventions.

Based on observation, interview, and record review the facility failed to ensure, based on comprehensive assessment of resident, that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choice for 1 of 6 residents (Resident #42) reviewed for quality of care. The facility failed to ensure LVN F clarified orders for ibuprofen (a non-steroidal anti-inflammatory drug used to decrease pain and swelling), after Resident #42 had oral surgery on 03/10/26, and her postoperative recommendations indicated to administer ibuprofen for pain and swelling. This failure could place residents at risk of a delay in treatment for the residents' conditions.Findings include: Record review of Resident #42's face sheet, dated 03/12/26, indicated a [AGE] year-old female who was re-admitted to the facility on [DATE]. Resident #42 had diagnoses which included dementia (a progressive decline in mental ability that interferes with daily life), major depressive disorder (serious mental health disorder characterized by persistent low mood and low self-esteem), heart disease, and high blood pressure. Record review of Resident #42's quarterly MDS assessment, dated 01/27/26, indicated she made herself understood and she understood others. Resident #42 had a BIMS score of 15, which meant she was cognitively intact. Resident #42 required total staff assistance with toileting, maximal assistance from staff for transfers, bed mobility, and showers, and she was independent with eating. Record review of Resident #42's care plan indicated: Resident #42 had a behavior problem related to occasional verbal outburst with staff yelling and argumentative with interventions for the staff to administer medications as ordered, anticipate and meet resident needs, explain all procedures, and minimize potential for resident behaviors with date initiated 10/31/25. Resident #42 had mouth surgery to monitor vital signs and report changes as needed with date initiated 03/11/26. There were no interventions included to address management of her pain after her mouth surgery. Record review of Resident #42's, undated, postoperative care instructions following her oral surgery on 03/10/26 indicated she was prescribed pain medication (hydrocodone-acetaminophen 5-325mg oral tablet), an antibiotic (amoxicillin oral capsule 500mg tablet), and to manage her pain it was recommended to alternate the prescribed pain medication with an NSAID (i.e. Ibuprofen 800 mg every 4 hours) and to swish with warm salt water (1/4 tsp salt +1 cup warm water) 3-4 times day. Record review of Resident #42's order summary report, dated as of 03/12/26, indicated she had an order for:1) amoxicillin oral capsule 500 MG Give 1 capsule by mouth four times a day for post oral surgery for 7 days with a start date of 03/11/26 and end date of 03/18/26.2) hydrocodone-acetaminophen oral tablet 5-325mg (hydrocodone-acetaminophen) give 1 tablet mouth every 6 hours as needed for post oral surgery with a start date of 03/10/26 with no end date. 3) ibuprofen oral tablet 200mg (ibuprofen) give 2 tablets by mouth every 4 hours for pain for 7 days while awake with a start date of 03/11/26 and an end date of 03/18/26.4) swish with warm salt water (1/4 tsp salt +1 cup warm water) 3-4 times a day, especially after eating, every 5 hours as needed for post op oral surgery 1/4 tsp salt+1 cup warm water) with a start date of 03/11/26 and no end date. 5) Tylenol oral tablet 325 MG (acetaminophen) Give 2 tablets by mouth every 6 hours as needed for elevated temperature; pain (2) 325mg tablets to equal 650 mg. not to exceed 3 gram/24 hours from all sources with a start date of 03/10/26 During an observation and interview on 03/11/26 at 8:45 AM, Resident #42 was in her room lying in her bed with some noted swelling to her mouth. Resident #42 said she was upset because LVN F argued with her all night over the medication orders the oral surgeon had given after her oral surgery on 03/10/2026. Resident #42 said after her oral surgery was on 03/10/2026, she returned to the facility in the evening, and LVN F refused to listen to her when she told her the instructions were that she received ibuprofen and Tylenol to help with her pain and swelling. Resident #42 said if LVN had followed the instructions from the oral surgeon, her mouth would not have swollen like it had since she returned to the facility. During an interview on 03/12/26 at 4:56 PM, LVN F said she worked on 03/10/26 from 6:00 PM until 03/11/2026 at 6:00 AM. LVN F said she received information in report that Resident #42 had oral surgery and she had a copy of the postoperative care following oral surgery for Resident #42. LVN F said Resident #42 was a challenge and Resident #42 had an issue every time she entered her room. LVN F said Resident #42 kept asking her to administer ibuprofen. LVN F said she was aware Resident #42's instructions indicated for her to receive ibuprofen as needed, but since there was no order in Resident #42's electronic medical record she did not administer it. LVN F said she should have called the doctor and received clarification for the medications Resident #42 was requesting, and this would have prevented all the problems with Resident #42, but she said she did not have time. LVN F said she did say that's why you are in a nursing home but she was talking to herself, she did not direct it at Resident #42. She said she understood why saying that could have made Resident #42 upset, feel bad, or feel as though she could not rely on her to take care of her. During an interview on 03/13/26 at 1:44 PM, the DON said the instructions Resident #42 arrived at the facility with, after her oral surgery, were only recommendations. The DON said she expected LVN F to listen to Resident #42, if she was requesting pain medications, and call the doctor to get orders for the ibuprofen, which was recommended on 03/10/26. The DON said failure of LVN F not getting orders clarified to start ibuprofen on 03/10/26 could have caused Resident #42 increased swelling or pain. The DON said she did not notice Resident #42 had facial swelling/bruising on 03/11/2026 when she observed her. During an interview on 03/13/26 at 1:54 PM, the Administrator said when Resident #42 returned to the facility after her oral surgery with postoperative recommendations LVN F should have called the doctor and received clarification for the medications recommended. The Administrator said not receiving clarification on the medications to administer to Resident #42 for her pain placed Resident #42 at risk of having discomfort. During an interview on 03/13/26 at 2:16 PM, the Administrator said they did not have a policy on quality of care. Record review of the facility's, undated, Physician's Orders policy indicated, Purpose: To monitor and ensure the accuracy and completeness of the medication orders, treatment orders, and ADL order for each resident. Person responsible: Medical Records/Designee Written Orders by the Physician or Nurse Practitioner 1. Nurse will review the order and if needed contact the prescriber for any clarifications.

Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level 1 assessment accurately reflected the resident's status for 2 of 5 residents (Resident #2, Resident #6) reviewed for PASRR Level 1 screenings. 1. The facility failed to ensure the PASRR Level 1 screening for Resident #2 was completed and submitted upon admission date of 08/14/24. 2.The facility failed to ensure the accuracy of the PASRR Level 1 screening for Resident #6. The PASRR 1 Level screening did not indicate a diagnosis of mental illness PTSD (post-traumatic stress disorder), although the diagnosis was present upon admission date on 05/01/25. These failures could place residents who had a mental illness at risk of not receiving a needed assessment (PASRR Evaluation), individualized care, or specialized services to meet their needs. Findings included: 1. Record review of Resident #2's face sheet dated 03/12/26 indicated she was a [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses which included dementia (a progressive decline in mental ability that interferes with daily life), bipolar disorder (chronic mental health condition characterized by extreme mood swings), and high blood pressure. Record review of Resident #2's quarterly MDS assessment dated [DATE] indicated she was able to make herself understood and she understood others. The MDS also indicated she had a BIMS score of 4 which indicated she had severely impaired cognition. Record review of Resident #2's PASRR Level 1 screening indicated it was completed after surveyor intervention on 03/12/26. During an interview on 03/12/26 at 4:25 PM the MDS Nurse said she guessed she just missed completing the PASRR Level 1 screening for Resident #2. The MDS Nurse said Resident #2 was private pay so she was unsure of what the risk would have been, but the PASRR Level 1 should have been completed upon admission. 2. Record review of Resident #6's face sheet dated 03/12/26 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with the diagnoses which included PTSD (mental health condition triggered by experiencing or witnessing terrifying events such as combat, abuse, or disasters), chronic obstructive pulmonary disease (progressive treatable lung disease that causes breathing difficulties), depression (common, serious mental health disorder characterized by low mood and loss of interest), and high blood pressure. Record review of Resident #6's quarterly MDS assessment dated [DATE] indicated he was able to make himself understood and understood others. The MDS also indicated Resident #6 had a BIMS score of 10 which indicated he had moderate cognitive impairment. The MDS also indicated Resident #6 had an active mood disorder, PTSD and depression. Record review of Resident #6's PASRR Level 1 screening dated 05/01/25 indicated it was completed and was marked negative for mental illness, intellectual disability, and developmental disability for Resident #6. Record review of Resident #6's comprehensive care plan dated 06/16/25 indicated he had PTSD and depression. During an interview on 03/13/26 at 11:15 AM The MDS Nurse said she refreshed her brain (thought about the positive PASRR diagnosis again) and should have listed PTSD as a yes on the PASRR for a mental illness. The MDS Nurse said she was unclear of why the correct information for mental illness was missing on the PASRR but knowing Resident #6 prior to admission, she did not realize the PASRR would have been positive. The MDS Nurse said she would have to do another PASRR for Resident #6 and notify the local authority (the company responsible for the PASRR process and inputting the PASRR evaluations into the system) for the facility. The MDS Nurse said the failure of the PASRR not being completed correctly placed a risk for residents not receiving services that residents could have from PASRR. During an interview on 03/13/26 at 2:08 PM the Administrator said she knew the PASRRs were timely and difficult (they took a lot of time and they were difficult to complete) but the completion of the PASRR gets the residents therapy, extra habilitation, and special equipment. The Administrator said she expected the PASRR to be input on admission and she expected them to be input correctly for diagnoses that were active for the residents for the residents to get the services they needed. Record review of the facility policy revised 03/06/19, PASRR Level 1 Screen Policy and Procedure indicated: Policy: It is the policy of facilities to obtain a PL1 screening form from the RE (referring entity) prior to admission to the NF. The PL1 will be submitted via Simple LTC (system used for data analytics for long-term care facilities) timely per PASRR Regulatory timeframes. PASRR is a federally mandated program requiring all states to pre-screen all individuals seeking admission to a Medicaid-certified nursing facility, regardless of payor source or age. The PASRR Program is important because it provides options for individuals to choose where they live, who they live with and the training and therapy they need to live as independently as possible.Procedure: 1. The Facility Admissions process will ensure a PL1 Screening Form is obtained from the RE on day of admission or prior to admission. A PL1 is obtained for every individual, regardless of payment type, seeking admission to a Medicaid-certified NF. 4. The Facility will enter the PL1 Form exactly as written except for corrections to identifying data. It is critical to submit timely PL1's due to the following: Late submission can cause delays in obtaining PASRR specialized services; Delays may cause difficulties entering the LTCMI form; HHS interpretive guidelines state the PL1 must be entered into the Portal upon admission or 72 hours after admission at the latest, but not before admission; and Submitting a PL1 months after an individual discharged or passed away (with dates of assessment after the individual left) could be considered fraud.

Based on interview and record review the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care for 1 of 2 residents (Resident #63) reviewed for baseline care plans.The facility failed to address Resident #63's dialysis on his baseline care plan.This deficient practice could place residents at risk of missed care or not receiving necessary care and services.Findings included:1. Record review of Resident #63's face sheet, dated 03/16/26 indicated Resident #63 was a [AGE] year-old male who was admitted to the facility on [DATE] with a diagnosis which included renal failure or kidney failure (occurs when kidneys cannot adequately filter waste from the blood, often resulting from diabetes or high blood pressure).Record review of Resident #63's medical record revealed the resident did not have an MDS in his medical record.Record review of Resident #63's physician order report, dated 03/08/26, indicated dialysis on Tuesday, Thursday, and Saturday chair time at 11:45am for diagnosis of renal failure.Record review of Resident #63's care plan, dated 03/09/26, did not indicate Resident #63 had a baseline care plan that addressed his dialysis.During an interview on 03/11/26 at 10:43 a.m., Resident #63 said he went to dialysis on Tuesday, Thursday, and Saturday. He said he went yesterday (03/10/26). During an attempted interview on 03/12/26 at 10:00 a.m., LVN J did not answer her phone, a message was left (nurse who did the baseline care plan).During an interview on 03/13/26 at 11:01 a.m., the MDS Nurse said she was responsible for long term care residents care plans. She said the charge nurse initiated the baseline care plan and then when she completed the initial MDS assessment she would complete the care plan based off the MDS indicators. She looked and verified Resident #63 did not have a baseline care plan for dialysis. She said care plans reflected the care the resident should receive. She said risk could be interventions could be missed.During an interview on 03/13/26 at 12:13 p.m., the DON looked and verified Resident #63 did not have a baseline care plan for his dialysis. She said the charge nurse was responsible for initiating the baseline care plan and the MDS Nurse was responsible for completing the base line care plans once she completed the first MDS assessment. She said the IDT was responsible for ensuring all care plans were correct and she did random checks of care plans in their weekly meetings. She said if the care plan was not done it could place Resident #63 at risk of not being properly cared for and nurses not knowing his needs. During an interview on 03/13/26 at 1:04 p.m., the Administrator said she expected the baseline care plans to include Resident #63's dialysis. The Administrator said the admission nurses were responsible for starting the baseline care plan. She said the MDS nurse was the overseer of care plans. She said without dialysis being on Resident #63's baseline care plan it could place him at risk because of the nurses not knowing what to look for and/or monitor.Record review of the facility policy titled Baseline Plan of Care, undated indicated, Completion and implementation of the baseline care plan within 48 hours of a resident's admission intended to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission.This facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care.

Based on observation, interviews, and record review, the facility failed to ensure the services provided, as outlined by the comprehensive care plan, met professional standards of quality, for 2 of 6 residents (Residents #47, and #7) reviewed for services provided to meet professional standards. 1. The facility did not ensure LVN A administered 2 puffs of Albuterol (medication used to prevent and treat wheezing, difficulty breathing, chest tightness and coughing) HFA Sulfate Inhalation Aerosol Solution instead of 1 puff to Resident #47. 2. The facility did not ensure LVN A primed Resident #7's Novolog FlexPen (insulin medication) according to the manufacturer's instructions. These failures could place residents at risk of inaccurate drug administration and not receiving the care and services to meet their individual needs. Findings included:1. Record review of Resident #47's face sheet, dated 03/12/26, reflected Resident #47 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnosis which included COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of Resident #47's quarterly MDS assessment, dated 01/05/26, reflected Resident #47 made herself understood, and understood others. Resident #47's BIMS score was 10, which reflected her cognition was moderately impaired. Record review of Resident #47's comprehensive care plan, revised on 08/14/25, reflected Resident #47 had Emphysema (long term lung condition that caused SOB)/COPD. The care plan interventions included give aerosols (spray that deliver medication directly to the lungs) or bronchodilators (medications that relax lung muscles and widen airways to help with breathing) as ordered. Record review of Resident #47's physician order summary report, dated 03/12/26, reflected Resident #47 had an active order for Albuterol HFA Sulfate Inhalation Aerosol Solution:180 (90 base) mcg/act: 2 puffs inhaled orally every six hours for COPD with a start date 03/19/25. During an observation and interview on 03/10/26 at 11:24 a.m., LVN A handed Resident #47 her inhaler and asked her to inhale 1 puff. Resident inhaled 1 puff and LVN A then handed Resident #47 a glass of water to rinse her mouth out. Once Resident #47 rinsed her mouth out, LVN A left the room. The state surveyor asked LVN A if Resident #47 should have gotten 1 puff or 2 puffs of her inhaler. LVN A stated Resident #47 should have gotten 2 puffs. She went back into the room and had Resident #47 inhale a second puff of her inhaler. LVN A said she usually did not walk Resident #47 through the steps of using her inhaler. She said she normally handed Resident #47 the inhaler and Resident #47 knew how to inhale 2 puffs. She stated that since the state surveyor was present, she failed to instruct Resident #47 to inhale 2 puffs. LVN A stated it was important for Resident #47 to receive the accurate dose of her breathing medication to prevent an exacerbation of breathing problems such as shortness of breath or dizziness that could have led to hospitalization. 2. Record review of Resident #7's face sheet, dated 03/12/26, reflected Resident #7 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnosis which included Type 2 diabetes mellitus (chronic condition where the pancreas makes little or no insulin, which leads to high blood sugar levels) with other specified complications. Record review of Resident #7's quarterly MDS assessment, dated 12/10/25, reflected Resident #7 made herself understood, and understood others. Resident #7's BIMS score was 15, which reflected her cognition was intact. Record review of Resident #7's comprehensive care plan, revised 02/24/26, reflected Resident #7 had Diabetes Mellitus. The care plan interventions included diabetes medication as ordered by the doctor, monitor/document for side effects/effectiveness and fasting serum blood sugar as ordered by the doctor. Record review of Resident #7's physician order summary report, dated 03/12/26, reflected Resident #7 had an active order for Novolog FlexPen: inject as per sliding scale. 1 unit.subcutaneously before meals and at bedtime related to diabetes mellitus with a start date 02/10/26. Record review of the licensed nurse proficiency audit dated 12/04/25 completed by the ADON reflected LVN A had been checked for insulin administration. During an observation and interview on 03/11/26 at 11:31 a.m., LVN A prepared Resident #7's Novolog FlexPen by removing the pen cap, placing a needle onto the pen, and turning the dose knob to 1 unit. LVN A administered the medication to Resident #7's LLQ. LVN A did not prime (removing the air from the needle and cartridge) the insulin pen by turning the dose knob into 2 units before turning the dose knob to 1 unit. LVN A stated she had never primed the insulin pen before administering Resident #7's insulin. LVN A stated it was important to ensure insulin was administered by the manufacturer's instructions to ensure the residents get the correct dosage. During a telephone interview on 03/12/26 at 2:56 p.m., the Pharmacist Consultant stated the insulin pen should be primed 2 units for the 1st use. The Pharmacist Consultant stated she did a medication pass every other month but had not watched insulin administration. The Pharmacist Consultant stated it was not much of a risk if she did not prime the insulin prior to administering the 1 unit. During an interview on 03/12/26 at 3:18 p.m., the DON stated she expected LVN A and the treatment nurse to follow the doctor's order. The DON stated if the Treatment Nurse was within the timeframe, she could have finished her medication pass and went back and got nasal spray out of the nurse's cart and administered the medication. The DON stated her expectation was for an insulin pen to have the needle prime with 2 units by releasing of air and then reset to dose of insulin the resident needed and administer the medication. The DON stated her and the ADON were responsible for medication administration compliance through competency check and random medication administration observations. The DON stated it was important that Resident #47 received 2 puffs instead of 1 puff to prevent SOB or wheezing. The DON stated it was important that Resident #52 received her nasal spray to prevent congestion or worsening of her allergies. The DON stated there was no risk of not priming the insulin prior to administration. During an interview on 03/12/26 at 3:48 p.m., the Administrator stated she expected doctor orders to be followed and administered within the timeframe. The Administrator stated it was best practice to prime the Novolog FlexPen 2 units before administering the 1 unit to get the most accurate dosage. The Administrator stated the DON or designee were responsible for monitoring and overseeing medication administration. The Administrator stated these failures could potentially cause SOB, respiratory distress, allergy discomfort and inaccurate dose. Record review of the manufacturer's guideline titled Novolog (insulin apart) injection Pen fill revised 02/2023, reflected. injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing: E. turn the dose select to select 2 units. Record review of the Subcutaneous Injection Administration policy, dated 3/2025, reflected. Insulin Injection. 1. Assure type of insulin, unit dosage. Record review of the Medication Administration and General Guidelines policy, dated 3/2025, reflected. Medications are administered as prescribed. 2. Medications are administered in accordance with written orders of the attending physician. checklist for completing proper steps in the administration of medications. Adhere to the 6 rights of medication administration. (1) right dose. (5) right time.

Based on interview and record review the facility failed to ensure the residents had a right to secure and confidential personal medical records and privacy during medical treatments for 1 of 22 residents (Resident #5) reviewed for resident rights. The facility did not ensure the Treatment Nurse used a secure telephonic device to communicate about Resident #5's medications with the facility Medical Director. This failure could place residents at risk for diminished quality of life, loss of dignity, self-worth and breach of confidentiality. Findings included:Record review of Resident #5's face sheet dated 03/12/26, reflected Resident #5 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnosis which included essential hypertension (high blood pressure). Record review of Resident #5's quarterly MDS assessment, dated 12/19/25, reflected Resident #5 usually made herself understood, and usually understood others. Resident #5's BIMS score was 11, which reflected her cognition was moderately impaired. Record review of Resident #5's comprehensive care plan, revised on 12/21/25, reflected Resident #5 had hypertension. The care plan interventions included give anti-hypertensive medications as ordered. Record review of Resident #5's physician order summary report, dated 03/12/26, reflected Resident #5 had an active order for Amlodipine Besylate 5mg; 1 tablet by mouth one time a day related to essential hypertension. The order reflected to hold for SBP (measured the blood was pushing against the artery walls when the heart beats) below 100, DBP (measured the blood pushing against the artery walls when the heart rests between beats) below 60 or heart rate less than 60 with a start date 12/17/25. Record review of Resident #5's physician order summary report, dated 03/12/26, reflected Resident #5 had an active order for Losartan Potassium 50 mg; 1 tablet by mouth one time day related to essential hypertension. The order reflected to hold for SBP (measured the blood was pushing against the artery walls when the heart beats) below 100, DBP (measured the blood pushing against the artery walls when the heart rests between beats) below 60 or heart rate less than 60 with a start date 12/17/25. Record review of a text message dated 03/11/26 beginning at 8:23 a.m. between the Treatment Nurse and the Medical Director reflected a message from her personal cell phone that stated Resident #5's full name that her blood pressure was 177/59 and it was below parameter, but it concerned her and was it ok to still give blood pressure medications. During an interview on 03/11/26 at 1:19 p.m., the Treatment Nurse stated the facility did not have an app to coordinate with the physician. The Treatment Nurse stated she was told by other nurses that the physician preferred to be notified via phone call. The Treatment Nurse stated she had contacted the physician via phone call, but he did not answer so she sent a text message. The Treatment Nurse stated Resident #5 was not a resident that the facility had to contact the physician regularly and she was not sure if he was familiar with her. The Treatment Nurse stated she should have put the resident room number instead of her full name. The Treatment Nurse stated this failure was a HIPPA violation and put Resident #5 at risk for confidentiality of her personal medical records. During a telephone interview on 03/12/26 at 3:23 p.m., the Medical Director stated he would like to be notified via phone or text. The Medical Director stated it was ok for the Treatment Nurse to text the resident full name using her personal cell phone. During an interview on 03/12/26 at 3:18 p.m., the DON stated staff normally notify the physician either by text or phone using their personal cell phone. The DON stated it was ok for the Treatment Nurse to put Resident #5's full name in the text message. During an interview on 03/12/26 at 3:48 p.m., the Administrator stated staff coordinated with the physicians via phone call or text using their personal cell phone. The Administrator stated she was not aware of staff texting the resident's full name. The Administrator stated the ideal would be to text the initials of the resident or their room number. The Administrator stated Resident #5's personal medical records could be comprised. The Administrator stated there was not a system in place for monitoring and overseeing the release of secured information. Record review of facility undated policy titled, Resident Rights did not address confidentiality of personal and medical information.

Based on interview and record review, the facility failed to make a comprehensive assessment of each residents' needs, strengths, goals, life history, and preferences within 14 calendar days after admission for 1 of 22 residents (Resident #19) reviewed for timeliness of assessments. The facility failed to complete Resident #19's admission MDS assessment, with an assessment reference date of 03/03/2026, within 14 days of admission. This failure could place residents at risk of not having their needs met.Findings included: Record review of a face sheet dated 03/13/2026 indicated Resident #19 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included severe dementia with other behavioral disturbance (severe loss of memory, language, problem solving and other thinking abilities severe enough to interfere with daily life with behaviors), hypertension (high blood pressure), and chronic kidney disease stage 3 (moderate reduction in kidney function). Record review of Resident #19's electronic health record on 03/10/2026 and 03/11/2026 indicated her admission MDS assessment with an assessment reference date of 03/03/2026 was in progress. Resident #19's electronic health record on 03/12/2026 indicated her admission MDS assessment had been completed. Record review of Resident #19's Comprehensive MDS assessment with an assessment reference date of 03/03/2026 indicated in Section A0310 it was an admission assessment (required by day 14). The MDS assessment for Resident #19 indicated in Section A1600 an entry date of 02/18/2026. Resident #19's MDS assessment in Section Z0500B was signed completed on 03/04/2026. In Section Z0400 the MDS Coordinator signed Sections I8000H, I8000I, I8000J on 03/12/2026. During an interview on 03/13/2026 at 10:53 AM, the MDS Coordinator said she sent the DON a list of MDS assessments that needed to be signed. The MDS Coordinator said the admission MDS assessment should be completed within 14 days from the date of admission. She said Resident #19's admission assessment should have been completed by 03/03/2026. The MDS Coordinator said Resident #19's MDS assessment with an ARD of 03/03/2026 should have been signed completed by the DON on 03/12/2026, and she must have sent the wrong signature date to the DON. The MDS Coordinator said she completed Resident #19's admission MDS assessment late because she was gathering information. The MDS Coordinator said it was important for the MDS assessments to be completed within the required timeframes for accurate reflection of the residents' care and to update the residents' care plans. During an interview on 03/13/2026 at 1:18 PM, the DON said she believed the admission assessment should be completed within 5 days of admission, but she was not familiar with the required timeframes. The DON said the MDS Coordinator sent her a list of MDS assessments that needed to be signed. The DON said when she signed Resident #19's MDS assessment with the date of 03/03/2026, she did not notice there was a signature from the MDS Coordinator on 03/12/2026. The DON said sine the MDS Coordinator signed sections on 03/12/2026, the MDS assessment should have been signed completed on 03/12/2026. The DON said it was important for the MDS assessments to be completed within the required timeframes to ensure they captured the right amount of care for the residents and so it did not affect billing. During an interview on 03/13/2026 at 1:34 PM, the Administrator said she expected the MDS assessments to be completed by the MDS Coordinator with the required timeframes. The Administrator said it was important for the MDS assessments to be completed within the required timeframes to ensure the best healthcare practices and because it reflected the patient care. During an interview on 03/13/2026 at 2:54 PM, the Regional Compliance Nurse said they did not have a policy for MDS assessments that they followed the Resident Assessment Instrument manual. Record review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11 updated October 2023 indicated, For the admission assessment, the MDS Completion Date (Z0500B) must be no later than 13 days after the Entry Date (A1600).

Based on observation, interview and record review, the facility failed to ensure that its medication error rate was not 5 percent or greater. The facility had a medication error rate of 10%, based on 2 errors out of 30 opportunities, which involved 2 of 6 residents (Residents #47 and #7) reviewed for medication administration. 1. The facility did not ensure LVN A administered 2 puffs of Albuterol (medication used to prevent and treat wheezing, difficulty breathing, chest tightness and coughing) HFA Sulfate Inhalation Aerosol Solution instead of 1 puff to Resident #47. 2. The facility did not ensure LVN A primed Resident #7's Novolog FlexPen (insulin medication) according to the manufacturer's instructions. These failures could place residents at risk of not receiving therapeutic effects of their medications and possible adverse reactions. Findings included:1. Record review of Resident #47's face sheet, dated 03/12/26, reflected Resident #47 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnosis which included COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of Resident #47's quarterly MDS assessment, dated 01/05/26, reflected Resident #47 made herself understood, and understood others. Resident #47's BIMS score was 10, which reflected her cognition was moderately impaired. Record review of Resident #47's comprehensive care plan, revised on 08/14/25, reflected Resident #47 had Emphysema (long term lung condition that caused SOB)/COPD. The care plan interventions included give aerosols (spray that deliver medication directly to the lungs) or bronchodilators (medications that relax lung muscles and widen airways to help with breathing) as ordered. Record review of Resident #47's physician order summary report, dated 03/12/26, reflected Resident #47 had an active order for Albuterol HFA Sulfate Inhalation Aerosol Solution:180 (90 base) mcg/act: 2 puffs inhaled orally every six hours for COPD with a start date 03/19/25. During an observation and interview on 03/10/26 at 11:24 a.m., LVN A handed Resident #47 her inhaler and asked her to inhale 1 puff. Resident #47 inhaled 1 puff and LVN A then handed Resident #47 a glass of water to rinse her mouth out. Once Resident #47 rinsed her mouth out, LVN A left the room. The state surveyor asked LVN A if Resident #47 should have gotten 1 puff or 2 puffs of her inhaler. LVN A stated Resident #47 should have gotten 2 puffs. She went back into the room and had Resident #47 inhale a second puff of her inhaler. LVN A said she usually did not walk Resident #47 through the steps of using her inhaler. She said she normally handed Resident #47 the inhaler and Resident #47 knew how to inhale 2 puffs. She stated that since the state surveyor was present, she failed to instruct Resident #47 to inhale 2 puffs. LVN A stated it was important for Resident #47 to receive the accurate dose of her breathing medication to prevent an exacerbation of breathing problems such as shortness of breath or dizziness that could have led to hospitalization. 2. Record review of Resident #7's face sheet, dated 03/12/26, reflected Resident #7 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnosis which included Type 2 diabetes mellitus (chronic condition where the pancreas makes little or no insulin, which leads to high blood sugar levels) with other specified complications. Record review of Resident #7's quarterly MDS assessment, dated 12/10/25, reflected Resident #7 made herself understood, and understood others. Resident #7's BIMS score was 15, which reflected her cognition was intact. Record review of Resident #7's comprehensive care plan, revised 02/24/26, reflected Resident #7 had Diabetes Mellitus. The care plan interventions included diabetes medication as ordered by the doctor, monitor/document for side effects/effectiveness and fasting serum blood sugar as ordered by the doctor. Record review of Resident #7's physician order summary report, dated 03/12/26, reflected Resident #7 had an active order for Novolog FlexPen: inject as per sliding scale. 1 unit.subcutaneously before meals and at bedtime related to diabetes mellitus with a start date 02/10/26. Record review of the licensed nurse proficiency audit dated 12/04/25 completed by the ADON reflected LVN A had been checked for insulin administration. During an observation and interview on 03/11/26 at 11:31 a.m., LVN A prepared Resident #7's Novolog FlexPen by removing the pen cap, placing a needle onto the pen, and turning the dose knob to 1 unit. LVN A administered the medication to Resident #7's LLQ. LVN A did not prime (removing the air from the needle and cartridge) the insulin pen by turning the dose knob into 2 units before turning the dose knob to 1 unit. LVN A stated she had never primed the insulin pen before administering Resident #7's insulin. LVN A stated it was important to ensure insulin was administered by the manufacturer's instructions to ensure the residents get the correct dosage. During a telephone interview on 03/12/26 at 2:56 p.m., the Pharmacist Consultant stated the insulin pen should be primed 2 units for the 1st use. The Pharmacist Consultant stated she did a medication pass every other month but had not watched insulin administration. The Pharmacist Consultant stated it was not much of a risk if she did not prime the insulin prior to administering the 1 unit. During an interview on 03/12/26 at 3:18 p.m., the DON stated she expected LVN A and the treatment nurse to follow the doctor's order. The DON stated if the Treatment Nurse was within the timeframe, she could have finished her medication pass and went back and got nasal spray out of the nurse's cart and administered the medication. The DON stated her expectation was for an insulin pen to have the needle prime with 2 units by releasing of air and then reset to dose of insulin the resident needed and administer the medication. The DON stated her and the ADON were responsible for medication administration compliance through competency check and random medication administration observations. The DON stated it was important that Resident #47 received 2 puffs instead of 1 puff to prevent SOB or wheezing. The DON stated it was important that Resident #52 received her nasal spray to prevent congestion or worsening of her allergies. The DON stated there was no risk of not priming the insulin prior to administration. During an interview on 03/12/26 at 3:48 p.m., the Administrator stated she expected doctor orders to be followed and administered within the timeframe. The Administrator stated it was best practice to prime the Novolog FlexPen 2 units before administering the 1 unit to get the most accurate dosage. The Administrator stated the DON or designee were responsible for monitoring and overseeing medication administration. The Administrator stated these failures could potentially cause SOB, respiratory distress, allergy discomfort and inaccurate dose. Record review of the manufacturer's guideline titled Novolog (insulin apart) injection Pen fill revised 02/2023, reflected. injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing: E. turn the dose select to select 2 units. Record review of the Subcutaneous Injection Administration policy, dated 3/2025, reflected. Insulin Injection. 1. Assure type of insulin, unit dosage. Record review of the Medication Administration and General Guidelines policy, dated 3/2025, reflected. Medications are administered as prescribed. 2. Medications are administered in accordance with written orders of the attending physician. checklist for completing proper steps in the administration of medications. Adhere to the 6 rights of medication administration. (1) right dose. (5) right time.

Based on observation, interview, and record review, the facility failed to ensure each resident received and the facility provided food that accommodated resident allergies, intolerances, and preferences for 1 of 1 resident (Resident #54) reviewed for food preferences and the accommodation of resident's meal choices. The facility failed to ensure Resident #54's preference for dislike of corn was honored on 03/10/26. This failure could result in a decrease in resident choices, diminished interest in meals, and weight loss. Findings include: Record review of Resident #54's face sheet, dated 03/12/26, reflected Resident #54 was an [AGE] year-old female, admitted to the facility on [DATE] with a diagnosis which included Alzheimer's (progressive disease that destroys memory and other important mental functions). Record review of Resident #54's quarterly MDS assessment, dated 01/29/26, reflected Resident #54 usually made herself understood, and usually understood others. Resident #54's BIMS score was 4, which reflected her cognition was severely impaired. Resident #54 was independent with eating. Record review of Resident #54's comprehensive care plan, revised on 08/25/25, reflected Resident #54 had a diet order of regular and was at risk for unplanned wight loss or gain. The care plan interventions included determined food preferences and provided within dietary limitations. Record review of Resident #54's order summary report, dated 03/12/26, reflected there was not an order for Resident #54 dislikes. Record review of Resident #54's lunch meal ticket reflected Resident #54 disliked corn. During an observation and interview on 03/10/26 at 12:46 p.m., Resident #54 was served corn. Resident #54 stated she could not have corn due to her diverticulitis (inflammation of irregular bulging pouches in the wall of the large intestines). During an interview on 03/11/26 at 3:56 p.m., [NAME] B stated she was responsible for ensuring Resident #54 received an alternative if corn was on the menu. [NAME] B stated she was unaware Resident #54 did not like corn. [NAME] B stated she should have reviewed the lunch meal ticket before preparing Resident #54's tray. [NAME] B stated she got nervous when the state surveyor was in the building. [NAME] B stated it was important for Resident #54's food dislikes to be followed because it was her right. During a telephone interview on 03/12/26 at 11:42 p.m., the Dietician stated the cooks should be observing the lunch tray card to make sure the residents preferences were being honored. The Dietician stated the nurses should be checking the trays also before the resident was served. The Dietician stated she monitored by observing meal service monthly. The Dietician stated it was important for Resident #54's food dislikes to be followed to meet the resident's needs. During an interview on 03/12/26 at 1:45 p.m., the treatment nurse stated she was responsible for ensuring Resident #54's dislike was not on the tray. The treatment nurse stated she was paying more attention to the diet. The treatment nurse stated it was important for Resident #54's food dislikes to be followed to prevent potential weight loss and her preference was honored. During an interview on 03/12/26 at 2:21 p.m., the Dietary Manager stated the cook was responsible for ensuring she received an alternative if those items were on the menu. The Dietary Manager stated when Dietary Aide D gave [NAME] B the tray, [NAME] B should have read the lunch tray card and reviewed the dislikes/likes. The Dietary Manager stated the nurses should have checked the trays and reviewed the tray card prior to serving the resident to ensure the tray was accurate. The Dietary Manager stated she monitored by observing meal services 2-3 times a week and in serviced staff. The Dietary Manager stated it was important for Resident #54's food dislikes to be followed to honor her wishes. During an interview on 03/12/26 at 3:18 p.m., the DON stated she expected food preferences/dislikes to be followed. The DON stated the nurses should be checking the trays prior to serving the residents and ensure an alternative was given. The DON stated her and the ADON monitored by observing meal service. The DON stated it was important for their food preferences/dislikes to be followed to prevent weight loss or an upset stomach. During an interview on 03/12/26 at 3:48 p.m., the Administrator stated she expected food preferences/dislikes to be followed. The Administrator stated the Dietary Manager was responsible for monitoring and overseeing meal service. The Administrator stated it was important for their food preferences to be followed to prevent a flare up and to honor Resident #54's preference. Record review of the facility's undated policy titled Resident Meal Service and HS Snack reflected, . Mealtimes can be adjusted per resident preference.3. If a resident, make food choices that do not include food items from all of the food groups, this will be addressed individually in the resident's care plan.

Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents (Resident #4) reviewed for infection control. The facility failed to ensure the Wound Treatment Nurse donned a gown when she provided wound care to Resident #4 on 3/12/2026. This failure could place residents at risk for cross-contamination and the spread of infection. Findings include: 1. Record review of Resident #4's face sheet, dated 3/13/2026, indicated an [AGE] year-old male who re-admitted to the facility on [DATE]. Resident #4 had a diagnosis which included non-ST elevation myocardial infarction (a heart attack caused by a partial blockage of a coronary artery, restricting blood flow and causing heart muscle damage). Record review of Resident #4's MDS admission assessment dated [DATE], indicated he was able to make himself understood and understood others. Resident #4's BIMS score was 14, which indicated his cognition was intact. Resident #4 was occasionally incontinent of bladder and often incontinent of bowel. Resident #4 had MASD (Moisture Associated Skin Damage) to the right and left buttock. Record review of Resident #4's comprehensive care plan, revised on 3/6/2026, indicated Resident #4 had actual impairment to skin integrity related to fragile skin and was at risk for frequent infections, pressure/venous/stasis ulcers. Care plan interventions included follow facility protocols for treatment of injury, and monitor/document/report to doctor as needed for signs and symptoms of infections to any open areas such as redness, pain, heat, swelling or pus formation. Record review of Resident #4's Order Summary Report, dated 3/12/2026, indicated: Nursing intervention: Enhanced barrier precautions every day and night shift Moisture Acquired Skin Damage-Left Buttock: Cleanse with Hibiclens, pat to dry, apply zinc, may leave to open air- Every day and night shift to promote wound healing.Moisture Acquired Skin Damage-Right Buttock: Cleanse with Hibiclens, pat to dry, apply zinc, may leave open to air- Every day and night shift to promote wound healing. During an observation and interview on 3/12/2026 at 2:25 PM, the Wound Care Nurse performed wound care for Resident #4 and did not wear PPE (gown). Observed was an EBP sign on the outside of the door and supplies at the doorway. The Wound Care Nurse stated she did not wear a gown while performing care because the order was new and she forgot. The Wound Care Nurse stated it was important to follow the ordered enhanced barrier precautions to prevent the spread of infection. During an interview on 3/13/2026 at 2:45 PM, the DON stated she expected nurses and anyone involved with patient care to follow enhanced barrier precautions when ordered. The DON stated EBP was necessary to prevent the spread of infection to other residents and staff. During an interview on 3/13/2026 at 1:10 PM, the Facility Administrator stated she expected all orders to be followed, which included EBP orders. The Facility Administrator stated it was best practice and necessary to stop the potential for the spread of infection and protect the staff. Record review of the facility's protocol Enhanced Barrier Precautions, dated 4/1/2024, indicated Enhanced Barrier Precautions are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities.

Based on observation, interview and record review the facility failed to establish policies, in accordance with applicable Federal, State, and local laws and regulations, regarding smoking, smoking areas, and smoking safety that also took into account nonsmoking residents for 1 of 1 facility reviewed for smoking policies. The facility failed to ensure Dietary Aide H followed the smoking policy, when she did not use the facility's assigned smoking area to smoke on 03/12/2026. This failure could place residents at risk of an unsafe smoking environment and an increased risk of injury related to smoking.Findings included: During an observation on 03/12/2026 at 11:38 AM, Dietary Aide H was smoking a cigarette on the sidewalk located in front of the facility that led up to the kitchen's back door. Dietary Aide H extinguished her cigarette on the ground in the dirt and went inside the kitchen. During an interview on 03/12/2026 at 1:11 PM, Dietary Aide H said when she smoked, she went inside her truck to smoke, or she could sit in the rocking chairs in front of the facility to smoke. Dietary Aide H said she was not supposed to smoke in the resident's designated smoking area. Dietary Aide H said if she was outside of the facility she could smoke anywhere. Dietary Aide H said she did not leave the cigarette butts on the ground she extinguished them and put them in her pocket. During an interview on 03/13/2026 at 1:39 PM, the Administrator said the designated smoking area was across from the dining area, and that was where she expected the staff and residents to smoke for safety. The Administrator said staff should not be smoking on the sidewalk that led up to the kitchen's back door because it was a safety risk and it did not provide a homelike environment to the residents. The Administrator said when employees were hired the Human Resources Coordinator gave them a tour of the facility and showed them where the designated smoking area was located. The Administrator said it was important for the employees to smoke only in the designated smoking area for safety and to provide a homelike environment. During an interview on 03/13/2026 at 1:44 PM, the Human Resources Coordinator said when new employees were hired, she showed them around the facility and showed them the designated smoking area across from the dining area. The Human Resources Coordinator said the smoking area for the employees was the same as for the residents. The Human Resources Coordinator said she did not remember if she was the Human Resources Coordinator when Dietary Aide H was hired. The Human Resources Coordinator said it was important for smoking to only take place in the designated smoking area because that was where the fire extinguisher and proper ash trays were located and for safety. Record review of the facility's undated Smoking Policy, indicated, Residents and employees are prohibited from smoking in any of the facility's buildings except in the designated smoking area. The designated smoking areas will be environmentally separate from all resident care areas and equipped with exhaust fans. The restrictions are intended to restrict smoking to a minimum and reduce risks to residents who smoke, including possible adverse effects on treatment; reduce risks of passive smoking for others; and reduce the risk of fire. Employees, medical staff, residents, and visitors are expected to adhere to the no smoking policy. Employees, medical staff, residents, and visitors must smoke in the designated outdoor area only. Employees, medical staff, residents, and visitors will receive instruction on the smoking policy upon employment/admission to the facility.

Based on observation, interview and record review, the facility failed to implement written policies and procedures that prohibit neglect, and abuse of residents, for 1 of 22 residents (Resident #42) reviewed for abuse. The facility failed to follow their policy to report to HHSC within 2 hours of an abuse allegation, when Resident #42 alleged that LVN F argued with her about her medications and told Resident #42 that's why you are in a nursing home. This failure could place residents at risk of abuse, neglect, physical harm, mental anguish, and emotional distress. Findings included: Record review of the facility policy revised 03/29/18, Abuse/Neglect indicated: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart.Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals.E. Reporting 1.Any person having reasonable cause to believe an elderly or incapacitated adult is suffering from abuse, neglect or exploitation must report this to the DON, administrator, state and/or adult protective services. State law mandates that citizens report all suspected cases of abuse, neglect or financial exploitation of the elderly and incapacitated persons.Facility employees must report all allegations of: abuse. neglect. exploitation, mistreatment of residents. misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter 19-17 dated 7/10/19. a. If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation. Record review of Resident #42's face sheet dated 03/12/26 indicated she was a [AGE] year-old female who re-admitted to the facility on [DATE] with the diagnoses which included dementia (a progressive decline in mental ability that interferes with daily life), major depressive disorder (serious mental health disorder characterized by persistent low mood and low self-esteem), heart disease, and high blood pressure. Record review of Resident #42's quarterly MDS assessment dated [DATE] indicated she made herself understood and she understood others. The MDS also indicated she had a BIMS score of 15 which meant that she was cognitively intact. The MDS also indicated she required total staff assistance with toileting, maximal assistance from staff for transfers, bed mobility, and showers, and she was independent with eating. Record review of Resident #42's care plan revised on 12/30/25 indicated she had a behavior problem related to occasional verbal outburst with staff by yelling and argumentative with interventions for the staff to administer medications as ordered, anticipate and meet resident needs, explain all procedures, and minimize potential for resident behaviors. Record review of the facility reported incident 1075295 in Tulip (system used for submitting log-term care licensure applications and health care regulations) indicated the incident was reported on 03/11/2026 at 11:33 AM (2 hours and 33 minutes after it was reported to the Administrator by the surveyor). During an observation and interview on 03/11/26 at 8:45 AM Resident #42 was in her room lying in her bed. Resident #42 said she was upset because LVN F argued with her all night over the medication orders the oral surgeon had given after her oral surgery on 03/10/2026. Resident #42 said after her oral surgery on 03/10/2026 she returned to the facility in the evening, and LVN F refused to listen to her when she told her the instructions were that she receive ibuprofen and Tylenol to help with her pain and swelling. Resident #42 said if LVN had followed the instructions from the oral surgeon, her mouth would not have swollen like it had since she returned to the facility. Resident #42 said when LVN F was walking out of her room she told her, that's why you are in a nursing home. Resident #42 said LVN F made her feel belittled. During an interview on 03/11/26 at 9:00 AM the surveyor reported to the Administrator that Resident #42 was upset and LVN F argued with her about her medications all night and then LVN F told Resident #42 that's why you are in a nursing home. The Administrator said she would get the appropriate person to go talk with Resident #42 to determine what happened. During an interview on 03/13/26 at 1:54 PM the Administrator said it took a little more time to input the information into the system as reasoning for the report not being reported within 2 hours. She said she initiated the report of the allegation abuse to HHSC at 10:50 AM or so but she was trying to ensure the staff was not going to be working at the facility until the investigation was completed. The Administrator said to her knowledge, she took everything seriously and was trying to get things in order and submitted timely. The Administrator said she knew the allegation made was an allegation of abuse when the surveyor reported the incident between Resident #42 and LVN F to her. The Administrator said she was the abuse coordinator, and she expected the staff to report to her immediately. The Administrator said allegations of abuse should be reported within 2 hours and other allegations were to be reported within 24 hours, and she felt as though the facility initiated the process immediately.

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 2 of 6 residents (Resident #'s 7 and 39) reviewed for medications.1.The facility failed to administer Refresh Tears Ophthalmic Solution 0.5 % (quickly alleviates dryness, irritation, and discomfort by replenishing moisture to the eyes) for Resident #39 on 03/10/26.2. The facility did not ensure LVN A primed Resident #7's Novolog FlexPen (insulin medication) according to manufacturer's instructions.This failure could place residents at risk for not receiving the therapeutic effects of their medications to include a diminished health status. Findings included:1.Record review of Resident #39's face sheet, dated 03/16/26 indicated Resident #39 was an [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE] with a diagnosis which included detachment of the retina of the left eye and macula (a small, specialized, yellowish area in the center of the retina at the back of the eye) of the left eye.Record review of Resident #39's quarterly MDS assessment dated [DATE], indicated Resident #39 understood and was understood by others. The MDS assessment indicated Resident #39 had a BIMS score of 15, indicating he was cognitively intact. The MDS assessment did not indicate Resident #39 had received any eye medication within the last 7 days of the look-back period. Record review of Resident #39's physician order dated 12/18/25, indicated Refresh Tears Ophthalmic Solution 0.5 % (Carboxymethylcellulose Sodium) Instill 1 drop in both eyes two times a day for dry eyes.Record review of Resident #39's Medication Administration Record dated 03/01/26 through 03/31/26 revealed Refresh Tears Ophthalmic Solution 0.5 % (Carboxymethylcellulose Sodium) Instill 1 drop in both eyes two times a day for dry eyes was not administered per physician order on 03/10/26 . Record review of Resident #39's progress notes on 03/10/26 revealed no documented rationale for not administering Refresh Tears Ophthalmic per physician's order.During an observation and interview on 03/11/2026 at 10:34 a.m., Resident #39 was sitting up in his recliner rubbing his eyes with a tissue. He said his eyes were stinging. He said he did not receive his eye drops last night nor this morning .During an interview on 03/11/26 at 10:38 a.m., LVN K said she had not completed her medication pass.During an interview on 03/11/26 at 10:50 a.m., Resident #39 said he had received his eye drops and his eyes felt better.During a phone interview on 03/12/26 at 4:59 p.m., LVN F said she was Resident #39's nurse. She said she worked 03/10/26. She said she does not recall giving Resident #39 his Refresh Tears Ophthalmic eye drops. She said she believed it was a busy night and she just forgot. She said she does not recall why he had an order for the eye drops but said it was prescribed by his physician then she should have given them. She said risk could be eye issues such as irritation. During an interview on 03/13/26 at 12:13 p.m., the DON said charge nurses were responsible for giving medication according to the orders. She said nurses should be reading the MAR and giving medication as indicated on the MAR. She said she was the overseer of the nurses. She said they had a clinical meeting every morning and would pull a report to see if any medications were missed on the prior day. She said she had identified that LVN F did not give Resident #39 his eye drop medication on 03/10/26. She said she did an incident report on the medication being missed. She said Resident #39 had dry eyes and he should be receiving his medication to prevent his eyes from drying out which could cause irritation.During an interview on 03/13/26 at 1:14 p.m., the Administrator stated the nurses were responsible for giving medication. She said they should be following the physician's orders. She said the DON was the overseer of the nurses. She said since Resident #39 had eye issues it was important for him to receive his eye drops.Record review of the incident report dated 03/11/26 at 1:58 p.m., indicated LVN F did not give Resident #38 his Refresh Tears Ophthalmic on 03/10/26. It revealed the physician was notified and no new orders were given. 2.Record review of Resident #7's face sheet, dated 03/12/26, reflected Resident #7 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnosis which included Type 2 diabetes mellitus (chronic condition where the pancreas makes little or no insulin, which leads to high blood sugar levels) with other specified complications.Record review of Resident #7's quarterly MDS assessment, dated 12/10/25, reflected Resident #7 made herself understood, and understood others. Resident #7's BIMS score was 15, which reflected her cognition was intact.Record review of Resident #7's comprehensive care plan, revised 02/24/26, reflected Resident #7 had Diabetes Mellitus. The care plan interventions included diabetes medication as ordered by the doctor, monitor/document for side effects/effectiveness and fasting serum blood sugar as ordered by the doctor.Record review of Resident #7's physician order summary report, dated 03/12/26, reflected Resident #7 had an active order for Novolog FlexPen: inject as per sliding scale. 1 unit.subcutaneously before meals and at bedtime related to diabetes mellitus with a start date 02/10/26.Record review of the licensed nurse proficiency audit dated 12/04/25 completed by the ADON reflected LVN A had been checked for insulin administration.During an observation and interview on 03/11/26 at 11:31 a.m., LVN A prepared Resident #7's Novolog FlexPen by removing the pen cap, placing a needle onto the pen, and turning the dose knob to 1 unit. LVN A administered the medication to Resident #7's LLQ. LVN A did not prime (removing the air from the needle and cartridge) the insulin pen by turning the dose knob into 2 units before turning the dose knob to 1 unit. LVN A stated she had never primed the insulin pen before administering Resident #7's insulin. LVN A stated it was important to ensure insulin was administered by the manufacturer's instructions to ensure the residents get the correct dosage.During a telephone interview on 03/12/26 at 2:56 p.m., the Pharmacist Consultant stated the insulin pen should be primed 2 units for the 1st use. The Pharmacist Consultant stated she did a medication pass every other month but had not watched insulin administration. The Pharmacist Consultant stated it was not much of a risk if she did not prime the insulin prior to administering the 1 unit.During an interview on 03/12/26 at 3:18 p.m., the DON stated her expectation was for an insulin pen to have the needle prime with 2 units by releasing of air and then reset to dose of insulin the resident needed and administer the medication. The DON stated her and the ADON were responsible for medication administration compliance through competency check and random medication administration observations. The DON stated there was no risk of not priming the insulin prior to administration.During an interview on 03/12/26 at 3:48 p.m., the Administrator stated it was best practice to prime the Novolog FlexPen 2 units before administering the 1 unit to get the most accurate dosage. The Administrator stated the DON or designee were responsible for monitoring and overseeing. The Administrator stated these failures could potentially cause inaccurate dose.Record review of the manufacturer's guideline titled Novolog (insulin apart) injection Pen fill revised 02/2023, reflected. injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing: E. turn the dose select to select 2 units.Record review of the Subcutaneous Injection Administration policy, dated 3/2025, reflected. Insulin Injection. 1. Assure type of insulin, unit dosage.Record review of facility policy titled, Medication Administration, by Pharmcare USA P&P (policy and procedure) dated 2025, indicated, Policy: Medications are administered as prescribed, in accordance with State Regulations using good nursing principles and practices and only by persons legally authorized to do so. Procedure: #1. Medications are prepared, administered, and recorded only by licensed nursing, medical, pharmacy, or other personnel authorized by state laws and regulations to administer medications. #2. Medications are administered in accordance with written orders of the attending physician. # The resident's MAR is initialed by the person administering a medication, in the space provided under the date and on the line for that specific medication dose administration. Or if utilizing an Electronic Medical Record, the initials of the nurse are electronically stamped into the record.

Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse for 1 of 22 residents (Resident #42) reviewed for resident abuse. The facility failed to ensure Resident #42 was not verbally abused by LVN F on 03/10/26, when she told Resident #42 that's why you are in a nursing home. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.Findings included: Record review of Resident #42's face sheet dated 03/12/26 indicated she was a [AGE] year-old female who re-admitted to the facility on [DATE] with the diagnoses which included dementia (a progressive decline in mental ability that interferes with daily life), major depressive disorder (serious mental health disorder characterized by persistent low mood and low self-esteem), heart disease, and high blood pressure. Record review of Resident #42's quarterly MDS assessment dated [DATE] indicated she made herself understood and she understood others. The MDS also indicated she had a BIMS score of 15 which meant that she was cognitively intact. The MDS also indicated she required total staff assistance with toileting, maximal assistance from staff for transfers, bed mobility, and showers, and she was independent with eating. Record review of Resident #42's care plan revised on 12/30/25 indicated she had a behavior problem related to occasional verbal outbursts (yelling and argumentative) with staff. Resident #42's interventions included for the staff to administer medications as ordered, anticipate and meet resident needs, explain all procedures, and minimize potential for resident behaviors. Record review of Resident #42's undated postoperative care instructions following her oral surgery on 03/10/26 indicated she was prescribed pain medication (hydrocodone-acetaminophen 5-325mg oral tablet), an antibiotic (amoxicillin oral capsule 500mg tablet), and to manage her pain it was recommended to alternate the prescribed pain medication with an NSAID (i.e. Ibuprofen 800 mg every 4 hours) and to swish with warm salt water (1/4 tsp salt +1 cup warm water) 3-4 times day. Record review of Resident #42's order summary report dated as of 03/12/26 indicated she had an order for:1) amoxicillin oral capsule 500 MG Give 1 capsule by mouth four times a day for post oral surgery for 7 days with a start date of 03/11/26 and end date of 03/18/26.2) hydrocodone-acetaminophen oral tablet 5-325mg (hydrocodone-acetaminophen) give 1 tablet by mouth every 6 hours as needed for post oral surgery with a start date of 03/10/26 with no end date. 3) ibuprofen oral tablet 200mg (ibuprofen) give 2 tablets by mouth every 4 hours for pain for 7 days while awake with a start date of 03/11/26 and an end date of 03/18/26.4) swish with warm salt water (1/4 tsp salt +1 cup warm water) 3-4 times a day, especially after eating, every 5 hours as needed for post op oral surgery 1/4 tsp salt+1 cup warm water) with a start date of 03/11/26 and no end date. 5) Tylenol oral tablet 325 MG (acetaminophen) Give 2 tablets by mouth every 6 hours as needed for elevated temperature; pain (2) 325mg tablets to equal 650 mg. not to exceed 3 gram/24 hours from all sources with a start date of 03/10/26 During an observation and interview on 03/11/26 at 8:45 AM, Resident #42 was in her room lying in her bed. Resident #42 said she was upset because LVN F argued with her all night over the medication orders the oral surgeon had given after her oral surgery on 03/10/2026. Resident #42 said after her oral surgery on 03/10/2026 she returned to the facility in the evening, and LVN F refused to listen to her when she told her the instructions were that she receive ibuprofen and Tylenol to help with her pain and swelling. Resident #42 said if LVN had followed the instructions from the oral surgeon, her mouth would not have swollen like it had since she returned to the facility. Resident #42 said when LVN F was walking out of her room she told her, that's why you are in a nursing home. Resident #42 said LVN F made her feel belittled when she told her that's why you are in a nursing home. During an interview on 03/11/2625 at 9:00 AM the surveyor reported to the Administrator that Resident #42 was upset because LVN F argued with her about her medications all night, and then LVN F told Resident #42 that's why you are in a nursing home. The Administrator said she would get the appropriate person to go talk with Resident #42 to determine what happened. During an interview on 03/11/26 at 10:16 AM the Administrator that she and the DON went to speak to Resident #42. The Administrator said Resident #42 told her she was not emotionally distraught, but LVN F was hateful towards her. During an interview on 03/12/26 at 2:00 PM, the Dietary Manager said on 03/11/26 a little after 4 AM she was making her rounds on the hall, and she overheard LVN F and Resident #42 arguing over pain medications. The Dietary Manager said Resident #42 was telling LVN F she was going to call her doctor because LVN F would not give her the medication, and LVN F told Resident #42 she could not call her doctor that she (LVN F) had to call the facility doctor for new orders. The Dietary Manager said she was just passing by Resident #42's room, and that was all she heard. During an interview on 03/12/26 at 4:56 PM LVN F said she worked on 03/10/26 from 6:00 PM until 03/11/2026 at 6:00 AM. LVN F said she received in report Resident #42 had oral surgery and she had a copy of the postoperative care following oral surgery for Resident #42. LVN F said Resident #42 was a challenge and Resident #42 had an issue every time she entered her room. LVN F said Resident #42 kept asking her to administer ibuprofen. LVN F said she was aware Resident #42's instructions indicated for her to receive ibuprofen as needed, but since there was no order in Resident #42's electronic medical record she did not administer it. LVN F said she should have called the doctor and received clarification for the medications Resident #42 was requesting, and this would have prevented all the problems with Resident #42.LVN F said she did say that's why you are in a nursing home but she was talking to herself, she did not direct it at Resident #42. She said she understood why saying that could have made Resident #42 upset, feel bad, or feel as though she could not rely on her to take care of her. LVN F said she should have just kept telling Resident #42 yes ma'am, and LVN F said it was just a misunderstanding. LVN F said she had 12 hours to try to make Resident #42 happy, and she could not accomplish it. During an interview on 03/13/26 at 1:44 PM the DON said she expected the charge nurses to speak to the residents with respect and dignity. The DON said she could see LVN F saying that's why you are in a nursing home as abuse from the resident's point of view, but the DON said the nurse left out of Resident #42's room because Resident #42 became argumentative. The DON said this placed Resident #42 at risk of anxiety and being upset. During an interview on 03/13/26 at 1:54 PM the Administrator said with LVN F saying that's why you are in the nursing home, she understood to where Resident #42 could have seen it as abuse and she did ask Resident #42 about being under any emotional distress but Resident #42 reported to her that she wanted to have good communication with LVN F about her medications and good communication with LVN F in general. Record review of the facility policy revised 03/29/18, Abuse/Neglect indicated: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart.Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals.C. Prevention The facility will provide the residents, families, and staff an environment free from abuse and neglect.

Based on observation, interview and record review, the facility failed to ensure each resident received it and the facility provided food prepared in a form designed to meet individual needs for 1 of 6 residents (Resident's #38) reviewed for food and drinks.The facility failed to ensure Resident #38, received her health shake on 03/10/26.This failure could place residents at risk for weight loss, and unmet nutritional needs.Findings Included:Record review of Resident #38's face sheet, dated 03/16/26, indicated a [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #38 had diagnoses which included malnutrition (a critical health condition caused by a diet lacking, or excessive in, nutrients and calories, leading to deficiencies, obesity, or chronic health issues), dementia (loss of memory), and dysphagia (problem swallowing).Record review of Resident #38's quarterly MDS assessment, dated 1/26/26, indicated Resident #38 was usually understood and was usually understood by others. Resident #38's BIMS score was 03, which indicated she was severely impaired. Resident #38 required assistance with dressing, personal hygiene, toileting, bathing, bed mobility, transfers, and set up for eating. The MDS during the 7-day look-back period did not indicate Resident #38 had weight loss.Record review of Resident #38's physician orders, dated 03/07/24, indicated pureed texture, regular consistency, with divided plate, no straws and house supplement with meals.Record review of Resident #38's care plan, revised date of 11/29/25, indicated Resident #38 had potential nutritional problems related to regular diet, pureed texture. The intervention was for staff to provide and serve diet and supplements as ordered.During an observation and interview on 03/10/26 at 12:46 p.m., Resident #38 was in her room being assisted by CNA G to eat her lunch. Her tray card read health shake with meals. Resident #38 did not have a health shake on her tray. CNA G read Resident #38's tray card and said it read health shake with meals. She said Resident #38 did not have a health shake on her tray. She said she was not aware who served Resident #38's lunch tray but said she came to assist her with her meal. CNA G said the nurses usually checked the trays before the CNAs passed them out. She said she was not aware why Resident #38 was supposed to have a health shake but said maybe for nutrition. During an interview on 03/10/26 at 1:10 p.m., the Dietary Manager looked and verified Resident #38 did not have a health shake on her lunch tray. She said Dietary Aide E was new and must have missed where it indicated for a health shake. She said she would get Resident #38 a health shake. She said health shakes were given for weigh loss.During an interview on 03/12/26 at 11:30 a.m., Dietary Aide E said she was responsible for ensuring health shakes were on the tray. She said she was new to the facility and still learning the process. She said she guessed she overlooked the health shake being written on Resident #38's tray card. During an interview on 03/13/26 at 12:03 p.m., LVN A said she checked lunch trays on Tuesday (03/10/26). She said she could not recall Resident #38's tray specifically but knew she was supposed to have a health shake for weight loss. She said when she checked trays and the health shake was missing; she would ask the dietary department to give her a health shake. During an interview on 03/13/26 at 12:13 p.m., the DON said she expected the diet order to be followed. She said the dietary department was supposed to put the health shake on the tray and the nurses should be checking the trays before they were served to ensure the tray ticket matched the tray. The DON said the Dietary Manager was responsible for monitoring the kitchen. She said the risk of not receiving the health shakes could lead to weight loss.During an interview on 03/13/26 at 1:04 p.m., the Administrator said it was a 2-step process for ensuring the residents were receiving what was ordered. She said the dietary staff placed the health shake on the tray and the nurses were responsible for ensuing it was on the tray before it was served. She said the dietary manager was responsible for the kitchen and the DON was responsible for the nurses. She said it was important for residents to receive supplements to nutritional issues or weight loss. Record review of the facility's, policy titled, Supplements, given out of the Dietary Services Policy & Procedure Manual dated 2012, indicated, We will provide supplements to residents in a safe and sanitary manner. Physician ordered supplements will be prepared and delivered by the Food and Nutrition Department according to facility policies.

Based on observation, interview, and record review the facility failed to ensure the resident environment was as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 6 residents (Resident #2) reviewed for accidents and hazards. The facility failed to ensure Resident #2's fall mat on her left side of her bed was in place on 03/11/26 while she was in her room lying in bed. This failure could place residents at risk of accidents that could result in serious injury, harm, impairment, or death.Findings included: 1. Record review of Resident #2's face sheet, dated 03/12/26, indicated a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included dementia (a progressive decline in mental ability that interferes with daily life), bipolar disorder (chronic mental health condition characterized by extreme mood swings), and high blood pressure. Record review of Resident #2's quarterly MDS assessment, dated 12/10/25, indicated she was able to make herself understood and she understood others. Resident #2 had a BIMS score of 4, which indicated she had severely impaired cognition. Resident #2 required total staff assistance for bathing, toileting, and transfers, and moderate assistance from staff for bed mobility, and setup for eating. Record review of Resident #2's order summary report, dated as of 03/12/26, indicated she had an order for:May have fall mats at bedside every shift for falls with a start date of 06/02/25 with no stop date. Record review of Resident #2's care plan, revised on 02/14/26 indicated she was risk for falls with interventions in place for fall mats to be at bedside while in bed. Record review of the facility incident reports dated 03/10/26 indicated Resident #2 had a fall from her bed to the fall mat on 03/9/26. During an observation on 03/11/26 at 9:35 AM revealed Resident #2 was in her room lying in bed. Resident #2's right side floor mat was on floor next to her bed and Resident #2's left side was not in place. The left side floor mat was standing against her bed. During an interview on 03/13/26 at 12:47 PM, LVN A said she expected the fall mats to be on the floor on both sides of Resident #2's bed. LVN A said it was possible that the CNAs changed her in the bed and forgot to replace the left side floor mat. LVN A said nurses and CNAs were responsible for ensuring the fall mats were in place and she would remind the CNAs. LVN A said she made rounds on the hallways to keep her eyes on the fall mats and call lights. LVN A said the failure placed a risk for falls with injury. During an interview on 03/13/26 at 1:49 PM, the DON said she expected the care plan to be always followed when Resident #2 was in bed. She said it was the nurses and CNAs responsibility and the failure of both fall mats not being in place, placed a risk for falls with injuries. During an interview on 03/13/26 at 2:12 PM, the Administrator said she expected the CNAs to ensure all interventions were in place for all residents. The Administrator said the failure off the fall mat not being in place was a risk for injury. Record review of the facility's undated, policy Fall Policy did not address the use of fall mats.

Based on interviews and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 8 (Resident #1) residents reviewed for quality of care. The facility did not ensure Resident #1 was assessed by a nurse after a fall. Resident #1 was improperly transferred to her bed by CNA G and CNA H without first being assessed by the nurse, LVN E. The noncompliance was identified as PNC. The IJ began on 1/30/24 and ended on 2/2/24. The facility had corrected the noncompliance before the investigation began. These failures could place residents at risk of serious harm, and not receiving the necessary interventions to reach their highest practicable physical, mental, and psychosocial well-being. Findings included: Record review of the undated face sheet revealed Resident #1 was an [AGE] year-old female that admitted [DATE]. Record review of the physician's orders dated 7/30/24 revealed Resident #1 had diagnoses that included: Alzheimer's Disease (a type of dementia that was progressive leading to loss of ability to carry on a conversation), chronic pain (long lasting or constantly recurring pain), Type 2 Diabetes (the body cannot control sugar), Osteoarthritis (flexible tissue at the ends of bones wears down), and Generalized Anxiety Disorder (severe, ongoing anxiety that interferes with daily activities), and hypertension (force of blood against the artery walls is too high). The physician's orders revealed she was on hospice services due to Alzheimer's disease at admit (9/11/23). Record review of the quarterly MDS revealed Resident #1 had no speech, rarely understood others and was sometimes understood by others. She had a BIMS score of 5 indicating severe cognitive impairment. Resident #1 required substantial/maximum assistance (staff did more than half the work) for her to go from a sitting to standing position and for her to walk 10 feet. She used a manual wheelchair. Record review of the care plan dated 10/6/23 revealed Resident #1 had impaired cognitive function/dementia or impaired thought processes. She was at risk for falls with interventions including: Anticipate and meet the resident's needs, provide a safe environment, and needs activities that minimize the potential for falls with diversion and distraction. Resident #1 was receiving hospice services due to a terminal illness. A care plan revision on 2/2/24 indicated she had a right hip fracture (break) and was totally dependent on staff for turning and repositioning in bed. Record review of an incident report dated 1/30/24 at 5:07 AM revealed Resident #1 was sitting on the couch in the common area and got up to walk, and fell on to her buttocks. Resident #1 was unable to give a description of what had happened. She was assessed with no bruises, scratches or skin tears, range of motion unchanged, voided and no complaints of pain or tenderness. Resident #1 was not taken to the hospital. The incident report indicated there were no injuries observed at the time of incident. Record review of the PIR dated 1/30/24 revealed: LVN A reported at 9:23 AM, Resident #1 was complaining of pain to her right hip/thigh area and was unable to bear weight on it. Right leg appeared to rotate outward. Resident #1 administered pain medication per PRN order. Call placed to hospice and MD with new order for x-ray of right hip/thigh with 2 views. Portable x-ray came out to perform an x-ray and the report was back at 7:16 PM indicating, There is an acute fracture of the proximal femur noted. There is not soft tissue swelling or foreign body identified. Record review of an undated, unsigned portion of the PIR indicated: Record review of a Neurological Assessment indicated Resident #1 had neurological assessments beginning 1/30/24 through 2/1/24 with no abnormal indications. Resident #1 was complaining of pain and refusing to bear weight on the morning of 1/20/24. LVN A performed an assessment and noticed possible external rotation to her right leg. LVN A notified the DON of her assessment and that the resident had a fall on the previous shift. LVN A notified the MD who gave an order for an x-ray and she administered pain medication. Resident #1 was kept in bed and monitored for the effectiveness of pain medication. The family was notified of Resident #1's status and the order for mobile x-ray, to which she agreed, rather than sending Resident #1 out to the ER due to her Alzheimer's diagnosis. X-ray results were received by LVN A around 6:00 PM on 1/30/24 confirming right femur fracture. ADM was notified of the X-ray results on 1/30/24 around 7:30 PM. Documentation was reviewed to determine how the fracture possibly occurred. Resident #1 had a fall on 1/30/24 during the early morning hours. The incident report was marked as witnessed; however, witness statements were unable to be located. LVN E, who was the charge nurse on duty at the time of the incident was interviewed to determine how the fall occurred and who witnessed the fall. LVN E stated that on 1/30/24 around 5:00 AM she was told by CNA's G and H that Resident #1 was sitting on the couch, stood up, then fell down. When she went to assess Resident #1, she was lying in bed toward her right side, she had her eyes closed with no signs or symptoms of pain or distress. LVN E pulled Resident #1's covers back and assessed her lying on her back, she noted no bruising or skin tears. She asked Resident #1 if she was hurting and her answer was no. On 1/31/24 CNA G stated that she saw Resident #1 going back into her room. She looked away for a second and when she looked back, Resident #1 kind of tripped on her foot and she went down slowly. As far as hearing anything Resident #1 didn't really make a sound. They transferred Resident #1 to her bed with CNA G holding her feet and CNA H holding her arms underneath. When they informed LVN E of the fall and what they did, it was round 4:40 AM or 4:50 AM. On 1/31/24 CNA G stated that Resident #1 was walking by herself towards her room, and she just collapsed to the ground. She was looking down at first and about 5 minutes later she looked up and heard like a thump and saw Resident #1 was on the floor. They transferred Resident #1 to bed with CNA H holding her top part and CNA G holding her feet. They got her off the floor because they didn't want to leave her there. CNA G and CNA explained to LVN E, that they didn't see her at first, so they proceeded to put her to bed together to get her off the floor. More than likely the fracture occurred from her falling to her right side. We were unable to determine when the fracture actually occurred. Therefore, the injury of unknown origin has been marked as inconclusive. Resident #1's pain will be managed. On 1/30/24 oxycodone 5 mg, 1 tab po every 4 hours PRN was added, and her codeine-acetaminophen 30 mg/300 mg 1 tab po was increased from every 6 hours to every 4 hours PRN. On 2/1/24 a new order was given for oxycodone 5 mg 1 tab every 8 hours routine. On 2/2/24 a wedge (cushion to aide in positioning for comfort) was obtained to help with the healing process and comfort. Resident #1 was placed on a low air loss mattress on 2/2/24 and received a foley catheter for comfort to help decrease the amount of time when will have to be moved for care. Record review of an Incident Statement from CNA H dated 1/31/24 indicated: Resident #1 was wearing a purple shirt, black shoes, and unsure on the pants. It was a clear area, nothing was round her (Resident #1). She was walking by herself towards her room and she just collapsed to the ground. I was looking down and at first and about 5 minutes later I looked up and heard a thump and seen Resident #1 was on the floor. Previously, before the incident she was up the majority of the night which was not normal for her. She would keep walking around and her leg was swollen. I reported to the nurse around 8-9:00 PM about Resident #1's leg being swollen when she walked into the unit. It was between 9-9:30 PM when Resident #1 was constantly keep getting up on her own, restless. Falling asleep and kept moving around and me and the other aide kept putting her in bed to give her feet some rest. CNA G seen the actual fall and I had just looked up when I heard a thump and seen Resident #1 on the ground. First when I seen her she was on the floor and me and CNA G around 2:30 AM or 3:00 AM went to the nurse station and I noticed Resident #1 wasn't there. So, me and CNA G got on both ends with CNA G holding her feet and me holding her top part we transferred Resident #1 onto the bed. We got her off the floor because we didn't want to leave her there. Resident #1 wasn't getting fussy until we had to get her in bed. We continued to do our checking through the unit and [illegible] waited on the nurse to come back. We started our actual round at 4:00 AM- 4:20 AM and did our normal routine going through residents. CNA G went in room on last round to check on Resident #1 and change her and that's when CNA G came out and notified me that Resident #1 was fussing about her side hurt. I was already getting ready to go out to B-wing to finish up my round and that's when I seen the nurse and notified what was going on. Nurse spoke and said thank you for letting me know and said she was going to go check in. Me and CNA G even explained to her and said we didn't see you at first and so me and CNA G proceeded to let her know we put her in bed together to get her off the floor. Nurse replied with thank you again. When talking to the nurse, when I seen her, it was about 4:40 AM. Record review of an Incident Statement dated 1/31/24 from CNA G indicated: Resident #1 was wearing black shoes, shirt, and pants. The area was well lit and the only thing that was round was the cart. There was no spills on the floor nor was there clutter. I saw Resident #1 going back into her room, I looked away for a second and I looked back. She kind of tripped on her foot and she went down slowly. She did not really make a sound. When we (CNA G and CNA H) transferred Resident #1 I had her feet and the other CNA had her arms underneath and we both picked her up and laid her in the bed. When informed the nurse that was working that night I let her know that while I was changing Resident #1 she was screaming in pain and she was fighting me which is not normal for her. I also informed the nurse that I did check for bruises or scars, red areas and I told the nurse I didn't see any. The nurse reply was 'Okay, that's fine and thank you for checking for bruises.' From the best of my knowledge the falfl happened around 2:00 AM and when we went to report the fall to the nurse she wasn't there but when I informed the nurse on my side of the story and I told her what I did it was around 4:40 AM or 4:50 AM . Record review of an Incident Statement dated 1/30/24 from LVN E indicated: 4:51 AM, CNA opened nurse station door and reported Resident #1 had fallen, that is all she said then left to go to B-wing to do a round. I went to assess Resident #1. Resident #1 was wearing black and white pajamas and tennis shoes. When I responded Resident #1 was in her bed. She was quiet and resting comfortably. I entered room, Resident #1 was resting, eyes closed, no signs or symptoms of pain or distress. I assessed her lying on her back. I noted no bruising or skin tears. I asked Resident #1 if she was hurting and she answered no. Record review of an Employee Disciplinary Report dated 1/30/24 indicated LVN E will be placed on an investigatory suspension pending an investigation into allegations of failure to report. The report indicated she would be suspended pending the investigation. CNA reported resident had fallen-nothing about pain, did not say they moved her to bed. Record review of an Employee Disciplinary Report dated 1/30/24 indicated LVN E will be placed on an investigatory suspension pending an investigation into allegations of delay to assess in a proper manner. Record review of an Employee Disciplinary Report indicated CNA G was suspended 1/30/24, terminated 2/7/24, and her last day to work was 1/30/24. Record review of an Employee Disciplinary Report indicated CNA H was suspended 1/30/24, terminated 2/7/24, and her last day to work was 1/30/24. Record review of an undated statement from the DON indicated: I [name], DON reviewed surveillance with the ADM after an event. A resident in the unit had a fall and it was reported that it was witnessed in the common area. I witnessed the aides transferring our resident inappropriately prior to being assessed by the nurse. The nurse was not notified until approximately 1 hour later. Record review of a statement from the ADM dated 2/6/24 indicated: I [name], ADM, reviewed surveillance with the DON after a fracture that allegedly occurred from a fall. The fall was around 3:53 AM. I witnessed CNA G and CNA H immediately take Resident #1 under her arms and drag her to her room. They notified the nurse at 4:51 AM. Record review of a Patient Report dated 1/30/24 indicated Resident #1 had a right radiologic examination, femur and the findings revealed: Acute fracture of the proximal femur notes .Acute commminuted fracture of the proximal femur is seen. During an interview on 7/29/24 at 4:16 PM, Family Member Y said Resident #1 had been on hospice since August of 2023. She said when Resident #1 fell on [DATE], 2 CNA's picked her up inappropriately, one by her feet and one under her arms before she was assessed by a nurse. She said the nurse, was checking in medications and did not know Resident #1 fell . She said the nurse did not know she fell until later. She said the CNA's did not follow protocol. She said Resident #1 was on a lot of narcotics but her pain was controlled. She said the staff fed her. She said Resident #1 was bed bound after the fall because she was not a candidate for surgery. She said Resident #1 passed away 5/20/24. During an interview on 7/30/24 at 12:30 PM, LVN D said she took care of Resident #1 sometimes after she came out of the secure unit. She said Resident #1 had fallen and broken her hip but she did not remember the date. She said she was bed bound after that. She said she was able feed herself until the very end and they provided cueing. She said she did not think the hip fracture led to her death, because she had a lot of comorbidities. She said Resident #1's pain was controlled with medication. She said she did not have a lot of pain meds, but she was on hospice and had scheduled pain medications. She said she did not seem groggy, and was easy to wake up if asleep. She said after the hip fracture Resident #1 could not get out of bed anymore. LVN D said when she cared for Resident #1 she was happy, talking, thriving, but she had declined mentally. She said mobility wise Resident #1 seemed happy. During an interview on 7/30/24 at 1:06 PM, the ADM said Resident #1 fell in the middle of the hall. She had been having snacks and she was coloring but not really engaging in the activity. The ADM said the CNA's moved her from the floor and should not have moved her. She said the CNA's got her back in bed and then told the nurse she had fallen. The ADM said she saw the video (no longer available-due to being recorded over). The video showed one CNA got her from behind and under the arms and the other CNA stood by. She said the CNA backed/dragged Resident #1 into her room and she did not know how they got her in the bed. She said she did not remember if Resident #1's feet were moving (as if stepping) or if dragging. She said when she saw the video she did not see anyone grab her by her feet but the video was in the hallway, not the bedroom. She said her bed was 10 feet from her fall. She said CNA's G and H were fired and both admitted they did not get the nurse (LVN E) before moving Resident #1. She said the video showed CNA G and CNA H coming out of the room after putting Resident #1 in bed. The ADM said the CNA's went to look for the nurse then when they did not see her they continued to do their rounds. As soon as the CNA's saw the nurse, in less than one hour, then they told her nurse about the fall. Resident #1 was asleep when LVN E went to assess her. When LVN E assessed Resident #1 she did not see anything [NAME]. She said LVN E reported to LVN A (the oncoming day nurse). The ADM said she thought the morning routine started then LVN A thought Resident #1 was in pain or the Resident #1 complained about pain. She said Resident #1 had multiple falls. ADM said she the CNA was behind her and got her to bed by holding her from under the arms and pulling backwards. During an interview on 7/30/24 at 1:35 PM, LVN A said she came on shift 1/30/24. She said she went to get Resident #1 up for some reason, maybe breakfast and her leg had an internal rotation. She said Resident #1 was complaining of pain when she tried to use her leg. She said she medicated her for pain and contacted the physician. She said she had an x-ray to the best of her knowledge but could not remember if they sent her out for the x-ray or if it was in-house, but the results showed a hip fracture. She said Resident #1 moved to A-wing shortly after (non-secure unit). She said they did not do surgery as she remembered. She said LVN E told her the aides had already transferred Resident #1 to the bed when she saw her, and the aides had done it wrong. She said she thought she had a femur or hip fracture. LVN A said Resident #1's hip could have broken then she fell , or fell and it caused the break, she said there was no way to know. She said prior to the fall Resident #1 needed help to walk and staff assisted her. She said she also used a wheelchair. She said she was not with it mentally, but could carry on a conversation and the subject changed repeatedly. She stated she could tell you if she was in pain. However, she was not reliable to tell you what had happened. During an interview on 7/30/24 at 3:16 PM, LVN F said she was not in the facility when Resident #1 fell and she did not work on the unit. She said after she left the secure unit she cared for her. She said after the fall Resident #1 got scheduled pain medications. She said she did not appear to be out of it and would try to get out of bed. She said she was not sedated. She said her scheduled pain medication put her in a good place. She said Resident #1 would yell sometimes from anxiety and she thought she had medication for that. She said she did not think the fall/fracture contributed to her death, because she was on hospice and lived for several months after the fall. She said CNA's cannot get residents up if they fall or are on the floor. A nurse had to assess the resident before they were moved. She said she believed all the CNA's knew that because they always went to get her to assess if a resident was found in the floor. During an attempted phone interview on 7/30/34 at 3:40 PM, called CNA G. She did not answer, and this surveyor left a message requesting a return call. During a phone interview on 7/30/34 at 3:51 PM, Resident #1's Hospice nurse said she had followed the natural progression of the Alzheimer's Disease process and did not believe the fall/fracture contributed to her death due to the time frame. After the fall her pain was well managed. She said the family and the Hospice Medical Director decided she was not a surgical candidate, so they kept her as comfortable as possible. She said Resident #1 was not groggy, had lots of visits with family and was able to hold her new grandbaby. She said her decline was natural. She said they gave her scheduled oxycodone and did a wedge (a type of pillow for positioning for comfort) positioner for her fracture. She said hospice made multiple medication changes to meet her needs regarding pain and comfort. During an interview on 7/30/24 at 6:23 PM, LVN E said CNA G and CNA H told her Resident #1 had fallen, and the CNA's had already put her back in bed. She said she told them they were not supposed to do that and did not remember their reaction. She said she was not sure how long it was from the time Resident #1 fell until she was told about it and assessed her. She said it was only a few minutes, not hours. She said the CNA's said they knew they were not supposed to transfer her until a nurse had assessed her. She did not know why they had done that. She said both CNA G and CNA H were fired. She said before the CNA's left to do their rounds on B hall they let her know that Resident #1 had fallen, and they had put her back into bed. LVN E said she went to assess Resident #1 as soon as the CNA's told her she had fallen. She said she did not take her clothes off and could not remember what she was wearing but said she could see her legs and nothing looked out of the ordinary. She said she had heavy thighs and had lost weight so she had some lose skin and she could have missed something because of that. She asked Resident #1 if she was in pain and said she denied any pain. She had no skin tears or bruising. She said she raised her top/shirt and did not see any injuries but did not remove the clothing from her bottom half and could not remember what she had on. She said either she turned Resident #1 to check her back or Resident #1 turned for her and she did not yell or appear to be in pain. She did not cry out when she turned. She said she checked leg length and bent both her legs and saw nothing out of the ordinary. She said when checking her legs and bending them Resident #1 did not appear to be in pain and did not complain of pain. During an interview on 7/31/24 at 8:14 AM, the DON said she assessed Resident #1 after LVN A. She asked her if she was having any pain and she said no, it only hurt when she moved her leg. She said she did not attempt to move her leg or her. She said she did not see a deformity of her leg. The DON said she did not remember what she was wearing or how she was able to see her legs. LVN A told her she had ordered an x-ray. She said it was hard to remember details, because it was in January. She said she did not do anything because the x-ray had been ordered. She said she did not document this assessment but was sure she made sure LVN A had given her pain medication. She said she did not have a good answer as to why she did not document her assessment. During an interview on 7/31/24 at 11:05 AM, LVN J said if a resident fell , she would assess, start neuros if unwitnessed, notify the MD, DON, family, and the ADM as soon as possible. She said she had been in-serviced on falls, X-ray's and numerous things regarding falls. She said a CNA should never transfer a resident after a fall, the nurse had to be notified to assess the resident. She said if a stat X-ray could not be done within 2 hours she would call the NP or the MD to see about sending the resident to the hospital. She said if a resident could not safely get off the floor after the nursing assessment, she would call the MD and EMS. She said if a resident was not in pain and she did not suspect a fracture, she could wait 4 hours on the X-ray. During an interview on 7/31/24 at 11:11 AM, RN B if a resident fell she would assess, do vitals, let the ADON, DON, and the nurse know. Notify the MD quickly, within 10-15 minutes. Call EMS if warranted (bleeding). She said she has been at the facility 2 weeks. She had in-services on fall prevention, X-rays, notification of MD, and numerous others. She said if a resident had a possible fracture, and the stat X-ray was not done within an hour she would call the MD to send the resident to the hospital. She said a CNA was never to transfer a resident that had fallen because they had to get the nurse to assess. She would call EMS if a resident could not safely be gotten up. During an interview on 7/31/24 at 11:12 AM, LVN T said if a resident fell she would assess the resident, take vital signs, and make sure they could move their limbs. She said a CNA would assist the nurse to move them back to bed. She said she would medicate the resident if needed, notify the doctor, family, the ADM, the ADON, and the DON. LVN T said she would do neurological assessments if the fall was unwitnessed. She said she would do a risk management Kardex and a fall note. If a fracture was suspected she would not move the resident, she would contact the MD and notify of a suspected fracture, call EMS and send the resident to the ER. Send to ER. She said she would notify the resident's family, and offer pain medication to the resident. She said for a STAT x-ray she would notify the doctor if they had not done the x-ray after a couple of hours. During an interview on 7/31/24 at 11:18 AM, LVN L said if a resident fell , she would assess the resident, then notify the the ADON, the DON, and the MD. She said she would get the resident off the floor and to their bed if fracture was not suspected. She said if a fracture was suspected she would call EMS and sent the resident to the hospital. She said she would notify all administration staff. LVN L said she would expect a STAT X-ray in 2-4 hours and if the resident did not get their x-ray timely she would notify MD to see if he wanted the resident to be sent to ER. During an interview on 7/31/24 at 11:21 AM, CNA K said if she found a resident in the floor, she would have someone stay with the resident while she found the nurse. She said if there was no one to stay with the resident she would turn the call light on and look out the door for someone to go get the nurse. She said you never ever transfer a resident that had fallen or was in the floor, no matter how long it took the nurse to get there. CNA K said you could hurt the resident worse than they were by transferring them. She said pulling a resident up by their arms or feet was improper and could hurt them and she stated staff had to use a gait belt, unless the resident required a hoyer lift then 2 staff were required. She said she had numerous in-services on resident's falling, notifying the nurse, fall prevention, etc. She said if she saw another CNA attempting to get a resident off the floor before a nurse assessment she would tell them to stop, the nurse had to assess for the safety of the resident. During an interview on 7/31/24 at 11:22AM, LVN V said if a resident fell he would do a total assessment in the location where he found the resident, check vital signs, assess for pain and medicate, check for wounds, and initiate neuros if necessary. LVN V said he would notify the DON, the ADM, family, and the MD. If a fracture was suspected, he would call 911. He said he would not wait on the X-ray company to arrive and if it was a STAT X-ray and they were not at the facility within an hour he would call the MD and send the resident to the hospital if necessary. During an interview on 7/31/24 at 11:27 AM, LVN L said if a resident fell she would assess the resident, then if no injury she would assist them to get back in bed. She said if there was an injury she would not move the resident and would call 911 for transport to the hospital. LVN L said she would notify the the MD, the DON, the ADM, and family immediately. She said 1-2 hours was too long for notification. She said 30 min-1 hour is reasonable time to give notification because you had to take care of the resident. She had in-services on fall prevention, ANE, x-rays, notification, SBAR, and many other in-services. She said 4 hours was reasonable if the resident had no suspected injury. If a resident was in pain, she felt 1 hour was reasonable. She said if a resident was in pain, and she suspected a fracture she would just send them out. She said if a resident fell or was found in the floor, a CNA had to get the nurse to assess the resident prior to moving the resident to prevent harm. During an interview on 7/31/24 at 11:48 AM, CNA W said if a resident fell she was going to get the charge nurse. She said she would stay with the resident and yell for a nurse if necessary. She said she would call someone on her phone, stick her head out the door and yell if she needed to because she could not leave the resident. If a long time passed, then they she would call EMS. Do not move the resident no matter what because you do not want to make an injury or fracture worse. It was important for the nurse to be notified so they could do a thorough assessment and ensure there were no injuries. She said she had many in-services on not moving a resident and getting the nurse as soon as possible. During an interview on 7/31/24 at 11:49 AM, CNA M said if a resident fell she would get a nurse. She said she would watch the resident and yell until she got a nurse to come. She said she could stick her head out the door and look for someone, call someone on her cell phone, but she would not leave them. She said if a nurse had not gotten there in 10 minutes she would call EMS. She said she would not move the resident no matter what. She said moving a resident before a nurse saw them could make their injury worse. The nurse had to see the resident to make sure nothing was broken or no internal injuries. She said she had numerous in-services on falls, notifying the nurse, and change in condition. No matter what the injury on the resident, or no injury, she had to get the nurse immediately. During an interview on 7/31/24 at 11:54 AM, CNA R said if a resident fell , she would notify the nurse and stay with the resident. She would attempt to find a nurse by yelling for one or using her phone to call the nurse. She would call EMS if necessary. She said the nurse had to be notified so the resident could be assessed and receive further treatment if needed. She would not move the resident. She said she had been in- serviced on residents falling and notifying the nurse. During an interview on 7/31/24 at 12:01, CNA N said she had many in-services regarding falls, change of condition, notifying the nurse, and abuse and neglect etc. She said if she found a resident in the floor, she would never move him/her or try to get them up. She said she had to get a nurse to assess the resident before touching the resident. She said she would make sure the resident was safe then stick her head out the door and holler for a nurse, call a nurse on the her phone, or have someone get a nurse. She said if the resident was screaming in pain and the nurse did not get there quickly, she would call 911. During an interview on 7/31/24 at 1:02 PM, LVN E said the night CNA's (CNA G and CNA H) never told her that Resident #1 was hurting or in pain after her fall. She said if they had, she would have reassessed her and sent her to the ER. During an interview on 7/31/24 at 1:43 PM, the ADON said the transfer with Resident #1 was an improper and dangerous transfer. She said the CNA's should not have done that. She said the risk could have been serious bodily injury. She said Resident #1 got a serious bodily injury that day, but it was unclear how. She said all staff had extensive in-services for an extended period of time and were trained and re-trained. All CNA's know that they should not ever move a resident prior to a nurse assessing them. During an interview on 7/31/24 at 1:51 PM, the DON said the CNA G and CNA H transferred Resident #1 improperly. She said that had the potential to result in serious bodily injury. She said Resident #1 had a femur fracture but it could not be determined if it occurred before the fall, after the fall, or the improper transfer. The CNA's were suspended pending investigation and then terminated after the investigation. She said LVN E was also suspended pending investigation. The DON said all staff had been in-serviced extensively regarding x-ray time expectations, reporting, change of condition, what to do in the event of a fall or a resident found in the floor, proper assessment, notifying the MD & family, all notifications, abuse and neglect, SBAR and several others. She said they did in-services for

45810 Based on observations, interviews, and record reviews 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 13 (Residents #7, #31, #208, #30, #39, #45, #32, #44, #28, #15, #16 , #34, #25 ) of 15 residents and 9 employees ( LVN B, MDS nurse, Dietary staff V, CNA D, Housekeeping Supervisor, Housekeeper Y, Housekeeper EE, CNA N, and CNA H ) out of 135 employees in the facility, 1 (RN DD) of 1 contract employees and 1 (clean cart) of 3 linen carts reviewed for infection control practices and transmission-based precautions. 1. The facility failed to ensure Residents #208 and #31 were separated after Resident #31 tested positive for COVID on 10/23/23, and Resident #208 did not. 2. The facility failed to ensure Residents #39 and #30 were separated after Resident #30 tested positive for COVID on 10/23/23, and Resident #39 did not. 3. The facility failed to ensure Residents #32 and #45 were separated after Resident #45 tested positive for COVID on 10/25/23, and Resident #32 did not. 4. The facility failed to ensure Residents #28 and #44 were separated after Resident #44 tested positive for COVID on 10/25/23, and Resident #28 did not. 5. The facility failed to ensure LVN B, MDS nurse, and Dietary staff V remained off from work for the policy requirement of 10 days while having COVID-19 symptoms. 6. The facility failed to ensure and Housekeeper Y utilized PPE appropriately to prevent cross contamination between residents positive with COVID-19 and residents who were not positive for the virus. 7. The facility failed to ensure CNA D utilized PPE appropriately to prevent cross contamination between Resident #15, who was positive with COVID-19, and residents who were not positive for the virus. 8. The facility failed to ensure Contract RN DD utilized PPE appropriately to prevent cross contamination between residents positive with COVID-19 and residents who were not positive for the virus. 9. The facility failed to ensure the Housekeeping Supervisor was not working with residents when she was covid positive . 10. The facility failed to ensure Resident #16 did not acquire COVID-19 on 11/01/23. 11. The facility failed to ensure housekeeper EE was using the covid cleaner properly in the resident rooms. 12. The facility failed to ensure CNA N performed hand hygiene after she changed her gloves during Resident #25's incontinent care. 13. The facility failed to ensure CNA H Performed hand hygiene and glove change while providing Resident #7's incontinent care. 14. The facility failed to ensure failed to ensure the clean linen cart was covered. An IJ was identified on 10/31/23. The IJ template was provided to the facility on [DATE] at 5:43 PM. While the IJ was removed on 11/01/23, the facility remained out of compliance at a scope of actual harm with a potential for more than minimal harm and a severity level of widespread because all staff had not been trained according to the plan of removal and the corrective systems had not been evaluated. These failures could place residents at increased risk for serious complications from a communicable disease that could diminish the resident's quality of life including hospitalization or death. The findings included: 1.Record review of Resident #31's face sheet dated 11/1/23 indicated she was an [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses of Alzheimer's (a common and devastating form of dementia that affects memory, thinking, and behavior), cerebral infarction, high blood pressure, diabetes, and cognitive communication deficit (difficulties with thinking and using language that occur after a neurological damage). Record review of Resident #31's quarterly MDS assessment dated [DATE] indicated she had a BIMS score of 8 which indicated she had moderate cognitive impairment. The MDS assessment also indicated she required extensive assistance with bed mobility, transfers, and toileting, total assistance with bathing, and supervision with eating. Record review of Resident #31's nursing progress note dated 10/23/23 at 23:28 (11:28 PM) indicated she tested positive for COVID-19. Record review of Resident #31's nursing progress notes dated 10/02-11/02/23 did not indicate that the resident was relocated to isolate. Record review of Resident #31's order summary report as of 11/01/23 indicated she did not have an order for isolation related to COVID-19. Record review of Resident #31's care plan initiated 11/01/23 indicated she had COVID-19 infection with interventions to ensure good infection control measures and personal protective equipment is used when working with her. During an observation on 10/30/23 at 10:24 AM Resident #31, who was positive for COVID-19, was in her bed asleep and Resident #208, who shared the room with Resident #31, was in the main dining area at a table sitting alone. 2. Record review of Resident #208's face sheet dated 11/01/23 indicated she was a [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses of senile degeneration of the brain, depression, and anxiety. Record review of Resident # 208's admission MDS assessment dated [DATE] indicated she had a BIMS score of 3 which indicated severely impaired cognition. The MDS assessment also indicated she required maximal assistance with toileting, bathing, and transfers. Record review of the facility's resident COVID testing dated 10/22/23-10/27/23 indicated Resident #208 was negative for COVID on 10/23/23, 10/25/23, and 10/27/23. 3.Record review of Resident #30's face sheet dated 11/1/23 indicated she was an [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses of Alzheimer's (a common and devastating form of dementia that affects memory, thinking, and behavior), major depression, and cognitive communication deficit (difficulties with thinking and using language that occur after a neurological damage). Record review of Resident #30's quarterly MDS assessment dated [DATE] indicated she had BIMS score of 7 which indicated severely impaired cognition. The MDS assessment also indicated she required extensive assistance from staff for bed mobility, transfers, toileting, dressing and bathing. Record review of Resident #30's nursing progress note dated 10/23/23 at 23:29 (11:29 PM) indicated she was positive for COVID-19. Record review of Resident #30's summary report as of 11/01/23 indicated she did not have an order for isolation related COVID-19. Record review of Resident #30's care plan initiated 11/01/23 indicated she had COVID-19 infection with interventions to ensure good infection control measures and personal protective equipment is used when working with her. During an observation on 10/30/23 at 10:29 AM Resident #30, who was positive for COVID-19, was in bed asleep and Resident #39, who shared a room with Resident #30, was wandering the secure unit. 4. Record review of Resident #39's face sheet indicated she was a [AGE] year-old female who readmitted to the facility on [DATE] with the diagnoses of dementia (a term for a range of conditions that affect the brain's ability to think, remember, and function normally), Alzheimer's (a common and devastating form of dementia that affects memory, thinking, and behavior), high blood pressure, and cognitive communication deficit (difficulties with thinking and using language that occur after a neurological damage). Record review of Resident #39's quarterly MDS assessment dated [DATE] indicated that she had a BIMS score of 0 which indicated severely impaired cognition. The MDS assessment also indicated that she required extensive assistance with bed mobility, transfers, dressing, and toileting, and total assistance with bathing. Record review of the facility's resident COVID testing dated 10/22/23-10/27/23 indicated Resident #39 was negative for COVID on 10/23/23, 10/25/23, and 10/27/23. 5.Record review of Resident #45's face sheet dated 11/01/23 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with the diagnoses of dementia (a term for a range of conditions that affect the brain's ability to think, remember, and function normally), heart disease, high blood pressure, and cognitive communication deficit (difficulties with thinking and using language that occur after a neurological damage). Record review of Resident #45's quarterly MDS assessment date 09/13/23 indicated he had a BIMS score of 3 which indicated severely impaired cognition. The MDS assessment also indicated that he required extensive assistance with bed mobility and limited assistance with transfers, dressing, toileting, and bathing. Record review of Resident #45's nursing progress note dated 10/25/23 at 17:45 (5:45 PM) indicated he tested positive for COVID-19 and he would be placed in droplet isolation. Record review of Resident #45's nursing progress note dated 10/31/23 at 15:34 (3:34 PM), after surveyor intervention, indicated he was moved from his room to another room. Record review of Resident #45's order summary report as of 11/01/23 indicated he did not have an order for isolation related COVID-19. Record review of Resident #45's care plan initiated 11/01/23 indicated he had COVID-19 infection with interventions to ensure good infection control measures and personal protective equipment is used when working with him. During an observation on 10/30/23 at 10:30 AM Resident #45, who was positive for COVID-19, was in his room lying in bed and Resident #32, who shared a room with Resident #45), was sitting in the dining area alone at a table. 6. Record review of #32's face sheet dated 11/01/23 indicated he was a [AGE] year-old male who readmitted to the facility 04/27/22 with the diagnoses of Alzheimer's disease (a common and devastating form of dementia that affects memory, thinking, and behavior), dementia (a term for a range of conditions that affect the brain's ability to think, remember, and function normally), cognitive communication deficit (difficulties with thinking and using language that occur after a neurological damage), and history of pulmonary embolism. Record review of Resident #32's significant change MDS assessment date 08/10/23 indicated he had a BIMS score of 4 which indicated severely impaired cognition. The MDS assessment also indicated he required supervision for transfers, bed mobility, dressing, and toileting, and extensive assistance with bathing. Record review of the facility's resident COVID testing dated 10/22/23-10/27/23 indicated Resident #32 was negative for COVID on 10/23/23, 10/25/23, and 10/27/23. 7.Record review of Resident #44's face sheet indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with the diagnoses of dementia (a term for a range of conditions that affect the brain's ability to think, remember, and function normally), Parkinson's disease, high blood pressure, anxiety, and cognitive communication deficit (difficulties with thinking and using language that occur after a neurological damage). Record review of Resident #44's quarterly MDS assessment dated [DATE] indicated he had a BIMS score of 3 which indicated severely impaired cognition. The MDS assessment also indicated he required limited assistance from staff for bed mobility, toileting, dressing, and eating, and extensive assistance with transfers. Record review of the facility's resident COVID testing dated 10/22/23-10/27/23 indicated Resident #44 was negative for COVID on 10/23/23 but was positive for COVID on 10/25/23. Record review of Resident #44's order summary report as of 11/01/23 indicated he did not have an order for isolation related COVID-19. Record review of Resident #44's care plan initiated 11/01/23 indicated he had COVID-19 infection with interventions to ensure good infection control measures and personal protective equipment is used when working with him. Record review of Resident #44's nursing progress notes dated 10/02/23-11/02/23 did not indicate he was COVID positive nor that he was relocated after being positive with COVID-19. During an observation on 10/30/23 at 09:55 AM Resident #44 who was COVID positive was lying in bed asleep and Resident #28, who shared the room with Resident #44, had left the room wandering the secure unit. 8. Record review of Resident #28's face sheet dated 11/02/23 indicated he was an [AGE] year-old male who admitted to the facility on [DATE] with the diagnoses of dementia (a term for a range of conditions that affect the brain's ability to think, remember, and function normally), psychotic disorder with hallucinations, high blood pressure, cognitive communication deficit (difficulties with thinking and using language that occur after a neurological damage), and cerebrovascular disease. Record review of Resident #28's admission MDS assessment dated [DATE] indicated he had a BIMS assessment of 4 which indicate severely impaired cognition. The MDS assessment also indicated he required limited assistance with transfers, bed mobility, toileting, and dressing, and total assistance with bathing. Record review of the facility's resident COVID testing dated 10/22/23-10/27/23 indicated Resident #28 was negative for COVID on 10/23/23, 10/25/23, and 10/27/23. 9.Record review of Resident #16's face sheet dated 11/01/23 indicated he was an [AGE] year-old male who readmitted to the facility on [DATE] with the diagnoses of dementia, chronic obstructive pulmonary disease (a type of progressive lung disease characterized by long-term respiratory symptoms and airflow limitation), and cognitive communication deficit (difficulties with thinking and using language that occur after a neurological damage). Record review of Resident #16's quarterly MDS assessment dated [DATE] indicated he had BIMS score of 10 which indicated moderately impaired cognition. Record review of Resident #16's order summary report as of 11/01/23 indicated he did not have an order for isolation related COVID-19. Record review of Resident #16's care plan initiated 11/01/23 indicated he had COVID-19 infection with interventions to ensure good infection control measures and personal protective equipment is used when working with him. 10.Record review of Resident #15's face sheet dated 11/07/23 indicated she was a [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses of schizoaffective disorder, depression, mild intellectual disabilities, and liver disease. Record review of Resident #15's quarterly MDS assessment dated [DATE] indicated she had a BIMS score of 8 which indicated she had moderately impaired cognition. The MDS assessment also indicated she required limited assistance from staff for transfers, bed mobility, and toileting, total assistance for bathing, and supervision for eating. Record review of the facility's resident COVID testing dated 10/22/23-10/27/23 indicated Resident #15 was positive for COVID on 10/24/23. Record review of Resident #15's care plan initiated on 11/01/23 indicated she had COVID-19 infection with interventions to ensure good infection control measures and personal protective equipment is used when working with her. Record review of Resident #15's summary report as of 11/07/23 indicated she did not have an order for isolation related COVID-19. During an observation and interview on 10/31/23 at 09:40 AM CNA D walked into the secure unit and did not DON PPE and continued down the hall and went into Resident #15's room, turned the call light off, attempted to assist her in bed and Resident #15 told her something inside was hurting her. CNA D moved Resident #15's bed side table and offered her water and did not have on PPE for COVID isolation which included an N95 mask, a gown, gloves, and a face shield. CNA D had on a pink KN95 mask. CNA D walked out of Resident #15's room and notified LVN B of Resident #15 needing her. CNA D said she did not realize she went into the unit and the COVID room with no PPE on. She said she should have used the PPE in the box outside of the room because it could have caused the risk of spreading COVID to other residents. During an interview on 10/31/23 at 09:42 AM LVN B she said CNA D knew better ( she had been verbally informed about using PPE in COVID isolation rooms). She said she instructed her on which residents were in isolation on the morning of 10/31/23 and that if the residents are positive, she should have placed all PPE on to go in the room and change when she exited the room. 11.Record review of a face sheet dated 11/02/2023 indicated Resident #34 originally admitted on [DATE] and readmitted on [DATE] with the diagnosis of memory deficit, anxiety, and high blood pressure. Record review of the face sheet indicated Resident #34 and #33 were in a shared room. Record review of the Annual MDS dated [DATE] indicated Resident #34 was usually understood and usually understands others. Resident #34's MDS indicated her BIMS was a 15 indicating she was cognitively intact. The MDS indicated Resident #34 required supervision of one staff to walk in the room and corridor. Record review of the consolidated physician orders dated 11/02/2023 failed to reveal Resident #34 was on droplet isolation precautions due to her exposure to Resident #33. Record review of Resident #34's comprehensive care plan dated 1/10/2022 failed to review Resident #34 was on isolation precautions for exposure to Covid 19. During an observation and interview on 10/30/2023 at 11:00 a.m., Resident #33 and Resident #34 were rooming together and on droplet precautions. Resident #33 said she tested positive for Covid 19. Resident #34 said she was Resident #33's family member and they wanted to stay together. Resident #34 was not wearing a mask while sitting beside Resident #33. Resident #34 said they hoped to be off droplet isolation soon. During an observation and interview on 10/30/23 at 11:17 AM Housekeeper EE said she had just started on 10/29/23. There was K-Quat in her cart that she said she cleaned the restroom with. She said she was unsure what the COVID cleaner was and said the only place she sprayed the K-Quat was in the restrooms. During an interview on 10/30/23 at 03:35 PM the ADON which is also the Infection Preventionist said she expected all staff in the building to wear surgical masks. She said since the increase in covid positive residents in the secured unit the facility had put in place for the staff to be donning PPE prior to going into the unit, and when they enter the covid positive rooms the staff should be changing PPE going in and exiting. She said it could have caused residents to contract covid if the staff were not wearing or changing PPE correctly. She said she was new to the facility and was continuing to learn her role. During an observation on 10/31/23 at 09:49 AM Contract RN DD presented to go in the room to see Resident #21, she had PPE on, and she did not put a shield on to the enter the room. RN DD had applied the lidoderm patch to the upper back/neck area. During an interview on 10/31/23 at 10:03 AM Contract RN DD she said she was not aware that a shield was required, but she would wear a shield next time. She said the risk to the resident was the spread of infection. Contract RN DD said she had not been in-serviced on PPE at the facility, but she had been in-serviced at her employment facility. During an observation and interview on 10/31/23 at 11:01 AM the Housekeeper Supervisor of 2 years was cleaning the hall railings. The Housekeeping Supervisor said the Covid 19 cleaner in the facility was K-Quat. The Housekeeping Supervisor said the K-Quat was to be used on high touch surfaces in the resident rooms and the kill time was 10 minutes (time lapse needed to kill the Covid 19 virus). The Housekeeping Supervisor said she was scheduled to come and in-service and train the new housekeeper on the facility's cleaning procedures, but the Housekeeping Supervisor said after she arrived at the facility, she felt so bad she left and went home. The Housekeeping Supervisor said she had bad allergies and slept with her mouth open which had caused her to feel bad. The Housekeeping Supervisor denied the notification of the nurse managers of her symptoms on 10/29/2023, 10/30/2023 and 10/31/2023 again she stated she had only bad allergies. During an interview on 10/31/2023 at 11:07 AM the RCN said she expected a sick employee to notify the nursing administration, then the facility would test the employee, and if positive determine whom they had contact with. She denied the housekeeping supervisor making her aware of her illness or about needing to go home on Sunday. During an interview on 10/31/2023 at 11:40 AM the RCN informed the surveyor that she sent the housekeeping supervisor home because she tested positive for covid-19 on 10/31/2023. During an observation on 10/31/2023 at 11:50 AM Dietary Staff V has her mask down below her nose assisting with preparing the lunch trays and dessert prep. During an interview with the Administrator on 10/31/23 at 03:56 PM she said she did not complete the IP training. The Administrator said she expected the staff to best of their ability to keep residents separated and re-direct as much as possible. She said she expected the staff to have the residents in the unit to be separated by positive and negative COVID status. The Administrator said she was made aware 10/31/23 that the facility had residents that were co-horted. She said the residents being co-horted was not their policy. She said the staff try to keep residents apart. The Administrator said the staff attempt to stop the visitors and reminded the staff and visitors to wear mask correctly per the facility policy and CDC guidelines for wearing the surgical mask and keeping distance. The Administrator said she expected all staff to DON and DOFF PPE as they were supposed to when they were entering and exiting COVID positive rooms. The Administrator said when the facility had positive staff who tested positive at home, the facility would question how long the staff had been had been having symptoms and the last time the staff had been in the facility working. She said if the staff member tests positive while in building it was considered an outbreak. The Administrator said the facility would have begun the known exposure contact testing and further testing. She said the MDS nurse was working in the secured unit, and she tested positive for COVID-19 on 10/22/23, and the residents were tested , and some were positive. The Administrator said LVN A wasn't feeling well and was tested and positive on 10/22/23 but left her shift after testing positive. LVN B just recovered but she thought there should have been 5 days from symptoms for her to return. LVN B tested positive on 10/24/23. The Administrator said Resident #34 and roommate, Resident #33, were thinking their symptoms were allergies and ended up with COVID as well. She said all staff are responsible for infection control and she expected all the staff to wear their mask the correct way. She said they needed to be stopped and reminded. The Administrator said all the failures placed the residents and staff at risk for spreading infection to other staff or other residents. During an interview on 10/31/23 at 05:30 PM Surveyor requested from RCN the isolation time required by the facility when a staff member tested positive for COVID-19. The RCN could not find the date in the policy stating the length of time for isolation of employee with COVID-19. 12. Record review of Resident #25 face sheet dated 11/02/23 indicated a [AGE] year-old female who initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #25's diagnoses included myotonic muscular dystrophy (genetic condition that causes progressive muscle weakness and wasting), intellectual disabilities (person with certain limitations in cognitive functioning and other skills), depression (persistent feeling of sadness), and heart failure (heart does not pump blood as well as it should). Record review of Resident #25's quarterly MDS assessment dated [DATE], indicated she was able to make herself understood and understood others. The MDS assessment indicated Resident #25 had a BIMS score of 12, which indicated her cognition was moderately impaired. The MDS indicated Resident #25 required extensive assistance with bed mobility, transfers, walking, locomotion, dressing, toileting, and personal hygiene. The MDS indicated Resident #25 was always incontinent of urine and bowel. Record review of Resident #25's comprehensive care plan dated 10/17/22 indicated she had bladder incontinence with interventions to monitor/document for signs and symptoms of UTI : pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, and change in eating patterns. During an observation and interview on 10/31/23 at 09:11 AM, CNA N entered Resident #25's room to provide incontinent care. During the incontinent care process, CNA N failed to perform hand hygiene when she removed her dirty gloves and applied clean gloves. CNA N said she should have hand sanitized in between glove changes and knew that when she finished. CNA N said she forgot because she was nervous. CNA N said by not performing hand hygiene in between glove changes placed Resident #25 at risk for infections. CNA N said she was responsible for performing proper incontinent care and hand hygiene. CNA N said she had been checked off with the previous ADON on her second day of hire. Record review of CNA N's nurse aide incontinence care proficiency assessment dated [DATE], indicated she had passed her skill check off. During an interview on 11/02/23 at 5:57 PM, the ADON said she expected CNA N to have washed her hands or used hand sanitizer in between gloves changes. The ADON said failure to perform hand hygiene in between glove changes placed the resident at risk for cross contamination and infection. The ADON said the aides were responsible for ensuring proper incontinent care and hand hygiene was being performed. During an interview on 11/02/23 at 6:43 PM, the Administrator said he expected the CNA N to maintain proper infection control and perform hand hygiene when incontinent care was provided. The Administrator said she expected CNA N to have hand sanitized in between glove changes and by not doing so placed Resident #25 at risk for infection. During an interview on 11/02/23 at 7:55 PM, the Regional Compliance Nurse said she expected CNA N to have performed hand hygiene prior to applying clean gloves and failure to do so placed Resident #25 at risk for infection. The Regional Compliance Nurse said the Infection Preventionist, and the DON were responsible for checking off the staff on their skills. The Regional Compliance Nurse said they did monthly random hand hygiene check offs. 13. Record review of Resident #7's face sheet, dated 11/1/2023, revealed Resident #7 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of hyperlipidemia (blood has too much fat), type 2 diabetes mellitus without complications ( characterized by high levels of sugar in the blood),hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (symptom that involves one-sided paralysis), unspecified lack of coordination ( Uncoordinated movement due to a muscle control problem that causes an inability to coordinate movements). Record review of Resident # 7's MDS assessment, dated 9/15/2023, indicated Resident #7 had a BIMS score of 15, indicating Resident #7 was cognitively intact and understood others as well as being understood. The MDS revealed Resident #7 had no behaviors or rejection of care during the look-back period. The MDS revealed Resident #7 required supervision with a one-person assistance for dressing, toilet use, and personal hygiene. Record review of Resident #7's comprehensive care plan, last revised on 8/29/2023, revealed Resident #7 has an ADL self-care performance deficit. Care plan goals included maintain current level of function in bed mobility, transfers, eating, dressing, toilet use and personal hygiene. The care plan interventions include, Resident # 7 requires extensive assist of one staff. During an observation on 10/31/2023 at 9:08 AM, CNA H provided incontinent care for Resident #7. During the incontinent care CNA H put on gloves and wiped Residents # 7's buttock. CNA H gloves were soiled with feces, and she picked up barrier cream and applied it to Resident # 7 buttock and replaced the cream on the bedside nightstand. CNA H then placed a fresh brief under Resident#7 and had her roll onto her back and proceeded to clean vaginal area without changing gloves. CNA H Performed hand hygiene when finished with incontinent care. During an interview on 10/31/2023 at 9:20 AM, CNA H stated she should have removed her gloves and performed hand hygiene after removing the dirty brief, she was nervous and forgot. CNA H stated it was important to do hand hygiene to prevent cross-contamination. CNA H stated the harm in not changing gloves would be cross-contamination that caused an infection. During an interview on 11/2/2023 at 4:29 PM, LVN R stated hand hygiene should be performed before starting care, after removing gloves, and when they are finished. LVN R stated they're individually responsible, but their direct supervisor was responsible for monitoring. LVN R stated the failure was it could contaminate the cream and it was not good infection control. During an interview on 11/2/2023 at 5:31 PM, the ADON stated hand hygiene should be performed before the start of care, while providing care, and after providing care. The ADON stated hand hygiene should be performed after glove removal to prevent infection. ADON stated nurse management was responsible for making sure the CNAs performed hand hygiene. The ADON stated in-services needed to be done to ensure staff were performing hand hygiene properly. The ADON stated the failure could be cross-contamination and infection. During an interview on 11/2/2023 at 6:35 PM, the administrator stated she expected the CNAs to perform hand hygiene while providing incontinent care to ensure proper infection control. The administrator stated the staff are expected to follow the hand hygiene protocol. The administrator stated it was important to perform hand hygiene to prevent infection. During an interview on 11/2/2023 at 7:58 PM, the Corporate Compliance nurse stated she expect hand hygiene to be done. The Corporate Compliance nurse stated the charge nurse or infection preventionist was responsible for monitoring. The Corporate Compliance nurse stated hand hygiene was important for maintaining infection control. The Corporate Compliance nurse stated the failure was risk for infection. 2. During an observation on 10/30/23 at 09:45 AM, PVC plastic linen cart sitting on the short hall with cover was open. During an observation on 10/31/23 at 12:00 PM, PVC plastic linen cart sitting on the short hall with cover was open. During an observation on 11/1/23 at 10:01 AM, PVC plastic linen cart sitting on the short hall with cover was open. During an interview on 10/31/2023 at 12:00 PM, CNA H stated the PVC plastic linen cart cover should be closed. CNA H stated it was important to keep the cover closed so the residents couldn't take things and no one needs to know what's on the cart. CNA H stated the failure would be the supplies and linens getting contaminated. During an interview on 11/1/2023 at 10:01 AM, CNA K stated th [TRUNCATED]

Based on observation, interview, and record review the facility failed to implement written polices and procedures to prohibit abuse by ensuring residents had the right to be free from abuse, and neglect for 3 of 18 residents reviewed for abuse and neglect (Resident #12, Resident #13, and Resident #14). Resident #12 was abused when LVN C put her hand over Resident #12's mouth to stop her from screaming. The LVN C also threatened to push Resident #12 into cold water if she did not stop screaming. The Administrator did not follow the abuse policy when she unfounded the abuse when the LVN admitted she had abused the resident. LVN C was suspended for part of her shift and returned to work the following day. Resident #13 was physically abused by Resident #12. Resident #12 slapped Resident #13 in the face. Resident #12 had a history of abusive behaviors. Resident #12 disliked Black people and targeted two Black residents on the secure unit Resident #13 and Resident #14. The facility did not follow their abuse policy and continued to allow Resident #12 with a history of abusive behaviors to continue to abuse residents. An Immediate Jeopardy (IJ) situation was identified on 10/3/23 at 6:00 p.m. The IJ template was provided to the facility on [DATE] at 6:00 p.m. While the IJ was removed on 10/4/23 at 6:30 p.m., the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These deficient practices could caused emotional and physical harm and could lead to additional pain and suffering. Finding included: Record review of the facility's Abuse/Neglect policy dated 3/29/18 indicated Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff or other residents. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting in physical harm, pain or mental anguish. Willful as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The facility will be responsible to identify, correct, and intervene in situations of possible abuse or neglect. The policy indicated neglect was the failure of the facility employees to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. 1.Record review of Resident #12's face sheet indicated she was an [AGE] year-old female admitted to the facility on [DATE]. Some of her diagnoses were dementia (impairment of memory) with other behavioral disturbances, psychotic disorder (a mental problem that causes people to perceive or interpret things differently from those around them), with delusions, cognitive communication deficit, and major depression. Record review of Resident #12's quarterly MDS dated [DATE] indicated her cognitive status was severely impaired. Record review of Resident #12's Care Plan dated 9/7/22 indicated a focus area of impaired cognition due to dementia or impaired thought processes. Some of the interventions were, use the residents preferred name, identify self at each interaction, face resident, and make eye contact when speaking and provide cues when necessary and stop and return, if agitated. Another focused area was Resident #12 has the potential to demonstrate physical behaviors. Some of the interventions were to analyze the time, the places, circumstances, triggers, and what escalate to behaviors and document. Communication provided with physical and verbal cues to alleviate, anxiety, give positive feedback, assist with verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff when agitated. When the resident becomes agitated intervene before agitation, escalated, remove from source of distress, engage calmly in conversation calmly, and if responses or aggressive staff were to walk away calmly and approach later. Resident # 12 also had a focus area of potential to demonstrate verbal abusive behaviors, with some of the same interventions in place. Record review of the facility Provider Investigation Report dated 8/10/23 indicated a Hospice CNA alleged that LVN C was unkind to Resident #12. The Report contained a statement written by LVN C that stated: The Hospice CNA asked her to assist with Resident #12 because she (Resident #12) was combative, and she (Resident #12) had slapped the aide in the face on a previous occasion. The LVN wrote they took Resident #12 into the shower room and removed her clothes. LVN C said the resident was screaming, and LVN C placed her hand over Resident #12's mouth, her intent was to distract Resident #12. LVN C said she often joked with the resident. She said she (LVN C) jokily asked the aide if the water was cold. The nurse said the Resident #12 did not present any type of respiratory distress. The report indicated LVN C said she had known the resident prior to her admission to the facility and was only joking. Record review of the Provider Investigation Report contained a statement from the Hospice CNA dated 8/10/23 at 12:43 p.m. which stated. I was prepping PT (Resident #12) for a shower, I required assistance with undressing due to PT disability. I stuck my head around the and there were no aides, so I asked the nurse. She said, Sure let's go. PT (Resident #12) was very combative and not cooperating. The nurse was a little abrasive while removing PTs, shirt, once the shirt was removed, I turned my back to PT (Resident #12) and the nurse (LVN C) to ensure safe water temp. Pt was screaming very loudly while my back was turned. Pt very abruptly stopped screaming. Approximately 10- 15 seconds. Later after PT stopped screaming, I turned back toward PT to fine nurse standing behind Pt with her hand firmly grasping PT face covering her mouth and partially covering her nose. When I (Hospice CNA) looked at the nurse, she said I'm sick of hearing this, Shit. At that point she let go of her face. I quickly checked the water temp again and reached for PT. The Nurse then aggressively shoved the PT toward the running water and said is it cold I said No! The with a sarcastic tone the nurse said Damn she then asked if I needed anything and left the room. Record review of the facility Investigation Summary indicated staff members, and all residents (on the secure unit) that LVN C cared for were interviewed on 8/10/23. They said they had never witnessed any misconduct by LVN C. There were no reported complaints, but many compliments. It was voiced that LVN C had humor and relationships with the resident she cared for. Resident #12 told LVN C I love You. The administrator checked in on Resident #12 every day since the incident and she had showed no signs of distress. The investigation findings were unfounded. An in-service was conducted with all staff on abuse and neglect. Resident #12's needs will continue to be anticipated and met and she will be treated with kindness and professionalism. The Report also had a disciplinary action indicating LVN C was suspended pending investigation findings. During an interview on 9/18/23 at 2:40 p.m. the Administrator said on the incident that was reported to the State Agency regarding LVN C and Resident #12 was unfounded. She said the Hospice aide that reported the incident had misperceived the situation. The Administrator said she had interviewed LVN C, the residents on the secured unit, and other staff about LVN C's behaviors and they all said only good things about LVN C. She said Resident #12 said she loved LVN C. The Administrator said LVN C had told her she was only playing with Resident #12 when she put her hand over her mouth, and jokingly said was that water still cold before motioning to push the resident into the water. The Administrator said Resident #12 was a dementia resident on the secured unit and did not have any effects from the incident, and she had unfounded the allegation of abuse. During an interview on 9/18/23 at 4:45 p. LVN C said she had worked at the facility for about [AGE] years. She said Resident #12 was not happy with herself or anyone else. She said she had been working 8 shifts a week and was tired but that was no excuse for what she did on 8/10/23. She said she worked 16 hours on MWF and on TTH she worked 8 hours. She said the Hospice aide asked for some assistance with giving Resident #12 a shower. She had gone into the shower and Resident #12 was just hollering at the top of her voice. LVN C said she put her hand over Resident #12's mouth, and she said it was wrong. LVN C said she knew she should not have put her hand over the resident's mouth and regretted it as soon as she did it. She said it did no good anyway because when she removed her hand the resident resumed screaming. She said she had jokingly asked the aide if the water was cold and pretended like she was going to push Resident #12 into the cold water. She said if she had seen an aide put their hand over any resident's mouth, she would have broken their arm trying to remove it from the resident's mouth. She said if she had seen someone doing what she did she would have reported it also, it was wrong. The nurse said Resident #12 had not hit her she was just screaming. During an interview and observation on 9/18/23 beginning at 7:30 p.m., CNA K said Resident #12 would become aggressive with staff and residents. Observation of she was speaking Resident #12 had said she wanted to go to bed. Observation showed Resident #12 sitting in the middle of the floor in her wheelchair, and she started to scream, loudly. CNA K told Resident 12 We will put you to bed in a minute and she (Resident #12) became quiet. During a telephone interview on 9/19/23 at 9:11 a.m., Hospice CNA said that on 8/10/23 Hospice CNA had asked LVN C to assist her giving Resident #12 a shower. They were in the shower room and the resident was in the chair just screaming and screaming at the top of her voice. She had her back turned and when she turned around, LVN C had her hand over Resident 12's mouth, just for a few seconds. She said LVN C did not appear to be intentionally trying to hurt the resident, it was not aggressively done or in anger. It was kind of in a playful manner. She said it was inappropriate but not abusive. She said once she took her hand off the resident, then LVN C asked if the water was still cold. The LVN told the resident she was going to put her in the cold water in a playful manner, but the water was no longer cold, and she did not put the resident in the water. During an interview on 9/19/23 at 1:30 p.m., the Administrator and HR person said LVN C was suspended one day on 8/10/23 in the middle of a shift. The Administrator said she determined no abuse occurred and LVN C retuned to work the next day. They paid her for the lost time. She was working a double that day and they had someone to finish her shift. During an interview and record review on 9/20/23 beginning at 8:47 a.m., Hospice CNA was asked about some of the things she put in her statement that she did not reveal in her interview. She said if she wrote in her statement that LVN C cursed, then she probably did. She said now that she thought back, yes LVN C did appear a little agitated at the resident on 8/10/23. However, the Hospice CNA said she felt bad about reporting what she thought was abuse at the time. She started to cry and said she really liked LVN C, but she felt it needed reporting at the time. She said now she was not sure. She said she worked with LVN C whenever she had to go to the secure unit and LVN C was always nice and friendly. She did not want to cause any issues for her. 2. Record review of Resident #13's face sheet dated 9/20/22 indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Some of her diagnoses were dementia unspecified severity with other behavioral disturbances, memory deficit, following a stroke, cognitive, communication deficit, bipolar disorder, mixed severe with psychotic features, Alzheimer's disease, and lack of coordination. Record review of a quarterly MDS dated [DATE] indicated Resident #13's cognitive status was severely impaired. Record review of Resident #13's care plan dated 12/10/22 indicated she had a focus area of impaired cognitive function/dementia or impaired thought process. Some of the interventions were to encourage the resident in simple, structured activities that avoid being overly demanding. Keep the residence routine consistent and try to provide consistent caregivers as much as possible to decrease confusion. Record review of a facility event behavior note dated 4/12/23 indicated a housekeeper stated that Resident #13 walked up to Resident #12's wheelchair and grabbed the armrest. Resident # 12 then prided Resident # 13's hand off the chair. Then Resident #13 hit Resident # 12 in the face and Resident # 12 hit Resident # 13 back on the arm. Record review of a Provider Investigation Report dated 9/7/23 indicated Resident #13 was self-propelled by Resident #12 and Resident #12 slapped Resident #13 in the face. Resident #13 was assessed for injuries. Resident #12 was sent to the hospital for an evaluation. The staff were in in serviced on abuse and neglect. Resident #12 was discharged with no new orders and Resident #13 did not remember the incident. During an interview on 9/18/23 at 4:45 p. LVN C said Resident #12 hit Resident #13 in the face. The facility sent Resident #12 after slapping Resident #13. She said the hospital and the hospital sent Resident #12 right back without any treatment. However, Resident # 12 had dementia and there was no real way to treat that. She said they just tried to watch Resident #12 because she did get agitated easily. During an observation and interview on 9/18/23 beginning at 4:57 p.m., Resident #12 was seen sitting in a wheelchair. She said that she was doing fine and had no problems with anyone, the staff were fine and so were the residents. During an observation and interview on 9/18/23 beginning at 4:58 p.m., Resident # 13 was sitting in the common area in a wheelchair. She said she was fine, and she was fine with all people. She said she wanted to go and kept repeating, come on let's go. During an interview on 9/20/23 at 2:15 p.m., the Administrator said she did not see Resident #12 slap Resident #13. The area where it happened was hard to see on the video. She said she was told that Resident #12 slapped Resident #12 for no reason. She said the aide that had witnessed the incident was off and she could not find her statement. During an interview on 9/20/23 at 2:20 p.m., LVN C said that she did not see the incident where Resident #12 slapped Resident #13. However, the aide should have known to keep those two apart. She said Resident #12 does not like Black people and Resident #12 and Resident #13 had an altercation in the past. LVN C said Resident #12 was aggressive usually during care but would hit other residents or become verbally aggressive with them from time to time. However, as a rule Resident #12 targeted Black people. They had a Black male(Resident #14z) on the unit, and she also targeted him. She said both Black( Resident #13 and Resident #14) residents stay away from Resident #12. During an interview on 9/20/23 at 2:27 p. m. the Hospice CNA said that Resident #12 can be abusive at times. 3. Record review of Resident #14's care plan dated 8/29/23 indicated he was an [AGE] year-old male admitted to the facility on [DATE]. He had diagnosis of psychotic disorder with hallucinations. He had a focus area of impaired cognitive function or impaired thought process. One of the interventions was to provide the resident with necessary cues, stop and return if agitated. Resident #14 had a Focus Area of ADL self-care performance deficit. The resident required supervision with ADLs. Record review of a SW note dated 9/29/23 at 3:48 p.m. indicated Resident #12 had an altercation with another resident( not named in the note) this afternoon and was irritated. The SW spoke to LVN C who said the resident was fine after the incident. Record review of nursing note dated 9/29/23 at 11:34 p.m. indicated Resident #12 was screaming at guest and another resident earlier. The resident is resting quietly in her bed at this time. During an interview on 9/20/23 at 2:56 p.m. the Therapy Director said Resident #12 did not like Black people, and she had called him names and would try to hit him in the past. He said he had a coworker that was Black, and Resident #12 called her names and did not like her. During an interview on 10/3/23 at 5:25 p.m. LVN W said Resident #12 had some behaviors over the weekend. She said apparently Resident #12 was making racial slurs to the family members of Resident #14 and was on a tear all weekend. They informed the doctor and Resident #12's Ativan was increased, and the resident had slept most of today. The LVN said she could not say with 100 percent certainty that Resident #12 targeted Black people. LVN W said she had not personally heard Resident #12 use racial slurs, but she had gotten reports of those behaviors more than once. During an interview on 10/3/23 at 5:40 p.m., CNA E said on 9/29/23, Resident #14's family had come to visit him. She said Resident #12 was in the dining room and started out by saying why were they there. CNA E said Resident #12 continued with her racial slurs until they had to take her to her room. She said Resident #12 was calling the Black family names, yelling, and screaming. She said Resident #12 kept saying they had no business here. CNA E said Resident #12 seemed to target Resident #13 and would go after Resident #13 if she was near her. The CNA said Resident #12 usually just yelled at Resident #14, maybe because he was a man. CNA E said Resident #12 did not appear to like either one of the Black residents. She said Resident #13 did get verbally aggressive with other residents and staff. She said mostly when staff were trying to provide care. However, Resident #12 would sit at the table and glare at Resident #13 and make remarks. During an interview on 10/3/21 at 6:51 p.m., MDS LVN said Resident #12 was normally abrasive and they kept her separated from everyone. She said the resident appeared to stay mad at everyone. The MDS nurse said Resident #14 walked aground and Resident #12 yelled at him. He touched things and would make Resident #12 mad. She said Resident #12 had hit her in the past. She said Resident #12 would often swing at people. The MDS nurse said she did not think Resident #12 liked Black people. She said she had heard her yell at Resident #13 but had never heard her call her a racial slur. During an interview on 10/4/23 at 5:50 p.m. SNA D said Resident #12 did not like Black people. She said on 9/29/23 the family of Resident #14 was in the dining room and Resident #12 called them racial slurs and glared at them. She said the resident was so disruptive she took her to her room. She said she was very hateful to Resident #13. She said Resident #13 did not do anything to Resident #12 to cause her hateful behaviors but for the most part Resident #13 and #14 stayed away from Resident #12. SNA D said Resident #12 was not as bad towards Resident #14, maybe because he was a man, she would holler at him for touching her door or something. She said whenever Resident #12 got a chance she was hateful to Resident #13. The SNA said she could be hateful and aggressive with any of the residents or staff but more so with Resident #13. During an interview with Activities Assistant, she said he was sitting one on one with Resident #12 today. She said it appeared Resident #12 did not like showers and had a Black shower aide with hospice in the past. She said it was always an issue with her showers during that time. Record review of the facility Abuse/Neglect policy dated 3/29/18 indicated Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff or other residents. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting in physical harm, pain or mental anguish. Willful as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The policy indicated neglect was the failure of the facility employees to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. This was determined to be an Immediate Jeopardy (IJ) on 10/03/23 at 6:00 p.m. The facility Administrator, ADON Q, and Regional Nurse Consultant were notified. The Administrator was provided with the IJ template on 10/03/23 at 6:00 p.m. The plan of removal was accepted on 10/4/29 at 12:49 p.m. Plan of Removal Problem: F607 Abuse and Neglect Interventions: LVN C was placed on suspension as of 10/3/23. Resident #12 was placed on 1:1 monitoring for behaviors on 10/3/23.??One on one monitoring until the telehealth visit with psych services is complete and the MD is consulted. MD was notified and Resident #12's medication was adjusted as of 10/3/23. Ativan 1 mg q AM and 2mg at supper for agitation. A head-to-toe assessment was performed on Resident #12 and Resident #1 by the charge nurse on 10/3/23. No injuries or skin issues noted.?Care plans updated as needed. Resident #1 was assessed for pain by the charge nurse on 10/3/23. Resident #1 was offered a shower by the charge nurse on 10/3/23. Resident safe surveys were completed on 10/3/23 by the Administrator /designee. No further complaints of abuse were noted. All residents were checked for showers and the need for incontinent care by the regional compliance nurse and charge nurses on 10/3/23. No further issues were identified. Psychiatric services were initiated for resident #12 and resident #1 on 10/3/23. Resident #12 and resident #1 care plans were reviewed and updated. Social Worker assessed on 10/4/23 residents #13 and other African American Male on the Unit, and no emotional distress noted from either resident. Resident #12 remains on 1:1 for monitoring and staff are aware to not have residents in the same immediate area. In-services: The following in-services were initiated on 10/3/23 and 10/4/23: Any staff member not present or in-service on 10/3/23 including new hires, agency, and PRN staff, will not be allowed to assume their duties until in-serviced.? In-services provided by Regional Compliance Nurse or Nurse Manager. All staff Abuse/Neglect Policy: what are the different types of abuse between staff to resident or resident to resident. ?? Abuse/Neglect Reporting: Abuse must be reported immediately to the Abuse Coordinator- Administrator and/or DON. Who to Report Abuse/Neglect to:??Abuse must be reported immediately to the Abuse Coordinator, Administrator and/or DON. Clinical Staff In-services provided by Regional Compliance Nurse or Nurse Manager Incontinent Care Policy?- every two-hour rounds and performing incontinent care timely. Bath/Tub/Shower Policy- following the shower schedule and offering to residents as needed. Behavior management Policy- managing residents with behaviors, de-escalation, and interventions. LVN C will be in-serviced 1:1 on the Abuse/Neglect Policy by the Regional Compliance Nurse on 10/4/23. LVN C was assigned Abuse and Neglect courses in Relias on 10/3/24. The Administrator was in-serviced 1:1 on the Abuse/Neglect Policy by Regional Compliance Nurse on 10/3/23. The medical director was notified of the immediate jeopardy situation on 10/3/23.?? An ADHOC QAPI meeting will be conducted with the IDT on 10/4/23 regarding the immediate jeopardy situation. Monitoring: The Administrator/Designee will interview 15 staff members per week if they have witnessed any abuse. Monitoring will take place 5 days per week x 6 weeks. The Administrator or designee will interview at least 5 residents daily for any indications of abuse and neglect. The Administrator or designee will interview at least 5 residents daily for completion of ADLs including showers and incontinent care. On 10/4/23 the investigator confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: During an interview on 1/4/23 at 2:50 p.m., the Regional Nurse Consultant said they hired a shower aide. They had in serviced with direct care staff about showers 3 times weekly and PRN. They were in serviced on providing correct documentation. She said all were in serviced, direct and non-direct on abuse and neglect and behavior. She said LVN C received one on one with all trainings and completed 3 courses on abuse and neglect on the computer, abuse neglect and behavior and the general that all staff took. The Regional Nurse Consultant said the Administrator received a one on one training about abuse and then same one everyone. She said they also conducted a mini-QA meeting to discuss interventions put into place with the medical director about the IJ concerns. During an interview on 10/4/23 at 4:39 p.m. Administrator said hired 6 new CNAs and had a class scheduled for October 16, 2023, for the SNAs in another facility. Record review of care plans for Residents 1, 12, 13, and 14 were conducted with no issues noted. There were updates to Resident #1 and #12's care plans. Record review of Resident #12's physician orders indicated Resident #12 had an order for 1 mg of Lorazepam PRN dated 9/21/23. On 10/2/23 the order indicated to give the resident 1mg of Lorazepam daily for agitation. She also had an order for 2mg once a day. Record review of the monitoring sheets for Resident #12 indicated one-to-one observation from 10/3/23 at 8:30 p.m. until present. Record review of a SW progress note dated 10/4/23 at 1:36 p.m. indicated Resident #12 was referred to psychiatric services and asked to be seen as soon as possible. Record review of a SW progress note dated 10/4/23 at 1:57 p.m. indicated Resident #1's family was consulted about Resident #1 receiving counseling services. Resident #1 declined the counseling services. Record Review of a #1's pain assessment dated [DATE] at 9:38 p.m. indicated she did not voice any pain. Record Review of an Employee Disciplinary Report dated 10/3/23 indicated LVN C was suspended due to and Investigatory Suspension. Record review of the facility policy and procedures on Abuse, Neglect, Behavior Management Policy, Bath and shower procedures, Bowel Incontinence Care and Urinary Incontinence procedures indicated the facility staff were in serviced on these policies and procedures. Record review of all residents' questionnaires dated 10/3/23 indicated none of the residents questioned had any current issues. Record review of the facility off cycle QA meeting dated 10/4/23 indicated the facility had discussed abuse neglect, behavior management, incontinence, Showers, and baths. They discussed Residents #12 and Resident #1 specifically to ensure systems were in place to prevent further abuse and neglect of residents. The form had signatures to include the Medical Director. The following Interviews were conducted on 10/4/23 between 3:51 p.m. and 7:15 p.m. At 3: 51 p.m. ADON/RN - P At 4:27 p.m. ADON/LVN Q At 4:59 LVN V worked 2 p to 10 p At 5:10 p.m. Dietary Manager, said she worked various hours At 5:25 p.m. LVN U worked 2p to 10 p At 5:40 p.m. CNA G worked 6a to 2 p At 5:50 p.m. SNA D worked 6a to 6p At 5:55 p.m. Activity Assistant said she worked various hours At 6:10 p.m. RN T worked 6a to 6 p At 6:15 p.m. SNA J said she worked 6a to 6p or 6p to 6a At 6:40 p.m. CNA S worked 6a to 6p At 6:50 p.m. SNA R worked 6p to 6a At 6:55 p.m. CNA M worked 6p to 6a Interviews with ADON P, ADON Q, RN T, LVN U, LVN V, Activities Director, and Dietary Manager indicated the staff listed above were able to verbalize knowledge and understanding of all in services provide. They said they were in serviced on showers, and ADLs. They stated they were instructed to monitor the aides' interactions with residents during care and monitor to ensure care was competed timely. They indicated they would do this by monitoring documentation of shower sheets and the facility computer programs. They indicated showers were to be completed on the designated days, MWF or TTHS, and if resident refused, they would check to see why. They said if the resident continued to refuse, they would contact the family to let them know. They indicated they would ask residents about their care and if they received showers as needed. They also indicated they would complete their own rounds on residents and on occasion assist the aide, so they were aware of their competency levels with providing care to residents. The two ADONs and the nurses said they were in served on behaviors and would monitor residents for changes in behaviors that might indicate physical problems like a UTI. They would remove the resident from other residents and try to determine the cause of the behaviors. If the resident was refusing care they would leave and approach the resident at a later time. They indicated they had been instructed to document behaviors and if the behaviors could not be resolved easily to contact the family and physician for instructions. All staff also indicated they were in serviced on abuse and neglect. They would monitor resident and staff interactions to ensure abuse and neglect did not occur and if they saw, hear, or it was reported to them they would report to the Abuse Coordinator the Administrator. Interviews with 6 aides listed above were able to verbalize knowledge and understanding of all in services provide. They indicated they were in serviced on showers, and ADLs. They stated they were instructed to complete Showers on the designated days, MWF or TTHS, and if resident refused, they would check to see if they switched persons if the resident would accept the shower or try later. If the resident continues to refuse, they would inform the nurse. They would fill out the shower sheets as they assessed for skin abnormalities and turn them in as required and complete the ADL information in the computer system. The aides indicated they would complete incontinence care rounds on residents every two hours and some residents more often. They said they would provide care as required. The aides said they were in served on behaviors and would monitor residents for changes in behaviors that might and notify the nurse of any change in behaviors. If the residents exhibited signs of aggression, they would inform the nurse. They would remove the resident from other residents. If the resident was refusing care they would leave and approach the resident at a later time. They indicated they had been instructed to document and notify the nurse of all behaviors. The staff also indicated they were in serviced on abuse and neglect. They would monitor resident and staff interactions to ensure abuse and neglect did not occur and if they saw, hear, or it was reported to them, they would report to the Abuse Coordinator the Administrator. During an interview on 10/4/23 at 7:05 p.m., the Administrator said she was in serviced on the abuse neglect policy. She said as the Abuse Coordinator it was her responsibility to identify and act on any allegation of abuse or neglect. She said she would suspend immediately the individual, follow policy, and follow the policy. She said with LVN C she did not feel that Resident #12 was abused because Resident #12 said she loved LVN C and LVN C was usually the only one that can get he [TRUNCATED]

Based on observation, interview, and record review the facility failed to ensure residents had the right to be free from abuse, and neglect for 3 of 18 residents reviewed for abuse and neglect (Resident #12, Resident #13, and Resident #14) in that: Resident #12 was abused when LVN C put her hand over Resident #12's mouth to stop her from screaming. LVN C also threatened to push Resident #12 into cold water if she did not stop screaming. Resident #13 was physically abused by Resident #12. Resident #12 slapped Resident #13 in the face. Resident #12 had a history of abusive behaviors. Resident #12 disliked Black people and targeted two Black residents on the secure unit, Resident #13, and Resident #14. An Immediate Jeopardy (IJ) situation was identified on 10/3/23 at 6:00 p.m. The IJ template was provided to the facility on [DATE] at 6:00 p.m. While the IJ was removed on 10/4/23 at 6:30 p.m., the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems These failures could cause emotional and physical harm and could lead to additional pain and suffering. Finding included: 1.Record review of Resident #12's face sheet indicated she was an [AGE] year-old female admitted to the facility on [DATE]. Some of her diagnoses were dementia (impairment of memory) with other behavioral disturbances, psychotic disorder (a mental problem that causes people to perceive or interpret things differently from those around them), with delusions, cognitive communication deficit, and major depression. Record review of Resident #12's quarterly MDS dated [DATE] indicated her cognitive status was severely impaired. Record review of Resident #12's Care Plan dated 9/7/22 indicated a focus area of impaired cognition due to dementia or impaired thought processes. Some of the interventions were, use the residents preferred name, identify self at each interaction, face resident, and make eye contact when speaking and provide cues when necessary and stop and return, if agitated. Another focused area was Resident #12 has the potential to demonstrate physical behaviors. Some of the interventions were to analyze the time, the places, circumstances, triggers, and what escalate to behaviors and document. Communication provided with physical and verbal cues to alleviate, anxiety, give positive feedback, assist with verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff when agitated. When the resident becomes agitated intervene before agitation, escalated, remove from source of distress, engage calmly in conversation calmly, and if responses or aggressive staff were to walk away calmly and approach later. Resident # 12 also had a focus area of potential to demonstrate verbal abusive behaviors, with some of the same interventions in place. Record review of the facility Provider Investigation Report dated 8/10/23 indicated a Hospice CNA alleged that LVN C was unkind to Resident #12. The Report contained a statement written by LVN C that stated: The Hospice CNA asked her to assist with Resident #12 because she (Resident #12) was combative, and she (Resident #12) had slapped the aide in the face on a previous occasion. The LVN wrote they took Resident #12 into the shower room and removed her clothes. LVN C said the resident was screaming, and LVN C placed her hand over Resident #12's mouth, her intent was to distract Resident #12. LVN C said she often joked with the resident. She said she (LVN C) jokily asked the aide if the water was cold. The nurse said the Resident #12 did not present any type of respiratory distress. The report indicated LVN C said she had known the resident prior to her admission to the facility and was only joking. Record review of the Provider Investigation Report contained a statement from the Hospice CNA dated 8/10/23 at 12:43 p.m. which stated. I was prepping PT (Resident #12) for a shower, I required assistance with undressing due to PT disability. I stuck my head around the and there were no aides, so I asked the nurse. She said, Sure let's go. PT (Resident #12) was very combative and not cooperating. The nurse was a little abrasive while removing PTs, shirt, once the shirt was removed, I turned my back to PT (Resident #12) and the nurse (LVN C) to ensure safe water temp. Pt was screaming very loudly while my back was turned. Pt very abruptly stopped screaming. Approximately 10- 15 seconds. Later after PT stopped screaming, I turned back toward PT to fine nurse standing behind Pt with her hand firmly grasping PT face covering her mouth and partially covering her nose. When I (Hospice CNA) looked at the nurse, she said I'm sick of hearing this, Shit. At that point she let go of her face. I quickly checked the water temp again and reached for PT. The Nurse then aggressively shoved the PT toward the running water and said is it cold I said No! The with a sarcastic tone the nurse said Damn she then asked if I needed anything and left the room. Record review of the facility Investigation Summary indicated staff members, and all residents (on the secure unit) that LVN C cared for were interviewed on 8/10/23. They said they had never witnessed any misconduct by LVN C. There were no reported complaints, but many compliments. It was voiced that LVN C had humor and relationships with the resident she cared for. Resident #12 told LVN C I love You. The administrator checked in on Resident #12 every day since the incident and she had showed no signs of distress. The investigation findings were unfounded. An in-service was conducted with all staff on abuse and neglect. Resident #12's needs will continue to be anticipated and met and she will be treated with kindness and professionalism. The Report also had a disciplinary action indicating LVN C was suspended pending investigation findings. During an interview on 9/18/23 at 2:40 p.m. the Administrator said on the incident that was reported to the State Agency regarding LVN C and Resident #12 was unfounded. She said the Hospice aide that reported the incident had misperceived the situation. The Administrator said she had interviewed LVN C, the residents on the secured unit, and other staff about LVN C's behaviors and they all said only good things about LVN C. She said Resident #12 said she loved LVN C. The Administrator said LVN C had told her she was only playing with Resident #12 when she put her hand over her mouth, and jokingly said was that water still cold before motioning to push the resident into the water. The Administrator said Resident #12 was a dementia resident on the secured unit and did not have any effects from the incident, and she had unfounded the allegation of abuse. During an interview on 9/18/23 at 4:45 p. LVN C said she had worked at the facility for about [AGE] years. She said Resident #12 was not happy with herself or anyone else. She said she had been working 8 shifts a week and was tired but that was no excuse for what she did on 8/10/23. She said she worked 16 hours on MWF and on TTH she worked 8 hours. She said the Hospice aide asked for some assistance with giving Resident #12 a shower. She had gone into the shower and Resident #12 was just hollering at the top of her voice. LVN C said she put her hand over Resident #12's mouth, and she said it was wrong. LVN C said she knew she should not have put her hand over the resident's mouth and regretted it as soon as she did it. She said it did no good anyway because when she removed her hand the resident resumed screaming. She said she had jokingly asked the aide if the water was cold and pretended like she was going to push Resident #12 into the cold water. She said if she had seen an aide put their hand over any resident's mouth, she would have broken their arm trying to remove it from the resident's mouth. She said if she had seen someone doing what she did she would have reported it also, it was wrong. The nurse said Resident #12 had not hit her she was just screaming. During an interview and observation on 9/18/23 beginning at 7:30 p.m., CNA K said Resident #12 would become aggressive with staff and residents. Observation of she was speaking Resident #12 had said she wanted to go to bed. Observation showed Resident #12 sitting in the middle of the floor in her wheelchair, and she started to scream, loudly. CNA K told Resident 12 We will put you to bed in a minute and she (Resident #12) became quiet. During a telephone interview on 9/19/23 at 9:11 a.m., Hospice CNA said that on 8/10/23 Hospice CNA had asked LVN C to assist her giving Resident #12 a shower. They were in the shower room and the resident was in the chair just screaming and screaming at the top of her voice. She had her back turned and when she turned around, LVN C had her hand over Resident 12's mouth, just for a few seconds. She said LVN C did not appear to be intentionally trying to hurt the resident, it was not aggressively done or in anger. It was kind of in a playful manner. She said it was inappropriate but not abusive. She said once she took her hand off the resident, then LVN C asked if the water was still cold. The LVN told the resident she was going to put her in the cold water in a playful manner, but the water was no longer cold, and she did not put the resident in the water. During an interview on 9/19/23 at 1:30 p.m., the Administrator and HR person said LVN C was suspended one day on 8/10/23 in the middle of a shift. The Administrator said she determined no abuse occurred and LVN C retuned to work the next day. They paid her for the lost time. She was working a double that day and they had someone to finish her shift. During an interview and record review on 9/20/23 beginning at 8:47 a.m., Hospice CNA was asked about some of the things she put in her statement that she did not reveal in her interview. She said if she wrote in her statement that LVN C cursed, then she probably did. She said now that she thought back, yes LVN C did appear a little agitated at the resident on 8/10/23. However, the Hospice CNA said she felt bad about reporting what she thought was abuse at the time. She started to cry and said she really liked LVN C, but she felt it needed reporting at the time. She said now she was not sure. She said she worked with LVN C whenever she had to go to the secure unit and LVN C was always nice and friendly. She did not want to cause any issues for her. 2.Record review of Resident #13's face sheet dated 9/20/22 indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Some of her diagnoses were dementia unspecified severity with other behavioral disturbances, memory deficit, following a stroke, cognitive, communication deficit, bipolar disorder, mixed severe with psychotic features, Alzheimer's disease, and lack of coordination. Record review of a quarterly MDS dated [DATE] indicated Resident #13's cognitive status was severely impaired. Record review of Resident #13's care plan dated 12/10/22 indicated she had a focus area of impaired cognitive function/dementia or impaired thought process. Some of the interventions were to encourage the resident in simple, structured activities that avoid being overly demanding. Keep the residence routine consistent and try to provide consistent caregivers as much as possible to decrease confusion. Record review of a facility event behavior note dated 4/12/23 indicated a housekeeper stated that Resident #13 walked up to Resident #12's wheelchair and grabbed the armrest. Resident # 12 then prided Resident # 13's hand off the chair. Then Resident #13 hit Resident # 12 in the face and Resident # 12 hit Resident # 13 back on the arm. Record review of a Provider Investigation Report dated 9/7/23 indicated Resident #13 was self-propelled by Resident #12 and Resident #12 slapped Resident #13 in the face. Resident #13 was assessed for injuries. Resident #12 was sent to the hospital for an evaluation. The staff were in in serviced on abuse and neglect. Resident #12 was discharged with no new orders and Resident #13 did not remember the incident. During an interview on 9/18/23 at 4:45 p. LVN C said Resident #12 hit Resident #13 in the face. The facility sent Resident #12 after slapping Resident #13. She said the hospital and the hospital sent Resident #12 right back without any treatment. However, Resident # 12 had dementia and there was no real way to treat that. She said they just tried to watch Resident #12 because she did get agitated easily. During an observation and interview on 9/18/23 beginning at 4:57 p.m., Resident #12 was seen sitting in a wheelchair. She said that she was doing fine and had no problems with anyone, the staff were fine and so were the residents. During an observation and interview on 9/18/23 beginning at 4:58 p.m., Resident # 13 was sitting in the common area in a wheelchair. She said she was fine, and she was fine with all people. She said she wanted to go and kept repeating, come on let's go. During an interview on 9/20/23 at 2:15 p.m., the Administrator said she did not see Resident #12 slap Resident #13. The area where it happened was hard to see on the video. She said she was told that Resident #12 slapped Resident #12 for no reason. She said the aide that had witnessed the incident was off and she could not find her statement. During an interview on 9/20/23 at 2:20 p.m., LVN C said that she did not see the incident where Resident #12 slapped Resident #13. However, the aide should have known to keep those two apart. She said Resident #12 does not like Black people and Resident #12 and Resident #13 had an altercation in the past. LVN C said Resident #12 was aggressive usually during care but would hit other residents or become verbally aggressive with them from time to time. However, as a rule Resident #12 targeted Black people. They had a Black male(Resident #14z) on the unit, and she also targeted him. She said both Black( Resident #13 and Resident #14) residents stay away from Resident #12. During an interview on 9/20/23 at 2:27 p. m. the Hospice CNA said that Resident #12 can be abusive at times. 3. Record review of Resident #14's care plan dated 8/29/23 indicated he was an [AGE] year-old male admitted to the facility on [DATE]. He had diagnosis of psychotic disorder with hallucinations. He had a focus area of impaired cognitive function or impaired thought process. One of the interventions was to provide the resident with necessary cues, stop and return if agitated. Resident #14 had a Focus Area of ADL self-care performance deficit. The resident required supervision with ADLs. Record review of a SW note dated 9/29/23 at 3:48 p.m. indicated Resident #12 had an altercation with another resident( not named in the note) this afternoon and was irritated. The SW spoke to LVN C who said the resident was fine after the incident. Record review of nursing note dated 9/29/23 at 11:34 p.m. indicated Resident #12 was screaming at guest and another resident earlier. The resident is resting quietly in her bed at this time. During an interview on 9/20/23 at 2:56 p.m. the Therapy Director said Resident #12 did not like Black people, and she had called him names and would try to hit him in the past. He said he had a coworker that was Black, and Resident #12 called her names and did not like her. During an interview on 10/3/23 at 5:25 p.m. LVN W said Resident #12 had some behaviors over the weekend. She said apparently Resident #12 was making racial slurs to the family members of Resident #14 and was on a tear all weekend. They informed the doctor and Resident #12's Ativan was increased, and the resident had slept most of today. The LVN said she could not say with 100 percent certainty that Resident #12 targeted Black people. LVN W said she had not personally heard Resident #12 use racial slurs, but she had gotten reports of those behaviors more than once. During an interview on 10/3/23 at 5:40 p.m., CNA E said on 9/29/23, Resident #14's family had come to visit him. She said Resident #12 was in the dining room and started out by saying why were they there. CNA E said Resident #12 continued with her racial slurs until they had to take her to her room. She said Resident #12 was calling the Black family names, yelling, and screaming. She said Resident #12 kept saying they had no business here. CNA E said Resident #12 seemed to target Resident #13 and would go after Resident #13 if she was near her. The CNA said Resident #12 usually just yelled at Resident #14, maybe because he was a man. CNA E said Resident #12 did not appear to like either one of the Black residents. She said Resident #13 did get verbally aggressive with other residents and staff. She said mostly when staff were trying to provide care. However, Resident #12 would sit at the table and glare at Resident #13 and make remarks. During an interview on 10/3/21 at 6:51 p.m., MDS LVN said Resident #12 was normally abrasive and they kept her separated from everyone. She said the resident appeared to stay mad at everyone. The MDS nurse said Resident #14 walked aground and Resident #12 yelled at him. He touched things and would make Resident #12 mad. She said Resident #12 had hit her in the past. She said Resident #12 would often swing at people. The MDS nurse said she did not think Resident #12 liked Black people. She said she had heard her yell at Resident #13 but had never heard her call her a racial slur. During an interview on 10/4/23 at 5:50 p.m. SNA D said Resident #12 did not like Black people. She said on 9/29/23 the family of Resident #14 was in the dining room and Resident #12 called them racial slurs and glared at them. She said the resident was so disruptive she took her to her room. She said she was very hateful to Resident #13. She said Resident #13 did not do anything to Resident #12 to cause her hateful behaviors but for the most part Resident #13 and #14 stayed away from Resident #12. SNA D said Resident #12 was not as bad towards Resident #14, maybe because he was a man, she would holler at him for touching her door or something. She said whenever Resident #12 got a chance she was hateful to Resident #13. The SNA said she could be hateful and aggressive with any of the residents or staff but more so with Resident #13. During an interview with Activities Assistant, she said he was sitting one on one with Resident #12 today. She said it appeared Resident #12 did not like showers and had a Black shower aide with hospice in the past. She said it was always an issue with her showers during that time. Record review of the facility Abuse/Neglect policy dated 3/29/18 indicated Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff or other residents. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting in physical harm, pain or mental anguish. Willful as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The policy indicated neglect was the failure of the facility employees to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. This was determined to be an Immediate Jeopardy (IJ) on 10/03/23 at 6:00 p.m. The facility Administrator, ADON Q, and Regional Nurse Consultant were notified. The Administrator was provided with the IJ template on 10/03/23 at 6:00 p.m. The plan of removal was accepted on 10/4/29 at 12:49 p.m. Plan of Removal Problem: F600 Abuse and Neglect Interventions: LVN C was placed on suspension as of 10/3/23. Resident #12 was placed on 1:1 monitoring for behaviors on 10/3/23.??One on one monitoring until the telehealth visit with psych services is complete and the MD is consulted. MD was notified and Resident #12's medication was adjusted as of 10/3/23. Ativan 1 mg q AM and 2mg at supper for agitation. A head-to-toe assessment was performed on Resident #12 and Resident #1 by the charge nurse on 10/3/23. No injuries or skin issues noted.?Care plans updated as needed. Resident #1 was assessed for pain by the charge nurse on 10/3/23. Resident #1 was offered a shower by the charge nurse on 10/3/23. Resident safe surveys were completed on 10/3/23 by the Administrator /designee. No further complaints of abuse were noted. All residents were checked for showers and the need for incontinent care by the regional compliance nurse and charge nurses on 10/3/23. No further issues were identified. Psychiatric services were initiated for resident #12 and resident #1 on 10/3/23. Resident #12 and Resident #1 care plans were reviewed and updated. Social Worker assessed Resident #13 and other African American Male on the Unit on 10/04/23 and no emotional distress noted from either resident. Resident #12 remains on 1:1 for monitoring and staff are aware to not have residents in the same immediate area. In-services: The following in-services were initiated on 10/3/23 and 10/4/23: Any staff member not present or in-service on 10/3/23 including new hires, agency, and PRN staff, will not be allowed to assume their duties until in-serviced.? In-services provided by Regional Compliance Nurse or Nurse Manager. All staff Abuse/Neglect Policy: what are the different types of abuse between staff to resident or resident to resident. ?? Abuse/Neglect Reporting: Abuse must be reported immediately to the Abuse Coordinator- Administrator and/or DON. Who to Report Abuse/Neglect to:??Abuse must be reported immediately to the Abuse Coordinator, Administrator and/or DON. Clinical Staff In-services provided by Regional Compliance Nurse or Nurse Manager Incontinent Care Policy?- every two-hour rounds and performing incontinent care timely. Bath/Tub/Shower Policy- following the shower schedule and offering to residents as needed. Behavior management Policy- managing residents with behaviors, de-escalation, and interventions. LVN C will be in-serviced 1:1 on the Abuse/Neglect Policy by the Regional Compliance Nurse on 10/4/23. LVN C was assigned Abuse and Neglect courses in Relias on 10/3/24. The Administrator was in-serviced 1:1 on the Abuse/Neglect Policy by Regional Compliance Nurse on 10/3/23. The medical director was notified of the immediate jeopardy situation on 10/3/23.?? An ADHOC QAPI meeting will be conducted with the IDT on 10/4/23 regarding the immediate jeopardy situation. Monitoring: The Administrator/Designee will interview 15 staff members per week if they have witnessed any abuse. Monitoring will take place 5 days per week x 6 weeks. The Administrator or designee will interview at least 5 residents daily for any indications of abuse and neglect. The Administrator or designee will interview at least 5 residents daily for completion of ADLs including showers and incontinent care. On 10/4/23 the investigator confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: During an interview on 1/4/23 at 2:50 p.m., the Regional Nurse Consultant said they hired a shower aide. They had in serviced with direct care staff about showers 3 times weekly and PRN. They were in serviced on providing correct documentation. She said all were in serviced, direct and non-direct on abuse and neglect and behavior. She said LVN C received one on one with all trainings and completed 3 courses on abuse and neglect on the computer, abuse neglect and behavior and the general that all staff took. The Regional Nurse Consultant said the Administrator received a one on one training about abuse and then same one everyone. She said they also conducted a mini-QA meeting to discuss interventions put into place with the medical director about the IJ concerns. During an interview on 10/4/23 at 4:39 p.m. Administrator said hired 6 new CNAs and had a class scheduled for October 16, 2023, for the SNAs in another facility. Record review of care plans for Resident #'s 1, 12, 13, and 14 were conducted with no issues noted. There were updates to Resident #1 and #12's care plans. Record review of Resident #12's physician orders indicated Resident #12 had an order for 1 mg of Lorazepam PRN dated 9/21/23. On 10/2/23 the order indicated to give the resident 1mg of Lorazepam daily for agitation. She also had an order for 2mg once a day. Record review of the monitoring sheets for Resident #12 indicated one-to-one observation from 10/3/23 at 8:30 p.m. until present. Record review of a SW progress note dated 10/4/23 at 1:36 p.m. indicated Resident #12 was referred to psychiatric services and asked to be seen as soon as possible. Record review of a SW progress note dated 10/4/23 at 1:57 p.m. indicated Resident #1's family was consulted about Resident #1 receiving counseling services. Resident #1 declined the counseling services. Record Review of a #1's pain assessment dated [DATE] at 9:38 p.m. indicated she did not voice any pain. Record Review of an Employee Disciplinary Report dated 10/3/23 indicated LVN C was suspended due to and Investigatory Suspension. Record review of the facility policy and procedures on Abuse, Neglect, Behavior Management Policy, Bath and shower procedures, Bowel Incontinence Care and Urinary Incontinence procedures indicated the facility staff were in serviced on these policies and procedures. Record review of all residents' questionnaires dated 10/3/23 indicated none of the residents questioned had any current issues. Record review of the facility off cycle QA meeting dated 10/4/23 indicated the facility had discussed abuse neglect, behavior management, incontinence, Showers, and baths. They discussed Residents #12 and Resident #1 specifically to ensure systems were in place to prevent further abuse and neglect of residents. The form had signatures to include the Medical Director. The following Interviews were conducted on 10/4/23 between 3:51 p.m. and 7:15 p.m. At 3: 51 p.m. ADON/RN - P At 4:27 p.m. ADON/LVN Q At 4:59 LVN V worked 2 p to 10 p At 5:10 p.m. Dietary Manager, said she worked various hours At 5:25 p.m. LVN U worked 2p to 10 p At 5:40 p.m. CNA G worked 6a to 2 p At 5:50 p.m. SNA D worked 6a to 6p At 5:55 p.m. Activity Assistant said she worked various hours At 6:10 p.m. RN T worked 6a to 6 p At 6:15 p.m. SNA J said she worked 6a to 6p or 6p to 6a At 6:40 p.m. CNA S worked 6a to 6p At 6:50 p.m. SNA R worked 6p to 6a At 6:55 p.m. CNA M worked 6p to 6a Interviews with ADON P, ADON Q, RN T, LVN U, LVN V, Activities Director, and Dietary Manager indicated the staff listed above were able to verbalize knowledge and understanding of all in services provide. They said they were in serviced on showers, and ADLs. They stated they were instructed to monitor the aides' interactions with residents during care and monitor to ensure care was competed timely. They indicated they would do this by monitoring documentation of shower sheets and the facility computer programs. They indicated showers were to be completed on the designated days, MWF or TTHS, and if resident refused, they would check to see why. They said if the resident continued to refuse, they would contact the family to let them know. They indicated they would ask residents about their care and if they received showers as needed. They also indicated they would complete their own rounds on residents and on occasion assist the aide, so they were aware of their competency levels with providing care to residents. The two ADONs and the nurses said they were in served on behaviors and would monitor residents for changes in behaviors that might indicate physical problems like a UTI. They would remove the resident from other residents and try to determine the cause of the behaviors. If the resident was refusing care they would leave and approach the resident at a later time. They indicated they had been instructed to document behaviors and if the behaviors could not be resolved easily to contact the family and physician for instructions. All staff also indicated they were in serviced on abuse and neglect. They would monitor resident and staff interactions to ensure abuse and neglect did not occur and if they saw, hear, or it was reported to them they would report to the Abuse Coordinator the Administrator. Interviews with 6 aides listed above were able to verbalize knowledge and understanding of all in services provide. They indicated they were in serviced on showers, and ADLs. They stated they were instructed to complete Showers on the designated days, MWF or TTHS, and if resident refused, they would check to see if they switched persons if the resident would accept the shower or try later. If the resident continues to refuse, they would inform the nurse. They would fill out the shower sheets as they assessed for skin abnormalities and turn them in as required and complete the ADL information in the computer system. The aides indicated they would complete incontinence care rounds on residents every two hours and some residents more often. They said they would provide care as required. The aides said they were in served on behaviors and would monitor residents for changes in behaviors that might and notify the nurse of any change in behaviors. If the residents exhibited signs of aggression, they would inform the nurse. They would remove the resident from other residents. If the resident was refusing care they would leave and approach the resident at a later time. They indicated they had been instructed to document and notify the nurse of all behaviors. The staff also indicated they were in serviced on abuse and neglect. They would monitor resident and staff interactions to ensure abuse and neglect did not occur and if they saw, hear, or it was reported to them, they would report to the Abuse Coordinator the Administrator. During an interview on 10/4/23 at 7:05 p.m., the Administrator said she was in serviced on the abuse neglect policy. She said as the Abuse Coordinator it was her responsibility to identify and act on any allegation of abuse or neglect. She said she would suspend immediately the individual, follow policy, and follow the policy. She said with LVN C she did not feel that Resident #12 was abused because Resident #12 said she loved LVN C and LVN C was usually the only one that can get her to take her medications. The Administrator said she received in service on ADLs. She said as the administrator her part was to monitor the system they have that tracks ADLs. She said they conducted morning meeting have assignments discussed. They also conducted Champion Rounds (where each department head had a section of the facility, they questions residents about their care). They would ask the residents how they were treated, if they got showers, beds made, and if they were getting the care they needed. She said each administrative staff had a section of the facility. She said that was not new, they just added the showers as part of the questions they ask residents. The Administrator said she was in serviced on the Behavior Management policy. She said they would like for everyone to recognize and communicate, anger, acting out, saying unkind things. She said she did not want those action to be the norm. She said she wanted her staff to report all behaviors. She said maybe the residents could medical issues such as a UTI that need medical attention. She wanted the aide to tell the nurse so they could contact the doctor. On 10/04/23 at 7:20 p.m., the Administrator, ADON, and Regional Nurse Consultant were informed the Immediate Jeopardy was removed; howev [TRUNCATED]

Based on observation, interview, and record review the facility failed to ensure sufficient staff to provide nursing related ser ices to ensure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident, for 13 of 18 residents reviewed for sufficient staff (Resident #1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 15, 16, and # 18.) The facility failed to have sufficient staff to provide timely incontinent care for Resident #1, Resident #3, and Resident #15. The facility failed to have sufficient staff to provide showers for 26 residents on 9/18/23. The facility failed to have sufficient staff to provide routine showers for Resident #'s 1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 15, 16, and 18. This failure placed dependent residents at risk for poor hygiene, not receiving care in a timely manner, and decreased quality of life. Findings included: Record Review of Time Sheets 9/1-9/19/23 indicated: 9/1/23: 2 CNAs from 5:45 am-5pm, 1 CNA from 6:26 am-5:04 pm; 2 SNAs from 6 am-6 pm, 1 SNA from 8 am-3pm, 1 CNA from 4 pm-11 pm, 1 SNA from 6 pm-6:30am; 9/2/23: 1 CNA from 5:45 am-6:15p., 1 CNA from 5:54 am-4:20pm, 1 SNA from 6 am-5:21 pm, 2 SNAs from 6 am-6 pm, 5 SNAs from 6 pm-6 am, 1 CNA from 6 pm-12 am; 9/3/23: 1 CNA from 6 am-4 pm, 1 CNA from 6 am-6:45 pm, 2 SNAs from 6 am-6pm, 2 SNAs from 3:30 pm-6:30 am, 1 SNA from 4:45 pm-6:20 am, 2 SNAs from 6 pm-6 am; 9/4/23: 2 CNAs from 6am-6pm, 1 CNA from 6 am-3 pm, 2 SNAs from 6 am-6 pm, 1 CNA from 8:45 a.m-4 pm, 2 SNAs from 5 pm-6 am, 1 SNA from 5:23 pm-6:39 am, 2 SNAs from 6 pm-6 am; 9/5/23: 2 CNAs from 6 am-8 pm, 1 CNA from 6 am-6 pm, 1 SNA from 6 am-8:46 pm, 1 SNA from 8 am-6 pm, 1 CNA from 9:29 pm-2:39 am, 1 SNA from 6 pm-6 am, 1 SNA from 8 pm-10:47 pm, 2 SNAs from 8 pm-12 am; 9/6/23: 1 CNA from 5:45 am-6:10 pm, 2 CNAs from 6 am-6:10 pm, 1 SNA from 6 am-8:28 pm, 1 SNA from 6:22 am-8:07 am, 1 SNA from 7:45 am-6:14 pm, 1 SNA from 6 pm-6:17 am, 1 SNAs from 10 pm-3:22 am; 9/7/23: 2 CNAs from 6 am-6 pm, 1 CNA from 6 am-4 pm, 2 SNAs from 6 am-6 pm, 1 SNA from 7:42 am-8:17 pm, 3 SNAs from 5:45 pm-6 am, 2 SNAs from 7 pm-6 am; . 9/8/23: 1 CNA from 6 am-6 pm, 1 CNA from 6 am-4 pm, 1 SNA from 6 am-2 pm, 1 SNA from 7 am-8 am, 1 SNA from 6 am-6 pm, 1 CNA from 12:15 pm-12:35 pm, 3 SNAs from 4 pm-6 am, 2 SNAs from 5 pm-6 am; 9/9/23: 2 CNAs from 6 am-6 pm, 1 SNA from 6 am-6 pm, 1 SNA from 8 am-4 pm, 2 SNAs from 6 pm-10 pm, 1 SNA from 6 pm-6 am; 9/10/23: 2 CNAs from 6 am-6 pm, 1 SNA from 6 am-10 pm, 2 SNAs from 6 pm-6 am; 9/11/23: 2 CNAs from 6 am-6 pm, 1 SNA from 6:30 am-10 pm, 1 SNA from 7:50 am-6 pm, 2 SNAs from 6 pm-6 am, 2 SNAs from 7 pm-3 am; 9/12/23: 2 CNAs from 6 am-6 pm, 1 CNA from 6 am-4 pm, 1 SNA from 6 am-6 pm, 1 SNA from 6 am-5 pm, 2 SNAs from 6 pm-6 am, , 2 SNAs from 6 pm-10:46 pm; 9/13/23: 3 CNAs from 6 am-6 pm, 1 SNA from 6 am-6 pm, 1 SNA from 7 am-1:30 pm, 1 SNA from 6 pm-9:14 pm, 1 CNA from 6 pm-6 am, 1 SNA from 7 pm- 6am, 1 SNA from 10 pm-6 am; 9/14/23: 1 SNA from 4 am-6 pm, 3 CNAs from 6 am-6 pm, 1 SNA from 6 am-7:30 pm, 1 SNA from 8 am-6 pm, 1 CNA from 6 pm-6 am, 2 SNA from 6 pm-6 am; 9/15/23: 2 CNAs from 6 am-6 pm, 1 CNA from 10 am-2 pm, 2 SNA from 6 am-6 pm, 1 SNA from 8 am-3 pm, 2 SNAs from 6 pm-6 am, 1 SNA from 8 pm-10 pm; 9/16/23: 1 CNA from 6 am-6 pm, 2 CNAs from 6 am-7 pm, 1 SNA from 6 am-6 pm, 1 SNA from 6 am-7:30 pm, 1 SNA from 7 pm-9:45 pm, 2 SNAs from 7:30 pm-6:132 am; 9/17/23: 2 CNAs from 6 am-6 pm, 1 CNA from 6 am- 4 pm, 2 SNAs from 6 am-6 pm, 1 CNA from 6 pm-5 am, 2 SNAs from 5:45 pm-6 am; 9/18/23: 1 CNA from 5:45 am-10 pm, 1 CNA from 6 am-6:30 pm, 1 SNA from 6:16 am-6:46 pm, 1 SNA from 6:25 pm-6:31 am, 1 CNA from 6:48 pm-6 am, 1 CNA from 10 pm-6 am. Observation and record review of the facility on 9/18/23 beginning at 2:30 revealed they had a census on 65 residents. They had three nurses and 2 CNAs. They had one SNA who was acting as a hospitality aide with a shoulder sling on one arm working on the secure unit. During an interview on 9/18/23 at 6:18 p.m. the Administrator said they were supposed to have 3 nurses on days and 4 aides. On nights they had two nurses and 2 to 3 aides but then they have not fully transitioned to 12-hour shifts and some of the staff work form 6p to 2p, 2p to 10 p and 10 p to 6a, and then some staff worked from 6a to 6p and from 6p to 6a. The Administrator said they used the schedule in the book at the nurse's station that the staff sign when they come in as their staffing schedule. The Administrator said they did not have a Nurse Staff Information sheet posted. Record review of the facility Resident Census and Conditions of Residents Report-(Form 672) dated 9/18/23 indicated they had a census of 65 residents. The report indicated independent residents were 4 residents that were capable of bathing independently, 2 residents that were independent for dressing, 11 residents independent for transfers, 10 that were independent for toilet use, and 9 that were independent for eating. The report indicated the residents that required the assistance of one or two staff were 33 for bathing, 60 for dressing, 49 for transfers, 49 for toilet use and 51 for eating. The report indicated resident's dependent for assistance were 28 for bathing, 3 for dressing, 5 for transfers, 6 for toilet use, and 5 for eating. Record review of the facility Care Plan Item Task Listing Report indicated on Monday 9/18/23 they had 26 residents scheduled for showers and no resident received a shower that day or night. 1. Record review of Resident #1's face sheet dated 9/19/23 indicated she was a [AGE] year-old female initially admitted to the facility 10/4/23. Some of her diagnoses were Spinal Stenosis(narrowing of the spinal column that causes pressure on the spinal cord._ Morbid obesity disease of upper respiratory tract, pain of unspecified joint, unsteadiness on feet, abnormalities of gait and mobility. She had anxiety disorder, and history of heart attack. Record review of Resident #1's quarterly MDS dated [DATE] indicated she was cognitively intact. Resident #1's bed mobility and transfer assistance were listed as extensive assistance with two people physical help. Record review of Resident #1's care plan dated 8/29/23 indicated a potential for pressure ulcer development and one of the interventions was to ensure incontinent care was provided after each episode. One Focus was the resident had the potential for uncontrolled pain. One of the interventions was to monitor the probable cause of each pain episode, remove or limit the cause if possible. Resident #1 had a focus area of desired independence in activities and would attend activities of choice. The resident loved the appetizer program, [NAME] and helping the Activity Director. She also liked therapy. The resident had a Focus are of bladder incontinence and one of the interventions was to apply barrier cream after each incontinent episode, and incontinence care at least every two hours. Resident #1 had a Focus are of self-care performance deficit. She required assisted of one staff for bed mobility, dressing, toileting, encourage the resident to use call light for assistance, and she used a wheelchair for ambulation. Record review of Resident #1's physician order dated 11/15/21 indicated the resident needed to be up in chair for all meals. An order dated 2/523 may use oxygen at 4 liters by nasal cannula, every shift. An order dated 7/23/23 for acetaminophen 500 mg give two tables by mouth as needed for pain. During an observation and interview on 9/18/23 beginning at 2:57 p.m. Resident #1's call light was on. The Activity Director went in the room and turned the call light off. She came out and told CNA A who was at the cart gathering supplies that Resident #1 said she need assistance. The Activity said Resident # 1 was waiting on an aide to come and change her. CNA A said she was going to assist a resident in another room and then she would help Resident #1. When the ADON and the investigator went in the room to check on Resident #1 CNA A came in to see if she could help, the resident at that point. During an observation and interview on 9/18/23 beginning at 3:02 p.m. Resident #1 was observed lying in bed. Resident #1 said she was soaking wet, her bed was wet, the sheets, the gown, and she had been laying in urine since early this morning. She said the last time she was changed was about 8:00 a.m. Resident #1 said she knew they were short staffed and doing the best they could. However, she was told before 11:00 a.m. they were going to try and get her up and then before 2:00 p.m. they were going to get up. Resident #1 said she had been waiting all day. Resident #1 started to cry. The Resident said she knew she was not the easiest person to provide care for. She said CNA A had come in her room only to turn off her call light and say they would be back. She said they had told her she was getting up by 11:00 a.m. to be a part of activities. They have appetizers at 11:00 a.m. and she had missed the appetizers, and she really enjoyed that activity. Resident #1 said she did not like to stay in bed all day and she had been made to miss all activities. Resident #1 said she was out of oxygen on her chair and aide came in and said she would bring some back. Resident #1 stated the aide brought in a brief, put it on the dresser and said they would be back. She told them to just put her in a gown because the day was mostly gone, the aide took down a gown and put it on the bed side table. Resident #1 said CNA A sit the gown on the bedside table and left and promised her they were coming back. Observation showed the brief on the dresser and the gown on the bedside table. Resident #1 said she was supposed to have a shower today. She said the aide told her she was not giving her a shower on today, because the shower aide was out. Resident #1 said she did not always get her showers like they are scheduled. She should get them on MWF and often only got two a week instead of three. She said most days they get her up and provide care like they are supposed to, but it depended on who was working or not working that day. Resident #1 said they would often come in and turn the call light off and say they would be back in a minute, and it would be a long time before they did. She said she would usually have to put the call light on again to receive assistance. Observation of Resident #1 with the ADON revealed she had on a brief; the brief was wet and soggy. The draw sheet, and sheet had a large wet area, and her gown was wet. Resident #1 said she had to eat her lunch in a wet soiled bed, and she was very uncomfortable. She said because she had laid down so long, she was hurting and asked the ADON for some Tylenol. During an observation and interview on 9/18/23 beginning at 3: 20 p.m., ADON P was seen with a medication cup taking medication to Resident #1's room. ADON P said she had Resident #1's Tylenol. During an interview on 9/18/23 beginning at 3:47 p.m., the Interim DON said she was informed Resident #1 had been found wet and saturated. She said that should not have happened and she was getting an in service together for the staff. She said she was not aware there was only two aides in the building until a few moments ago. She was new to the facility and was only helping until they hired a new DON. During an interview on 9/18/23 at 4:12 p.m., CNA A said this was her third day on the job. She started to work at 6 a.m. this morning and it was just her and CNA B today, all day long. She said she had not given any showers and had a hard time trying to answer call lights. She said that Resident #1 had requested to get up all day and changed but she was just trying to keep up as best she could. She said she had apologized to Resident #1 but was doing the best she could. There were a few residents she had not gotten up today. She said she did not have any Hoyer lifts on that hall but Resident #1 should be a Hoyer lift transfer. She said that she had the short hall today and it had 25 residents. During an interview on 9/19/23 at 8:45 am., the Activity Director said Resident #1 liked to come to activities every day. The Activity Director said she had something called appetizers where they offered different foods and all the residents loved that. She said Resident #1 liked to be up by 11 a.m. During an interview and observation on 9/19/23 beginning at 9:00 a.m. Resident #1 was laying in her bed. She said staff had promised her today they would get her up by 10:00 a.m. She said she had to be weighed every day and would like to get a shower today since she missed yesterday. She said that it was painful for her to lay in bed all day and night. Resident #1 said she felt agitated, angry, and hopeless because she was dependent on someone else for help. She said her feelings were hurt that the staff basically lied to her all day. 2. During an observation and interview on 9/18/23 at 3:13 p.m. Resident #2 was sitting on his bed, fully dressed, and said he did not get a shower today. They are short staffed, and he was supposed to get one on Saturday, but Thursday was his last shower. He said he did not know what his regular scheduled shower days were because, he may or may not get one. Resident #2 said some days they would offer, and it might be any day of the week. Resident #2 said he usually only got about two showers a week and sometimes one. Resident #2 said that was his only problem he goes to the bathroom unassisted and did not really need anything else. 3. During an observation and interview on 9/18/23 at3:24 p.m. Resident #3 was observed in bed. Resident #3 she had not been changed since early this morning, but the pads hold a lot, and they would probably be in in another hour to change her. Observation of her brief with the ADON's assistance revealed it was wet and soggy, but the sheets were not wet. Resident# 3 said she did not receive a shower today and she was supposed to have them on MWF. Resident # 3 said no one asked her if she wanted a shower today, she knew they were short staffed and at least once a week missed a shower. Resident #3 said she did get a shower on Friday. 4. During an observation and interview on 9/18/23 at 3:40 p.m. said Resident #5 said the aides did not get her up today they were short staffed. Resident #5 said she liked to eat breakfast in the dining room. She said a staff was trying to put two briefs on her and she said no. Resident #5 said the CNA had recently changed her. Resident #5 said she required a Hoyer lift and they have not gotten up since Friday. Resident #5 said she stayed in bed all weekend because they did not have staff to get her up or they were too lazy to do so. Resident #5 said she did not take a shower today said there was not anyone here to give a shower. Resident #5 said she liked to go to some of the activities and see some of her friends. Resident #5 said she had pulled her call light and told the aide she needed help to straighten up in bed. She said she was told by the aide she needed some help and did not come back. Resident #5 said the facility needed more help. During an interview and observation on 9/18/23 beginning at 3:47 p.m. the Interim DON said she was informed Resident #1 had been found wet and saturated. She said that should not have happened and she was getting an in service together for the staff. She said she was not aware there was only two aides in the building until a few moments ago. She was new to the facility and was only helping until they hired a new DON. 5. During an interview and observation on 9/18/23 at 3: 56 p.m. observation showed Resident #6 had her call light on. Resident said she had been waiting a while. She said the aide had come in at least once and turned the off the light. Resident #6 refused to allow the interim DON and the investigator to see how wet she was. She said she had a BM also. Resident #6 started to cry. During an interview on 9/18/23 at 3:58 p.m. CNA B said she had been in Resident #6's room, but had not changed her since about 11:00 a.m. She said she knew she should have been in the room more frequently to change Resident #6 and she was trying to get to her as quickly as she could. She said it was just her and another aide in the building. CNA B said she came in at 6:00 a.m. this morning and it had just been her and one other aide all day. She was trying as hard as she could to take care of all the residents, but she was overwhelmed. She had the long hall with 20 residents, she also had 17 residents on the unit. She said on the unit they had about 3 residents that went to the bathroom themselves, but all the residents needed to be assisted with toileting. She said there were 3 residents on the hall at the back that were assigned to her. CNA B said she had 9 residents that required Hoyer lift transfers or two people assist and she had gotten up who she could today. She said the administrative staff were aware they were short staffed. She said some of the office staff had helped to pass breakfast and lunch trays and pick up trays. She said all staff were answering call lights but if the residents needed changing the staff usually just turned off the light and informed her what they needed. She said she had not given any showers today. She said she had about 40 residents' total. CNA B said some days they have 4 or 5 aides on the halls and some like today they were short staffed. She began to cry and said she was tired and overwhelmed. During an interview on 9/18/23 at 4:12 p.m. CNA A said it took her about 10 minutes a resident to clean them up but if they had had a large or runny BM it could take her longer and in-between, she was trying to keep most of the residents satisfied. She said by the time she got to one end of the hall it was past time to start on the other end of the hall. She said every resident that required assistance had been assisted at least once today. However, there had not been every two-hour care today. The administration was aware they were short staff. Some of the office staff had helped to pass and take up breakfast and lunch trays. If they had not done so it could have been worse. She said the administrative staff had also helped to answer call lights with small things, but if care needed to be provided. She had done the care as best she could manage. During an interview on 9/18/23 at 4:20 p.m. the ADON said short hall had 25 residents and CNA A was working that hall today. She said the long hall had 20 residents and CNA B was working that hall today. She said on the secure unit they had 17 residents and SNA H who was on restricted duty due to having a sling on her arm was on the secured unit. The ADON said when SNA H needed help, she would come and get someone. She said on the unit some were continent, but they all needed supervision. During an interview on 9/18/23 at 4:35 p.m. SNA H she said she had been hurt on the job while trying to assist a resident. She will not see the doctor until 10/14/23 for a release and mean while she was not supposed to lift more than 5 pounds. She had been assigned to the secured unit today. She said she was not familiar with the residents on the unit she usually worked up front. She said the only thing she could do was turn off lights and try to make beds. During an interview on 9/18/23 at 4:45 p.m. LVN C said that all together she had worked at the facility for about [AGE] years. She said they had 17 residents on the unit. She said that they had about 3 that were continent, but they all required supervision, with toileting. LVN C said she helped when she could. She said they needed more staff. During an interview on 9/18/23 at 5:50 p.m. ADON said they get shower sheet check offs when showers are complete. She said there are no shower sheets for today. 6. During an interview on 9/18/23 at 6:02 p.m. #18 had his call light on. He said he was wet and needed to be changed. He said that he has no idea when his showers are scheduled. There is no rhyme or reason to when he gets a shower. He said on Saturday he got a shower because he had bad diarrhea. He did not know when he had received one before then. Two aides from day shift went to change him. During an interview on 9/19/23 at 4: 57 a.m. CNA K said she was leaving at 5a.m., she had completed her rounds, and SNA D was taking over. During an interview on 9/19/23 at 5:00 a.m. SNA J said she had not done any showers the night before. 7. During an interview and observation on 9/19/23 at 5:05 p.m. SNA D said she was getting residents up on the secured unit. She said CNA K said on the night shad not gotten anyone up. Observation of room Resident #15 room showed him standing beside the bed with the aide trying to direct him. He had his right leg behind him and could not seem to understand he needed to turn to sit in the wheelchair. He sat down on the wet bed several time before he was able to turn around and sit in the wheelchair. SNA D said the night shift staff had left the resident wet. Observation of the sheets on the bed showed they were wet, and the plastic mattress had a pool of liquid in on the mattress. SNA D said the Resident #15 was that wet with urine. Resident #15 would not speak when spoken to him, he would only smile and nod. SNA D said she was mad because the resident should not have been left in that kind of condition. Observation of the bag where Resident #15's brief was showed a wet and soggy brief. SNA D said it took her about 10 to 15 minutes to get each resident cleaned up and dressed. It depended on how soiled they were or like Resident #14 how confused they were. She said she would take the solid brief and sheets and come back later to make the bed. The beds had to be sanitized and let dry and then put the sheets on them. 8. During an observation and interview on 9/19/23 at 8:30 a.m. of Resident #16 showed in in the bed with his bed facing the door. He said that he had told them when the aides he wanted to be turned around and straightened up in the bed. They had come in and tuned off the call light and said they would be back. He said he was uncomfortable, and he could not watch his TV from the way the bed was turned. During an observation and interview on 9/19/23 at 9:21 a.m. Resident #16 said he had pulled his call light again. He said the staff were supposed to be coming to turn him around but had not. At 9:31 a.m. CNA M went in to assist the resident. SNA E and CNA M said that they were aware the resident wanted to be turned but they had to do some else first. During an interview on 9/19/23 at 10:10 a.m. the Corporate RN said residents should have their showers completed according to their shower schedule. She said if the shower showed not applicable it either was not done or it was on the shower sheet tool and did not get transcribed over. She said showers should be completed in the computers under the task, and they could be scheduled or PRN showers. Reviewed bath sheets from the computer system for 9/2023 indicated: Resident #7 should have had a shower/bath on 9/6, 9/11, 9/15, 9/18/23 a shower was done on 9/13/23. PRN bath 9/8/23. Clinical alert showed no showers 3 days prior to 9/7, 9/12, and 9/16/23. Resident #4 did not received bath on 9/8 and 9/13/23. Resident #8 had no showers on 9/12, 9/14, 9/16/23. Last shower was 9/15/23 PRN Resident #9 had no showers noted 9/5-9/19/23. Showers should be TTHS Resident #10 had 1 shower on 9/16/23, no other showers. Showers should be TTHS Resident #11 had shower on 9/7 and 9/12/23, no other showers. Showers should be TTHS Record review of the facility Care Plan Task Listing Report indicated they had 26 residents that were to receive showers on MWF and 39 that were to receive showers on TTHS. . During an interview on 9/19/23 at 1:25 p.m. Resident #4 was up in wheelchair at bedside. Said he does not always get his showers. He said he missed yesterday's shower because they were short staffed. He said he was supposed to take one today but because he had therapy, he opted for a quick bed bath. He said it does take a while for staff to come help him because they are short staffed a lot. He said when he pulled the call light staff would come in and turn the light off tell him they will come back but do not always come back to help him. During an interview on 9/19/23 at 1:40 p.m. LVN C said it was hard to get showers for the secured unit due to resident cognition and behaviors, most residents received showers. LVN C said she believed Resident # 8 and Resident # 9, and Resident # 10 refused the showers today. LVN C stated CNAs will report when residents refused showers. During an interview on 9/19/23 at 1:45 p.m. SNA D said Resident # 8 refused his shower today but let her shave him. She said most likely he would take a shower tomorrow. She documented refusals. She said Resident #9 got a shower today but is unsure of the rest of the month. Resident # 10 got a shower today, but she was sure of the rest of the month- she was out over 10 days this month. Sometimes SNA E would shower residents for her when she helped in the secure unit, but she was not sure about her documentation. During an interview on 9/19/23 at 1:50 p.m. SNA E said she worked in the secured unit sometimes. She said she gave showers to Resident #9 and Resident #10 last week she thought she documented them on the computer. SNA E said she worked the unit with SNA D. She struggles to give showers on both units because of lack of staff. During an interview on 9/19/23 at 2:20 p.m. Corporate RN, Interim DON, and Administrator are both trying to cover the schedules. She is unsure what shifts/positions the facility currently has open because she does not normally cover this facility. She said she talked with upper management today on trying to get agency in to help with staffing concerns until the facility gets stabilized. During an interview on 9/20/23 at 9:00 a.m. the Administrator and Area Director of Operations were informed of the concerns with ADL care and residents not receiving showers. They said they had gotten the ADL deficiency on 9/3/23 and had not had a chance to correct the problem. They had just received their deficiencies. They said they were aware of the problem on 9/3/23 and had conducted an in-service. They said the deficiency had already been cited; however, they could not say why the ADL issues had not been fixed. During an interview on 9/20/23 at 11:45 Resident #4's family member said they had not gotten Resident #4 up today. The family member said the biggest concern is there is not enough staff. The family member said Resident #4 had not gotten a shower today and he did not get one on Monday. She said the way they treat the residents by making them stay in bed all day was cruel and abusive. Record review of an in-service dated 9/3/23 indicated staff were informed shower are scheduled for every resident in the building. If the resident refused a shower report to the charge nurse. The nurse should ask the resident, if they still refuse, contact the responsible party and document both in the nurse's notes. If a shower is missed on the day shift it should be given on the 6p to 6a shift. It will be reported to the oncoming nurse and aide. During an interview on 9/19/23 at 1:25pm Resident #4 was up in wheelchair at bedside. Said he does not always get his showers. He said he missed yesterday's shower because they were short staffed. He said he was supposed to take one today but because he had therapy, he opted for a quick bed bath. He said it does take a while for staff to come help him because they are short staffed a lot. He said when he pulled the call light staff would come in and turn the light off tell him they will come back but don't always come back to help him. During an interview on 9/20/23 at 9:15 a.m. Resident #17 said She said they were always short staffed, and it took long periods of time for them to answer the call light most days. During an interview on 9/20/23 at 11:28 a.m. LVN C said she had never been the only nurse in the building. She said she has occasionally had to split long hall with maybe the ADON or DON but normally she stayed on the secure unit. She said she has seen staffing be shorter here recently, but she had never been the only one here. She is unsure who worked with her on the 14th, but she is sure she wasn't the only one alone in here. She said that the short staffing had not affected her, but she is sure that it could possibly affect others getting tasks done up front. During an interview on 9/20/23 at 11:35 a.m. LVN F said she had a worked several times where she was here with only nurse in the facility. She said normally when that happens its only for a couple of hours until they get another nurse in to assist. She said the facility was frequently short staffed on CNAs and when they are short staffed with CNAs the residents did not get changed as frequently as they need or get turned/repositioned as much. During an interview on 9/20/23 at 11:45 Resident #4's family member said they had not gotten Resident #4 up today. The family member said the biggest concern is there is not enough staff. The family member said Resident #4 had not gotten a shower today and he did not get one on Monday. She said the way they treat the residents by making them stay in bed all day was cruel and abusive. Just let them lay there Record review of an in serviced dated 9/18/23 indicated staff were informed shower are scheduled for every resident in the building. If the resident refused a shower report to the charge nurse. The nurse should ask the resident, if they still refuse, contact the responsible party and document both in the nurses notes. If a shower is missed on the day shift it should be given on the 6p to 6a shift.

Based on observation, interview, and record review the facility failed to ensure residents who were unable to carry out ADLS received necessary services to maintain personal hygiene were provided for 13 of 18 residents reviewed for ADLs (Resident #1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 14, 16, and # 18.) The facility failed to provide timely incontinent care for Resident #1, Resident #3, and Resident #15. The facility failed to provide showers for 26 residents on 9/18/23. The facility failed to provide routine showers for Resident #1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 15, 16, and # 18. This failure could place dependent residents at risk for poor hygiene, skin infections and decreased quality of life. Findings included: 1. Record review of Resident #1's face sheet dated 9/19/23 indicated she was a [AGE] year-old female initially admitted to the facility 10/4/23. Some of her diagnoses were Spinal Stenosis (narrowing of the spinal column that causes pressure on the spinal cord. Morbid obesity disease of upper respiratory tract, pain of unspecified joint, unsteadiness on feet, abnormalities of gait and mobility. She had anxiety disorder, and history of heart attack. Record review of Resident #1's quarterly MDS dated [DATE] indicated she was cognitively intact. Resident #1's bed mobility and transfer assistance were listed as extensive assistance with two people physical help. Record review of Resident #1's care plan dated 8/29/23 indicated a potential for pressure ulcer development and one of the interventions was to ensure incontinent care was provided after each episode. One Focus was the resident had the potential for uncontrolled pain. One of the interventions was to monitor the probable cause of each pain episode, remove or limit the cause if possible. Resident #1 had a focus area of desired independence in activities and would attend activities of choice. The resident loved the appetizer(snacks) program, Bingo and helping the Activity Director. She also liked therapy. Resident #1 had a focus are of bladder incontinence and one of the interventions was to apply barrier cream after each incontinent episode, and incontinence care at least every two hours. Resident #1 had a focus are of self-care performance deficit. Resident #1 required assisted of one staff for bed mobility, dressing, toileting, encourage the resident to use call light for assistance, and she used a wheelchair for ambulation. Record review of Resident #1's physician order dated 11/15/21 indicated the resident needed to be up in chair for all meals. An order dated 2/5/23 may use oxygen at 4 liters by nasal cannula, every shift. An order dated 7/23/23 for acetaminophen 500 mg give two tables by mouth as needed for pain. During an observation and interview on 9/18/23 at 2:57 p.m. Resident #1's call light was on. The Activity Director went in the room and turned the call light off. She came out and told CNA A who was at the cart gathering supplies that Resident #1 said she need assistance. The Activity said Resident # 1 was waiting on an aide to come and change her. CNA A said she was going to assist a resident in another room and then she would help Resident #1. During an observation and interview on 9/18/23 beginning at 3:02 p.m. Resident #1 was observed lying in bed. Resident #1 said she was soaking wet, her bed was wet, the sheets, the gown, and she had been laying in urine since early this morning. She said the last time she was changed was about 8:00 a.m. Resident #1 said she knew they were short staffed and doing the best they could. However, she was told before 11:00 a.m. they were going to try and get her up and then before 2:00 p.m. they were going to get up. Resident #1 said she had been waiting all day. Resident #1 started to cry. The Resident said she knew she was not the easiest person to provide care for. She said CNA A had come in her room only to turn off her call light and say they would be back. She said they had told her she was getting up by 11:00 a.m. to be a part of activities. They have appetizers at 11:00 a.m. and she had missed the appetizers, and she really enjoyed that activity. Resident #1 said she did not like to stay in bed all day and she had been made to miss all activities. Resident #1 said she was out of oxygen on her chair and aide came in and said she would bring some back. Resident #1 stated the aide brought in a brief, put it on the dresser and said they would be back. She told them to just put her in a gown because the day was mostly gone, the aide took down a gown and put it on the bed side table. Resident #1 said CNA A sit the gown on the bedside table and left and promised her they were coming back. Observation showed the brief on the dresser and the gown on the bedside table. Resident #1 said she was supposed to have a shower today. She said the aide told her she was not giving her a shower on today, because the shower aide was out. Resident #1 said she did not always get her showers like they are scheduled. She should get them on MWF and often only got two a week instead of three. She said most days they get her up and provide care like they are supposed to, but it depended on who was working or not working that day. Resident #1 said they would often come in and turn the call light off and say they would be back in a minute, and it would be a long time before they did. She said she would usually have to put the call light on again to receive assistance. Observation of Resident #1 with the ADON P revealed she had on a brief; the brief was wet and soggy. The draw sheet, and sheet had a large wet area, and her gown was wet. Resident #1 said she had to eat her lunch in a wet soiled bed, and she was very uncomfortable. She said because she had laid down so long, she was hurting and asked the ADON P for some Tylenol. During an observation and interview on 9/18/23 beginning at 3: 20 p.m. ADON P was seen with a medication cup taking medication to Resident #1's room. The ADON P said she had Resident #1 requested Tylenol. During an interview on 9/18/23 beginning at 3:47 p.m., the Interim DON said she was informed Resident #1 had been found wet and saturated. She said that should not have happened and she was getting an in service together for the staff. She said she was not aware there was only two aides in the building until a few moments ago. She was new to the facility and was only helping until they hired a new DON. During an interview on 9/18/23 at 4:12 p.m., CNA A said this was her third day on the job. She started to work at 6 a.m. this morning and it was just her and CNA B today, all day long. She said she had not given any showers and had a hard time trying to answer call lights. She said that Resident #1 had requested to get up all day and changed but she was just trying to keep up as best she could. She said she had apologized to Resident #1 but was doing the best she could. There were a few residents she had not gotten up today. She said she did not have any Hoyer lifts on that hall but Resident #1 should be a Hoyer lift transfer. She said that she had the short hall today and it had 25 residents. During an interview on 9/19/23 at 8:45 am., the Activity Director said Resident #1 liked to come to activities every day. The Activity Director said she had something called appetizers where they offered different foods and all the residents loved that. She said Resident #1 liked to be up by 11 a.m. During an interview and observation on 9/19/23 beginning at 9:00 a.m. Resident #1 was laying in her bed. She said staff had promised her today they would get her up by 10:00 a.m. She said she had to be weighed every day and would like to get a shower today since she missed yesterday. She said that it was painful for her to lay in bed all day and night. Resident #1 said she felt agitated, angry, and hopeless because she was dependent on someone else for help. She said her feelings were hurt that the staff basically lied to her all day. 2. During an observation and interview on 9/18/23 beginning at 3:13 p.m. Resident #2 was sitting on his bed, fully dressed, and said he did not get a shower today. They are short staffed, and he was supposed to get one on Saturday, but Thursday was his last shower. He said he did not know what his regular scheduled shower days were because, he may or may not get one. Resident #2 said some days they would offer, and it might be any day of the week. Resident #2 said he usually only got about two showers a week and sometimes one. Resident #2 said that was his only problem he goes to the bathroom unassisted and did not really need anything else. 3. During an observation and interview on 9/18/23 beginning at 3:24 p.m. Resident #3 was observed in bed. Resident #3 she had not been changed since early this morning, but the pads hold a lot, and they would probably be in in another hour to change her. Observation of her brief with the ADON's assistance revealed it was wet and soggy, but the sheets were not wet. Resident# 3 said she did not receive a shower today and she was supposed to have them on MWF. Resident # 3 said no one asked her if she wanted a shower today, she knew they were short staffed and at least once a week missed a shower. Resident #3 said she did get a shower on Friday. 4. During an observation and interview on 9/18/23 at 3:40 p.m. said Resident #5 said the aides did not get her up today they were short staffed. Resident #5 said she liked to eat breakfast in the dining room. She said a staff was trying to put two briefs on her and she said no. Resident #5 said the CNA had recently changed her. Resident #5 said she required a Hoyer lift and they have not gotten up since Friday. Resident #5 said she stayed in bed all weekend because they did not have staff to get her up or they were too lazy to do so. Resident #5 said she did not take a shower today said there was not anyone here to give a shower. Resident #5 said she liked to go to some of the activities and see some of her friends. Resident #5 said she had pulled her call light and told the aide she needed help to straighten up in bed. She said she was told by the aide she needed some help and did not come back. Resident #5 said the facility needed more help. During an interview and observation on 9/18/23 beginning at 3:47 p.m. the Interim DON said she was informed Resident #1 had been found wet and saturated. She said that should not have happened and she was getting an in service together for the staff. She said she was not aware there was only two aides in the building until a few moments ago. She was new to the facility and was only helping until they hired a new DON. 5. During an interview and observation on 9/18/23 at 3: 56 p.m. inidcated Resident #6 had her call light on. Resident said she had been waiting a while. She said the aide had come in at least once and turned the off the light. Resident #6 refused to allow the interim DON and the investigator to see how wet she was. She said she had a BM also. Resident #6 started to cry. During an interview on 9/18/23 at 3:58 p.m. CNA B said she had been in Resident #6's room, but had not changed her since about 11:00 a.m. She said she knew she should have been in the room more frequently to change Resident #6 and she was trying to get to her as quickly as she could. She said it was just her and another aide in the building. CNA B said she came in at 6:00 a.m. this morning and it had just been her and one other aide all day. She was trying as hard as she could to take care of all the residents, but she was overwhelmed. She had the long hall with 20 residents, she also had 17 residents on the unit. She said on the unit they had about 3 residents that went to the bathroom themselves, but all the residents needed to be assisted with toileting. She said there were 3 residents on the hall at the back that were assigned to her. CNA B said she had 9 residents that required Hoyer lift transfers or two people assist and she had gotten up who she could today. She said the administrative staff were aware they were short staffed. She said some of the office staff had helped to pass breakfast and lunch trays and pick up trays. She said all staff were answering call lights but if the residents needed changing the staff usually just turned off the light and informed her what they needed. She said she had not given any showers today. She said she had about 40 residents total to take care of. CNA B said some days they have 4 or 5 aides on the halls and some like today they were short staffed. She began to cry and said she was tired and overwhelmed. During an interview on 9/18/23 at 4:12 p.m. CNA A said it took her about 10 minutes a resident to clean them up but if they had had a large or runny BM it could take her longer and in-between, she was trying to keep most of the residents satisfied. She said by the time she got to one end of the hall it was past time to start on the other end of the hall. She said every resident that required assistance had been assisted at least once today. However, there had not been every two-hour care today. The administration was aware they were short staff. Some of the office staff had helped to pass and take up breakfast and lunch trays. If they had not done so it could have been worse. She said the administrative staff had also helped to answer call lights with small things, but if care needed to be provided. She had done the care as best she could manage. During an interview on 9/18/23 at 4:20 p.m. the ADON said short hall had 25 residents and CNA A was working that hall today. She said the long hall had 20 residents and CNA B was working that hall today. She said on the secure unit they had 17 residents and SNA H who was on restricted duty due to having a sling on her arm was on the secured unit. The ADON said when SNA H needed help, she would come and get someone. She said on the unit some were continent, but all the residents needed supervision. During an interview on 9/18/23 at 4:35 p.m. SNA H she said she had been hurt on the job while trying to assist a resident. She will not see the doctor until 10/14/23 for a release and mean while she was not supposed to lift more than 5 pounds. She had been assigned to the secured unit today. She said she was not familiar with the residents on the unit she usually worked up front. She said the only thing she could do was turn off lights, and try to make beds. During an interview on 9/18/23 at 4:45 p.m. LVN C said that all together she had worked at the facility for about [AGE] years. She said they had 17 residents on the unit. She said that they had about 3 that were continent, but they all required supervision, with toileting. LVN C said she helped when she could. She said they needed more staff. During an interview on 9/18/23 at 5:50 p.m. ADON said they get shower sheet check offs when showers are complete. She said there are no shower sheets for today. 6.During an interview on 9/18/23 at 6:02 p.m. Resident #18 had his call light on. He said he was wet and needed to be changed. Resident #18 said that he has no idea when his showers are scheduled. Resident #18 stated there was no rhyme or reason to when he gets a shower. He said on Saturday he got a shower because he had bad diarrhea. He did not know when he had received one before then. Two aides from day shift went to change him. During an interview on 9/19/23 at 4: 57 a.m. CNA K said she was leaving at 5a.m., she had completed her rounds, and SNA D was taking over. During an interview on 9/19/23 at 5:00 a.m. SNA J said she had not done any showers the night before. 6.During an interview and observation on 9/19/23 beginning at 5:05 p.m. SNA D said she was getting residents up on the secured unit. She said CNA K said the night shift had not gotten anyone up. Observation of Resident #15's room showed Resident #15 standing beside the bed with the aide trying to direct him. Resident #15 had his right leg behind him and could not seem to understand he needed to turn to sit in the wheelchair. He sat down on the wet bed several time before he was able to turn around and sit in the wheelchair. SNA D said the night shift staff had left the resident wet. Observation of the sheets on the bed showed they were wet, and the plastic mattress had a pool of liquid in on the mattress. SNA D said the Resident #15 was that wet with urine. Resident #15 would not speak when spoken to him, he would only smile and nod. SNA D said she was mad because the resident should not have been left in that kind of condition. Observation of the bag where Resident #15's brief was showed a wet and soggy brief. SNA D said it took her about 10 to 15 minutes to get each resident cleaned up and dressed. It depended on how soiled they were or like Resident #14 how confused they were. She said she would take the solid brief and sheets and come back later to make the bed. The beds had to be sanitized and let dry and then put the sheets on them. 7.Observation and interview on 9/19/23 beginning at 8:30 a.m. of Resident #16 showed in in the bed with his bed facing the door. He said that he had told the aides he wanted to be turned around and straightened up in the bed. They had come in and tuned off the call light and said they would be back. He said he was uncomfortable, and he could not watch his TV from the way the bed was turned. During an observation and interview on 9/19/23 beginning at 9:21 a.m. Resident #16 said he had pulled his call light again. He said the staff were supposed to be coming to turn him around but had not. At 9:31 a.m. CNA M went in to assist the resident. SNA E and CNA M said that they were aware the resident wanted to be turned but they had to do some else first. During an interview on 9/19/23 at 10:10 a.m. the Corporate RN said residents should have their showers completed according to their shower schedule. She said if the shower showed not applicable it either was not done or it was on the shower sheet tool and did not get transcribed over. She said showers should be completed in the computers under the task, and they could be scheduled or PRN showers. Reviewed bath sheets from the computer system for 9/2023 indicated: Resident #7 should have had a shower/bath on 9/6, 9/11, 9/15, 9/18/23 a shower was done on 9/13/23. PRN bath 9/8/23. Clinical alert showed no showers 3 days prior to 9/7, 9/12, and 9/16/23. Resident #4 did not received bath on 9/8/23 and 9/13/23. Resident #8 had no showers on 9/12, 9/14, 9/16/23. Last shower was 9/15/23 PRN Resident #9 had no showers noted 9/5/23-9/19/23. Showers should be TTHS Resident #10 had 1 shower on 9/16/23, no other showers. Showers should be TTHS Resident #11 had shower on 9/7/23 and 9/12/23, no other showers. Showers should be TTHS Record review of the facility Care Plan Task Listing Report indicated they had 26 residents that were to receive showers on MWF and 39 that were to receive showers on TTHS. . During an interview on 9/19/23 at 1:25pm Resident #4 was up in wheelchair at bedside. Said he does not always get his showers. He said he missed yesterday's shower because they were short staffed. He said he was supposed to take one today but because he had therapy, he opted for a quick bed bath. He said it does take a while for staff to come help him because they are short staffed a lot. He said when he pulled the call light staff would come in and turn the light off tell him they will come back but don't always come back to help him. During an interview on 9/19/23 at 1:40pm LVN C said it was hard to get showers for the secured unit due to resident cognition and behaviors, most residents received showers. LVN C said she believed Resident # 8 and Resident # 9, and Resident # 10 refused the showers today. CNAs will report when residents refused showers. During an interview on 9/19/23 at 1:45pm SNA D said Resident # 8 refused his shower today but let her shave him. She said most likely he would take a shower tomorrow. She documented refusals. She said Resident # 9 got a shower today but was unsure of the rest of the month. Resident # 10 got a shower today, but she was sure of the rest of the month- she was out (not at work) over 10 days this month. Sometimes SNA E would shower residents for her when she helped in the secure unit, but she was not sure about her documentation. During an interview on 9/19/23 at 1:50 p.m. SNA E said she worked in the secured unit sometimes. She said she gave showers to Resident #9 and Resident #10 last week, she thought she documented them on the computer. SNA E said she worked the unit with SNA D. She struggles to give showers on both units because of lack of staff. During an interview on 9/19/23 at 2:20 p.m. Corporate RN, Interim DON, and Administrator are trying to cover the schedules. She was unsure what shifts/positions the facility currently has open because she does not normally cover this facility. She said she talked with upper management today on trying to get agency in to help with staffing concerns until the facility gets stabilized. During an interview on 9/20/23 at 9:00 a.m. the Administrator and Area Director of Operations were informed of the concerns with ADL care and residents not receiving showers. They said they had gotten the ADL deficiency on 9/3/23 and had not had a chance to correct the problem. They had just received their deficiencies. They said they were aware of the problem on 9/3/23 and had conducted an in-service. They said the deficiency had already been cited; however, they could not say why the ADL issues had not been fixed. Record review of an in-service dated 9/3/23 indicated staff were informed showers are scheduled for every resident in the building. If the resident refused a shower report to the charge nurse. The nurse should ask the resident, if they still refuse, contact the responsible party and document both in the nurse's notes. If a shower was missed on the day shift it should be given on the 6p to 6a shift. It will be reported to the oncoming nurse and aide. During an interview on 9/20/23 at 11:45 Resident #4's family member said they had not gotten Resident #4 up today. The family member said the biggest concern wasis there is not enough staff. The family member said Resident #4 had not gotten a shower today and he did not get one on Monday. Family member said the way they treat the residents by making them stay in bed all day was cruel and abusive. Record review of an in serviced dated 9/18/23 indicated staff was informed shower are scheduled for every resident in the building. If the resident refused a shower report to the charge nurse. The nurse should ask the resident, if they still refuse, contact the responsible party and document both in the nurse's notes. If a shower is missed on the day shift it should be given on the 6p to 6a shift. Record review of the facility Bath Shower procedure dated 2003 indicated a daily shower is preferred and necessary for some, the aging skin can be maintained by bathing every two days or with partial bathing as needed. The goals are the resident will experience improved comfort and cleanliness by bathing, maintain intact skin integrity, be free form soil, odor, dryness and pruritus' following bathing.

Based on observation, interview, and record review the facility failed to ensure pain management was provided to residents who require such services consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 1 resident reviewed for pain management. (Resident #1) The facility failed to ensure Resident #1 had effective pain management by failing to have pain medication available and failing to administer pain medication with complaints of pain. This failure resulted in identification of Immediate Jeopardy (IJ) on 08/09/2023 at 4:20 p.m. The IJ was removed on 8/10/2023 at 3:10 p.m. While the IJ was removed, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate, due to the facility's need to complete in-servicing and monitoring interventions. This failure could place resident at risk for increased pain causing undo suffering. Findings included: Record review of Resident #1's Face Sheet dated August 2023 indicated Resident #1 was a [AGE] year-old female admitted to the facility on [DATE]. Resident #1's diagnoses included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), cerebral infarction (damage to the brain from interruption of its blood supply), and type II diabetes (your body doesn't make enough insulin or can't use it as well as it should). Record review of Resident #1's significant change MDS assessment dated [DATE], revealed Resident #1 had short- and long-term memory impairment. Resident #1wandered daily. Resident #1 ambulated with unsteady balance that was stabilized without staff assistance. Resident #1 required supervision assistance with ambulation in room and in corridor. No falls were noted on Resident #1's MDS. No indicators of pain were noted on the MDS. Resident #1 lived on the secured unit until 07/11/2023, she was then moved off the secured unit because she no longer ambulated independently. Record review of Resident #1's care plan dated 01/20/2023 revealed, Resident #1 was at risk for increased falls and fractures as evidenced by: unsteady gait /cognitive impairment/ physical impairment. Intervention was listed as Resident #1 to be in wheelchair when up related to poor balance on 02/19/2023. No pain care plan was noted. Record review of Resident #1's physician orders for July 2023 revealed: An order with a start date of 05/23/2023 for Morphine sulfate 20mg/ml give 0.5ml every 1 hour as needed for pain or shortness of breath. The order for Morphine sulfate was discontinued on 07/06/2023. An order for Morphine sulfate 20mg/ml administer 0.25ml every 4 hours for pain or shortness of breath as needed was started on 07/13/2023 An order dated 05/09/2023 for acetaminophen 325 mg give two tablets every 6 hours as needed for pain. An order for Tramadol 50 mg administer one every 8 hours as needed for pain beginning on 07/06/2023 and discontinued on 07/11/2023 An order for Tramadol 50mg administer one every 6 hours routinely was began on 07/11/2023 and was discontinued on 07/13/2023. An order for Norco 5-325mg administer one every 6 hours routinely beginning on 07/13/2023. An order for Norco 5-325mg administer one every 4 hours as needed for breath through pain. Record review of Resident #1's incident and accident report dated 07/06/2023 at by RN D indicated, SN (skilled nurse) called by CNA that resident had fallen, fall was unwitnessed and in hallway of secure unit. Resident is c/o pain on right wrist, lump presented on right side of her forehead and small abrasion on left elbow. Resident was assessed and transferred to a wheelchair for continued observation. Hospice was called at 4:09 a.m., and fall was reported, Message sent to DON and Admin. Contact attempted with husband but was unsuccessful. Neuros within normal limits at the time. The incident and accident report also indicated Resident #1 complained of right wrist pain at a 5 on a scale of 1-10. Record review of Resident #1's nurses notes written on 07/06/2023 at 3:57 a.m. by RN D, indicated skilled nurse called by CNA that resident had fallen, fall was unwitnessed and in hallway of secure unit. Resident complains of pain on right wrist, lump has presented to right side of her forehead and small abrasion to left elbow. Resident is assessed and transferred to a wheelchair for continued observation. The hospice company was called at 4:09 a.m. and fall was reported. Message sent to DON and Administrator. Contact attempted with husband but was unsuccessful. Neuro checks within normal limits at this time. Record review of Resident #1's nurse notes indicated, no nurse notes from 07/07/2023 until 07/09/2023. No documented assessments of pain noted. Record review of Resident #1's nurse notes for 07/09/2023 written by RN D indicated, called to resident room related to resident screaming in pain, unable to verbalize location of pain but yells louder when turned toward R side, tramadol is administered per hospice pain management orders. Record review of nurse notes revealed no nurses' notes written on 07/10/2023. Record review of Resident #1's hospice communication notes for 07/10/2023 at 6:12 p.m., written by RN G indicated, Hospice Aide H, contacted this am to report patient was 'very different' today. She would not stand up 'at all' today. She reported she was in wheelchair during her visit and staff had her up in dining area for meal. RN G asked Hospice Aide H if Tramadol had been given, she reported she was not aware, but wanted RN to know of change since last Friday. Hospice Aide H stated patient had 'new' bruises but staff not able to tell her if she fell or when. RN G advised patient to be seen in am and will follow up then. Record review of Resident #1's Hospice encounter notes from 07/11/2023 at 9:55 a.m., written by RN G, Last week, patient was ambulatory without use of assistive device (due to cognitive deficits); Yesterday, Hospice Aide noted patient would not bear weight when she was trying to transfer to shower chair, or change her brief. She 'acted like' she was having increased pain with position changes. Facility CNA's also report this was noted since they 'returned to work' yesterday- there was no documentation over the weekend of her mobility status from facility staff. Fall was documented by facility nurse 07/06/2023 on 'night shift' with no specific information re: events surrounding fall except 'no injuries noted'. Patient is seen with furrowed brows, whimpering, sitting up in wheelchair but appears uncomfortable. LVN E, was preparing Tramadol to give Resident #1 as staff had just informed LVN E, she was 'whimpering and acting like she is uncomfortable'. Record review of Resident #1's nurse notes for 07/11/2023 at 10:52 a.m., written by LVN E indicated, Hospice nurse here with new order noted :(1) X-ray bilateral hips today related to pain. (2) Tramadol 50mg 1 orally every 6 hours routinely. (3) Discontinue routine fingerstick blood sugar checks. Husband present and aware of all new orders. Record review of Resident #1's nurse notes for 07/11/2023 at 1:12 p.m., written by LVN E indicated, Results of x-ray show: Interval development of an acute right subcapital hip fracture. Hospice notified and hospice nurse notified family and will consult them with hospice doctor to decide course of treatment for resident. MD F, resident's primary care physician also notified with no new orders at this time, awaiting hospice plan of treatment. Resident currently in bed with positioning pillows for comfort. Record review of the July 2023 MAR for Resident #1 revealed no pain medication was administered from the time she fell and complained of wrist pain at a 5 on a scale of 1-10, at 4:00 a.m. on 07/06/2023 until 07/07/2023 at 11:33 a.m. Resident #1 was administered nothing for pain from the time of the fall until Tramadol was administered on 07/07/23, nothing on 07/08/2023, administered Tramadol on 07/09/2023, and 07/11/23.There were no assessments for effectiveness of pain medication on the MAR. During observation on 08/08/2023 at 9:10 a.m., Resident #1 was lying in bed with eyes closed. No signs or symptoms of pain noted. During observation on 08/08/2023 at 2:15 p.m., Resident #1 was lying in bed facing window. Resident #1 had eyes closed and no facial grimace was noted. During observation on 08/09/2023 at 10:10 a.m., Resident #1 was lying in bed facing door. Resident #1 was awake and talking to herself with no signs of facial grimace noted. During an interview on 08/09/2023 at 8:35 a.m., RN D stated she was the nurse in charge of Resident #1 on the morning of 07/06/2023. RN D stated the CNA on duty came and got her from the nurse's station to alert her Resident #1 was on the floor in the secured unit. RN D stated she immediately went and assessed Resident #1 for injury. RN D stated Resident #1 complained of pain to right wrist, the right side of her forehead and had a large abrasion to her left upper arm. RN D stated Resident #1 verbalized a 5 on a scale of 1-10 as her pain level after the fall. RN D stated there was no pain medication in the building for Resident #1 or she would have treated her pain. RN D stated the resident had been out of the prn morphine for 3 or 4 days and she contacted hospice herself several times for refills. RN D stated the hospice RN had not wanted the morphine given unless Resident #1 was actively dying. RN D stated she thought Resident #1 had an order for Tylenol but she was unsure. RN D stated she contacted the on-call hospice number about the fall. RN D stated she did not directly contact the MD; she left that up to hospice. RN D stated on 07/09/2023 she was called to Resident #1's room because Resident #1 was screaming in pain and administered the tramadol ordered by hospice to replace the morphine Resident #1 previously had ordered. RN D stated it was when Resident #1 rolled to her right side that she screamed. RN D stated she did not notify the MD of the amount of pain or that it was positional pain. RN D stated hospice was already aware of Resident #1's pain and the hospice MD chose to discontinue the morphine Resident #1 had been taking and start her on tramadol. RN D stated she was unaware Resident #1 had a fractured hip because her last day to work at the facility was 07/09/2023. During an interview an interview on 08/09/2023 at 2:00 p.m., RN G stated she was the hospice nurse that followed Resident #1's care. RN G stated she was in the facility on 07/06/2023 in the afternoon to discontinue Resident #1's morphine and start her on tramadol prn. RN G stated MD I wanted morphine to be given as an end-of-life medication to ease the transition when a resident was actively dying. RN G stated Resident #1 was not dying, so when the morphine ran out, she advised the nurses to use acetaminophen and call if they needed something stronger for Resident #1. RN G stated Resident #1 never presented with pain before she was notified of the pain Resident #1 was experiencing on 07/10/2023 by Hospice CNA H. RN G stated no one from the facility reported pain or the fall to the hospice company. RN G stated Resident #1 was now on routine Norco and prn tramadol for breakthrough pain, and it seemed to be effective. During an attempted interview on 08/09/2023 at 2:15 p.m., weekend day shift nurse was not avaiable. Message left with no returned call. During an attempted interview on 08/09/2023 at 2:30 p.m., weekend CNA responsible for Resident #1's care had a phone number that was not inservice. During an interview on 08/09/2023 at 2:45 p.m., the DON was not available. The corporate RN stated the facility normally contacted the hospice and the hospice would immediately contact the hospice MD for orders. The corporate RN stated she was unsure of why the RN D had not ensured the hospice notified the MD by calling again and asking for orders. During an interview on 08/09/2023 at 2:50 p.m., the Administrator stated it was in their policy to notify the MD with all changes in conditions and they used the SBAR (situation-background-assessment-recommendation) system to notify the MD and get the MD response even if the resident were on hospice. No SBAR was done on Resident #1 with the fall on 7/06/2023. During an interview on 08/09/2023 at 2:20 p.m., MD I stated Morphine sulfate was an end-of-life drug and in collaboration with the hospice nurse it was decided to discontinue the Morphine sulfate for Resident #1 based on the information at the time that she was not actively dying and was not presenting with pain. MD I stated it was decided the facility would start with acetaminophen to treat pain and if that was ineffective to let hospice know and we would consider other medications. During an interview on 08/09/2023 at 3:20 p.m., the Administrator stated she was unaware that RN G had discontinued the Morphine sulfate for Resident #1. The Administrator stated the last time she talked with RN G she said she was putting the morphine on hold until Resident #1's pain was assessed, and the correct pain medication was prescribed for Resident #1. The Administrator stated it was important to have pain medication available for the residents and the facility to be communicated with about the residents' care. Record review of the policy on Pain Management dated 08/10/2021 indicated the community recognizes that a resident's response to pain is subjective and individual. The community will treat the resident under the premise that pain is present whenever the resident says that it is. The physician will order appropriate pain medications intervention both routine and PRN to address the individual's pain. This failure resulted in identification of Immediate Jeopardy (IJ) on 08/09/2023 at 4:20 p.m. The Plan of Removal was accepted on 08/10/2023 at 12:00 p.m., and included the following: -The facility failed to provide Resident #1 with pain medication following a fall with complaints of pain -The facility failed to ensure ordered pain medications was available to dispense for complaints of pain for Resident #1. -The facility failed to follow their pain policy. Interventions: o As of 8/9/23 resident # 1 was assessed for pain. Orders received as of 8/9/23 for scheduled and PRN pain meds. o As of 8/9/23, 100% audit was completed on all resident pain medications to ensure medications are available in the facility. Audit completed by DON 8/10/23 at 300am. o All residents in the facility were assessed for any increased pain by the DON and Charge Nurses as of 8/9/23. No additional issues were found. In-services: In-services were initiated for charge nurses on 8/9/23 by the Compliance Nurse/DON/ADON regarding the following and will be completed on 8/10/2023 by 8am. All nurses including agency staff, new hires, and PRN staff not in-serviced by 8am on 8/10/23 will not be allowed to work their assigned position until completion of these in-services: This will be ongoing. DON and ADON were in-serviced by Compliance Nurse. Notification of change of condition to the physician immediately including fractures, increased pain, decreased mobility, or a change in eating habits. Implementation of physician orders immediately upon receipt including the administration of pain medications and notifying the physician if medication is not available to be administered. A head-to-toe assessment will be performed every time by the charge nurse on all residents who complain of increased pain. Effectiveness of pain medication administrated i=for increased pain will be charted on the EMAR. A licensed nurse will complete a follow up assessment for effectiveness of pain. In-services were initiated for all nursing staff were in-serviced on 8/9/23 by the Compliance Nurse/DON/ADON regarding the following and will be completed on 8/10/2023 by 8am. All staff not in-serviced by 8am on 8/10/23 including agency staff, new hires and PRN staff will not be allowed to work their assigned schedule until the completion of these in-services. Notification of change of condition to the charge nurse, immediately including falls, injuries, increased pain and decreased mobility. Pain: Signs and symptoms of pain verbal and non-verbal. (crying, whining, groaning, facial expressions, grimacing, frowning, protecting body movements, guarding, or clutching) Medical Director was notified by the DON on 8/9/23 at 5:15 pm about the Immediate Jeopardies. An AD HOC QAPI meeting will be held on 8/10/23 by the Interdisciplinary Team to discuss the Immediate Jeopardies and review the Plan of Removal. The Director of Nursing or designee will implement this written Plan of Removal and will continue to monitor completion and compliance of this written Plan of Removal. Monitoring: o The DON and/or designee will monitor Real Time clinical software and the PCC Dashboard for clinical alerts for any resident change of condition including new or increased pain at least 5 days per week to ensure physician/NP were notified. Monitoring will begin 8/10/23 and will continue x 4 weeks. o The DON and/or designee will monitor Real Time clinical software and the PCC dashboard at least 5 days per week, to ensure any new physician/NP orders were implemented immediately. Monitoring will begin 8/10/23 and will continue x 4 weeks. The DON/designee will make daily rounds on all residents. The DON/designee will ask 4 nurses per week what they would do if a resident had a change of condition, or it was reported to them that a resident had a change in condition X 4 weeks. The DON/ADON/Designee will audit all resident pain medications twice per week to ensure a 4-to-7-day supply of medications are present and maintained. * Resident #1 had completed pain assessments that showed no pain on 08/08/2023, 08/09/2023 and 08/10/2023. * During observation on 08/08/2023 at 9:10 a.m., Resident #1 was lying in bed with eyes closed. No signs or symptoms of pain noted. * During observation on 08/08/2023 at 2:15 p.m., Resident #1 was lying in bed facing window. Resident #1 had eyes closed and no facial grimace was noted. * During observation on 08/09/2023 at 10:10 a.m., Resident #1 was lying in bed facing door. Resident #1 was awake and talking to herself with no signs of facial grimace noted. * During an attempted interview on 08/09/2023 at 2:15 p.m., weekend day shift nurse was not avaiable. Message left with no returned call. * During an attempted interview on 08/09/2023 at 2:30 p.m., weekend CNA responsible for Resident #1's care had a phone number that was not inservice. Verification of the Plan of Removal was as follows: Reviewed in-service training on 08/09/2023 and 08/10/23 for all nursing staff, on all shifts. The nursing staff were in-serviced on notification of change of condition to the physician immediately including fractures, increased pain, decreased mobility, or a change in eating habits. A head-to-toe assessment was performed by the charge nurse on all residents who present with a change in condition. Notification of change of condition to the charge nurse immediately including falls, injuries, increased pain, and decreased mobility. The charge nurse performed pain assessments on all residents who presented with signs/symptoms or complaint of pain. Interviews conducted 8/10/2023 between 1:25 p.m. and 3:00 p.m. revealed LVN M, P, R, U, T, V, and AA, as well as RN Q all stated they had received in-servicing provided by the facility as part of the plan of removal and all had knowledge and understanding of notification of change of condition to the physician immediately including fractures, increased pain, decreased mobility, or a change in eating habits. And doing a head-to-toe assessment performed by the charge nurse on all residents who present with a change in condition. The nurses were educated on reordering medications timely to ensure 5-7-day supply is present. Medications need to be re-ordered as indicated on the medication card. The Charge Nurse will review the order status in EHR (electronic health record) under the residents MAR for medications needing to the reordered and reorder if needed. DON/ADON will audit all pain medication weekly to ensure medications are received. An Immediate Jeopardy (IJ) was identified on 08/09/2023 at 4:20 p.m. The IJ was removed on 8/10/2023 at 3:10 p.m. While the IJ was removed, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate, due to the facility's need to complete in-servicing and monitoring interventions.

Based on interview and record review the facility failed to ensure residents received care and services in accordance with professional standards of practice for 1 of 6 residents (Resident #1) reviewed for quality of care. -The facility failed to treat Resident#1 after a fall with injury and reports of pain. -The facility failed to have prescribed pain medication available for Resident #1. -The facility failed to notify the MD of the fall with injury and Resident #1 was diagnosed with a fractured right hip on 07/11/2023. This failure resulted in identification of Immediate Jeopardy (IJ) on 08/09/2023 at 4:20 p.m. The IJ was removed on 8/10/2023 at 3:10 p.m. While the IJ was removed, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate, due to the facility's need to complete in-servicing and monitoring interventions. This failure could place residents at risk for not receiving appropriate care and interventions and/or death. Findings included: Record review of Resident #1's Face Sheet dated August 2023 indicated Resident #1 was a [AGE] year-old female admitted to the facility on [DATE]. Resident #1's diagnoses included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), cerebral infarction (damage to the brain from interruption of its blood supply), and type II diabetes (the body does not make enough insulin or cannot use it as well as it should). Record review of Resident #1's significant change MDS assessment dated [DATE], revealed Resident #1 had short- and long-term memory impairment. Resident #1wandered daily. Resident #1 ambulated with unsteady balance that was stabilized without staff assistance. Resident #1 required supervision assistance with ambulation in room and in corridor. No falls were noted on Resident #1's MDS. No indicators of pain were noted on the MDS. Resident #1 lived on the dementia unit until 07/11/2023. Record review of Resident #1's care plan dated 01/20/2023 revealed, Resident #1 was at risk for increased falls and fractures as evidenced by: unsteady gait /cognitive impairment/ physical impairment. Intervention was listed as Resident #1 to be in wheelchair when up related to poor balance on 02/19/2023. No pain care plan was noted. Record review of Resident #1's physician orders for July 2023 revealed an order with a start date of 05/23/2023 for Morphine sulfate 20mg/ml give 0.25ml every 4 hours as needed for pain. This order for Morphine sulfate was discontinued on 07/06/2023 and restarted on 07/13/2023. An order dated 05/09/2023 for acetaminophen 325 mg give two tablets every 6 hours as needed for pain. An order for Eliquis (anticoagulant) 2.5mg twice daily was ordered 01/23/2023. Record review of Resident #1's incident and accident report dated 07/06/2023 at by RN D indicated, SN (skilled nurse) called by CNA that resident had fallen, fall was unwitnessed and in hallway of secure unit. Resident is c/o pain on right wrist, lump presented on right side of her forehead and small abrasion on left elbow. Resident was assessed and transferred to a wheelchair for continued observation. Harbor hospice was called at 4:09 a.m., and fall was reported, Message sent to DON and Admin. Contact attempted with husband but was unsuccessful. Neuros within normal limits at the time. The incident and accident report also indicated Resident #1 complained of right wrist pain at a 5 on a scale of 1-10. Record review of Resident #1's nurses notes written on 07/06/2023 at 3:57 a.m. by RN D, indicated skilled nurse called by CNA that resident had fallen, fall was unwitnessed and in hallway of secure unit. Resident complains of pain on right wrist, lump has presented to R side of her forehead and small abrasion to left elbow. Resident was assessed and transferred to a wheelchair for continued observation. Hospice was called at 4:09 a.m. and fall was reported. Message sent to DON and Administrator. Contact attempted with husband but was unsuccessful. Neuro checks within normal limits at this time. Record review of Resident #1's notes indicated, no nurse notes from 07/07/2023 until 07/09/2023. Record review of Resident #1's nurse notes for 07/09/2023 written by RN D indicated, called to resident room related to resident screaming in pain, unable to verbalize location of pain but yells louder when turned toward right side, tramadol was administered per hospice pain management orders. Record review of nurse notes revealed no nurses' notes written on 07/10/2023. Record review of Resident #1's hospice communication notes for 07/10/2023 at 6:12 p.m., written by RN G indicated, Hospice Aide H, contacted this am to report patient was 'very different' today. She would not stand up 'at all' today. She reported she was in wheelchair during her visit and staff had her up in dining area for meal. RN G asked Hospice Aide H if Tramadol had been given, she reported she was not aware, but wanted RN to know of change since last Friday. Hospice Aide H stated patient had 'new' bruises but staff not able to tell her if she fell or when. RN G advised patient to be seen in a.m. and will follow up then. Record review of Resident #1's Hospice encounter notes from 07/11/2023 at 9:55 a.m., written by RN G, Last week, patient was ambulatory without use of assistive device (due to cognitive deficits); Yesterday, Hospice Aide noted patient would not bear weight when she was trying to transfer to shower chair, or change her brief. She 'acted like' she was having increased pain with position changes. Facility CNA's also report this was noted since they 'returned to work' yesterday- there was no documentation over the weekend of her mobility status from facility staff. Fall was documented by facility nurse 07/06/2023 on 'night shift' with no specific information re: events surrounding fall except 'no injuries noted'. Patient is seen with furrowed brows, whimpering, sitting up in wheelchair but appears uncomfortable. LVN E, was preparing Tramadol to give Resident #1 as staff had just informed LVN E, she was 'whimpering and acting like she is uncomfortable'. Record review of Resident #1's nurse notes for 07/11/2023 at 10:52 a.m., written by LVN E indicated, Hospice nurse here with new order noted :(1) X-ray bilateral hips today related to pain. (2) Tramadol 50mg 1 orally every 6 hours routinely. (3) Discontinue routine fingerstick blood sugar checks. Husband present and aware of all new orders. Record review of Resident #1's nurse notes for 07/11/2023 at 1:12 p.m., written by LVN E indicated, Results of x-ray show: Interval development of an acute right subcapital hip fracture. Hospice notified and hospice nurse notified family and will consult them with hospice doctor to decide course of treatment for resident. MD F, resident's primary care physician also notified with no new orders at this time, awaiting hospice plan of treatment. Resident currently in bed with positioning pillows for comfort. Record review of Resident #1's July 2023 MARS indicated, Resident #1 was administered nothing for pain from the time of the fall until Tramadol was administered on 07/07/23, nothing on 07/08/2023, administered Tramadol on 07/09/2023, and 07/11/23.There were no assessments for effectiveness of pain medication on the MAR. During observation on 08/08/2023 at 9:10 a.m., Resident #1 was lying in bed with eyes closed. No signs or symptoms of pain noted. During observation on 08/08/2023 at 2:15 p.m., Resident #1 was lying in bed facing window. Resident #1 had eyes closed and no facial grimace was noted. During observation on 08/09/2023 at 10:10 a.m., Resident #1 was lying in bed facing door. Resident #1 was awake and talking to herself with no signs of facial grimace noted. During an interview on 08/09/2023 at 8:35 a.m., RN D stated she was the nurse in charge of Resident #1 on the morning of 07/06/2023. RN D stated the CNA on duty came and got her from the nurse's station to alert her Resident #1 was on the floor in the secured unit. RN D stated she immediately went and assessed Resident #1 for injury. RN D stated Resident #1 complained of pain to right wrist, the right side of her forehead and had a large abrasion to her left upper arm. RN D stated Resident #1 verbalized a 5 on a scale of 1-10 as her pain level after the fall. RN D stated there was no pain medication in the building for Resident #1 or she would have treated her pain. RN D stated the resident had been out of the prn morphine for 3 or 4 days and she contacted hospice herself several times for refills. RN D stated the hospice RN had not wanted the morphine given unless Resident #1 was actively dying. RN D stated she contacted the on-call hospice number about the fall. RN D stated she did not directly contact the MD; she left that up to hospice. RN D stated on 07/09/2023 she was called to Resident #1's room because Resident #1 was screaming in pain and administered the tramadol ordered by hospice to replace the morphine Resident #1 previously had ordered. RN D stated it was when Resident #1 rolled to her right side that she screamed. RN D stated she did not notify the MD of the amount of pain or that it was positional pain. RN D stated hospice was already aware of Resident #1's pain and the hospice MD chose to discharge the morphine Resident #1 had been taking and start her on tramadol. RN D stated she was unaware Resident #1 had a fractured hip because her last day to work at the facility was 07/09/2023. During an interview on 08/09/2023 at 2:00 p.m., RN G stated she was the hospice nurse that followed Resident #1's care. RN G stated she was in the facility on 07/06/2023 in the afternoon to discontinue Resident #1's morphine and start her on tramadol prn. RN G stated she was never notified Resident #1 had a fall that a.m. RN G stated Resident #1 was asleep in the bed when she was there. RN G stated she was notified about the fall by hospice CNA H on 07/10/2023. RN G stated she was called by CNA H during the afternoon of 07/10/2023 and was told Resident #1 was in a wheelchair and was unable to bear weight when transferring from the wheelchair to the shower chair. CNA H observed new bruising to right leg and right arm. RN G stated she came to the facility the next morning (07/11/2022) to assess Resident #1 and found the resident in pain. RN G contacted the MD, and he ordered a x ray of both hips. RN G stated she asked the nurses about any falls, and they stated she fell on [DATE] but no injuries were reported on the incident report. RN G stated x rays were obtained, and it was noted that she had a right hip fracture. During an attempted interview on 08/09/2023 at 2:15 p.m., weekend day shift nurse was not avaiable. Message left with no returned call. During an interview on 08/09/2023 at 2:20 p.m., MD I stated he could not recall being contacted about the fall for Resident #1 on 07/06/2023. MD I stated he would have remembered being called at 4:00 a.m. MD I stated had he been contacted with the information of right wrist pain, a lump on the right forehead and an abrasion to her left arm, he would have ordered to send her to the ER ( emergency room ) if the family wished for her to go. If the family had not wanted her to go he would have ordered in house x rays. MD I stated Resident #1 was on anticoagulant medications that can cause bleeding on the brain that can lead to death. MD I stated anyone on anticoagulant therapy would be sent to the ER if they hit their heads. MD I stated anyone that complained of bone pain after a fall would get an x ray either at the facility or at the hospital. During an attempted interview on 08/09/2023 at 2:15 p.m., weekend day shift nurse was not avaiable. Message left with no returned call. During an attempted interview on 08/09/2023 at 2:30 p.m., weekend CNA responsible for Resident #1's care had a phone number that was not inservice. During an interview on 08/09/2023 at 2:40 p.m., NP J stated she was not called about the fall for Resident #1. NP J stated she should not have been called about her because she did not follow hospice residents. During an interview on 08/09/2023 at 2:45 p.m. the DON was not available. The corporate RN stated the facility normally contacted the hospice and the hospice would immediately contact the hospice MD for orders. The corporate RN stated she was unsure of why the RN D had not ensured the hospice notified the MD by calling again and asking for orders. During an interview on 08/09/2023 at 2: 50 p.m., the Administrator stated it was in their policy to notify the MD with all changes in conditions and they used the SBAR (situation-background-assessment-recommendation) system to notify the MD and get the MD response even if the resident were on hospice. No SBAR was done on Resident #1 with the fall on 7/06/2023. During an interview on 08/09/2023 at 3:00 p.m., MD F stated he was not notified about the fall for Resident #1 by the facility or by the hospice company. During an interview on 08/09/2023 at 3:20 p.m., the Administrator stated she was unaware that RN D had not contacted the MD to report Resident #1's fall and her injuries. The Administrator stated it was the job of the charge nurse to assess residents, treat their pain, contact the physicians for intervention related to injury during falls. The Administrator stated contacting the physician was required even if the resident was on hospice services for acute issues such as falls with injuries. Record review of the facility policy titled Notifying the Physician in a Change of Status, dated 03/11/2013 indicated the physician is notified promptly of any significant change in resident status. This failure resulted in identification of Immediate Jeopardy (IJ) on 08/09/2023 at 4:20 p.m. The Plan of Removal was accepted on 08/10/2023 at 12:00 p.m., and included the following: -The facility failed to notify the physician of a fall with injury that occurred on 7/6/23. -The facility failed to notify the hospice agency and hospice physician. -The facility failed to treat Resident #1's pain due to not having her prescribed pain medication available. -The facility failed to send resident #1 to the hospital or get x-rays after the resident fell and sustained a lump to the right side of her forehead, complained of right wrist pain, and an abrasion to her left elbow. -The facility failed to follow their policy on notifying physician of change condition. Interventions: o As of 8/9/23 resident # 1 was assessed for change of condition and increased pain without any new findings. Attending Physician and hospice services notified of fall, fracture, and pain. Orders received as of 8/9/23 for scheduled and PRN pain meds. o As of 8/10/23, 100% audit was completed on all resident pain medications to ensure medications are available in the facility. o All residents in the facility were assessed for any increased pain and change of condition by the DON and Charge Nurses as of 8/9/23. No additional issues were found. In-services: o In-services were initiated for charge nurses on 8/9/23 by the Compliance Nurse/DON/ADON regarding the following and will be completed on 8/10/2023 by 8am. All nurses including agency staff, new hires and PRN staff not in-serviced by 8am on 8/10/23 will not be allowed to work their assigned position until completion of these in-services: This will be ongoing. DON and ADON were in-serviced by Compliance Nurse. Notification of change of condition to the physician immediately including falls, fractures, increased pain, decreased mobility, or a change in eating habits. The Charge Nurse will follow physician's orders on transferring resident to hospital as ordered. Notification of the change of conditions to the hospice service for Residents on hospice. Implementation of physician orders immediately upon receipt including the administration of pain medications and notifying the physician if medication is not available to be administered. A head-to-toe assessment will be performed by the charge nurse on all residents who complain of increased pain. Reordering medications timely to ensure 5-7-day supply is present. Medications need to be re-ordered as indicated on the medication card. The Charge Nurse will review the order status in PCC under the residents MAR for medications needing to the reordered and reorder if needed. DON/ADON will audit all pain medication weekly to ensure medications are received. All residents on hospice services who have a fall or change in condition the Charge Nurse will notify the attending physician and hospice nurse. In-services were initiated for all nursing staff were in-serviced on 8/9/23 by the Compliance Nurse/DON/ADON regarding the following and will be completed on 8/10/2023 by 8am. All staff not in-serviced by 8am on 8/10/23 including agency staff, new hires and PRN staff will not be allowed to work their assigned schedule until the completion of these in-services. Notification of change of condition to the charge nurse immediately including falls, injuries, increased pain, and decreased mobility using the Stop and Watch. Pain: Signs and symptoms of pain verbal and non-verbal. (crying, whining, groaning, facial expressions, grimacing, frowning, protecting body movements, guarding, or clutching) Medical Director was notified by the DON on 8/9/23 at 5:15pm about the Immediate Jeopardies. An AD HOC QAPI meeting will be held on 8/10/23 by the Interdisciplinary Team to discuss the Immediate Jeopardies and review the Plan of Removal. The Director of Nursing or designee will implement this written Plan of Removal and will continue to monitor completion and compliance of this written Plan of Removal. Monitoring: o The DON and/or designee will monitor Real Time clinical software and the PCC Dashboard for clinical alerts for any resident with falls or change of condition including new or increased pain at least 5 days per week to ensure physician/NP were notified. Monitoring will begin 8/10/23 and will continue x 4 weeks. o The DON and/or designee will monitor Real Time clinical software and the PCC dashboard at least 5 days per week, to ensure any new physician/NP orders were implemented immediately. Monitoring will begin 8/10/23 and will continue x 4 weeks. The DON/designee made daily rounds on all residents. The DON/designee asked 4 nurses per week what they would do if a resident had a change of condition, or it was reported to them that a resident had a change in condition X 4 weeks. The DON/ADON audited all pain medication weekly to ensure medications are received x 4 weeks. * Resident #1 had completed pain assessments that showed no pain on 08/08/2023, 08/09/2023 and 08/10/2023. * During observation on 08/08/2023 at 9:10 a.m., Resident #1 was lying in bed with eyes closed. No signs or symptoms of pain noted. * During observation on 08/08/2023 at 2:15 p.m., Resident #1 was lying in bed facing window. Resident #1 had eyes closed and no facial grimace was noted. * During observation on 08/09/2023 at 10:10 a.m., Resident #1 was lying in bed facing door. Resident #1 was awake and talking to herself with no signs of facial grimace noted. * During an attempted interview on 08/09/2023 at 2:15 p.m., weekend day shift nurse was not avaiable. Message left with no returned call. * During an attempted interview on 08/09/2023 at 2:30 p.m., weekend CNA responsible for Resident #1's care had a phone number that was not inservice. Verification of the Plan of Removal was as follows: Reviewed in-service training on 08/09/2023 and 08/10/23 for all nursing staff, on all shifts. The nursing staff were in-serviced on notification of change of condition to the physician immediately including fractures, increased pain, decreased mobility, or a change in eating habits. Head-to-toe assessment were performed by the charge nurse on all residents who present with a change in condition. Notification of change of condition to the charge nurse immediately including falls, injuries, increased pain, and decreased mobility. The charge nurse performed pain assessments on all residents who presented with signs/symptoms or complaint of pain. Interviews conducted 8/10/2023 between 1:25 p.m. and 3:00 p.m. revealed LVN M, P, R, U, T, V, and AA, as well as RN Q all stated they had received in-servicing provided by the facility as part of the plan of removal and all had knowledge and understanding of notification of change of condition to the physician immediately including fractures, increased pain, decreased mobility, or a change in eating habits. And doing a head-to-toe assessment performed by the charge nurse on all residents who present with a change in condition. The nurses were aware of the process of notification of the change of conditions to the hospice service for Residents on hospice. They were aware to implement physician orders immediately upon receipt including the administration of pain medications and notifying the physician if medication is not available to be administered. They were aware they are responsible for completing a head-to-toe assessment on all residents who complain of increased pain. The nurses were educated on reordering medications timely to ensure 5-7-day supply is present. Medications need to be re-ordered as indicated on the medication card. The Charge Nurse will review the order status in PCC under the residents MAR for medications needing to the reordered and reorder if needed. DON/ADON will audit all pain medication weekly to ensure medications are received. The nurses know all residents on hospice services who have a fall or change in condition the Charge Nurse will notify the attending physician and hospice nurse. An Immediate Jeopardy (IJ) was identified on 08/09/2023 at 4:20 p.m. The IJ was removed on 8/10/2023 at 3:10 p.m. While the IJ was removed, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate, due to the facility's need to complete in-servicing and monitoring interventions.

Based on record review and interviews, the facility failed to immediately consult with the resident's primary care physician and/or resident's hospice provider/physician following a fall resulting in a hip fracture for 1 of 6 residents (Resident #1) reviewed for resident rights. The facility failed to inform the attending physician, NP, hospice physician and hospice provider for Resident #1 following a fall with injury on 07/06/2023. This failure resulted in identification of Immediate Jeopardy (IJ) on 08/09/2023 at 4:20 p.m. The IJ was removed on 8/10/2023 at 3:10 p.m. While the IJ was removed, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate, due to the facility's need to complete in-servicing and monitoring interventions. This failure could place residents at risk for not receiving appropriate care and interventions and/or death. Findings included: Record review of Resident #1's Face Sheet dated August 2023 indicated Resident #1 was a [AGE] year-old female admitted to the facility on [DATE]. Resident #1's diagnoses included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), cerebral infarction (damage to the brain from interruption of its blood supply), and type II diabetes (the body does not make enough insulin or cannot use it as well as it should). Record review of Resident #1's significant change MDS assessment dated [DATE], revealed Resident #1 had short- and long-term memory impairment. Resident #1wandered daily. Resident #1 ambulated with unsteady balance that was stabilized without staff assistance. Resident #1 required supervision assistance with ambulation in room and in corridor. No falls were noted on Resident #1's MDS. Resident #1 was on the secured dementia unit until 07/11/2023. Record review of Resident #1's care plan dated 01/20/2023 revealed, Resident #1 was at risk for increased falls and fractures as evidenced by: unsteady gait /cognitive impairment/ physical impairment. Intervention was listed as Resident #1 to be in wheelchair when up related to poor balance on revised on 02/19/2023. Record review of Resident #1's incident and accident report dated 07/06/2023 by RN D indicated, SN (skilled nurse) called by CNA that resident had fallen, fall was unwitnessed and in hallway of secure unit. Resident was complaining of pain on right wrist, lump has presented on right side of her forehead and small abrasion on left elbow. Resident was assessed and transferred to a wheelchair for continued observation. Hospice was called at 4:09 a.m. and fall was reported, Message sent to DON and Administrator. Contact attempted with husband but was unsuccessful. Neuros within normal limits at this time. The incident and accident report also indicated Resident #1 complained of right wrist pain at a 5 on a scale of 1-10. Record review of Resident #1's nurses notes written on 07/06/2023 at 3:57 a.m. by RN D, indicated skilled nurse called by CNA that resident had fallen, fall was unwitnessed and in hallway of secure unit. Resident complains of pain on right wrist, lump has presented to right side of her forehead and small abrasion to left elbow. Resident was assessed and transferred to a wheelchair for continued observation. Hospice was called at 4:09 a.m. and fall was reported. Message sent to DON and Administrator. Contact attempted with (Family Member) but was unsuccessful. Neuro checks within normal limits at this time. Record review of Resident #1's nurse notes revealed, no nurse notes were recorded from 07/07/2023 until 07/09/2023. Record review of Resident #1's nurse notes for 07/09/2023 written by RN D indicated, called to resident room related to resident screaming in pain, unable to verbalize location of pain but yells louder when turned toward right side, tramadol was administered per hospice pain management orders. Record review of nurse notes revealed no nurses' notes written on 07/10/2023. Record review of Resident #1's hospice communication notes for 07/10/2023 at 6:12 p.m., written by RN G indicated, Hospice Aide H, contacted this a.m. to report patient was 'very different' today. She would not stand up 'at all' today. She reported (the resident) was in wheelchair during her visit today and staff had her up in dining area for a meal. RN G asked (Hospice Aide H) if Tramadol had been given, she reported she was not aware, but wanted RN G to know of change since last Friday 07/07/2023. Hospice Aide H stated patient had 'new' bruises but staff not able to tell her if she fell or when. RN G advised patient to be seen in am and will follow up then. Record review of Resident #1's Hospice encounter notes from 07/11/2023 at 9:55 a.m., written by RN G, Last week, patient was ambulatory without use of assistive device (due to cognitive deficits); Yesterday, Hospice Aide noted patient would not bear weight when she was trying to transfer to shower chair, or change her brief. Resident 'acted like' she was having increased pain with position changes. Facility CNAs also reported this was noted since they 'returned to work' yesterday. There was no documentation over the weekend of her mobility status form facility staff. Fall was documented by facility nurse 07/06/2023 on 'night shift' with no specific information re: events surrounding fall except 'no injuries noted'. Patient (Resident #1) was seen with furrowed brows, whimpering, sitting up in wheelchair but appears uncomfortable. LVN E, was preparing Tramadol to give her (Resident #1) as staff had just informed LVN E, she was 'whimpering and acting like she was uncomfortable'. Record review of Resident #1's nurse notes for 07/11/2023 at 10:52 a.m., written by LVN E indicated, Hospice nurse here with new order noted :(1) X-ray bilateral hips today r/t pain. (2) Tramadol 50mg 1 po q 6 hours routinely. (3) D/C routine fingerstick blood sugar checks. Record review of Resident #1's nurse notes for 07/11/2023 at 1:12 p.m., written by LVN E indicated, Results of x-ray show: Interval development of an acute right subcapital hip fracture. Hospice notified and hospice nurse notified family and will consult them with hospice doctor to decide course of treatment for resident. MD F, resident's primary care physician also notified with no new orders at this time, awaiting hospice plan of treatment. Resident currently in bed with positioning pillows for comfort. Record review of Resident #1's July 2023 MARS indicated, Resident #1 was administered nothing for pain from the time of the fall until Tramadol was administered on 07/07/23, nothing on 07/08/2023, administered Tramadol on 07/09/2023, and 07/11/23.There were no assessments for effectiveness of pain medication on the MAR. During observation on 08/08/2023 at 9:10 a.m., Resident #1 was lying in bed with eyes closed. No signs or symptoms of pain noted. During observation on 08/08/2023 at 2:15 p.m., Resident #1 was lying in bed facing window. Resident #1 had eyes closed and no facial grimace was noted. During observation on 08/09/2023 at 10:10 a.m., Resident #1 was lying in bed facing door. Resident #1 was awake and talking to herself with no signs of facial grimace noted. During an interview on 08/09/2023 at 8:35 a.m., RN D stated she was the nurse in charge of Resident #1 on the morning of 07/06/2023. RN D stated the CNA on duty came and got her from the nurse's station to alert her Resident #1 was on the floor in the secured unit. RN D stated she immediately went and assessed Resident #1 for injury. RN D stated Resident #1 complained of pain to right wrist, the right side of her forehead and had a large abrasion to her left upper arm. RN D stated Resident #1 verbalized a 5 on a scale of 1-10 as her pain level after the fall. RN D stated there was no pain medication in the building for Resident #1 or she would have treated her pain. RN D stated she contacted the on-call hospice number about the fall. RN D stated she did not directly contact the MD; she left that up to hospice. RN D stated on 07/09/2023 she was called to Resident #1's room because Resident #1 was screaming in pain and administered the tramadol ordered by hospice. RN D stated it was when Resident #1 rolled to her right side that she screamed. RN D stated she did not notify the MD of the amount of pain or that it was positional pain. RN D stated hospice was already aware of Resident #1's pain and the hospice MD chose to discontinue the morphine Resident #1 had been taking and started her on tramadol. RN D stated she was unaware Resident #1 had a fractured hip because her last day to work at the facility was 07/09/2023. During an interview on 08/09/2023 at 2:00 p.m., RN G stated she was the hospice nurse that followed Resident #1's care. RN G stated she was in the facility on 07/06/2023 in the afternoon to discontinue Resident #1's morphine and start her on tramadol prn. RN G stated she was never notified Resident #1 had a fall that a.m. RN G stated Resident #1 was asleep in the bed when she was there. RN G stated she was notified about the change in condition of Resident #1 by hospice CNA H on 07/10/2023. RN G stated she was called by CNA H during the afternoon of 07/10/2023 and was told Resident #1 was in a wheelchair and was unable to bear weight when transferring from the wheelchair to the shower chair. CNA H observed new bruising to right leg and right arm on 07/10/2023. RN G stated she came to the facility the next morning (07/11/2023) to assess Resident #1 and found the resident in pain. RN G contacted the MD, and he ordered her to x ray both hips. RN G stated she asked the facility nurses about any falls, and they (the facility nurses) stated she fell on [DATE] but no injuries were reported on the incident report. RN G stated x rays were obtained on 07/11/2023, and it was noted that she had a right hip fracture. During an attempted interview on 08/09/2023 at 2:15 p.m., weekend day shift nurse was not avaiable. Message left with no returned call. During an interview on 08/09/2023 at 2:20 p.m., MD I stated he could not recall being contacted about the fall for Resident #1 on 07/06/2023. MD I stated he would have remembered being called at 4:00 a.m. MD I stated had he been contacted with the information of right wrist pain, a lump on the right forehead and an abrasion to her left arm, he would have ordered to send her to the ER (emergency room ) if the family wished for her to go. If the family had not wanted her to go, or he would have ordered in house x rays. MD I stated Resident #1 was on anticoagulant medications that can cause bleeding on the brain that can lead to death. MD I stated anyone on anticoagulant therapy would be sent to the ER if they hit their heads. MD I stated anyone that complained of bone pain after a fall would get an x ray either at the facility or at the hospital. During an attempted interview on 08/09/2023 at 2:30 p.m., weekend CNA responsible for Resident #1's care had a phone number that was not inservice. During an interview on 08/09/2023 at 2:45 p.m., the DON was not available. The corporate RN stated the facility normally contacted the hospice and the hospice would immediately contact the hospice MD for orders. The corporate RN stated she was unsure of why the RN D had not ensured the hospice notified the MD by calling again and asking for orders. During an interview on 08/09/2023 at 2:50 p.m.,The Administrator stated it was in their policy to notify the MD with all changes in conditions and they used the SBAR (situation-background-assessment-recommendation) system to notify the MD and get the MD response even if the resident were on hospice. No SBAR was done on Resident #1 with the fall on 7/06/2023. During an interview on 08/09/2023 at 2:40 p.m., NP J stated she was not called about the fall for Resident #1. NP J stated she should not have been called about her because she did not follow hospice residents. During an interview on 08/09/2023 at 3:00 p.m., MD F stated he was not notified about the fall for Resident #1 by the facility or by the hospice company. Record review of the facility policy titled Notifying the Physician in a Change of Status, dated 03/11/2013 indicated the physician is notified promptly of any significant change in resident status. This failure resulted in identification of Immediate Jeopardy (IJ) on 08/09/2023 at 4:20 p.m. The Plan of Removal was accepted on 08/10/2023 at 12:00 p.m., and included the following: Plan of Removal F580 o All residents in the facility were assessed for any change of condition by the DON and Charge Nurses as of 8/9/23. No additional issues were found. o All charge nurses were in-serviced on 8/9/23 by the Compliance Nurse/DON/ADON regarding the following and all nurses including agency staff, new hires and PRN. Staff not in-serviced by 8/9/23 will not be allowed to work their assigned position until completion of these in-services: This will be ongoing. DON and ADON were in-serviced by Compliance Nurse. Notification of change of condition to the physician immediately including fractures, increased pain, decreased mobility, or a change in eating habits. A head-to-toe assessment will be performed by the charge nurse on all residents who present with a change in condition. In-services were initiated for all nursing staff on 8/9/23 by the Compliance Nurse/DON/ADON regarding the following and will be completed on 8/10/2023 by 8am. All staff not in-serviced on 8/9/23 including agency staff, new hires and PRN staff will not be allowed to work their assigned schedule until the completion of these in-services. Notification of change of condition to the charge nurse immediately including falls, injuries, increased pain and decreased mobility. MD I, Medical Director, was notified by the DON on 8/9/23 at 5:15p.m. about the Immediate Jeopardies. An AD HOC QAPI meeting will be held on 8/10/23 by the Interdisciplinary Team to discuss the Immediate Jeopardies and review the Plan of Removal. The Director of Nursing or designee will implement this written Plan of Removal and will continue to monitor completion and compliance of this written Plan of Removal. Monitoring: o The DON and/or designee will monitor Real Time clinical software and the EHR dashboard for clinical alerts for any resident change of condition including new or increased pain at least 5 days per week to ensure physician/NP were notified. Monitoring began 8/10/23 and will continue x 4 weeks. o The DON and/or designee will monitor Real Time clinical software and the EHR dashboard at least 5 days per week, to ensure any new physician/NP orders were implemented immediately. Monitoring began 8/10/23 and will continue x 4 weeks. * Resident #1 had completed pain assessments that showed no pain on 08/09/2023, 08/10/2023 and 08/11/2023. * During observation on 08/08/2023 at 9:10 a.m., Resident #1 was lying in bed with eyes closed. No signs or symptoms of pain noted. * During observation on 08/08/2023 at 2:15 p.m., Resident #1 was lying in bed facing window. Resident #1 had eyes closed and no facial grimace was noted. * During observation on 08/09/2023 at 10:10 a.m., Resident #1 was lying in bed facing door. Resident #1 was awake and talking to herself with no signs of facial grimace noted. * During an attempted interview on 08/09/2023 at 2:15 p.m., weekend day shift nurse was not avaiable. Message left with no returned call. * During an attempted interview on 08/09/2023 at 2:30 p.m., weekend CNA responsible for Resident #1's care had a phone number that was not inservice. Verification of the Plan of Removal was as follows: Reviewed in-service training dated 08/09/2023 and 08/10/23 for all nursing staff, on all shifts. The nursing staff were in-serviced on notification of change of condition to the physician immediately including fractures, increased pain, decreased mobility, or a change in eating habits. A head-to-toe assessment was performed by the charge nurse on all residents who present with a change in condition. The charge nurse performed pain assessments on all residents who presented with signs/symptoms or complaint of pain. Interviews conducted 8/10/2023 between 1:25 p.m. and 3:00 p.m. revealed CNA J, K, L, N. S, U, W, X Y and Z all stated they had received in-servicing provided by the facility as part of the plan of removal and all had knowledge and understanding of reporting changes in condition by using a Stop and Watch form and giving a copy to the charge nurse, and DON. Interviews revealed LVN M, P, R, U, T, V, and AA, as well as RN Q all stated they had received in-servicing provided by the facility as part of the plan of removal and all had knowledge and understanding of notification of change of condition to the physician immediately including fractures, increased pain, decreased mobility, or a change in eating habits and doing a head-to-toe assessment performed by the charge nurse on all residents who present with a change in condition. Notification of change of condition to the charge nurse immediately including falls, injuries, increased pain, and decreased mobility. An Immediate Jeopardy (IJ) was identified on 08/09/2023 at 4:20 p.m. The IJ was removed on 8/10/2023 at 3:10 p.m. While the IJ was removed, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate, due to the facility's need to complete in-servicing and monitoring interventions.

Based on observation, interview, and record review the facility failed to ensure residents were free from sexual abuse for 2 of 4 residents (Resident # 2, Resident #3 Resident #5, Resident #6) reviewed for abuse from Resident #1 The facility failed to protect cognitively impaired female residents from unwanted sexual behaviors from Resident #1. The facility failed follow their Abuse Policy in providing an environment free from abuse. The facility failed to develop or update a care plan that provided actual interventions for Resident #1's aggressive sexual behaviors. The facility failed to notify/consult with the physician regarding Resident #1'scontinuous sexual inappropriate behaviors. Resident #1 resided on a Dementia care unit with 6 female residents' and his sexual aggressive behaviors were not monitored. An Immediate Jeopardy (IJ) situation was identified on 4/22/22 at 2:43 p.m. While the IJ was removed on 4/23/22, the facility remained out of compliance at no actual harm with potential for more than minimal harm with a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed residents on the secure unit at risk of diminished abuse and neglect. Findings included: Review of the facility census report indicated there was a census of 11 residents on the locked unit. There were 7 males and 6 females. 1.)Review of Resident #1's Admission Records -Information Sheet indicated he was an [AGE] year-old male admitted to the facility on [DATE]. Resident #1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident # 1's MDS dated [DATE] indicated his cognitive status was 4 (0-7 severely impaired.) The balance during transition and walking indicated it did not occur for standing, walking or moving on and off the toilet. His functional status was he required extensive assist of one person to transfer. His locomotion on the unit was supervision set up help only, and locomotion off the unit was supervision one set up only. The MDS indicated behavioral symptoms not directed toward others physical symptoms such as hitting or scratching, self-pacing, rummaging, or public sexual acts occurred 1-3 times a week. He also had a behavior of wandering that occurred daily. Resident #1 care area assessment indicated that he had a behavioral symptom that triggered review. Review of Resident #1's care plan dated 2/2/22 indicated a focus area of behavior sexually inappropriate as evidenced by referral to a behavioral hospital on 9/27/2021 related to sexual behaviors. [MEDICATION(S)] increased to 60 mg. A focus area of urology consult made for possible removal of penile implant device dated 9/28/21 some interventions were report incidents of inappropriate sexual behavior to charge nurse if other residents CNA or involved immediately intervening to protect the safety of all residents. The goal was resident will have no episodes of sexually inappropriate behavior in the next 90 days. The interventions were to evaluate the resident's ability to understand behavior and consequences of their behavior and explain to the resident the acceptable expressions of sexually based on the cognitive. A focus area indicated Resident #1 has impaired cognitive function dementia or impaired thought process. The resident also had a focused area of he is at risk for wandering the goal was resident number one would not leave the facility unattended. Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Behavior Nursing notes dated 9/27/22, and 9/28/22 indicated to monitor Resident #1 for sexual behaviors toward residents and staff. There were no other Behavior notes noted. Review of Resident #1's nursing notes indicated: On 9/25/21 at 7:28 a.m. resident is being monitored for sexual behaviors. He continued to have intermittent impulsive behaviors at times. He is easily redirected MD made aware. Increase [MEDICATION(S)] to 60 mg and continue to monitor behaviors. On 9/29/21 at 12:15 p.m. in appropriate behaviors with female resident. Resident relocated to a different area. On 1/21/22 at 4:35 p.m. CNA reported the resident was being sexually inappropriate in the unit dining room. The nurse spoke with the resident, but he does not recall anything. Review of Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An order dated 2/24/22 indicated to discontinue [MEDICATION(S)] 0.5 mg. Review of Resident #1's nursing notes indicated: On 2/15/22 at 10:23 a.m. staff reported resident grabbing her in her private area and saying vulgar things to her, administrator notified. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's nursing notes dated 4/10 /22 at 12:36 p.m. indicated, Resident noted to be sexually inappropriate with several female residents. Attempted to redirect without success the resident went into another room and this nurse showed him where his room was, and he went into his room and was sleeping in the chair when last observed the nurse spoke with the resident and told him he cannot be touching females. The resident argued that he didn't know why, stated he was just helping her put her pants, on administrator notified. (Note written by LVN H) Review of Resident #1's Diagnostic Evaluation dated 9/3/21 indicated the nursing staff stated the Resident was recently involved in a consensual sexual interaction but he was also sexually inappropriate with staff. He has some delusional thought process present. The resident has problems with social situations. Increased the Residents [MEDICATION(S)] to 40 mg. Psychiatric notes dated 11/30/21 and 2/16/22 indicated no sexual contact or exposure without consent. There was no other mention of sexual behaviors. The plan was to discharge the resident from services, [MEDICATION(S)] was added. The resident was discharged from services on 2/16/22. 2.) Review of Resident #2's MDS dated [DATE] indicated she was an [AGE] year-old female admitted to the facility on [DATE]. Her cognitive skills for daily decision making was 3 indicating Severely Impaired. She had behaviors that occurred 4 of 6 days. Behavioral symptoms directed towards others (hitting, kicking, pushing, scratching, grabbing, abuse other sexually) also other behavioral symptoms not directed toward others (physical symptoms such as hitting, or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing, or smearing food or bodily wastes, or verbal symptoms like screaming or disruptive sounds.) she had a behavior of rejection of care 4 to 6 days. Resident #2's functional status was she required extensive assistance for bed mobility transfer, she did not walk in the corridor, she required extensive assist of two people for dressing and toilet use. She required extensive assist with meals of one person. Resident # 2 used a manual wheelchair for mobility. Some of her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's care plan dated 3/30/22 indicated a focus area of cognitive function dementia or impaired thought process. Some of the interventions were the resident needed assistance or supervision with all decision making. 3.) Review of Resident #3's Admission Records -Information Sheet indicated she was [AGE] year-old female. She was admitted to the facility on [DATE]. Her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident # 3's MDS dated [DATE] indicated her cognitive skills for daily decision making was 2 indicating moderately impaired. Resident # 3's behaviors were wandering, and this type of behavior occurred daily. The MDS indicated that Resident #3's functional status was in walking room with the supervision one person assist. The MDS indicated Resident #3's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's care plan dated 2/2/22 indicated Resident #3 had a focused area of communication problem. Some of the interventions were be conscious of Resident #3's position when in groups, and activities consistent simple directive sentences and provide a safe environment. Provide her with necessary cues, stop and return if agitated. The care plan indicated Resident #3 had a focus area of wandering. Resident #3 had a focus area of ADL self-care performance deficit. Some of the interventions were toilet use in personal hygiene and the interventions was dressing required one person assist. Review of Resident #5's Admission Records -Information Sheet indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Some of her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #6's Admission Records -Information Sheet indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Some of her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #6's care plan dated 11/1/21 indicated a focus area of sexually inappropriate behavior as evidenced by enhanced interest in male visitors. At times she is more visual, other times she attempts to reach out for the person. The initial start dated was 7/20/21, a revision was done on 8/20/21. An intervention was to evaluate Resident #6's ability to understand behavior and consequences of that behavior. Review of Resident #6's Event Nurses Notes dated 9/3/21 and 9/4/21 indicated she would not stay away from male resident, inappropriate sexual behaviors with male resident, and will not stay out of male resident room. During an interview with LVN B on 4/20/22 at 2:50 p.m. she said Resident #1 was very confused. Sometimes he got sexually aggressive with other residents. He had a penial implant. The urologist deflated the implant however, he still had times he got sexually inappropriate, he would masturbate, and tried to touch female residents, and staff. They put him on anti-depressants. When he was inappropriate, we try to move him and get his mind somewhere else. There was only one resident on the unit that would be able to complain. Resident #5 will scream if he goes near her door. She said she was not aware of any inappropriate behaviors by Resident #1 towards Resident #5. They do not get along, but she does not know why. . During an interview on 4/21/22 at 9:30 a.m. SNA C said Resident #1 was sexually inappropriate. She said he tried to play with himself in front of staff. She said she saw him touch a female resident in the past (Resident #6) and that resident was now discharged . During an interview on 4/21/22 at 9:39 a.m. LVN D said Resident #1 had dementia and was diabetic. LVN said he was not actually aggressive but had sexual behaviors. He would expose himself to anyone and masturbated in front of other people. LVN said Resident #1 thought other women were his wife. LVN D said she saw him touch the aides sometime. He tried to touch female residents occasionally. LVN said one resident (Resident #6) thought he was her husband but she passed away. Some of the ladies in the past welcomed his touch. During an interview on 4/21/22 at 10:15 a.m. with CNA F said Resident #1 would play with himself in the dining room in front of other residents. She said he tried to touch her inappropriately. He would try to touch female residents on the leg. A few weeks ago, he was masturbating in the dining room. She took him to his room and told him it was inappropriate. He said, Why? It feels good. During an interview on 4/21/22 at 10:39 a.m. the MDS Coordinator LVN G said she was also responsible for completing care plans. She said Resident #1 had a penile implant that was malfunctioning to the point it would not go down in September 2021. He was sent to the urologist and they deflated it. They said he had a button in his testicles that was pushed to deflate it. It could also be pushed and inflate it if he wanted. She said the care plans dated 9/27/21 and 9/28/21 concerned his behaviors at that time and his trip to the urologist for deflation. The MDS coordinator said occasionally, Resident #1 had a tendency of sexually inappropriate behaviors. She said those were his only care plans dealing with the sexual behaviors. She said he would play with himself and others if he could do so. During an interview on 4/21/22 at 11:20 a.m. the DON said she never actually saw sexually inappropriate behaviors from Resident #1. He liked to antagonize Resident #5. The DON said she only saw Resident #1 go to her door. Resident #5 had a very traumatic childhood if said anything inappropriate. It could upset her. Resident #5 would scream when he went near her room. She said when Resident # 1 was inappropriate he would be redirected. The DON said she had heard other staff say Resident #1 was inappropriate in the past. She was not aware of any recent issues. During an interview with the Administrator on 4/21/22 at 12:11 p.m. the Administrator said she did not know the timeline with Resident #1. When he started to be aggressive with staff they reached out to the urologist. They reached out to his family. There was a female resident (Resident #6) that was sexually promiscuous. She enticed Resident #1 back in September of last year. According to the Administrator that was when Resident #1 started exhibiting sexually inappropriate behaviors. She said the two residents would hold hands and her behavior escalated his behaviors. Resident #6 thought Resident #1 was her husband or boyfriend. His family told us she looked like his wife. His behaviors were masturbating and touching the CNAs. According to the Administrator that type of behavior stopped months ago. The Administrator said the nurse did not tell her about the incident on 4/10/22 that was in the nursing notes. During a telephone interview on 4/21/22 at 12:37 p.m. with LVN H (the nurse who wrote the note on 4/10/22) said she was glad to be called. LVN H said on 4/10/22 Resident #2 was sitting at a table in the dining room. Resident #1 was observed rubbing Resident #2's left breast. He saw LVN H and he started rubbing Resident #2's arm. Resident #1 was moved away from the female resident. Resident #3 went into a vacant room to use the bathroom. LVN H said when she entered the room Resident #3 was sitting on the bed with her brief around her ankle. Resident #1 was sitting in his wheelchair in front of the bed and had his hand on his upper thigh. She and RN I helped her get dressed Resident #3 dressed and helped Resident #1 out of the room. The DON had a death in her family, and she did not want to call her. LVN H said she called and left a message on administrators' phone and the Administrator never returned the call. She said she placed the call on 4/10/22 12:46 p.m. (A screenshot of her phone was sent with the date and time. The administrator verified that was her number.) LVN H said in between times Resident #1 rolled toward a female resident (she could not remember who) flickering his tongue in a provocative way. Later in the afternoon she told the Activity Director the exact same story. She said she put a vague description in the nurses note. She did not know what to chart or how to chart. She did not notify the family members or call the physician. LVN H said she told the aides to watch Resident #1, she told them he was touching female residents. During an interview on 4/21/22 at 12:47 p.m. the, Activity Director said Resident #1 was who he was. He wanted to be with women. The Activity Director said she had no idea what LVN H said about Resident #1. She did say something about Resident #1, but she complained about everything and everyone. The Activity Director said all she knew about Resident #1 was that he liked women, and he will rub on them. She said some of the staff said Resident #1 would follow females around. During an interview on 4/21/22 at 1:22 p.m. CNA J said Resident #1 had days when he is really perverted, he will try to touch on female butts. She said she had not seen him touch residents but had seen him touch staff. She had not heard him say anything vulgar. She said if she talked to him, he would have a conversation. A couple of months ago he tried to touch her bottom, but after she told him to stop, he stopped. According to CNA J he understood what stop meant. She said it had probably been about 2 months since she saw him do anything. However, she had only worked on the unit once or twice this month. During an interview on 4/21/22 at 1:31 p.m., CNA F said she was not working in the unit on 4/10/22. She said when she went to Unit the nurse, LVN H said on 4/10/22 to watch Resident#1. He was touching Resident #2 or Resident #3. CNA F said she could not remember exactly what she said. It was around lunch time. CNA F said Resident #3 for certain. LVN H did not go into details. She had seen Resident #1 on two occasions in the past sitting at the table in the dining room masturbating and told him that was not appropriate. He was at the dining room table and other residents were with him. The last time was about 3 weeks ago, another resident pointed him out. CNA F said she did not see him doing anything. She left to go and do something and when she returned, he was out in the open masturbating. Sometimes when Resident #1 was changed he would try to touch the aide. Resident #1 did not know the difference between staff and residents he touched her on the bottom. He did not know from the back who the CNA was, according to her she could have been a resident. CNA F said Resident #3 would walk down the hall in only her brief. She is really confused sometimes. Resident #3 would take her clothes off but could not put them back on by herself. She often went to others room to use the bathroom. CNA F said she did not think Resident #2 and Resident # 3 could say no to sexual overtures. CNA F said usually Resident # 5 was the one that says things to Resident #1. During a telephone interview on 4/21/22 at 1:48 p.m., RN I said on 4/10/22 she saw Resident #1 in the room with Resident #3. RN I said she did not know what he was doing, she had not his hands. When she came into the room what she saw was Resident #1 in the room with Resident #3. She saw Resident #3's pants and brief were down. She thought LVN H charted his behavior. RN I said she did not remember what exactly was said, she was anxious that day it was her first day on the job. She remembered LVN H called and left a message on administrations phone. She said LVN H told the aides on the unit to watch him, and the two nurses watched him on the camera. An interview with the Administrator and observation of the facility video monitoring of the unit was done on 4/21/22 at 2:27 p.m. The date observed was 4/10/22. Resident #3 was observed to be walking all morning. Resident #3 walked to a chair in the dining room and sat down in a chair with arm rests. The video showed at approximately 8:58 a.m. Resident #1 wheeled up to Resident #3. They had a conversation. There is no volume on the video. He started to rub and pat Resident #3 on the arm for about a minute. His fingers are seen moving up and down. Both residents were facing the same direction. He was sitting on her right side. Resident #1 reached his right hand over and started to rub Resident #3's knee and his hand went higher. Resident #3 got up and wandered around the building. Approximately 3 or 4 minutes later she came back and sat down in the same chair. This time Resident #1 wheeled closer to the front of Resident #3. He reached over and started to rub her knee, it appeared to be her left knee. Resident #1's hand immediately went higher up her leg toward the inside of Resident #3's thigh. It was hard to tell exactly how high the rubbing went because of the view of the camera. This went on for about 30 seconds. Resident # 3 got up and started to walk again. At approximately 9:19 a.m. Resident #1 wheeled up to Resident # 2, who was sitting at a table facing away from the camera. He looked around first, he was facing the camera. He was on her left side. Then Resident #1 took his hand and ran it through her hair. Resident #2 just sat there and did not move. He then started to rub on her left arm. Resident #2 did not move. He then reached his hands into her chest area and started to rub. He rubbed for a several seconds. Resident #2 moved her arm down to the table and blocks his access to her chest area. A few minutes later he started to rub her chest area again and a nurse moved him away from the Resident #2. The Administrator said that was not where Resident #2's breast was located. She did say she would not want a man rubbing her in the chest regardless of where her breast was located. Review of a facility self-report dated 4/21/22 indicated Resident #1 was reported to have been sexually inappropriate with residents on the morning of 4/10/22. This was discovered on 4/21/22 when surveyor read a progress note and inquired further into the events of 4/10/22. Resident #1 was placed on 15-minute checks and the physician was notified. During an interview on 4/22/22 at 10:12 a.m. the DON said they received Resident #1's notes from the psychiatrist's office. They were not in Resident #1's chart or at the facility until she requested them on yesterday. During an interview on 4/22/22 at 10:43 a.m. the Administrator said they did not know what to do with Resident #1. When they tried to send him to the behavioral hospital in September 2021the hospital would not take him due to his Wernicke's diagnosis, and the family said you can do what you need to do. She said he was on medications and the only other interventions was redirection. She said yesterday she made a facility self-report and put Resident # 1 on 15-minute monitoring to see how he is doing. She said that would last for 72 hours. After that time the DON would determine his baseline. From that 72-hour determination they would make changes if necessary. The Administrator said she had no idea prior to yesterday Resident #1 continued to exhibit sexually inappropriate behavior. She had not heard any issues since February. She said it was LVN H's perception of what had occurred. During an interview on 4/22/22 at 11:01 a.m. Activities Assistant said she had seen Resident #1 be sexually inappropriate a few weeks ago. Resident #1 was speaking inappropriately to Resident #3 but Resident #3 did not understand. The Activity Assistant said sometimes Resident #1 acted like he did not know what he is saying. Then there are days when he said things like. Come lay down with me, and I will make you feel good. The Activities Assistant said a few months ago he touched her on the bottom. She said she told the nurse but did not know who the nurse was. During an interview on 4/22/22 at 11:09 a.m. LVN D said no one told her anything recently about Resident #1. Resident #1 was currently on 15-minute monitoring. She said Resident #1 would misinterpret anything more than just minimal contact as something intimate. LVN D said she had not seen the note for 4/10/22. During an interview on 4/22/22 at 12:02 p.m. the SW she said she had worked part time for the facility for about a year. She would visit with Resident #1 when going through the unit. Resident #1 had never done anything vulgar with her. She said she heard bits and pieces about his behavior over the last year or so. However, she had not heard anything recently. During an interview on 4/22/22 at 1:47 p.m. Resident #1's MD said he increased Resident #1's medication because of his sexually inappropriate behaviors. He said he was not aware his sexual behaviors had continued. He said in Resident #1's case mediations would not be 100 percent effective. He could not say what he would do because he does not have all the facts. The MD said he needed to know how often his behaviors occurred, are they sporadic, are they getting worse. he said he might consider a medication adjustment if he had all the facts. Review the facilities abuse policy last revised 3/29/2018 indicated: The resident has the right to be free from abuse. The resident should not be subject to abuse by anyone including but not limited to facility staff or other residents . The facility will provide and ensure the promotion and protection of resident's rights. It is everyone's responsibility to recognize, report, and promptly investigate alleged abuse. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled using technology. Willful as used in this definition of abuse means the individual must have acted deliberately not that the individual must have intended to inflict injury or harm. Prevention the facility will provide the residents family and staff and environment free from abuse and neglect. The facility will be responsible to identify correct and intervene in situations of possible abuse neglect. The facility has placed a method to identify events such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse. Review of the facility Secure Environment Admission Criteria and Process policy dated 2/1/17. The policy said the goal of the Secure Care Environment is meet the individual needs of residents with dementia related to illnesses. The Secure Care Environment will provide a safe environment that maximizes independence and provides an activity intensive atmosphere. Residents eligible for admission will have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The residents admitted , if they exhibit physical abusive and or combative behaviors, they must be manageable through therapeutic approaches and or low to moderate medications. During an interview on 4/22/22 at 2:43 p.m. RN compliance nurse-Regional nurse consultant and Administrator were informed of the IJ situation. They were provided with the IJ template and it was explained to them. They were told they need to provide a Plan of Removal. The following Plan of Removal was submitted by the facility on 4/22/22 at 6:05 p.m. 4/22/2022 Plan of Removal Problem: Sexual Abuse Interventions: An additional designated staff member will be 1 on 1 for resident who initiated the encounter began on 4/22/22. 1 on 1 monitoring until discharge from the facility. The resident who initiated the encounters had his care plan updated on 4/22/22 regarding his sexual behaviors and the need for 1 on 1 supervision at this time. The ADM/DON/ADON/Human Resources Coordinator will interview other interview able residents regarding any inappropriate behavior from other residents on 4/22/22. The DON/ADON/MDS Nurse will complete a skin assessment on all residents on the secured unit. The ADM/DON/ADON will interview staff assigned to the secured unit regarding if they have observed any inappropriate/sexual behavior among residents on 4/22/22. After interviews, determine if other residents have the potential to act sexually inappropriate, if so, act accordingly with placing the resident on 1 on 1 supervision and get a social service or psychological evaluation. The ADM/DON/ADON will begin in-service on 4/22/22 for all staff. If staff is not working, they will be in serviced on 4/23/22. If staff are not in-serviced, they will be in-serviced prior to assuming their duties on their next scheduled shift regarding: o Abuse/Neglect including resident sexual abuse/inappropriateness. Sexual abuse can occur when 1 or more residents are unable to consent to sexual activity that includes touching or exposure of breast, anus or genitalia. Sexual inappropriateness can be masturbating in a public area and/or, rubbing other areas of another resident's body (arm, back, legs) and kissing when 1 or both residents are unable to give consent. o If observed or reported: Separate the residents immediately The resident who instigated the act will be placed 1 on 1 supervision until further direction from Administrator or DON. Report any sexual abuse/inappropriateness to the administrator and DON immediately either in person or by speaking with them on the phone. The Regional Compliance nurse in-serviced the DON and Administrator on 4/22/22 regarding residents who are sexually inappropriate, including: o Continuing 1 on 1 supervision o Social Service and Psychological evaluations as needed if sexual inappropriate behaviors are identified. o Discharging the resident to psychiatric care, home, or another facility that can meet the resident's needs. i.e. a resident discharge to a same sex facility or unit. o Report any sexual abuse/inappropriateness to the physician immediately. The medical director was notified regarding this plan on 4/22/22 at 4:16pm. During an interview on 4/22/22 at 5:10 p.m. the administered said thy have a QA meeting at least once a month. She said she, the DON, Medical director and 15 department heads attend the meeting and aides are invited. She said the way their QA program works was they had QA daily reviews. That was how they determined what to look at during the actual meeting. She said they do real time evaluations such as the 24-hour reports. However, they had not discussed Resident #1's behavior during the QA meeting. During an interview on 4/22/22 at 4:52 p.m. LVN K said occasionally, Resident #1 would try to touch a female resident. He used to always hold his penis. He would try to touch ladies on the legs and anywhere he could. He was easily redirected. He had two ladies that were chasing after him back in September 2021 and they were both discharged . It has been a while since she saw him do anything. During an interview on 4/22/22 at 5:10 p.m. the Administered said thy had a QA meeting at least once a month. She said she, the DON, Medical director and 15 department heads attend the meeting and aides are invited. She said their QA program worked because they had QA daily reviews. That was how they determined what to look at during the actual meeting. She said they do real time evaluations such as the 24-hour reports. However, they had not discussed Resident #1's behavior during the QA meeting. Review of Resident #1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Skin Assessments dated 4/22/22 for 11 residents on the locked unit did not indicate any issues. Review of written interviews dated 4/22/22 with 8 staff who worked the unit did not indicate any current issues of inappropriate behaviors. Review of Safe Survey Questionnaire on Sexual Abuse dated 4/22 and 4/23/22 for 45 interview able residents of the facility with no concerns noted. Interviews with 2 LVN (10-6), 1 RN and 1 LVN (weekend doubles) 2 CNAs, 2 SNAs, 1 laundry staff, Dietary Manager, Activity Director, and 1 MA revealed they had received the in service on abuse, inappropriate behaviors, notification, and identification of resident-to-resident behaviors and they appeared knowledgable of the training [TRUNCATED]

Based on interview and record review the facility failed to administer medications as prescribed by the physician resulting in a significant medication error for 1 of 2 resident reviewed for medications. (Resident #4) The facility failed to administer Resident #4 [MEDICATION(S)]- [MEDICATION(S)] (blood thinner) as prescribed for a DVT. After 4 days without the medications the Residents leg was swollen and painful. He was sent back to the hospital for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] This was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could place residents at risk for pain, discomfort, and jeopardized his health and safety. Finding included: Review of Resident #4's Admission Records -Information Sheet indicated he was a [AGE] year-old male admitted to the facility on [DATE]. Some of Resident #4's diagnoses were metabolic [CONDITION(S)] (problem in the brain caused by a chemical imbalance in the blood) unspecified dementia (loss of memory, problem solving skills and other thinking abilities) without behavioral disturbances, and unspecified abnormalities of gait and mobility. Review of Resident #4's nursing notes indicated he was transferred to the hospital on 2/6/22 at 7:15 a.m. related to venous Doppler (technique used to evaluate blood flow through the veins.) The results were positive for DVT ([CONDITION(S)] or blood clot in a deep vein) to the right leg. Review of Resident #4's hospital discharge medication list dated 2/11/22 indicated to continue [MEDICATION(S)] twice daily orally, 10 mg for two more days and then 5 mg two times a day after that for at least three months. Review of nurse's notes dated 2/11/22 at 12:49 p.m. indicated Resident #4 was readmitted with orders for [MEDICATION(S)] 10 mg tablet by mouth for two days for DVT. Then change to 5mg by mouth for 3 months. Review of nurse's notes dated 2/11/22 at 7:36 p.m. indicated Resident #4 orders for [MEDICATION(S)] 10 mg tablet by mouth for two days then dose change not available signed by LVN A. Review of the February 2022 MAR for Resident #4 revealed [MEDICATION(S)] 10 mg tablet given by mouth two times a day for DVT for two days and change to 5mg. The MAR indicated the medication was never given and was discontinued on 2/11/22 at 4:55 p.m. Review of Resident #4's February 2022 MAR indicated [MEDICATION(S)] 5mg by mouth two times a day for DVT for 3 months. The MAR indicated it was never given and was discontinued on 2/11/22 at 4:56 p.m. Review of nursing note dated 2/14/22 at 12:01 a.m. indicated Resident #4's right leg swollen about twice the size as it was yesterday. The Resident was [NAME] in pain. The nurse was unable to palpate pulse but foot warm with noted pillar, physician note sent resident to ER. Review of Resident #4's A hospital note dated 2/14/22 at 2:00 a.m. indicated the patient presented with pain, swelling, and redness. The onset of symptoms of episode began to occur gradually. Symptom's severity department were unchanged he was here for pain in his leg and swelling initially reported by the nursing home. They said it started yesterday and it's gotten quite worse. However, some of their paperwork dated 2/3/22 noted he was going to be started on [MEDICATION(S)] for DVT in the leg. The patient was not on thinners currently and no diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The patient was discharged from here on 2/11/22 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician consult report dated 2/14/22 at 2:16 a.m. indicated Resident #4 with apparent known DVT to right lower extremity here for right lower extremity pain and swelling doesn't appear to be on thinners with start [MEDICATION(S)]. Review of Resident #4's nursing note dated 2/15/22 at 12:50 PM stated residents sent back to at the hospital around 4:00 AM with redness warmth and swelling too left lower extremity. Nurses were in serviced on the importance of transcribing orders correctly from hospital paperwork once admitted back to the facility. Review of Resident #4's Hospital patient report dated 2/18/22 and 8:57 AM indicated the resident right lower extremity venous Doppler sonogram examination was positive for DVT. Review of a nursing note dated 2/19/22 at 1:55 a.m. indicated resident here from the hospital for readmit he was awake responsive. Review of a Medication Error Form indicated the error occurred on 2/11/22 at 4:55 p.m. Upon returning from the hospital LVN A discontinued new orders for [MEDICATION(S)] which had been entered into the computer on a previous shift. LVN A said, I thought it meant to discontinue medications since it was under the discharged medications tab on return orders for the hospital. Actions taken to correct or prevent reoccurrence was to continue education and medication reconciliation and physician notification. The form was signed 2/14/22. Review of a facility self-report dated 2/14/22 indicated Resident #4 as admitted back to the facility from the hospital on 2/11/22 with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The report indicated on 2/14/22 Resident #4 was sent to the ER and the physician noted that this order was not followed. Attached to the report was medication error monitoring forms from 2/16 through 3/2/22. During an interview on 4/20/22 at 1:25 p.m. the Administrator said Resident #4 came to the facility with an order to start [MEDICATION(S)]-blood thinner. She said that [MEDICATION(S)] was discontinued on his medication list. He was at the facility for a few days but started having an issue with his leg. The Administrator stated the Resident #4 was discharged back to the hospital and came back. The doctor gave a regimen of [MEDICATION(S)], he got better, and he went home. During an interview and record review on 4/21/22 at 11:20 a.m. the DON said LVN A was the nurse that failed to transcribe Resident #4's physician order. He had a DVT which was a deep vine [CONDITION(S)] a blood clot. Resident #4 record review with DON indicated Resident #4's initial admitted was 1/6/22. He was sent to the hospital on 2/6/22 and came back to the facility on [DATE]. He did not receive [MEDICATION(S)] for his DVT diagnosis. He was sent back to the hospital on 2/15/22. The DON said LVN A put the order on MAR and discontinued it on the same day. The DON said LVN A said it was not available. During an interview on 4/22/22 at 3:45 p.m. LVN A said after she reviewed Resident #4's hospital orders and her notes she determined the medication error was all her fault. She looked at the hospital discharge medications list and thought it indicated to discontinue the medications. She was counseled and received am in serviced on medication transcription errors. It was determined these failures were corrected prior to the surveyor entering the facility. Facility took the following actions to correct the non-compliance: Review of an Inservice training dated 2/22/22 indicated it was essential that residents ordered anticoagulation medication [MEDICATION(S)] or [MEDICATION(S)] or receiving this medication, all new admit orders need to be checked for accuracy and we have to ensure medications or enter correctly going forward our residents on [MEDICATION(S)] will have their have a narcotic sign off sheet for all administered doses. Please make sure you are reordering medications at least three days before dose on card to ensure pharmacy has adequate time to refill. All residents currently on [MEDICATION(S)] takes two times a day so please order when you were down to eight to six doses left on the card. Review of a nursing note dated 3/29/22 indicated the Resident #4 was discharged to an assisted living with medications and belonging he left the facility via transport per wheelchair propelled by staff.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and that each resident received adequate supervision to prevent accidents for 1 of 4 residents (#1) whose care was reviewed for accidents and hazards in that: CNA B failed to ensure Resident #1 was positioned properly in her tilt wheelchair (that allowed for positioning) while being transported resulting in Resident #1's right foot hitting the door frame of her room- causing a hair line fracture to her right Tibia bone. This failure could place residents at risk for not receiving proper treatment resulting in injury, pain, and hospitalization . Findings included: Record review of consolidated physician orders dated 10/13/21 indicated Resident #1 was [AGE] years old, admitted to the facility on [DATE] with diagnoses of [CONDITION(S)] (disabling disease of the brain and spinal cord), Alzheimer's Disease (degeneration of the brain), Type II Diabetes Mellitus, and Hypertension (high blood pressure). Record review of the most recent comprehensive MDS dated [DATE] indicated Resident #1 usually made herself understood, usually understood others, and was cognitively intact. The MDS indicated Resident #1 required total assistance with bed mobility, transferring, toileting, personal hygiene, and bathing. The MDS indicated Resident #1 had an impairment to both lower extremities. Record review of the care plan dated 10/01/21 indicated Resident #1 had an ADL self-care deficit requiring extensive to total one person assistance. The care plan indicated Resident #1 used a tilt wheelchair for mobility. Record review of a nurses event note dated 9/20/21 at 6:00 p.m., completed by RN A revealed AD came to this nurse and stated that CNA B had run Resident #1's wheelchair into the doorframe and she felt resident needed to be assessed. RN A assessed Resident #1 and determined it was safe to reposition her correctly in her wheelchair with the assistance of others. Additional assessment was completed to right lower extremity. This nurse found that Resident #1 had no limitation of range of motion to ankle or knee and that there was no visible swelling, redness, or discoloration to her lower leg. There was no guarding or bracing by resident observed. The nurses event note indicated Resident #1 was assessed for pain and indicated her ankle only hurt when it hit the door frame. The nurses event note indicated the MD was not notified immediately due to no immediate injury noted. Record review of a 24-hour nursing report dated 9/20/21 for the 2:00 p.m. to 10:00 p.m. shift revealed RN A documented monitor Resident #1 for pain and if needed obtain order for x-ray to right ankle. Record review of a weekly skin assessment dated [DATE], completed by the ADON indicated Resident #1's lower extremities were assessed and there was no swelling, redness, or bruising, and no complaints of pain were made by Resident #1. Record review of a nurses note dated 9/22/21 at 3:00 p.m., completed by the DON indicated the MD made rounds and was made aware of the incident on 9/20/21. MD assessed Resident #1's right lower extremity. The nurses noted indicated MD ordered x-ray to right ankle to rule out an unseen injury. Record review of physician's order dated 9/22/21 indicated Resident #1 had an order to obtain an x-ray to right ankle. Record review of an x-ray dated 9/22/21 indicated an acute non-displaced fracture, (the bone breaks but does not move out of alignment) of the distal Tibia. Record review of a nurses note dated 9/22/21 at 5:00 p.m., completed by the DON revealed the physician was notified of the x-ray results and a new order was received for immobilizer to right leg and follow up with Orthopedics on 9/23/21. During an interview on 10/12/21 at 11:15 a.m., Resident #1 said that she remembered the incident on 9/20/21 but that she did not want to get anyone in trouble. Resident #1 said she liked CNA B very much but that on that day she felt like she was rushed. She said that CNA B was pushing her back to her room from the dining room and that her wheelchair was hard to maneuver. She said CNA B made the turn into her room and her right foot hit the door frame. Resident #1 said when her foot hit the door frame it hurt for a couple of minutes but then RN A came into her room and performed assessments on her foot, and administered her routine pain medication. She said that RN A told her if the medication did not help the pain then to inform her and she would contact the MD for further orders. Resident #1 said she did not have further pain until 9/22/21 when she informed the AD that it felt like her leg was broken. Resident #1 said she did not inform her nurse but that it was within an hour that the MD made rounds and ordered an x-ray. Resident #1 did not have the immobilizer on because she said she had a follow up with an Orthopedic physician who recommended removal of the immobilizer, monitor, and follow up as needed. During an interview on 10/12/21 at 2:25 p.m., CMA C said she was working on the day of the incident. She said that she was getting Resident #1's medication ready when she observed CNA B wheeling Resident # back to her room from the dining room. CMA C said that Resident #1 was not in her tilt wheelchair correctly and that her right leg was hanging off of the foot of the chair. CMA C said it appeared CNA B was wheeling the Resident quickly and after CNA B turned the tilt wheelchair into the door way Resident #1's foot hit the door frame and bended back. CMA C said that Resident #1 said you broke my foot. CMA C said that she reported the incident to the RN A who assessed Resident #1. During an interview on 10/12/21 at 11:00 a.m., the AD said that she had witness the incident on 9/20/21 and reported it immediately to the charge nurse. The AD said that she saw CNA B pushing Resident #1 back to her room from the dining room. The AD said that it appeared Resident #1 was improperly positioned in her tilt wheelchair with her right leg hanging off of the footrest. She said that CNA B appeared to be pushing the wheelchair quickly and when she attempted to make the turn into the room Resident #1's foot hit the door frame of her room. The AD said Resident #1 said you broke my leg. During an interview on 10/12/21 at 2:36 p.m., CNA B said that she was pushing Resident #1 back to her room and that the tilt wheelchair started swaying as she was turning into the doorway. CNA B said Resident #1's foot accidentally hit the door frame. CNA B said she was not wheeling Resident #1 quickly but that the tilt wheelchair wheels had malfunctioned. CNA B said immediately following the incident Resident #1 complained of a little pain to her right foot. CNA B said that Resident #1 should have been repositioned in the chair prior to pushing her back to her room. CNA B said that staff were in-serviced 9/20/21 at 7:00 p.m., on ensuring residents were properly positioned in their wheelchairs before moving them and promptly reporting incidents to administration. CNA B said she could not remember if she had been trained on positioning residents in the past. During an interview on 10/12/21 at 2:45 p.m., the DON said she expected staff to report any changes to the physician. The DON said she thought RN A forgot this step because she did not complete the incident report right away and she did not believe Resident #1 was injured. She said RN A should have contacted the physician. The DON said she monitored documentation daily to ensure completion. She said that she monitored physician notification as well as family or responsible party notification of changes. The DON said a risk of not notifying the physician is a possible delay in care. The DON said the facility policy was to notify the physician and responsible party of any event. During an interview on 10/13/21 at 11:05 a.m., the administrator said she expected physicians to be notified of any changes in condition so that the resident received timely care. Record review of the undated facility policy Event Reporting: Completion Of revealed, the facility will complete an event report on variances that occur within the facility .All events resulting in a change of status must be reported immediately to the attending physician.

Based on observation, interview, and record review, the facility failed to ensure treatment and care was provided in accordance with professional standards of practice, the comprehensive person-centered care plan, and choices for 1 of 6 residents reviewed for assessment. (Resident #1) The facility did not provide appropriate treatment to Resident #1 for signs and symptoms of infection for 3 days. Resident #1 had a fever, drainage from a surgical abdominal wound, and complaints of headaches. A physician order was obtained to have the shunt checked; the shunt was not checked. On 3/9/18 the resident was sent to the emergency room where he was diagnosed with [REDACTED]. Resident #1 who had a cerebrospinal fluid drainage device recently had a [MEDICATION NAME] pump placed 2/5/18. This failure contributed to a delay in treatment for [REDACTED]. This failure could place the census of 48 residents at risk for not receiving care and treatment to meet their needs. The findings included: Physician orders dated 3/1/18 indicated Resident #1 admitted [DATE], was [AGE] years old, and had [DIAGNOSES REDACTED]. The orders indicated to monitor surgical incision to the left lower abdomen due to placement of a [MEDICATION NAME] pump (a pump inserted to deliver metered dosages of an antispasmotic medication). There were no orders regarding the cerebrospinal fluid drainage device. The history and physical dated 5/29/17 indicated Resident #1 had a stable VP (ventriculoperitoneal) shunt at that time. An operative report dated 2/5/18 indicated Resident #1 received a 3 cm incision to have an [MEDICATION NAME] programmable pump placed in the abdomen. The incision was closed with Prineo (Dermabond a topical skin adhesive closure system). An After Visit Summary printed 2/6/18 indicated Resident #1 was hospitalized [DATE] and discharged [DATE] with an incision to the left abdomen and left back. The Summary of Your hospitalization indicated the Resident was to contact their provider if they exhibited symptoms that included: *temperature greater than 100.4 degrees or higher for more than one day, *severe uncontrolled pain, *redness, tenderness, or signs of infection (pain, swelling, redness, odor or green/yellow discharge around the site) *excessive redness, bleeding, swelling, or drainage from the wound, and *Headache or visual disturbances A patient transfer form dated 2/6/18 indicated Resident #1 had a [DIAGNOSES REDACTED]. The form indicated leave dressing in place and abdominal binder. The MDS dated [DATE] indicated Resident #1 was cognitively intact. The MDS indicated he required the limited assistance of one staff for bed mobility and the total assistance of two staff for transfer. The MDS indicated Resident #1 had [MEDICAL CONDITION], or [MEDICAL CONDITION]. The care plan dated 2/6/18 indicated Resident #1 had a high risk for alteration in skin integrity due to a [MEDICATION NAME] pump insertion. A Weekly Skin Assessment indicated the following for Resident #1 indicated the following: *2/8/18 no areas of skin impairment, *2/16/18 see skin Grid *3/1/18 see skin Grid A Skin Assessment Flow Sheet -Non-Pressure Ulcer Conditions indicated on 2/8/18 Resident #1 had a lateral left abdomen surgical site with the following notes: *2/16/18 unable to determine size due to dermabond (a topical skin adhesive that provides strength to maintain barrier and wound closure integrity) in place *3/1/18 - measurements 2.5 cm x 0.6 cm. No description of the area was noted. A care plan revised 3/14/18 indicated Resident #1 had a problem of a [MEDICATION NAME] pump to the left quadrant with a start date of 2/19/18. Interventions included monitor unhealed post-surgical site for signs and symptoms of infection and notify the physician if noted, and protect the pump site from irritation. The resident had a problem of pain. Interventions included report any increased or uncontrolled pain to the physician. The care plan did not address Resident #1's cerebrospinal fluid drainage device (shunt). During a telephone interview on 3/14/18 at 1:25 p.m., Resident #1 said a nurse (unknown name) told him it was normal for his wound site to leak. He said it started leaking on 3/6/18. He said the drainage was yellow and it stink. He said an (unknown named) nurse looked at his wound site. He said he had no abdominal pain on 3/6/18, but he had a fever and body aches. He said he told the facility he needed to go to the hospital, but he said they told him there was no physician order to send him to the hospital. He said on 3/8/18 he had bad pain, a 10 (on the 0-10 pain scale), in his stomach and a headache. He said he had a small amount of white/yellow drainage from his surgical wound. He said he told LVN H he did not feel good and he said she said he was faking. He said there was a small yellow stain on his shirt from the drainage. He said on 3/9/18 he threw up and the physician pushed on his stomach and it really hurt. He said he was sent to the emergency room . The following nursing notes for Resident #1 indicated: *3/6/18 6:30 a.m., completed by LVN K, resident complained of a headache received Tylenol. *3/6/1810:30 a.m., completed by LVN K, Resident stated no relief from Tylenol. *3/6/18 12:30 p.m., completed by LVN K, Resident given Tylenol. Response pending from physician. *3/6/18 7:45 p.m., completed by RN G, Resident complained of aches to body. The resident had a temperature of 101.0 degrees. The physician was notified by fax. A fax to the physician dated 3/6/18 completed by LVN K complained of headaches received Tylenol 500 mg has not been effective today. The fax indicated the physician was asked to advise. The fax indicated a new order of needs to have shunt checked. The fax indicated a response to the order was the shunt was checked 2/22/18 and was working well. (The fax did not notify of the temperature) A faxed SBAR Communication Form completed by RN G dated 3/6/18 indicated Resident #1 had body aches and a temperature of 101.0. The resident received Tylenol 500 mg, two tablets given. The form indicated new orders for flu test, CBC, urinary analysis immediately. A nursing note dated 3/7/18 9:00 a.m. completed by LVN K indicated Resident #1 had a temperature of 100.7 degrees. New orders stat CBC (immediate complete blood count), urinary analysis, and flu test. A laboratory report dated 3/7/18 indicated Resident #1 had slightly elevated white blood cells at 12.2 (reference range 4.0-10.0) and no urinary tract infection. A fax to the physician dated 3/7/18 12:46 p.m. indicated Resident #1 had a moderate amount of serosanguinuous drainage on his surgical incision. The text indicated the DON requested the physician be updated due to his fever. The fax indicated the physician was asked to advise. The response to the fax was an order for [REDACTED]. The following nursing notes for Resident #1 indicated: *3/8/18 completed by LVN L1:00 a.m. Temperature 99 continues with drainage at left abdomen incision site. *3/8/18 completed by LVN K 10:45 a.m. Resident #1's surgeon faxed regarding surgical site drainage, awaiting response. During an interview on 3/15/18 at 12:58 p.m., the administrator said she could not find the fax LVN K sent to the surgeon 3/8/18. A nursing note dated 3/8/18 6:00 p.m. completed by LVN H indicated Resident #1 complained of a headache, had a temperature of 100.4 degrees and received Tylenol 500 mg. The physician was notified by phone. A message was left and fax sent. A fax to the physician dated 3/8/18 fax 6:00 p.m. completed by LVN H indicated Resident #1 had a temperature of 100.4 and was given Tylenol. A hand written note on the fax dated 3/8/18 indicated the physician could not fax a response to the facility. A hand written new order was noted for 3/9/18 for Keflex (antibiotic). The following nursing notes for Resident #1 indicated: *3/8/18 9:00 p.m. temperature 99.8 *3/9/18 12:30 a.m. completed by LVN L temperature 100.1. Doubled 4x4 to left abdomen. *3/9/18 5:30 a.m. completed by LVN L Resident requested and received milk of magnesia 30 cc by mouth, abdomen firm, rounded, non-tender. *3/9/18 5: 45 a.m. completed by LVN L threw up milk of magnesia. Vital signs: temperature 99.8 degrees, pulse 112, blood pressure 139/75, respirations 18. *3/9/18 8:30 a.m. completed by LVN M Temperature 101.6 degrees, administered Tylenol 500 mg, two tablets. Noted serosanguinous/purulent (sic) drainage from [MEDICATION NAME] pump surgical site, covered with absorbent dressing. Abdomen round, non-tender. No signs or symptoms of distress, bowel sounds in all four quadrants. *3/9/18 9:40 a.m. completed by LVN M, the resident complained of severe abdominal pain to right lower quadrant, vomited large amount of liquid emesis, physician assessed resident, noted to have rebound pain. New orders to send to the emergency room by ambulance. The emergency room physician documentation dated 3/9/18 indicated Resident #1 arrived at the emergency room at 10:40 a.m. with complaints of abdominal pain, and nausea/vomiting. The note indicated the pain started 3 days ago. The resident was noted to have moderate abdominal tenderness in the right lower quadrant and a temperature of 101.4. The resident was transferred by a fixed wing aircraft to a hospital in another city at 10:14 p.m. The Consultation-Surgery record from the local hospital dated 3/9/18 indicated Resident #1 had an incision in the left mid abdomen from his [MEDICATION NAME] pump with an opening in the middle that had a foul smelling drainage. The resident was noted to have pain on the right and left quadrant of the abdomen with the right being worse. He had a 2 inch incision over the lumbar (back) area from the insertion site of the [MEDICATION NAME] pump. The assessment indicated the resident [MEDICAL CONDITIONS] leukocytosis, and fever. The Discharge Summary Notes from a hospital indicated Resident #1 admitted to the hospital on [DATE] and discharged [DATE]. The brief hospital course indicated the resident presented with a headache, fever and drainage from an incision site. The resident was positive [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus) and required surgical removal of the VP shunt and [MEDICATION NAME] pump. During an interview on 3/14/18 at 8:45 a.m., CNA A said every time she showered Resident #1 he had a bandage over his surgical site on his abdomen so she never saw the incision. She said there was tape over the incision site to prevent it from getting wet. She said a couple of times after she showered him the bandage would look pale yellow. She said she thought she saw the yellow drainage on 3/6/18 after she showered him. She said she told LVN K. She said after lunch on 3/6/18 Resident #1 complained of a headache. She said she notified LVN K he had a headache. CNA A said she cared for Resident #1 on 3/9/18 and he was in pain and nauseated. During an interview on 3/14/17 at 9:42 a.m., the ADON said Resident #1 had orders to leave the surgical dressing in place. The ADON indicated each shift was to monitor the surgical site for signs and symptoms of infection. The ADON indicated the TAR was where the monitoring was documented. She said the surgical wound was covered with a dermabond type tape. She said there was no documentation in the resident's chart the surgical site was assessed. She said on 3/7/18 the physician and the surgeon were faxed about a moderate amount of serosanguinous drainage, and a temperature. She said the physician was faxed on 3/8/18 about a temperature of 100.4. She said the physician saw the resident on 3/9/18. The ADON said any drainage should have been documented, the facility should have physically gotten in contact with the physicians. She said they should have gotten an order for [REDACTED]. During an interview on 3/14/18 at 10:28 a.m., the DON said RN G talked to her about Resident #1's fever and the body aches on 3/7/18, the physician was notified, and laboratory services were completed. Resident #1 was checked for the flu because of the body aches but he did not have the flu. She said she did not know if the surgical site drainage was addressed by the physician on 3/7/18 because there were no concerns about the surgical site at that time. The DON said it was hard to say if she would have sent him to the emergency room because he was up and about, had a temperature, but was not complaining. The DON said the drainage should have been documented. During an interview 3/14/18 at 11:11 a.m., CNA E said on 3/5/18 Resident # 1 had a bandage on his side. She said the bandage on his side had some drainage. She said it was the size of a quarter and had a brown color. She said a brown stain was on his shirt. She said she reported the stain on the bandage and shirt to LVN K. She said on 3/8/18 she and CNA C took him to the bathroom. She said he was very weak and had some nausea and diarrhea. She said there was a bandage on his wound, but she does not remember if it had drainage or not. She said he said he did not feel good, and was nauseated. She said she reported his not feeling well to LVN K. She said LVN K said he was being tested for the flu. During an interview on 3/14/18 at 12:09 p.m. CNA F said she cared for Resident #1 on 3/9/18. She said he was sick. She said he threw up. She said he said he had pain in his stomach. She said she told LVN N Resident #1 threw up and complained of pain. She said on 3/8/18 Resident #1 had a spot on his shirt that was light brown. She said the nurse saw him and she did not know what the nurse did or said. During an interview on 3/14/18 at 1:47 p.m., the DON said Resident #1 had a bandage on the surgical site where the [MEDICATION NAME] pump was place. She said she did not know why the bandage was placed on the site. She said the orders were to leave dressing in place and abdominal binder. She said she did not know when the dermabond came off Resident #1's surgical wound. The DON said there was no order to put a bandage on the wound. She said she did not know when a bandage was first put on Resident #1's wound. She said she did not know when Resident #1's surgical wound started draining. She said she did not know he asked to go to the hospital. She said no one told her he wanted to go to the hospital. She said if a resident wanted to go to the hospital, they send them to the hospital. She said she knew he had body aches and a headache. She said it would be a big problem if any nurse told a resident they were faking it. The DON said they were monitoring the wound because nurses from each shift were initialing on the TAR. During an interview on 3/14/18 at 2:21 p.m., RN G said on 3/6/18 Resident #1 had aches and pains and she faxed an SBAR to the physician. She said he had a temperature of 101 degrees, but she did not think of an infection because the wound was closed. She said she gave him Tylenol for the temperature, not a headache. She said he did not complain of a headache to her. She said looking back she should have considered calling the physician on 3/6/18 since the physician had not responded to the fax (SBAR sent 3/6/18). She said he did not have a bandage on his wound on 3/7/18. She said the dermabond was off of the wound on 2/20/18. She said she did not know when the dermabond came off. During an interview on 3/14/18 at 2:40 p.m., LVN H said on 3/8/18 she left a message at 6:00 p.m. for the physician to call her regarding Resident #1 having a temperature. She said she worked the 2:00 p.m. to 10:00 p.m. shift that day. She said she passed onto the oncoming nurse he had a fever and she had given Tylenol. She said she did not call the physician back when she did not hear from him because his temperature had gone down some. She said his wound site was closed and had no drainage on 3/8/18. She said she did not measure the surgical site but indicated it was closed, and approximately 2.5 cm in length and 0.1 or less wide. She said it had no redness, warmth, or signs and symptoms of infection. She said about 5-5:30 pm she gave Resident #1 Tylenol for a headache and about 8:30 p.m. he said his headache was gone. During an interview on 3/14/18 at 3:11 p.m. the ADON said she did not know when the dermabond came off of Resident #1's surgical site. She said she was unable to determine from reviewing the chart and the nurses notes when the dermabond came off after 2/5/18. She said when the dermabond came off the wound, the wound should have been assessed and the assessment should have been documented. During an interview on 3/14/18 at 3:35 p.m. the DON said she was not able to find the TAR for (MONTH) (YEAR) documenting Resident #1's surgical site was monitored as ordered. She said the TAR for (MONTH) (YEAR) indicated the surgical site was monitored each shift from 3/1/18 through 3/9/18. During an interview on 3/14/18 at 3:39 p.m., LVN K said Resident #1 had his [MEDICATION NAME] pump checked by the surgeon on 2/22/18. She indicated they did not receive documentation from the physician regarding the status of the surgical site on 2/22/18. She said if she needed to notify the physician of a resident's change of status she usually faxed instead of calling. LVN K said she got a better response from faxes. She said on 2/20/18 when the resident had drainage coming from the surgical site she called the surgeon's office and was advised to fax. She said on 3/6/18 the only complaint from the resident was a headache. She said she faxed the physician on 3/6/18 and did not get a response from the physician on 3/6/18 regarding her fax. She said on 3/7/18 she received orders from the physician documented on the SBAR for a urinalysis, CBC, and flu test. She said on 3/7/18 the resident had a temperature of 100.7 degrees and slight drainage from the surgical site that was clear with a tinge of yellow. She said she faxed the physician about the drainage and the fever and she received a new order for a culture and sensitivity. She said she educated the resident to keep the elastic from his shorts off of the site and to be sure and not pick or touch it. She said she gave him Tylenol for a headache. She said the spot of the drainage was the size of a half dollar. During an interview 3/14/18 at 4:15 p.m., the administrator and the DON said neither of them knew when the dermabond came off of the surgical site. The administrator and the DON said no one called or followed up on his wound orders, no one measured the surgical wound, and neither of them can find the TAR for (MONTH) (YEAR). The administrator and the DON said the physician was faxed, but sometimes there was not a response and no follow up call. The administrator said everyone knew the resident had a shunt. During an interview 3/15/18 at 8:16 a.m., the physician said he received a fax on 3/6/18 regarding Resident #1's fever and headache. He said he ordered labs on 3/7/18 and was in the facility, but he did not assess the resident. He said he was notified of serosanguinous drainage from the surgical wound on 3/8/18. He said on 3/9/18 Resident #1 had diarrhea, a tender belly, and fever. He said he had no complaints before that of a tender belly. He said the [MEDICATION NAME] pump would be taken out if it was infected. During an interview on 3/15/18 at 11:49 p.m., LVN L said she took care of Resident #1 during the night shift 3/8/15 through 3/9/15. She said Resident #1 had a 4x4 in place over his surgical wound with no drainage. She said she did not remove the 4x4. She said he was constipated and she gave him 30 cc of MOM (milk of magnesia), his abdomen was firm, he thought he was constipated and she did too. She said he vomited the MOM up. She said he had a temp of 99.5 degrees. LVN L said she would not give Tylenol or call the MD for a temperature of 99.5 degrees. She said she would call the MD if the temperature was over 100 degrees. She said she would have given Tylenol if Resident #1 had been in pain or asked for it. During an interview 3/15/18 at 12:19 p.m., the physician said if he had known the shunt had not been checked on 2/22/18 it probably would not have made a difference. He said he was not sure how often a shunt needed to be checked. He said he was looking for a source of the problem and thought maybe Resident #1 had [MEDICAL CONDITION]. During an interview on 3/15/18 at 1:29 p.m., RN G said she was not sure what the signs and symptoms were for a malfunctioning shunt. She said I have never dealt with a shunt before. She said on 2/28/18 when Resident #1complained of a headache and she gave him Tylenol he had gotten relief and went to sleep. During an interview on 3/15/18 at 1:39 p.m., the Regional Clinical Director said they did not have a policy on physician notification. A policy and procedure dated 07/2017 regarding Change of Condition provided by the Regional Clinical Director on 3/15/18 indicated: Policy To follow state and federal guidelines regarding a change of condition of a resident. .2.A significant change in the resident's physical, mental or psychosocial status such as a deterioration in health, mental, or psychosocial status, in life-threatening conditions or clinical complications; 3. A need to alter treatment significantly. Procedure .If necessary due to the seriousness of the change in condition or as ordered by the physician transfer the resident to the hospital by ambulance or appropriate transportation. The website https://medlineplus.gov/ency/patientinstructions/ 9.htm accessed 3/21/18 indicated major signs of an infected or blocked shunt consisted of fever of 101°F or higher, pain in the belly that does not go away, headache, veins on the head or scalp that look larger than they used to, and bulging or tenderness in the soft spot at the top of the head. The Dermabond Prineo specification dated 4/19/16 indicated the system would need to remain in place until the incision was healed which was typically 7-14 days. A fax dated 3/22/18 inidicated on 3/13/18 one resident who was hospitalized had a [MEDICATION NAME] pump. The CMS-672 dated 3/15/18 indicated the census was 48.

Based on observation, interview, and record review, the facility failed to ensure a comprehensive person-centered care plan was developed and implemented that included measurable objectives and time frames to meet the medical and psychosocial needs for 1 of 6 residents reviewed for care plans. (Resident #1) The facility did not develop and implement a comprehensive person-centered care plan that addressed Resident #1's VP (ventriculoperitoneal) shunt. Resident #1 had a fever, and complaints of headaches. A physician order was obtained to have the shunt checked on 3/6/18; the shunt was not checked. On 3/10/18 the resident was positive [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus) and required surgical removal of the VP shunt. This failure contributed to a delay in treatment for [REDACTED]. This failure could place the census of 48 residents at risk for not receiving care and treatment to meet their needs. The findings included: Physician orders dated 3/1/18 indicated Resident #1 admitted [DATE], was [AGE] years old, and had [DIAGNOSES REDACTED]. There were no orders regarding the shunt. The history and physical dated 5/29/17 indicated Resident #1 had a stable VP (ventriculoperitoneal) shunt at that time. The MDS dated [DATE] indicated Resident #1 was cognitively intact. The MDS indicated he required the limited assistance of one staff for bed mobility and the total assistance of two staff for transfer. The MDS indicated Resident #1 had [MEDICAL CONDITION], or [MEDICAL CONDITION]. A care plan revised 3/14/18 did not have a plan to address Resident #1's cerebrospinal fluid drainage device (shunt) During a telephone interview on 3/14/18 at 1:25 p.m., Resident #1 said on 3/6/18 he had a fever and body aches. He said he told the facility he needed to go to the hospital, but he said they told him there was no physician order to send him to the hospital. He said on 3/8/18 he had bad pain, a 10 (on the 0-10 pain scale), in his stomach and a headache. He said he told LVN H he did not feel good and he said she said he was faking. He said he was sent to the emergency room . The following nursing notes and faxes for Resident #1 indicated: *3/6/18 6:30 a.m. completed by LVN K complained of a headache received Tylenol. *3/6/1810:30 a.m. completed by LVN K Resident stated no relief from Tylenol. *3/6/18 12:30 p.m. completed by LVN K Resident given Tylenol. Response pending from physician. *3/6/18 7:45p.m. completed by RN G Resident complained of aches to body. The resident had a temperature of 101.0 degrees. The physician was notified by fax. *3/6/18 (fax) completed by LVN K complained of headaches received Tylenol 500 mg has not been effective today. The fax indicated the physician was asked to advise. The fax indicated a new order of needs to have shunt checked. The fax indicated a response to the order was the shunt was checked 2/22/18 and was working well. (The fax did not notify of the temperature.) *3/7/18 9:00 a.m. completed by LVN K Temperature 100.7 degrees. A laboratory report dated 3/7/18 indicated Resident #1 had slightly elevated white blood cells and no urinary tract infection. *3/8/18 6:00 p.m. completed by LVN H Resident complained of a headache, had a temperature of 100.4 degrees and received Tylenol 500 mg. Physician notified by phone, message left and fax sent. *3/8/18 fax 6:00 p.m. completed by LVN H temperature of 100.4 received Tylenol. (The fax did not note the resident complained of a headache). A hand written note on the fax dated 3/8/18 indicated the physician could not fax a response to the facility. A hand written new order was noted for 3/9/18 for Keflex (antibiotic) *3/8/18 9:00 p.m. temperature 99.8 *3/9/18 (2430 sic12:30 a.m.) completed by LVN L temperature 100.1 *3/9/18 8:30 a.m. completed by LVN M Temperature 101.6 degrees, administered Tylenol 500 mg, two tablets. *3/9/18 9:40 a.m. completed by LVN M complained of severe abdominal pain to right lower quadrant, vomited large amount of liquid emesis, physician assessed resident, noted to have rebound pain. New orders to send to the emergency room by ambulance. The emergency room physician documentation dated 3/9/18 indicated Resident #1 arrived at the emergency room at 10:40 a.m. with complaints of abdominal pain, and nausea/vomiting. The note indicated the pain started 3 days ago. The resident was noted to have moderate abdominal tenderness in the right lower quadrant and a temperature of 101.4. The Discharge Summary Notes from a hospital indicated Resident #1 admitted to the hospital on [DATE] and discharged [DATE]. The brief hospital course indicated the resident presented with a headache, fever and drainage from an incision site. The resident was positive [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus) and required surgical removal of the VP shunt and [MEDICATION NAME] pump. During an interview on 3/14/18 at 8:45 a.m., CNA A said on 3/6/18 Resident #1 complained of a headache. She said she notified LVN K he had a headache. CNA A said she cared for Resident #1 on 3/9/18 and he was in pain and nauseated. During an interview on 3/14/17 at 9:42 a.m., the ADON said on 3/8/18 the physician was faxed about Resident #1 having a temperature of 100.4. She said on 3/8/18 the physician was unable to response back to a fax because the fax was not working. She said the physician saw the resident on 3/9/18. The ADON said she would have sent him out on 3/6/18 when Resident #1 did not receive relief from the Tylenol for the headache at 10:30 a.m. During an interview on 3/14/18 at 10:28 a.m., the DON said RN G talked to her about Resident #1's fever and the body aches on 3/7/18, the physician was notified, and laboratory services were completed. The DON said the headache was a concern because of the shunt. During an interview on 3/14/18 at 1:47 p.m., the DON said no one told her Resident #1 wanted to go to the hospital on [DATE]. She said she knew he had body aches and a headache. During an interview on 3/14/18 at 2:21 p.m., RN G said on 3/6/18 Resident #1 had aches and pains and she faxed an SBAR to the physician. She said he had a temperature of 101 degrees, but she did not think of an infection. She said she gave him Tylenol for the temperature, not a headache. She said he did not complain of a headache to her. She said looking back she should have considered calling the physician on 3/6/18 since the physician had not responded to the fax (SBAR sent 3/6/18). During an interview on 3/14/18 at 2:40 p.m., LVN H said on 3/8/18 she left a message at 6:00 p.m. for the physician to call her regarding Resident #1 having a temperature. She said she worked the 2:00 p.m. to 10:00 p.m. shift that day. She said she passed onto the oncoming nurse he had a fever and she had given Tylenol. She said she did not call the physician back when she did not hear from him because his temperature had gone down some. She said about 5-5:30 pm she gave Resident #1 Tylenol for a headache and about 8:30 p.m. he said his headache was gone. During an interview on 3/14/18 at 3:39 p.m., LVN K said Resident #1 complained of a headache with no relief on 3/6/18. She said she faxed the physician on 3/6/18 and did not get a response from the physician on 3/6/18 regarding her fax. She said on 3/7/18 she received orders from the physician documented on the SBAR for a urinalysis, CBC, and flu test. She said on 3/7/18 the resident had a temperature of 100.7 degrees. She said she gave him Tylenol for a headache. During an interview on 3/15/18 at 1:29 p.m., RN G said she was not sure what the signs and symptoms were for a malfunctioning shunt. She said I have never dealt with a shunt before. She said on 2/28/18 when Resident #1complained of a headache and she gave him Tylenol. During an interview on 3/15/18 at 1:34 p.m., the DON said to check a resident for problems with a shunt she would check for any overall changes with the resident and begin investigating from there. During an interview on 3/14/18 at 4:15 p.m., the administrator said everyone knew Resident #1 had a shunt, but it was not care planned. The website https://medlineplus.gov/ency/patientinstructions/ 9.htm accessed 3/21/18 indicated major signs of an infected or blocked shunt consisted of fever of 101°F or higher, pain in the belly that does not go away, headache, veins on the head or scalp that look larger than they used to, and bulging or tenderness in the soft spot at the top of the head. The CMS-672 dated 3/15/18 indicated the census was 48.

Based on observation, interview, and record review, the facility failed to assess, evaluate, and revise pain relief interventions to ensure adequate pain relief for 1 of 8 residents reviewed for pain. (Resident #1) Resident #1 exhibited pain symptoms while receiving treatment to his left great toe and abdomen. LVN E did not complete a pain assessment or provide pain medications prior to the treatment. The facility did not evaluate and assess their interventions to ensure pain control. This failure could place 28 residents receiving pain management at risk for unrelieved pain. Findings included: Physician orders [REDACTED]. Resident #1 was to receive [MEDICATION NAME]-[MEDICATION NAME] solution 7.5-500 mg/15 ml (narcotic pain medication) via [MEDICAL CONDITION] tube every 4 hours as needed for pain. Resident #1 did not have an order for [REDACTED]. MDS dated [DATE] indicated Resident #1 required the assistance of two persons for bed mobility and transfers. Resident #1 had no pain, and was unable to understand others or make himself understood. A nursing care plan dated 06/26/13 indicated Resident #1 had the potential to experience pain due to multiple contractures, wounds, and decreased mobility. A goal was to decrease potential to experience pain. Interventions included the following: address complaints of pain promptly with medication as ordered by physician; assess pain intensity prior and after providing interventions; assess effectiveness of pain medication regime; assess location, frequency, duration and intensity of pain; document assessment and report any increased or uncontrolled pain to the physician and staff should use the PAINAD scale (a behavior-observation tool developed for use in patients whose dementia is so advanced that they can not verbally communicate pain) to measure level of pain. A physician telephone order dated 07/21/13 timed 6:00 a.m., indicated Resident #1's left great toe was to be cleaned, hydrogel (moisture-based gel to aid with wound healing) applied, covered with gauze, and secured with [MEDICATION NAME] tape daily until healed. The clinical record for Resident #1 had no documented PAINAD assessment. Nursing notes dated 08/12/13 timed 5:30 p.m. indicated Resident #1 had a stage II pressure ulcer on his abdomen with drainage and odor. Nursing notes dated 08/13/13 timed 10:30 p.m., indicated Resident #1 moaned when the nurse touched his feeding tube. At 11:20 p.m. Resident #1 was given [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]) [MEDICATION NAME] 7.5/500/15 ml for pain. During an observation and interview on 08/14/13 at 9:40 a.m., Resident #1 was in bed on his back. LVN E provided treatment to the pressure sore on Resident #1's left great toe and abdomen. Resident #1, tensed up, grimaced, flinched, and moaned in pain throughout the treatments. LVN E continued to clean the wounds without assessing Resident #1's level of pain. She told him several times, "It will be ok " , while she patted his leg. LVN E said Resident #1 moaned if he experienced pain. LVN E said Resident #1 was given pain medication earlier that morning by the previous shift. She said she did not check to see what time the pain medication was administered. Nursing notes dated 08/14/13 timed 10:00 a.m. indicated Resident #1 had a physician order [REDACTED]. Medication treatment records dated August 2013 indicated Resident #1 was administered [MEDICATION NAME]-[MEDICATION NAME] schedule III solution 7.5-500 mg/15 ml via [MEDICAL CONDITION] tube for pain on 08/13/13 at 11:20 p.m. There was no other documentation of pain medication being administered for August 2013. During an interview on 08/14/13 at 2:10 p.m., the DON said Resident #1 did not have quarterly assessments for pain. The pain policy dated 04/2012 indicated: " ...pain will be assessed on admission, re-admission, the onset or an increase in pain, quarterly, and whenever there is a significant change in condition that may cause an increase in pain". Nursing staff will identify situations or interventions where an increase in the resident's pain may be anticipated (i.e. wound care). Pain medication will be offered appropriately preceding these identified activities. Residents will be assessed 30-60 minutes after pain management interventions to determine the effectiveness of the intervention. " A CMS 672 dated 08/16/13 indicated 28 residents received pain management.

Based on interview and record review the facility failed to ensure a license to operate a [MEDICAL TREATMENT] program was obtained in compliance with Federal and State laws and regulations to provide care and services for 9 of 9 residents reviewed for [MEDICAL TREATMENT] treatment. (Resident #s 10, 15, 16, 17, 18, 19, 20, 21 and 22) The facility allowed a RN to perform [MEDICAL TREATMENT] for Resident #s 10, 15, 16, 17, 18, 19, 20, 21, and 22 at the facility from [DATE] until [DATE]. The RN did not have an [MEDICAL CONDITION] or HCSSA [MEDICAL TREATMENT] license. Resident #s 15, 16, and 17 died shortly after receiving [MEDICAL TREATMENT]. Resident #s 18, 19, 20, 21, and 22 were hospitalized shortly after receiving [MEDICAL TREATMENT]. An Immediate Jeopardy was identified that existed from [DATE] through [DATE]. The facility identified a failure in care and services related to providing [MEDICAL TREATMENT] treatment to residents at the facility and discharged the final 3 residents to the hospital which resulted in the removal of the immediacy prior to the survey on [DATE]. The facility remained out of compliance at a pattern of actual harm due to the need to institute corrective measures for the failures that caused the Immediate Jeopardy. This failure could place 9 residents who received [MEDICAL TREATMENT] at the facility at risk for a lack of medical intervention and death. Findings included: According to the Texas Health and Safety Code, Chapter 251, End Stage [MEDICAL CONDITION] Facilities, Subchapter B, Section 251.011 and Section 251.012, effective [DATE], "...a person may not operate and end stage [MEDICAL CONDITION] facility without a license issued under this chapter..." with the following exceptions: *a HCSSA licensed under Chapter 142 with a home [MEDICAL TREATMENT] designation; *a hospital providing inpatient [MEDICAL TREATMENT] or during a disaster or for the department of Criminal Justice; *an end stage [MEDICAL CONDITION] facility operated as part of a managed care provider; or *in a physician office. During an interview on [DATE] at 9:25 a.m., the administrator said she started [DATE] and the program for providing [MEDICAL TREATMENT] in the facility was already in place. The administrator said the medical director provided general care for all of the residents that received [MEDICAL TREATMENT] but the nephrologist that was hired by the [MEDICAL TREATMENT] RN was responsible for providing orders for [MEDICAL TREATMENT] treatment. The administrator said she was told by the [MEDICAL TREATMENT] RN that he did not need a license to perform [MEDICAL TREATMENT] in the nursing facility because he worked under the facility's license. The administrator said on [DATE] the previous DON held a meeting about [MEDICAL TREATMENT] protocols and she assumed they received physician orders. She said protocols were put in place for the residents that received [MEDICAL TREATMENT] after the meeting was held. The administrator said she was not aware the residents who received [MEDICAL TREATMENT] did not have physician orders, or orders for laboratory services. The administrator said she never met or saw the nephrologist. She said they did not have a signed contract with him because he was hired by the [MEDICAL TREATMENT] RN. An Agreement for Renal Replacement Services ([MEDICAL TREATMENT]) signed [DATE] by the owner and the [MEDICAL TREATMENT] RN indicated the facility would provide acute [MEDICAL TREATMENT] treatments for those patients (residents) of the facility as requested by a physician in good standing on the facility's medical staff and duly credentialed by facility. (4. A) Normal operating hours for the services are 8 a.m. to 5 p.m., Monday through Saturday. During an interview on [DATE] at 11:42 a.m. the medical director said he was not notified when new residents that received [MEDICAL TREATMENT] were admitted . He said he discovered new residents that received [MEDICAL TREATMENT] when he or the NP visited the facility or received a call about a problem. He said he attended a meeting in [DATE] to correct this problem. He said at the meeting he told staff that all residents that received [MEDICAL TREATMENT] were to be admitted by the nephrologist who would provide physician orders for the residents ' [MEDICAL TREATMENT] care. The medical director said the nephrologist was responsible for physician visits for residents receiving [MEDICAL TREATMENT]. He said he was not aware of a [MEDICAL TREATMENT] policy and procedure. During an interview on [DATE] at 1:15 p.m., the former interim DON, RN P, said staff had not been in-serviced on protocols or received any training regarding residents that received [MEDICAL TREATMENT]. She said in October or [DATE] a QA meeting about residents that received [MEDICAL TREATMENT] was held with the medical director, all administrative staff, and the [MEDICAL TREATMENT] RN. RN P said they discussed the problem of no protocols for resident receiving [MEDICAL TREATMENT], not having physician orders for [MEDICAL TREATMENT] or a signed consent for receiving [MEDICAL TREATMENT] at the facility. RN P said at the meeting the medical director said [MEDICAL TREATMENT] residents were being admitted without his knowledge and any future [MEDICAL TREATMENT] residents needed to be admitted by the nephrologist. RN P said after the meeting they received the nephrologist ' s contact number, the [MEDICAL TREATMENT] RN ' s phone and a few protocols. RN P said there was nothing in place to ensure the identified problems were addressed. During an interview on [DATE] at 5:00 p.m., the nephrologist said he had not made rounds on any of the residents that received [MEDICAL TREATMENT], and he had not documented any progress notes. He said [MEDICAL TREATMENT] residents were admitted without his knowledge and the [MEDICAL TREATMENT] RN did not always communicate with him. The nephrologist said when the facility started providing [MEDICAL TREATMENT] for residents he was told by the [MEDICAL TREATMENT] RN that another nephrologist was giving orders for the residents' [MEDICAL TREATMENT] care. The nephrologist said he signed physician standing orders provided to him by the [MEDICAL TREATMENT] RN on [DATE] but there was a period of time (5 months) that there were no standing orders for [MEDICAL TREATMENT] residents. He said he did not like the original standing orders and made some changes to them. The nephrologist said the [MEDICAL TREATMENT] RN and the facility owner brought a stack of standing orders to his home that were dated September, October, November, and [DATE] and he stamped them with his signature. During an interview on [DATE] at 7:45 a.m., the previous DON said she voiced her concerns regarding the [MEDICAL TREATMENT] residents several times to the administrator and the facility owner. The residents did not have orders for [MEDICAL TREATMENT] and the nephrologist never came as scheduled. She said the nephrologist would schedule a visit to come to the facility but never showed up. The previous DON said the owner and the administrator told her everything was " ok " and not to worry about the [MEDICAL TREATMENT] orders or physician visits. 1. Physician orders dated [DATE] indicated Resident #15 was [AGE] years old and admitted [DATE], with [DIAGNOSES REDACTED]. No [MEDICAL TREATMENT] orders were noted on the chart. During an interview on [DATE] at 10:00 a.m. the SW said Resident #15 did not have orders for [MEDICAL TREATMENT] treatment in the entire clinical record. The most recent MDS dated [DATE] indicated Resident #15 had clear comprehension, clear speech, and could make herself understood. Her BIMS score was "13" (score of ,[DATE] = cognitively intact.) She was totally dependent for all of her ADL care. The MDS indicated she received [MEDICAL TREATMENT], suctioning and [MEDICAL CONDITION] care. An undated care plan indicated Resident #15 received [MEDICAL TREATMENT] due to [MEDICAL CONDITION]. Interventions included: order labs per physician, monitor for altered level of consciousness, shortness of breath, increased weight/[MEDICAL CONDITION], low blood pressure, irregular heart rhythm, muscle cramps, nausea, vomiting, headache, confusion and monitor catheter site for infection and patency. The nursing progress notes included the following for Resident #15: *[DATE] at 10:51 a.m., on [MEDICAL TREATMENT] 3 times a week *[DATE] at 5:47 p.m., [MEDICAL TREATMENT] being done in facility on Tuesday, Thursday and Saturday. *[DATE] at 1:15 a.m., at the beginning of shift at 10:00 p.m., resident receiving [MEDICAL TREATMENT] at bedside with beside monitoring. *[DATE]-[DATE] receiving [MEDICAL TREATMENT] on Tuesday, Thursday and Saturday. * [DATE] at 3:17 a.m., received [MEDICAL TREATMENT] at the facility on Monday, Wednesday and Friday. * [DATE] at 9:59 a.m., [MEDICAL TREATMENT] Monday, Wednesday, and Friday, * [DATE] at 2:33 a.m., resident unresponsive, unable to palpate blood pressure, or auscultate apical heart rate, bilateral lower extremities starting to mottle (lack of blood perfusion), CPR started at 12:15 a.m., 911 called and resident left the facility at 12:25 a.m. per emergency medical services. Resident expired 2. Consolidated physician orders dated [DATE] indicated Resident #16 was [AGE] years old and admitted [DATE] with [DIAGNOSES REDACTED]. The orders indicated Resident #16 was to have a complete blood count, renal function panel, and [MEDICATION NAME] level on the days he received [MEDICAL TREATMENT]. The orders were signed by the NP. The MDS dated [DATE] indicated Resident #16 had [MEDICAL TREATMENT], could understand and could make herself understood, required assistance of 2 staff for all ADLS. A care plan dated [DATE] indicated Resident #16 would have [MEDICAL TREATMENT]. Interventions were to monitor fistula, graph, for signs/symptoms of redness, welling and report abnormalities to physician, coordinate with the [MEDICAL TREATMENT] staff to ensure effective interchange of information for my care and safety, laboratory services as ordered by the physician, monitor special dietary regimen, dietary restrictions, fluid restrictions, and weight as ordered by the physician. Nursing notes dated [DATE] at 11:40 p.m. indicated Resident #16 experienced [MEDICAL CONDITION] and CPR was initiated. Emergency medical services arrived at 11:50 p.m. and transported the resident to the hospital where he died . The [MEDICAL TREATMENT] flow sheets dated [DATE], [DATE], [DATE], and [DATE] indicated Resident #16 received [MEDICAL TREATMENT] by the [MEDICAL TREATMENT] RN. 3. [DATE] consolidated physician orders signed by the NP indicated Resident #17 was [AGE] years old and admitted [DATE] with [DIAGNOSES REDACTED]. These orders indicated Resident #13 was to receive [MEDICATION NAME] units/ml IV daily in the evenings. This treatment was to be administered along with [MEDICAL TREATMENT] s which was to be done on Monday, Wednesday, and Friday per the orders of the nephrologist. A respiratory note dated [DATE] at 5:30 p.m. indicated the respiratory therapist found Resident #17unresponsive in her room and her fingers were " slightly " purple. Resident #17 had a code of do not resuscitate. The note indicated the therapist from the previous shift reported Resident #17 had high pressure alarms all night but refused suctioning. The therapist recorded that Resident #17 "was anxious most of the night after completing [MEDICAL TREATMENT] that started at 10:11 p.m. and ended at 11:30 p.m." The MDS dated [DATE] and [DATE] indicated Resident #17 was dependent on 2 staff for all ADLs, was ventilator dependent, could understand others, could be understood and was on [MEDICAL TREATMENT]. An undated care plan indicated Resident #17 received [MEDICAL TREATMENT] and was at risk for complications. Interventions included, monitor fistula, graph, for signs/symptoms of redness, welling and report abnormalities to physician, coordinate with the [MEDICAL TREATMENT] staff to ensure effective interchange of information for care and safety, laboratory services as ordered by the physician, monitor special dietary regimen, dietary restrictions, fluid restrictions, and weight as ordered by the physician. The [MEDICAL TREATMENT] flow sheets dated [DATE], [DATE], and [DATE] indicated Resident #17 received [MEDICAL TREATMENT] by the [MEDICAL TREATMENT] RN. 4. Unsigned consolidated physician orders dated [DATE] indicated Resident #21 was [AGE] years old and admitted [DATE] with [DIAGNOSES REDACTED]. The resident was 49. There were no orders for [MEDICAL TREATMENT], or laboratory services. A hospital emergency room note dated [DATE] at 11:00 a.m. indicated Resident #21 was transferred to the hospital from the nursing home on [DATE] because she required [MEDICAL TREATMENT] and the machine at the nursing home was broken. This indicated the nursing home medical director was called on [DATE] at 12:55 p.m. and wanted Resident #21 admitted to the hospital to rule out bacteremia. The [MEDICAL TREATMENT] flow sheets dated [DATE] and [DATE] indicated Resident #21 received [MEDICAL TREATMENT] by the [MEDICAL TREATMENT] technician, not the [MEDICAL TREATMENT] RN. Nursing notes dated [DATE] at 3:26 p.m. indicated at 2:30 p.m. Resident # 21 received [MEDICAL TREATMENT]. Nursing notes dated [DATE] at 4:08 p.m. indicated at 2:00 p.m. Resident # 21 received [MEDICAL TREATMENT]. 5. Physician orders dated [DATE] indicated Resident #18 was [AGE] years old and admitted [DATE] with [DIAGNOSES REDACTED]. Resident #18's orders indicated she had a feeding tube, (tube for providing nutrition), [MEDICAL CONDITION]/ventilator dependence (required mechanical support for breathing). Her orders did not include orders for [MEDICAL TREATMENT] instructions. The most recent MDS for Resident #18 dated [DATE] indicated she was in a vegetative state, was totally dependent for all ADLs, incontinent of bowel and bladder, and received [MEDICAL TREATMENT] and ventilator support. The undated Care plan for Resident #18 indicated she was dependent on a ventilator for breathing and received [MEDICAL TREATMENT] for end stage [MEDICAL CONDITION]. The [MEDICAL TREATMENT] flow sheets indicated Resident #18 received [MEDICAL TREATMENT] in the facility on the following dates: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], 01/ ,[DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. 6. Unsigned consolidated physician orders dated [DATE] indicated Resident #10 was [AGE] years old and admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. There was no order for [MEDICAL TREATMENT], but included an order to "discontinue [MEDICAL TREATMENT] " per physician. The MDS dated [DATE] indicated Resident #10 was admitted on [DATE] and had the ability to express his ideas/wants and he understood verbal content. That MDS indicated Resident #10 received [MEDICAL TREATMENT]. The nursing notes dated [DATE] and [DATE]indicated Resident #10 received [MEDICAL TREATMENT] on these days. The care plan dated [DATE] indicated Resident #10 was no longer on [MEDICAL TREATMENT]. 7. Unsigned consolidated physician orders dated [DATE] indicated Resident #20 was [AGE] years old and admitted [DATE] with [DIAGNOSES REDACTED]. There was no order for [MEDICAL TREATMENT] or [MEDICAL TREATMENT] labs. An MDS dated [DATE] indicated Resident #20 was comatose (persistent vegetative state/no discernible consciousness), totally dependent on staff for ADLs, incontinent of bowel and bladder. The MDS indicated the resident received [MEDICAL TREATMENT]. A care plan dated [DATE] indicated Resident #20 received [MEDICAL TREATMENT] for [MEDICAL CONDITION], interventions included: coordinate with the [MEDICAL TREATMENT] staff to ensure effective interchange of information for my care and safety, have labs as ordered by physician and assess, document and report any abnormal findings to the physician. Resident #20's [MEDICAL TREATMENT] flow sheets indicated her [MEDICAL TREATMENT] s began [DATE] and [MEDICAL TREATMENT] was performed on the following days: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], & [DATE]. A nursing note dated [DATE] indicated Resident #20 was transferred to the hospital due to a change in condition. 8. Consolidated physician orders dated [DATE] signed by the nurse practitioner indicated Resident #19 was [AGE] years old and admitted [DATE] with [DIAGNOSES REDACTED]. There were no physician orders for [MEDICAL TREATMENT]. A History and Physical dated [DATE] indicated Resident #19 was seen by the physician [DATE]. An MDS dated [DATE] indicated Resident #19 had modified independence in his cognitive skills. He was totally dependent on staff for ADLs, incontinent of bowel and had an indwelling urinary catheter. The MDS indicated the resident received [MEDICAL TREATMENT]. A care plan dated [DATE] indicated Resident #19 received [MEDICAL TREATMENT] for [MEDICAL CONDITION], interventions include:-coordinate with the [MEDICAL TREATMENT] staff to ensure effective interchange of information for care and safety, have labs as ordered by physician, assess, document and report any abnormal findings to physician, and monitor my weight as ordered by physician. The [MEDICAL TREATMENT] flow sheets indicated Resident #19 started [MEDICAL TREATMENT] on [DATE]. The resident received [MEDICAL TREATMENT] on [DATE] and [DATE]. His [MEDICAL TREATMENT] on [DATE] could not be completed because " unable to get adequate blood flow from HD catheter " . A nursing note dated [DATE] indicated Resident #19 was transferred to the hospital due to a change in condition. 9. Consolidated physician orders dated [DATE] signed by the nurse practitioner indicated Resident #22 was [AGE] years old and admitted [DATE] with [DIAGNOSES REDACTED]. There was no order for [MEDICAL TREATMENT] other than what was sent from the discharging hospital. A MDS dated [DATE] indicated Resident #22 was totally dependent on staff for ADLs and was incontinent of bowel and bladder. The MDS indicated the resident received [MEDICAL TREATMENT]. An undated care plan indicated Resident #22 received [MEDICAL TREATMENT] for [MEDICAL CONDITION], interventions included: coordinate with the [MEDICAL TREATMENT] staff to ensure effective interchange of information for care and safety, have labs as ordered by physician, assess, document and report any abnormal findings to physician The [MEDICAL TREATMENT] flow sheets indicated Resident #22 began [MEDICAL TREATMENT] s [DATE]. The resident received s on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] A list provided by the DON dated [DATE] indicated 0 residents currently received [MEDICAL TREATMENT] and 9 previously received [MEDICAL TREATMENT].

Based on interview and record review the facility failed to ensure care and services for [MEDICAL TREATMENT] treatment was provided in accordance with the comprehensive assessments and plan of care for 9 of 9 residents reviewed for [MEDICAL TREATMENT]. (Resident #s 10, 15, 16, 17, 18, 19, 20, 21 and 22) The facility allowed a contract RN to provide [MEDICAL TREATMENT] in the facility for Resident #s 10, 15, 16, 17, 18, 19, 20, 21 and 22 using recalled [MEDICAL TREATMENT] products, without valid physician orders for the procedures, without required laboratory blood analysis, without a license to perform [MEDICAL TREATMENT], without the residents' consent, and/or without the residents being seen by a physician. Resident #s 15, 16, and 17 died shortly after receiving [MEDICAL TREATMENT]. Resident #s 18, 19, 20, 21, and 22 were hospitalized shortly after receiving [MEDICAL TREATMENT]. An Immediate Jeopardy was identified that existed from [DATE] through [DATE]. The facility identified a failure in care and services related to providing [MEDICAL TREATMENT] treatment to residents at the facility and discharged the final 3 residents to the hospital which resulted in the removal of the immediacy prior to the survey on [DATE]. The facility remained out of compliance at a pattern of actual harm due to the need to institute corrective measures for the failures that caused the Immediate Jeopardy. This failure could place 9 residents who received [MEDICAL TREATMENT] treatment at the facility at risk for a lack of medical intervention and death. Findings included: During an interview on [DATE] at 11:42 a.m. the medical director said he was not notified when new residents who received [MEDICAL TREATMENT] were admitted . He said he discovered new residents who received [MEDICAL TREATMENT] when he or the NP visited the facility or received a call about a problem. He said he attended a meeting in [DATE] to correct this problem. He said at the meeting he told staff that all residents that received [MEDICAL TREATMENT] were to be admitted by the nephrologist who would provide physician orders for the residents' [MEDICAL TREATMENT] care. The medical director said the nephrologist was responsible for physician visits for residents receiving [MEDICAL TREATMENT]. He said he was not aware of a [MEDICAL TREATMENT] policy and procedure. During an interview on [DATE] at 1:15 p.m., the former interim DON, RN P, said staff had not been in-serviced on protocols for [MEDICAL TREATMENT] or received any [MEDICAL TREATMENT] training prior to the admission of residents who received [MEDICAL TREATMENT]. She said in October/[DATE] a meeting was held with the medical director, all administrative staff, and the [MEDICAL TREATMENT] RN. RN P said the need for [MEDICAL TREATMENT] protocols were discussed, because there were no signed standing physician orders, no consent for [MEDICAL TREATMENT] treatment at the facility and no order for [MEDICAL TREATMENT] treatment. RN P said the medical director said [MEDICAL TREATMENT] residents were being admitted without his knowledge. RN P said a plan was developed that consisted of developing protocols for residents that received [MEDICAL TREATMENT] and any future [MEDICAL TREATMENT] residents needed to be admitted by the nephrologist. RN P said after the meeting they received the nephrologist contact number, the [MEDICAL TREATMENT] RN phone number and a "few protocols." During an interview on [DATE] at 2:50 p.m., the [MEDICAL TREATMENT] RN said he reviewed laboratory reports prior to [MEDICAL TREATMENT]; he said the nephrologist made rounds with him on the weekends, signed orders and wrote progress notes on the residents that received [MEDICAL TREATMENT]. During an interview on [DATE] at 5:00 p.m., the nephrologist said he did not make rounds on any of the [MEDICAL TREATMENT] residents, and there were no progress notes. He said [MEDICAL TREATMENT] residents were admitted without his knowledge and the [MEDICAL TREATMENT] RN did not always communicate with him. The nephrologist said when they first started [MEDICAL TREATMENT] at the facility; he was told by the [MEDICAL TREATMENT] RN that another nephrologist was giving orders for residents' [MEDICAL TREATMENT] care. The nephrologist said the [MEDICAL TREATMENT] RN did not always communicate important information to him. The nephrologist said he signed some standing orders on [DATE] but there was a period of time before the facility had any standing physician orders for [MEDICAL TREATMENT] residents. He said he did not like the original standing orders and had recently made some changes to them. . During an interview on [DATE] at 7:45 a.m., the previous DON said she voiced her concerns regarding the [MEDICAL TREATMENT] residents several times to the administrator and the facility owner. The residents did not have orders for [MEDICAL TREATMENT] and the nephrologist never came as scheduled. She said the nephrologist would schedule a visit to come to the facility but never showed up. The previous DON said the owner and the administrator told her everything was " ok " and not to worry about the [MEDICAL TREATMENT] orders or physician visits. During an interview on [DATE] at 11:00 a.m., the administrator said the day ([DATE]) she started at the facility a QA meeting was held regarding [MEDICAL TREATMENT] care. She said she thought everything had been corrected and was not aware there continued to be issues. The administrator said she had not followed up on [MEDICAL TREATMENT] care to ensure concerns had been resolved. During an interview on [DATE] at 10:30 a.m., the staffing nurse said she had never seen the nephrologist in the facility to see the residents that received [MEDICAL TREATMENT]. She said the nurses were voicing concerns regarding no orders for the [MEDICAL TREATMENT] residents and no physician visits to for the residents. She said staff had complained to the administrator and the DON on several occasions. During an interview on [DATE] at 3:30 p.m., LVN W said she never saw the nephrologist make a visit to see the [MEDICAL TREATMENT] residents. LVN W said residents received [MEDICAL TREATMENT] late in the evening hours by one RN, and she was told to notify him of any problems with the residents. She said she voiced her concerns to the administrator that there were no orders for [MEDICAL TREATMENT] for the residents that received [MEDICAL TREATMENT], but she was told everything was " ok " . During an interview on [DATE] at 10:15 a.m., LVN Q said the nurses were concerned about [MEDICAL TREATMENT] assessments (pre and post) because they had no physician orders and no nephrologist progress notes. LVN Q said they also had concerns with clogged catheters. She said the [MEDICAL TREATMENT] RN provided [MEDICAL TREATMENT] for a resident (not known which one) for only 30 minutes on Monday, the catheter would become clogged and the [MEDICAL TREATMENT] RN did not complete the procedure. During an interview on [DATE] at 4:10 p.m., LVN 0 said she had never seen signed physician orders, laboratory services, or physician progress notes [REDACTED]. During an interview on [DATE] at 4:40 p.m., LVN T said when the facility began admitting [MEDICAL TREATMENT] residents, many of the nurses did not feel comfortable caring for them. LVN T said she had not received any training or in-services at the facility for caring for [MEDICAL TREATMENT] patients. She said the residents receiving [MEDICAL TREATMENT] did not have physician orders for [MEDICAL TREATMENT] treatment, consents for [MEDICAL TREATMENT] treatment or laboratory services ordered by the nephrologist. LVN T said the [MEDICAL TREATMENT] RN never consulted with the nephrologist when the [MEDICAL TREATMENT] RN was in the facility. LVN T said Resident #15 was alert and oriented, and wanted to get strong enough to "get up and go home". During an interview on [DATE] at 1:30 p.m., the DON said she started at the facility in [DATE] and in-serviced staff in [DATE] about pre and post [MEDICAL TREATMENT] assessment. The DON said the failures with the residents who received [MEDICAL TREATMENT] were a result of the lack of communication with the [MEDICAL TREATMENT] RN. The DON said the residents that received [MEDICAL TREATMENT] did not have signed physician orders for [MEDICAL TREATMENT] and the nephrologist did not assess the residents. The DON said she followed up on orders for one [MEDICAL TREATMENT] resident but did not check all of the residents ' records for physician orders for [MEDICAL TREATMENT]. The inservice records for [DATE] through [DATE] indicated: *[DATE] [MEDICAL TREATMENT] - attendees included administrative staff, the medical director, the RN that provided [MEDICAL TREATMENT] and facility owner. The focus was on quality and continuity of care for [MEDICAL TREATMENT] residents. *[DATE] indicated pre and post flow sheet. Nurses caring for [MEDICAL TREATMENT] residents attended this meeting. *[DATE] critical care vent and [MEDICAL TREATMENT] patients. All staff attended this meeting (nurses and CNAs). The website <http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm 0.htm accessed [DATE]> indicated " (UPDATED [DATE]) FDA issued a Class I Recall notice for Fresenius Medical Care North America [MEDICATION NAME] Liquid Acid Concentrate and [MEDICATION NAME] GranuFlo (powder) Acid Concentrate. Inappropriate prescription of these products can lead to a high serum [MEDICATION NAME] level in patients undergoing [MEDICAL TREATMENT]. This may contribute to metabolic alkalosis, which is a significant risk factor associated with low blood pressure, hypokalemia, hypoxemia, hypercapnia and cardiac arrhythmia, which, if not appropriately treated, may culminate in cardiopulmonary arrest. This product may cause serious adverse health consequences, including death. " Delivery notices dated [DATE] and [DATE] indicated recalled [MEDICATION NAME] [DATE] and [DATE] were delivered to the facility. During an interview on [DATE] at 9:40 a.m. LVN R said she was not in-serviced or trained regarding [MEDICAL TREATMENT]. She said she did not receive instructions from the [MEDICAL TREATMENT] RN. LVN R said there were news reports regarding recalled [MEDICAL TREATMENT] products that were causing deaths in residents. She said she obtained a copy of the name of the recalled products and witnessed these products being used in for [MEDICAL TREATMENT] treatments for Resident #s 15, 16, and 17. LVN R said all three of these residents experienced [MEDICAL CONDITION] in the facility. LVN R said she discussed this with the administrator and the DON and provided written information on the recalled [MEDICAL TREATMENT] products after the death of Resident #15. She said after notifying the administration the products continued to be used. During an interview on [DATE] at 1:15 p.m., the former interim DON, RN P, said she, LVN CC, LVN Q, the DON and the administrator observed recalled [MEDICAL TREATMENT] products in the storage room. RN P said the DON stated, "We'll have to get these out of here." During an interview on [DATE] at 2:50 p.m., the [MEDICAL TREATMENT] RN said he had continued to use [MEDICATION NAME] ([DATE] and [DATE]) concentrate during [MEDICAL TREATMENT] for the residents despite his knowledge that the product had been recalled by the FDA. The [MEDICAL TREATMENT] RN said the recall was a lot of media hype. During an interview on [DATE] at 10:15 a.m., LVN Q said she was aware of the recalled [MEDICAL TREATMENT] products. LVN Q said she, the RN and the administrator looked at the [MEDICAL TREATMENT] products and the administrator said she would talk to the [MEDICAL TREATMENT] RN about the products. LVN Q said she emailed the [MEDICAL TREATMENT] RN about the recalled [MEDICAL TREATMENT] product and she never heard back from him. 1. Physician orders dated [DATE] indicated Resident #15 was [AGE] years old and admitted [DATE], with [DIAGNOSES REDACTED]. No [MEDICAL TREATMENT] orders were noted on the chart. During an interview on [DATE] at 10:00 a.m. the SW said Resident #15 did not have orders for [MEDICAL TREATMENT] treatment in the entire clinical record. A physician progress notes [REDACTED]. The note indicated the plan was for the resident to receive a C- diff culture and obtain laboratory services per [MEDICAL TREATMENT] physician. There were no other physician progress notes [REDACTED]. The most recent MDS dated [DATE] indicated Resident #15 had clear comprehension, clear speech, and could make herself understood. Her BIMS score was "13" (score of ,[DATE] = cognitively intact.) She was totally dependent for all of her ADL care. The MDS indicated she received [MEDICAL TREATMENT], suctioning and tracheotomy care. An undated care plan indicated Resident #15 received [MEDICAL TREATMENT] due to [MEDICAL CONDITION]. Interventions included: order labs per physician, monitor for altered level of consciousness, shortness of breath, increased weight/[MEDICAL CONDITION], low blood pressure, irregular heart rhythm, muscle cramps, nausea, vomiting, headache, confusion and monitor catheter site for infection and patency. The nursing progress notes included the following for Resident #15: *[DATE] at 6:23 p.m., arrived from hospital, Quinton catheter ([MEDICAL TREATMENT] catheter) left chest, had moderate swelling to arms, legs and feet. *[DATE] at 10:51 a.m., on [MEDICAL TREATMENT] 3 times a week *[DATE] at 2:49 p.m., called NP regarding labs. She ordered [MEDICAL CONDITION] labs and stated, "Let nephrologist (kidney physician) decide what labs...when [MEDICAL TREATMENT] administered." *[DATE] at 5:47 p.m., [MEDICAL TREATMENT] being done in facility on Tuesday, Thursday and Saturday. *[DATE] at 10:20 p.m., panic potassium level 1.9 (potassium, normal value- 3XXX,[DATE].0). Called nurse practitioner. NP said get [MEDICAL TREATMENT] physician, contact numbers for [MEDICAL TREATMENT] and company name, [MEDICAL TREATMENT] progress notes, weights should be on resident's chart from now on. She ordered 40 meq of potassium chloride give one time now, draw potassium level in a.m. *[DATE] at 1:15 a.m., at the beginning of shift at 10:00 p.m., resident receiving [MEDICAL TREATMENT] at bedside with beside monitoring. Resident had 2 + [MEDICAL CONDITION] to lower extremities. Weight before [MEDICAL TREATMENT] 148.5 lbs. and post [MEDICAL TREATMENT] 142.6 *[DATE]-[DATE] receiving [MEDICAL TREATMENT] on Tuesday, Thursday and Saturday. * [DATE] at 3:17 a.m., received [MEDICAL TREATMENT] at the facility on Monday, Wednesday and Friday. Resident's blood pressure continues to be low at ,[DATE], resident placed in trendelenberg position (flat on the back with the feet higher than the head), blood pressure at ,[DATE], when her head was elevated, would drop back down. There was no documentation the physician was notified of the change of condition. * [DATE] at 9:59 a.m., [MEDICAL TREATMENT] Monday, Wednesday, and Friday, Quinton catheter intact with redness. There was no documentation the physician was notified of the change of condition. * [DATE] at 3:42 a.m., [MEDICAL TREATMENT] completed at 12 midnight. At 2:45 a.m., resident found with dried blood from mouth, down her chin and neck. Had bitten her own lip. * [DATE] at 2:33 a.m., resident unresponsive, unable to palpate blood pressure, or auscultate apical heart rate, bilateral lower extremities starting to mottle (lack of blood perfusion), CPR started at 12:15 a.m., 911 called and resident left the facility at 12:25 a.m. per emergency medical services. Resident expired A [MEDICAL TREATMENT] communication form dated [DATE] had blank spaces for the heart rate, breathing rate, or temperature for Resident #15. A pre-[MEDICAL TREATMENT] weight of 143.2 pounds and blood pressure of ,[DATE] was documented. The post [MEDICAL TREATMENT] weight was 142.5 pounds and the blood pressure was BP ,[DATE]. During an interview on [DATE] at 1:35 p.m., LVN N said the nurses documented pre and post [MEDICAL TREATMENT] vital signs (heart rate, breathing rate, temperature, and blood pressure) and weight on the [MEDICAL TREATMENT] communication sheet. She said, until recently all of the residents received [MEDICAL TREATMENT] on the night shift (10 p.m. - 6 a.m.). LVN N said she called the primary, the nephrologist and RN that provided the [MEDICAL TREATMENT] if she had concerns for [MEDICAL TREATMENT] residents. She said several residents that received [MEDICAL TREATMENT] had expired. She said Resident #15 "crashed" at the facility on the 10 p.m. to 6 a.m. shift. She said there were times she could not contact either the primary physician or the nephrologist when [MEDICAL TREATMENT] residents were not doing well. LVN N said if she did not reach a physician; she would send the resident to the hospital if their family wanted them sent. She said the residents receiving [MEDICAL TREATMENT] did not have consents, laboratory reports and signed physician standing orders. She said she requested consents, orders for laboratory services and signed physician standing orders to care for the residents receiving [MEDICAL TREATMENT] but these were not provided. During an interview on [DATE] at 9:40 a.m. LVN R said Resident #15 was the first [MEDICAL TREATMENT] resident at the facility. LVN R said she obtained a copy of the name of the recalled products and witnessed these products being used in for [MEDICAL TREATMENT] treatments for Resident #s 15, 16, and 17. LVN R said she discussed this with the administrator and the DON and provided written information on the recalled [MEDICAL TREATMENT] products after the death of Resident #15. LVN R said when Resident #15's, potassium was low the nurse practitioner was called because they could not contact the nephrologist. LVN R said the former interim DON implemented a new protocol to call the nephrologist, the [MEDICAL TREATMENT] RN and then the NP. 2. [DATE] consolidated physician orders signed by the NP indicated Resident #17 was [AGE] years old and admitted [DATE] with [DIAGNOSES REDACTED]. These orders indicated Resident #13 was to receive [MEDICATION NAME] units/ml IV daily in the evenings. This treatment was to be administered along with [MEDICAL TREATMENT] treatments which were to be done on Monday, Wednesday, and Friday per the orders of the nephrologist. A [MEDICAL TREATMENT] communication form dated [DATE], time not recorded, signed by the [MEDICAL TREATMENT] RN, indicated Resident #17 received [MEDICAL TREATMENT], but no laboratory services were drawn. No fluid removal amount was indicated on this report. The pre-[MEDICAL TREATMENT] weight was recorded as 301.6 pounds and her post-[MEDICAL TREATMENT] weight was 297 pounds, a difference of 4.6 pounds. The MDS dated [DATE] and [DATE] indicated Resident #17 was dependent on 2 staff for all ADLs, was ventilator dependent, could understand others, could be understood and was on [MEDICAL TREATMENT]. An undated care plan indicated Resident #17 received [MEDICAL TREATMENT] and was at risk for complications. Interventions included, monitor fistula, graph for signs/symptoms of redness, swelling and report abnormalities to physician, coordinate with the [MEDICAL TREATMENT] staff to ensure effective interchange of information for care and safety, laboratory services as ordered by the physician, monitor special dietary regimen, dietary restrictions, fluid restrictions, and weight as ordered by the physician. [MEDICAL TREATMENT] communication forms dated [DATE], [DATE], and [DATE] indicated Resident #17 had no labs done on those dates when [MEDICAL TREATMENT] was performed. The [MEDICAL TREATMENT] flow sheets dated [DATE], [DATE], and [DATE] indicated Resident #17 received [MEDICAL TREATMENT] from the [MEDICAL TREATMENT] RN. A respiratory note dated [DATE] at 5:30 p.m. indicated the respiratory therapist found Resident #17 unresponsive in her room and her fingers were "slightly " purple. Resident #17 had a code of do not resuscitate. The note indicated the therapist from the previous shift reported Resident #17 had high pressure alarms (indication of a mucus clog) all night but refused suctioning. The therapist recorded that Resident #17 "was anxious most of the night after completing [MEDICAL TREATMENT] that started at 10:11 p.m. and ended at 11:30 p.m." A nursing note dated [DATE] indicated Resident # 17 was pronounced dead at 6:06 p.m. The clinical record for Resident #17 did not have documentation of the following: - complete blood count, renal function panel, or [MEDICATION NAME] labs on the days she received [MEDICAL TREATMENT], -progress notes that indicated the [MEDICAL TREATMENT] physician saw her, -[MEDICAL TREATMENT] orders signed by the [MEDICAL TREATMENT] physician. 3. Unsigned consolidated physician orders dated [DATE] indicated Resident #21 was [AGE] years old and admitted [DATE] with [DIAGNOSES REDACTED]. The resident was 49. There were no orders for [MEDICAL TREATMENT] treatment, or laboratory services. A hospital emergency room note dated [DATE] at 11:00 a.m. indicated Resident #21 was transferred to the hospital from the nursing home on [DATE] to rule out bacteremia (bacteria in the blood). An admission nursing note dated [DATE] at 3:40 p.m. indicated Resident #21 was alert and oriented to person, place and time. She was nauseated and vomited a small amount. Speaking took great effort. Resident #21 was placed on ventilator support via her tracheotomy. She was incontinent of bowel and had a Foley catheter. A respiratory note dated [DATE] at 3:40 p.m. indicated Resident #21 arrived at the facility via ambulance and appeared tired and in mild respiratory distress. Her respirations were 26 oxygen saturations were ,[DATE]%. She was placed on ventilator support and her respiratory distress decreased. A [MEDICAL TREATMENT] communication form dated [DATE] and [DATE] indicated Resident #21 did not receive laboratory services on these dates when [MEDICAL TREATMENT] was performed. The [MEDICAL TREATMENT] flow sheets dated [DATE] and [DATE] indicated Resident #21 received [MEDICAL TREATMENT] by the [MEDICAL TREATMENT] technician, not the [MEDICAL TREATMENT] RN. Nursing notes dated [DATE] at 3:26 p.m. indicated at 2:30 p.m. Resident # 21 received [MEDICAL TREATMENT]. Nursing notes dated [DATE] at 4:08 p.m. indicated at 2:00 p.m. Resident # 21 received [MEDICAL TREATMENT]. The clinical record for Resident #21 did not have documentation of a consent for [MEDICAL TREATMENT] treatment, signed orders for [MEDICAL TREATMENT], orders for [MEDICAL TREATMENT] laboratory services (complete blood count, renal function panel, or [MEDICATION NAME] labs on the days she received [MEDICAL TREATMENT]), and physician progress notes [REDACTED]. 4. Consolidated physician orders dated [DATE] indicated Resident #16 was [AGE] years old and admitted [DATE] with [DIAGNOSES REDACTED]. The orders indicated Resident #16 was to have a complete blood count, renal function panel, and [MEDICATION NAME] level on the days he received [MEDICAL TREATMENT]. The orders were signed by the NP. There were no orders for [MEDICAL TREATMENT] treatment The MDS dated [DATE] indicated Resident #16 had [MEDICAL TREATMENT], could understand and could make herself understood, required assistance of 2 staff for all ADLS. A care plan dated [DATE] indicated Resident #16 would have [MEDICAL TREATMENT]. Interventions were to monitor fistula, graph for signs/symptoms of redness, swelling and report abnormalities to physician, coordinate with the [MEDICAL TREATMENT] staff to ensure effective interchange of information for my care and safety, laboratory services as ordered by the physician, monitor special dietary regimen, dietary restrictions, fluid restrictions, and weight as ordered by the physician. A nursing note dated [DATE] at 1:30 p.m. indicated Resident #16 experienced [MEDICAL CONDITION], CPR was initiated, and the resident was transported via emergency medical services to the hospital and returned to the facility on [DATE] at 8:15 p.m. A nursing note dated [DATE] indicated at 11:09 p.m. Resident #16's [MEDICAL TREATMENT] was completed with post weight the same as the pre weight. The [MEDICAL TREATMENT] RN said he "took off a little fluid but the resident's blood pressure dropped so he administered fluid." There was no indication in the clinical record the nephrologist or medical director was notified. A nursing note dated [DATE] at 5:01 a.m. indicated Resident #16 had no noted complications from [MEDICAL TREATMENT] on the previous shift. A nursing note dated [DATE] at 4:30 p.m. indicated Resident #16 was receiving [MEDICAL TREATMENT]. Nursing notes dated [DATE] at 11:40 p.m. indicated Resident #16 experienced [MEDICAL CONDITION] and CPR was initiated. Emergency medical services arrived at 11:50 p.m. and transported the resident to the hospital where he died . The [MEDICAL TREATMENT] flow sheets dated [DATE], [DATE], [DATE], and [DATE] indicated Resident #16 received [MEDICAL TREATMENT] by the [MEDICAL TREATMENT] RN. A [MEDICAL TREATMENT] communication form dated [DATE] indicated [MEDICAL TREATMENT] was initiated at 6:18 p.m. and completed 10:18 p.m. with no labs drawn for Resident #16. A [MEDICAL TREATMENT] communication form dated [DATE] indicated [MEDICAL TREATMENT] was initiated at 7:09 p.m. and completed at 11:09 p.m. for Resident #16. The pre weight and post weight were the same. This form indicated labs were drawn at the end of [MEDICAL TREATMENT] at 11:09 p.m. The clinical record did not have documentation of laboratory services. A [MEDICAL TREATMENT] communication form dated [DATE] indicated [MEDICAL TREATMENT] was initiated at 6:04 p.m. and completed 10:19 p.m. with no pre weight or post weight done for Resident #16. This form indicated admission labs were drawn. A [MEDICAL TREATMENT] communication form dated [DATE] indicated [MEDICAL TREATMENT] was initiated at 5:14 p.m. and completed at 7:29 p.m. for Resident #16 with no pre weight or post weight obtained and no labs were drawn. The clinical record for Resident #16 did not have documentation of consent for [MEDICAL TREATMENT] treatment, signed orders for [MEDICAL TREATMENT],and physician progress notes [REDACTED]. During an interview on [DATE] at 11:45 a.m., the medical director said he never visited any of the residents that received [MEDICAL TREATMENT] but his NP might have. The medical director said he was not informed when they admitted a resident that received [MEDICAL TREATMENT] until they were already admitted . 5. Unsigned consolidated physician orders dated [DATE] indicated Resident #20 was [AGE] years old and admitted [DATE] with [DIAGNOSES REDACTED]. There was no order for [MEDICAL TREATMENT] or [MEDICAL TREATMENT] laboratory services. An MDS dated [DATE] indicated Resident #20 was comatose (persistent vegetative state/no discernible consciousness), totally dependent on staff for ADLs, incontinent of bowel and bladder. The MDS indicated the resident received [MEDICAL TREATMENT]. A care plan dated [DATE] indicated Resident #20 received [MEDICAL TREATMENT] for [MEDICAL CONDITION], interventions included: coordinate with the [MEDICAL TREATMENT] staff to ensure effective interchange of information for my care and safety, have labs as ordered by physician and assess, document and report any abnormal findings to the physician. Resident #20's [MEDICAL TREATMENT] flow sheets indicated her [MEDICAL TREATMENT] treatments began [DATE] and [MEDICAL TREATMENT] treatments were performed on the following days: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], & [DATE]. The clinical record indicated Resident #20 had one laboratory report dated [DATE] although the [MEDICAL TREATMENT] communication forms indicated laboratory services were done by the [MEDICAL TREATMENT] RN on [DATE], [DATE], and [DATE]. The [MEDICAL TREATMENT] flow sheets indicated Resident #20 did not receive laboratory services on the following days: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], & [DATE]. Resident #20's [MEDICAL TREATMENT] flow sheets indicated no pre or post weights were done on the following days: -[DATE], -[DATE], -[DATE], -[DATE], -[DATE], -[DATE], and -[DATE]. A Progress note dated [DATE] indicated Resident #20 was transferred to the hospital due to a change in condition. No documentation was found in the clinical record that Resident #20 was seen a physician or that informed written consent for [MEDICAL TREATMENT] was given. 6. Consolidated physician orders dated [DATE] signed by the nurse practitioner indicated Resident #19 was [AGE] years old and admitted [DATE] with [DIAGNOSES REDACTED]. There were no physician orders for [MEDICAL TREATMENT] treatment. An MDS dated [DATE] indicated Resident #19 had modified independence in his cognitive skills. He was totally dependent on staff for ADLs, incontinent of bowel and had an indwelling urinary catheter. The MDS indicated the resident received [MEDICAL TREATMENT]. A care plan dated [DATE] indicated Resident #19 received [MEDICAL TREATMENT] for [MEDICAL CONDITION], interventions include:-coordinate with the [MEDICAL TREATMENT] staff to ensure effective interchange of information for care and safety, have labs as ordered by physician, assess, document and report any abnormal findings to physician, and monitor weight as ordered by physician. [MEDICAL TREATMENT] communication forms dated [DATE] and [DATE] indicated the [MEDICAL TREATMENT] RN drew pre and post [MEDICAL TREATMENT] laboratory services and admission laboratory services on each day. There were no signed physician orders for these laboratory services. The [MEDICAL TREATMENT] flow sheets indicated Resident #19 started [MEDICAL TREATMENT] treatment on [DATE]. The resident received treatment on [DATE] and [DATE]. His treatment on [DATE] could not be completed because " unable to get adequate blood flow from HD catheter " . A Progress note dated [DATE] indicated Resident #19 was transferred to the hospital due to a change in condition. A signed informed consent to receive [MEDICAL TREATMENT] treatment was not in the clinical record for Resident #19. 7. Consolidated physician orders dated [DATE] signed by the nurse practitioner indicated Resident #22 was [AGE] years old and admitted [DATE] with [DIAGNOSES REDACTED]. There was no order for [MEDICAL TREATMENT] other than what was sent from the discharging hospital. A MDS dated [DATE] indicated Resident #22 was totally dependent on staff for ADLs and was incontinent of bowel and bladder. The MDS indicated the resident received [MEDICAL TREATMENT]. An undated care plan indicated Resident #22 received [MEDICAL TREATMENT] for [MEDICAL CONDITION], interventions included: coordinate with the [MEDICAL TREATMENT] staff to ensure effective interchange of information for care and safety, have labs as ordered by physician, assess, document and report any abnormal findings to physician The [MEDICAL TREATMENT] flow sheets indicated Resident #22 began [MEDICAL TREATMENT] treatments [DATE]. The resident received treatments on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] The [MEDICAL TREATMENT] communication records indicated laboratory services were collected on [DATE] for Resident #22. There was no signed physician order for [REDACTED]. A Progress note dated [DATE] indicated Resident #22 was transferred to the hospital due to a change in condition. No documentation was found in the clinical record that Resident #22 was seen a physician or that informed written consent for [MEDICAL TREATMENT] was given. 8. Physician orders dated [DATE] indicated Resident #18 was [AGE] years old and admitted [DATE] with [DIAGNOSES REDACTED]. Resident #18's orders indicated she had a feeding tube, (tube for providing nutrition), tracheotomy/ventilator dependence (required mechanical support for breathing). Her orders did not include orders for [MEDICAL TREATMENT]. The most recent MDS for Resident #18 date

Based on interview, and record review, the administrator and DON failed to ensure resources were used effectively and efficiently to provide appropriate care and services for 9 of 9 residents reviewed for [MEDICAL TREATMENT] treatment. The quality assessment and assurance committee identified problems with physician orders, protocols, consent to receive [MEDICAL TREATMENT] at the facility and visits by the nephrologist for residents that received [MEDICAL TREATMENT] in [DATE]. A plan was not developed and interventions were not followed up on. The staff was not trained on [MEDICAL TREATMENT] until [DATE]. Resident #s 10, 15, 16, 17, 18, 19, 20, 21, and 22 did not have physician orders or consent for [MEDICAL TREATMENT] and the residents were not seen in the facility by the nephrologist. . Resident #s 15, 16, and 17 died shortly after receiving [MEDICAL TREATMENT]. Resident #s 18, 19, 20, 21, and 22 were hospitalized shortly after receiving [MEDICAL TREATMENT]. An Immediate Jeopardy was identified that existed from [DATE] through [DATE]. The facility identified a failure in care and services related to providing [MEDICAL TREATMENT] treatment to residents at the facility and discharged the final 3 residents to the hospital which resulted in the removal of the immediacy prior to the survey on [DATE]. The facility remained out of compliance at a pattern of actual harm due to the need to institute corrective measures for the failures that caused the Immediate Jeopardy. This failure could place 9 residents who received [MEDICAL TREATMENT] at the facility at risk for a lack of medical intervention and death. Findings included: During an interview on [DATE] at 1:30 p.m., the DON said she started at the facility in [DATE] and in-serviced staff in [DATE] about pre and post [MEDICAL TREATMENT] assessment. The DON said the failures with the residents who received [MEDICAL TREATMENT] were a result of the lack of communication with the [MEDICAL TREATMENT] RN. The DON said the residents that received [MEDICAL TREATMENT] did not have signed physician orders for [MEDICAL TREATMENT] and the nephrologist did not assess the residents. The DON said she followed up on orders for one [MEDICAL TREATMENT] resident but did not check all of the residents ' records for physician orders for [MEDICAL TREATMENT]. During an interview on [DATE] at 11:42 a.m. the medical director said he was not notified when new residents that received [MEDICAL TREATMENT] were admitted . He said he discovered new residents that received [MEDICAL TREATMENT] when he or the NP visited the facility or received a call about a problem. He said he attended a meeting in [DATE] to correct this problem. He said at the meeting he told staff that all residents that received [MEDICAL TREATMENT] were to be admitted by the nephrologist who would provide physician orders for the residents ' [MEDICAL TREATMENT] care. The medical director said the nephrologist was responsible for physician visits for residents receiving [MEDICAL TREATMENT]. He said he was not aware of a [MEDICAL TREATMENT] policy and procedure. During an interview on [DATE] at 1:15 p.m., the former interim DON, RN P, said staff had not been in-serviced on protocols or received any training regarding residents that received [MEDICAL TREATMENT]. She said in October or [DATE] a QA meeting about residents that received [MEDICAL TREATMENT] was held with the medical director, all administrative staff, and the [MEDICAL TREATMENT] RN. RN P said they discussed the problem of no protocols for resident receiving [MEDICAL TREATMENT], not having physician orders for [MEDICAL TREATMENT] or a signed consent for receiving [MEDICAL TREATMENT] at the facility. RN P said at the meeting the medical director said [MEDICAL TREATMENT] residents were being admitted without his knowledge and any future [MEDICAL TREATMENT] residents needed to be admitted by the nephrologist. RN P said after the meeting they received the nephrologist ' s contact number, the [MEDICAL TREATMENT] RN ' s phone and a few protocols. RN P said there was nothing in place to ensure the identified problems were addressed. During an interview on [DATE] at 5:00 p.m., the nephrologist said he had not made rounds on any of the residents that received [MEDICAL TREATMENT], and he had not documented any progress notes. He said [MEDICAL TREATMENT] residents were admitted without his knowledge and the [MEDICAL TREATMENT] RN did not always communicate with him. The nephrologist said when the facility started providing [MEDICAL TREATMENT] for residents he was told by the [MEDICAL TREATMENT] RN that another nephrologist was giving orders for the residents' [MEDICAL TREATMENT] care. The nephrologist said he signed physician standing orders provided to him by the [MEDICAL TREATMENT] RN on [DATE] but there was a period of time (5 months) that there were no standing orders for [MEDICAL TREATMENT] residents. He said he did not like the original standing orders and made some changes to them. The nephrologist said the [MEDICAL TREATMENT] RN and the facility owner brought a stack of standing orders to his home that were dated September, October, November, and [DATE] and he stamped them with his signature. During an interview on [DATE] at 7:45 a.m., the previous DON said she voiced her concerns regarding the [MEDICAL TREATMENT] residents several times to the administrator and the facility owner. The residents did not have orders for [MEDICAL TREATMENT] and the nephrologist never came as scheduled. She said the nephrologist would schedule a visit to come to the facility but never showed up. The previous DON said the owner and the administrator told her everything was " ok " and not to worry about the [MEDICAL TREATMENT] orders or physician visits. During an interview on [DATE] at 10:30 a.m., the staffing nurse said she had never seen the nephrologist in the facility to see the residents that received [MEDICAL TREATMENT]. She said the nurses were voicing concerns regarding no orders for the [MEDICAL TREATMENT] residents and no physician visits to for the residents. She said staff had complained to the administrator and the DON on several occasions. During an interview on [DATE] at 3:30 p.m., LVN W said she never saw the nephrologist make a visit to see the [MEDICAL TREATMENT] residents. LVN W said residents received [MEDICAL TREATMENT] late in the evening hours by one RN, and she was told to notify him of any problems with the residents. She said she voiced her concerns to the administrator that there were no orders for [MEDICAL TREATMENT] for the residents that received [MEDICAL TREATMENT], but she was told everything was " ok " . During an interview on [DATE] at 1:35 p.m., LVN N said she called the primary, the nephrologist and RN that provided the [MEDICAL TREATMENT] if she had concerns for [MEDICAL TREATMENT] residents. She said several residents that received [MEDICAL TREATMENT] had expired. She said Resident #15 "crashed" at the facility on the 10 p.m. to 6 a.m. shift. She said there were times she could not contact either the primary physician or the nephrologist when [MEDICAL TREATMENT] residents were not doing well. LVN N said when she did not reach a physician; she would send the resident to the hospital if their family wanted them sent. She said the residents receiving [MEDICAL TREATMENT] did not have consents, laboratory reports and signed physician standing orders. She said she requested consents, orders for laboratory services and signed physician standing orders to care for the residents receiving [MEDICAL TREATMENT] but they were not provided During an interview on [DATE] at 4:10 p.m., LVN 0 said she had never seen signed physician orders, laboratory services, or physician progress notes [REDACTED]. During an interview on [DATE] at 10:15 a.m., LVN Q said the nurses were concerned about [MEDICAL TREATMENT] assessments (pre and post) because they had no physician orders and no nephrologist progress notes. LVN Q said they also had concerns with clogged catheters. She said the [MEDICAL TREATMENT] RN provided [MEDICAL TREATMENT] for a resident for 30 minutes on Monday, the catheter would become clogged and he would instill medicine to declog the catheter, but then the [MEDICAL TREATMENT] RN would not return until Wednesday to provide [MEDICAL TREATMENT] for the resident again. During an interview on [DATE] at 10:45 a.m., the ADON said the last QA meeting was on [DATE]. She said the medical director was present and knew that the [MEDICAL TREATMENT] residents had been discharged and said he would help with finding them placements. The ADON did not know if there had been a Q/A meeting [DATE]. The Quality Assurance/Performance Improvement policy dated ,[DATE] said they, " .....strive to improve and provide quality, cost effective care by utilizing a standardized QA/Performance Improvement program. The QA program will strive to improve the facility's governance, managerial, clinical, financial and support processed through a system which will monitor, analyze, trend/evaluate and identify areas that would benefit from additional focus. " 1. 1. Physician orders dated [DATE] indicated Resident #15 was [AGE] years old and admitted [DATE], with [DIAGNOSES REDACTED]. No [MEDICAL TREATMENT] orders were noted on the chart. Nursing progress notes dated [DATE] indicated Resident #15 was found unresponsive and CPR was initiated. She later expired. 2. Consolidated physician orders dated [DATE] indicated Resident #16 was [AGE] years old and admitted [DATE] with [DIAGNOSES REDACTED]. The orders indicated Resident #16 was to have a complete blood count, renal function panel, and [MEDICATION NAME] level on the days he received [MEDICAL TREATMENT]. The orders were signed by the NP. The MDS dated [DATE] indicated Resident #16 had [MEDICAL TREATMENT], could understand and could make herself understood, required assistance of 2 staff for all ADLS. A care plan dated [DATE] indicated Resident #16 would have [MEDICAL TREATMENT]. Interventions were to monitor fistula, graph, for signs/symptoms of redness, welling and report abnormalities to physician, coordinate with the [MEDICAL TREATMENT] staff to ensure effective interchange of information for my care and safety, laboratory services as ordered by the physician, monitor special dietary regimen, dietary restrictions, fluid restrictions, and weight as ordered by the physician. Nursing notes dated [DATE] at 11:40 p.m. indicated Resident #16 experienced [MEDICAL CONDITION] and CPR was initiated. Emergency medical services arrived at 11:50 p.m. and transported the resident to the hospital where he died . The [MEDICAL TREATMENT] flow sheets dated [DATE], [DATE], [DATE], and [DATE] indicated Resident #16 received [MEDICAL TREATMENT] by the [MEDICAL TREATMENT] RN. The clinical record for Resident #16 did not have documentation of consent for [MEDICAL TREATMENT], signed orders for [MEDICAL TREATMENT], and physician progress notes [REDACTED]. 3. [DATE] consolidated physician orders signed by the NP indicated Resident #17 was [AGE] years old and admitted [DATE] with [DIAGNOSES REDACTED]. These orders indicated Resident #13 was to receive [MEDICATION NAME] units/ml IV daily in the evenings. This treatment was to be administered along with [MEDICAL TREATMENT] s which was to be done on Monday, Wednesday, and Friday per the orders of the nephrologist. A respiratory note dated [DATE] at 5:30 p.m. indicated the respiratory therapist found Resident #17unresponsive in her room and her fingers were " slightly " purple. Resident #17 had a code of do not resuscitate. The note indicated the therapist from the previous shift reported Resident #17 had high pressure alarms all night but refused suctioning. The therapist recorded that Resident #17 "was anxious most of the night after completing [MEDICAL TREATMENT] that started at 10:11 p.m. and ended at 11:30 p.m." The MDS dated [DATE] and [DATE] indicated Resident #17 was dependent on 2 staff for all ADLs, was ventilator dependent, could understand others, could be understood and was on [MEDICAL TREATMENT]. An undated care plan indicated Resident #17 received [MEDICAL TREATMENT] and was at risk for complications. Interventions included, monitor fistula, graph, for signs/symptoms of redness, welling and report abnormalities to physician, coordinate with the [MEDICAL TREATMENT] staff to ensure effective interchange of information for care and safety, laboratory services as ordered by the physician, monitor special dietary regimen, dietary restrictions, fluid restrictions, and weight as ordered by the physician. The [MEDICAL TREATMENT] flow sheets dated [DATE], [DATE], and [DATE] indicated Resident #17 received [MEDICAL TREATMENT] by the [MEDICAL TREATMENT] RN. The clinical record for Resident #17 did not have documentation of -progress notes that indicated the [MEDICAL TREATMENT] physician saw her, [MEDICAL TREATMENT] orders signed by the [MEDICAL TREATMENT] physician. Were they signed by any MD? 4. Unsigned consolidated physician orders dated [DATE] indicated Resident #21 was [AGE] years old and admitted [DATE] with [DIAGNOSES REDACTED]. The resident was 49. There were no orders for [MEDICAL TREATMENT], or laboratory services. A hospital emergency room note dated [DATE] at 11:00 a.m. indicated Resident #21 was transferred to the hospital from the nursing home on [DATE] because she required [MEDICAL TREATMENT] and the machine at the nursing home was broken. This indicated the nursing home medical director was called on [DATE] at 12:55 p.m. and wanted Resident #21 admitted to the hospital to rule out bacteremia. The [MEDICAL TREATMENT] flow sheets dated [DATE] and [DATE] indicated Resident #21 received [MEDICAL TREATMENT] by the [MEDICAL TREATMENT] technician, not the [MEDICAL TREATMENT] RN. Nursing notes dated [DATE] at 3:26 p.m. indicated at 2:30 p.m. Resident # 21 received [MEDICAL TREATMENT]. Nursing notes dated [DATE] at 4:08 p.m. indicated at 2:00 p.m. Resident # 21 received [MEDICAL TREATMENT]. The clinical record for Resident #21did not have documentation of consent for [MEDICAL TREATMENT], signed orders for [MEDICAL TREATMENT], and physician progress notes [REDACTED]. 5. Physician orders dated [DATE] indicated Resident #18 was [AGE] years old and admitted [DATE] with [DIAGNOSES REDACTED]. Resident #18's orders indicated she had a feeding tube, (tube for providing nutrition), [MEDICAL CONDITION]/ventilator dependence (required mechanical support for breathing). Her orders did not include orders for [MEDICAL TREATMENT] instructions. The most recent MDS for Resident #18 dated [DATE] indicated she was in a vegetative state, was totally dependent for all ADLs, incontinent of bowel and bladder, and received [MEDICAL TREATMENT] and ventilator support. The undated Care plan for Resident #18 indicated she was dependent on a ventilator for breathing and received [MEDICAL TREATMENT] for end stage [MEDICAL CONDITION]. The [MEDICAL TREATMENT] flow sheets indicated Resident #18 received [MEDICAL TREATMENT] in the facility on the following dates: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], 01/ ,[DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. Progress notes that indicated Resident #18 was seen by a physician since admission and informed written consent for [MEDICAL TREATMENT] was not in the clinical record. 6. Unsigned consolidated physician orders dated [DATE] indicated Resident #10 was [AGE] years old and admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. There was no order for [MEDICAL TREATMENT], but included an order to "discontinue [MEDICAL TREATMENT] " per physician. The MDS dated [DATE] indicated Resident #10 was admitted on [DATE] and had the ability to express his ideas/wants and he understood verbal content. That MDS indicated Resident #10 received [MEDICAL TREATMENT]. The nursing notes dated [DATE] and [DATE]indicated Resident #10 received [MEDICAL TREATMENT] on these days. The care plan dated [DATE] indicated Resident #10 was no longer on [MEDICAL TREATMENT]. Progress notes that indicated Resident #10 was seen by a physician and informed written consent for [MEDICAL TREATMENT] was not in the clinical record. 7. Unsigned consolidated physician orders dated [DATE] indicated Resident #20 was [AGE] years old and admitted [DATE] with [DIAGNOSES REDACTED]. There was no order for [MEDICAL TREATMENT] or [MEDICAL TREATMENT] labs. An MDS dated [DATE] indicated Resident #20 was comatose (persistent vegetative state/no discernible consciousness), totally dependent on staff for ADLs, incontinent of bowel and bladder. The MDS indicated the resident received [MEDICAL TREATMENT]. A care plan dated [DATE] indicated Resident #20 received [MEDICAL TREATMENT] for [MEDICAL CONDITION], interventions included: coordinate with the [MEDICAL TREATMENT] staff to ensure effective interchange of information for my care and safety, have labs as ordered by physician and assess, document and report any abnormal findings to the physician. Resident #20's [MEDICAL TREATMENT] flow sheets indicated her [MEDICAL TREATMENT] s began [DATE] and [MEDICAL TREATMENT] was performed on the following days: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], & [DATE]. A nursing note dated [DATE] indicated Resident #20 was transferred to the hospital due to a change in condition. The clinical record did not contain a progress notes that indicated Resident #20 was seen by a physician and informed written consent for [MEDICAL TREATMENT] at the facility was obtained. 8. Consolidated physician orders dated [DATE] signed by the nurse practitioner indicated Resident #19 was [AGE] years old and admitted [DATE] with [DIAGNOSES REDACTED]. There were no physician orders for [MEDICAL TREATMENT]. A History and Physical dated [DATE] indicated Resident #19 was seen by the physician [DATE]. An MDS dated [DATE] indicated Resident #19 had modified independence in his cognitive skills. He was totally dependent on staff for ADLs, incontinent of bowel and had an indwelling urinary catheter. The MDS indicated the resident received [MEDICAL TREATMENT]. A care plan dated [DATE] indicated Resident #19 received [MEDICAL TREATMENT] for [MEDICAL CONDITION], interventions include:-coordinate with the [MEDICAL TREATMENT] staff to ensure effective interchange of information for care and safety, have labs as ordered by physician, assess, document and report any abnormal findings to physician, and monitor my weight as ordered by physician. The [MEDICAL TREATMENT] flow sheets indicated Resident #19 started [MEDICAL TREATMENT] on [DATE]. The resident received [MEDICAL TREATMENT] on [DATE] and [DATE]. His [MEDICAL TREATMENT] on [DATE] could not be completed because " unable to get adequate blood flow from HD catheter " . A nursing note dated [DATE] indicated Resident #19 was transferred to the hospital due to a change in condition. A signed informed consent to receive [MEDICAL TREATMENT] was not in the clinical record for Resident #19. 9. Consolidated physician orders dated [DATE] signed by the nurse practitioner indicated Resident #22 was [AGE] years old and admitted [DATE] with [DIAGNOSES REDACTED]. There was no order for [MEDICAL TREATMENT] other than what was sent from the discharging hospital. A MDS dated [DATE] indicated Resident #22 was totally dependent on staff for ADLs and was incontinent of bowel and bladder. The MDS indicated the resident received [MEDICAL TREATMENT]. An undated care plan indicated Resident #22 received [MEDICAL TREATMENT] for [MEDICAL CONDITION], interventions included: coordinate with the [MEDICAL TREATMENT] staff to ensure effective interchange of information for care and safety, have labs as ordered by physician, assess, document and report any abnormal findings to physician The [MEDICAL TREATMENT] flow sheets indicated Resident #22 began [MEDICAL TREATMENT] s [DATE]. The resident received s on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] Progress notes that indicated Resident #22 was seen by a physician and informed written consent for [MEDICAL TREATMENT] was not in the clinical record. The [MEDICAL TREATMENT] Consent Policy dated [DATE] indicated " Every patient must have an informed consent for [MEDICAL TREATMENT] on their chart prior to treatment. Chronic patients with consent for treatment on their outpatient chart must resign for inpatient ..... " A policy and procedure for admission orders admission orders [REDACTED]. If the attending physician or their alternate can not be reached, the facility shall contact the Medical Director for receipt of temporary orders until the attending physician can be contacted for confirmation or revision of orders." A list provided by the DON dated [DATE] indicated 0 residents currently received [MEDICAL TREATMENT] and 9 previously received [MEDICAL TREATMENT].

Based on interview and record review the facility failed to ensure the right to be fully informed of the medical care for [MEDICAL TREATMENT] at the facility was provided for 9 of 9 residents reviewed for [MEDICAL TREATMENT]. (Resident #s 10, 15, 16, 17, 18, 19, 20, 21 and 22) Resident #s 10, 15, 16, 17, 18, 19, 20, 21, and 22 were not given information of the risks and benefits of receiving the [MEDICAL TREATMENT] procedure at the facility. Resident #s 15, 16, and 17 died shortly after receiving [MEDICAL TREATMENT]. Resident #s 18, 19, 20, 21, and 22 were hospitalized shortly after receiving [MEDICAL TREATMENT]. An Immediate Jeopardy was identified that existed from [DATE] through [DATE]. The facility identified a failure in care and services related to providing [MEDICAL TREATMENT] treatment to residents at the facility and discharged the final 3 residents to the hospital which resulted in the removal of the immediacy prior to the survey on [DATE]. The facility remained out of compliance at a pattern of actual harm due to the need to institute corrective measures for the failures that caused the Immediate Jeopardy. Findings included: 1. Physician orders dated [DATE] indicated Resident #15 was [AGE] years old and admitted [DATE], with [DIAGNOSES REDACTED]. No [MEDICAL TREATMENT] orders were noted on the chart. The most recent MDS dated [DATE] indicated Resident #15 had clear comprehension, clear speech, and could make herself understood. Her BIMS score was "13" (score of ,[DATE] = cognitively intact.) She was totally dependent for all of her ADL care. The MDS indicated she received [MEDICAL TREATMENT], suctioning and [MEDICAL CONDITION] care. An undated care plan indicated Resident #15 received [MEDICAL TREATMENT] due to [MEDICAL CONDITION]. Interventions included: order labs per physician, monitor for altered level of consciousness, shortness of breath, increased weight/[MEDICAL CONDITION], low blood pressure, irregular heart rhythm, muscle cramps, nausea, vomiting, headache, confusion and monitor catheter site for infection and patency. The nursing progress notes included the following for Resident #15: *[DATE] at 6:23 p.m., arrived from hospital, Quinton catheter ([MEDICAL TREATMENT] catheter) left chest, had moderate swelling to arms, legs and feet. *[DATE] at 10:51 a.m., on [MEDICAL TREATMENT] 3 times a week *[DATE] at 5:47 p.m., [MEDICAL TREATMENT] being done in facility on Tuesday, Thursday and Saturday. *[DATE] at 1:15 a.m., at the beginning of shift at 10:00 p.m., resident receiving [MEDICAL TREATMENT] at bedside with beside monitoring. Resident had 2 + [MEDICAL CONDITION] to lower extremities. Weight before [MEDICAL TREATMENT] 148.5 lbs. and post [MEDICAL TREATMENT] 142.6 *[DATE]-[DATE] receiving [MEDICAL TREATMENT] on Tuesday, Thursday and Saturday. * [DATE] at 3:17 a.m., received [MEDICAL TREATMENT] at the facility on Monday, Wednesday and Friday. Resident's blood pressure continues to be low at ,[DATE], resident placed in trendelenberg position (flat on the back with the feet higher than the head), blood pressure at ,[DATE], when her head was elevated, would drop back down. There was no documentation the physician was notified of the change of condition. * [DATE] at 9:59 a.m., [MEDICAL TREATMENT] Monday, Wednesday, and Friday, Quinton catheter intact with redness. There was no documentation the physician was notified of the change of condition. * [DATE] at 3:42 a.m., [MEDICAL TREATMENT] completed at 12 midnight. At 2:45 a.m., resident found with dried blood from mouth, down her chin and neck. Had bitten her own lip. * [DATE] at 2:33 a.m., resident unresponsive, unable to palpate blood pressure, or auscultate apical heart rate, bilateral lower extremities starting to mottle (lack of blood perfusion), CPR started at 12:15 a.m., 911 called and resident left the facility at 12:25 a.m. per emergency medical services. Resident expired During an interview on [DATE] at 1:35 p.m., LVN N said several residents that received [MEDICAL TREATMENT] had expired. She said Resident #15 "crashed" at the facility on the 10 p.m. to 6 a.m. shift. She said the residents who received [MEDICAL TREATMENT] did not have informed consents for [MEDICAL TREATMENT]. She said she requested consents, but they were not provided. During an interview on [DATE] at 1:15 p.m., the former interim DON, RN P, said in October/[DATE] a meeting was held with the medical director, all administrative staff, and the [MEDICAL TREATMENT] RN. RN P said the need for [MEDICAL TREATMENT] protocols were discussed, because there were no signed standing physician orders, no consent for [MEDICAL TREATMENT] treatment at the facility and no order for [MEDICAL TREATMENT] treatment. RN P said a plan was developed that consisted of developing protocols for residents that received [MEDICAL TREATMENT]. RN P said after the meeting she said they received a " few protocols " . 2. [DATE] consolidated physician orders signed by the NP indicated Resident #17 was [AGE] years old and admitted [DATE] with [DIAGNOSES REDACTED]. These orders indicated Resident #13 was to receive [MEDICATION NAME] units/ml IV daily in the evenings. This treatment was to be administered along with [MEDICAL TREATMENT] which were to be done on Monday, Wednesday, and Friday per the orders of the nephrologist. A respiratory note dated [DATE] at 5:30 p.m. indicated the respiratory therapist found Resident #17unresponsive in her room and her fingers were " slightly " purple. Resident #17 had a code of do not resuscitate. The note indicated the therapist from the previous shift reported Resident #17 had high pressure alarms all night but refused suctioning. The therapist recorded that Resident #17 "was anxious most of the night after completing [MEDICAL TREATMENT] that started at 10:11 p.m. and ended at 11:30 p.m." The MDS dated [DATE] and [DATE] indicated Resident #17 was dependent on 2 staff for all ADLs, was ventilator dependent, could understand others, could be understood and was on [MEDICAL TREATMENT]. An undated care plan indicated Resident #17 received [MEDICAL TREATMENT] and was at risk for complications. Interventions included, monitor fistula, graph, for signs/symptoms of redness, welling and report abnormalities to physician, coordinate with the [MEDICAL TREATMENT] staff to ensure effective interchange of information for care and safety, laboratory services as ordered by the physician, monitor special dietary regimen, dietary restrictions, fluid restrictions, and weight as ordered by the physician. The [MEDICAL TREATMENT] flow sheets dated [DATE], [DATE], and [DATE] indicated Resident #17 received [MEDICAL TREATMENT] by the [MEDICAL TREATMENT] RN. A nursing note dated [DATE] indicated Resident # 17 was pronounced dead at 6:06 p.m. The consent for [MEDICAL TREATMENT] treatment was not in the clinical record for Resident #17. 3. Unsigned consolidated physician orders dated [DATE] indicated Resident #21 was [AGE] years old and admitted [DATE] with [DIAGNOSES REDACTED]. The resident was 49. There were no orders for [MEDICAL TREATMENT] treatment, or laboratory services. A hospital emergency room note dated [DATE] at 11:00 a.m. indicated Resident #21 was transferred to the hospital from the nursing home on [DATE] because she required [MEDICAL TREATMENT] and the machine at the nursing home was broken. The note indicated the nursing home medical director was called on [DATE] at 12:55 p.m. and wanted Resident #21 admitted to the hospital to rule out bacteremia. The [MEDICAL TREATMENT] flow sheets dated [DATE] and [DATE] indicated Resident #21 received [MEDICAL TREATMENT] by the [MEDICAL TREATMENT] technician, not the [MEDICAL TREATMENT] RN. Nursing notes dated [DATE] at 3:26 p.m. indicated at 2:30 p.m. Resident # 21 received [MEDICAL TREATMENT]. Nursing notes dated [DATE] at 4:08 p.m. indicated at 2:00 p.m. Resident # 21 received [MEDICAL TREATMENT]. A hospital emergency room note dated [DATE] at 11:00 a.m. indicated Resident #21 was transferred to the hospital from the nursing home on [DATE] to rule out bacteremia (bacteria in the blood). The consent for [MEDICAL TREATMENT] treatment was not in the clinical record for Resident #21. 4. Consolidated physician orders dated [DATE] indicated Resident #16 was [AGE] years old and admitted [DATE] with [DIAGNOSES REDACTED]. The orders indicated Resident #16 was to have a complete blood count, renal function panel, and [MEDICATION NAME] level on the days he received [MEDICAL TREATMENT]. The orders were signed by the NP. The MDS dated [DATE] indicated Resident #16 had [MEDICAL TREATMENT], could understand and could make herself understood, required assistance of 2 staff for all ADLS. A care plan dated [DATE] indicated Resident #16 would have [MEDICAL TREATMENT]. Interventions were to monitor fistula, graph, for signs/symptoms of redness, welling and report abnormalities to physician, coordinate with the [MEDICAL TREATMENT] staff to ensure effective interchange of information for my care and safety, laboratory services as ordered by the physician, monitor special dietary regimen, dietary restrictions, fluid restrictions, and weight as ordered by the physician. A nursing note dated [DATE] at 1:30 p.m. indicated Resident #16 experienced [MEDICAL CONDITION], CPR was initiated, and the resident was transported via emergency medical services to the hospital and returned to the facility on [DATE] at 8:15 p.m. A nursing note dated [DATE] indicated at 11:09 p.m. Resident #16's [MEDICAL TREATMENT] was completed with post weight the same as the pre weight. The [MEDICAL TREATMENT] RN said he "took off a little fluid but the resident's blood pressure dropped so he administered fluid." There was no indication in the clinical record the nephrologist or medical director was notified. A nursing note dated [DATE] at 5:01 a.m. indicated Resident #16 had no noted complications from [MEDICAL TREATMENT] on the previous shift. A nursing note dated [DATE] at 4:30 p.m. indicated Resident #16 was receiving [MEDICAL TREATMENT]. Nursing notes dated [DATE] at 11:40 p.m. indicated Resident #16 experienced [MEDICAL CONDITION] and CPR was initiated. Emergency medical services arrived at 11:50 p.m. and transported the resident to the hospital where he died . The [MEDICAL TREATMENT] flow sheets dated [DATE], [DATE], [DATE], and [DATE] indicated Resident #16 received [MEDICAL TREATMENT] from the [MEDICAL TREATMENT] RN. Nursing notes dated [DATE] at 11:40 p.m. indicated Resident #16 experienced [MEDICAL CONDITION] and CPR was initiated. Emergency medical services arrived at 11:50 p.m. and transported the resident to the hospital where he died . During an interview on [DATE] at 11:45 a.m., the medical director said he never visited any of the residents that received [MEDICAL TREATMENT] but his NP might have. The medical director said he was not informed when they admitted a resident that received [MEDICAL TREATMENT] until they were already admitted . The consent for [MEDICAL TREATMENT] treatment was not in the clinical record for Resident #2. 5. Unsigned consolidated physician orders dated [DATE] indicated Resident #20 was [AGE] years old and admitted [DATE] with [DIAGNOSES REDACTED]. There was no order for [MEDICAL TREATMENT] or [MEDICAL TREATMENT] laboratory services. An MDS dated [DATE] indicated Resident #20 was comatose (persistent vegetative state/no discernible consciousness), totally dependent on staff for ADLs, incontinent of bowel and bladder. The MDS indicated the resident received [MEDICAL TREATMENT]. A care plan dated [DATE] indicated Resident #20 received [MEDICAL TREATMENT] for [MEDICAL CONDITION], interventions included: coordinate with the [MEDICAL TREATMENT] staff to ensure effective interchange of information for my care and safety, have labs as ordered by physician and assess, document and report any abnormal findings to the physician. Resident #20's [MEDICAL TREATMENT] flow sheets indicated her [MEDICAL TREATMENT] treatments began [DATE] and [MEDICAL TREATMENT] treatments were performed on the following days: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], & [DATE]. A Progress note dated [DATE] indicated Resident #20 was transferred to the hospital due to a change in condition. The consent for [MEDICAL TREATMENT] treatment was not in the clinical record for Resident #20. 6. Consolidated physician orders dated [DATE] signed by the nurse practitioner indicated Resident #19 was [AGE] years old and admitted [DATE] with [DIAGNOSES REDACTED]. There were no physician orders for [MEDICAL TREATMENT] treatment. An MDS dated [DATE] indicated Resident #19 had modified independence in his cognitive skills. He was totally dependent on staff for ADLs, incontinent of bowel and had an indwelling urinary catheter. The MDS indicated the resident received [MEDICAL TREATMENT]. A care plan dated [DATE] indicated Resident #19 received [MEDICAL TREATMENT] for [MEDICAL CONDITION], interventions include:-coordinate with the [MEDICAL TREATMENT] staff to ensure effective interchange of information for care and safety, have labs as ordered by physician, assess, document and report any abnormal findings to physician, and monitor my weight as ordered by physician. The [MEDICAL TREATMENT] flow sheets indicated Resident #19 started [MEDICAL TREATMENT] treatment on [DATE]. The resident received treatment on [DATE] and [DATE]. His treatment on [DATE] could not be completed because " unable to get adequate blood flow from HD catheter " . A Progress note dated [DATE] indicated Resident #19 was transferred to the hospital due to a change in condition. The consent for [MEDICAL TREATMENT] treatment was not in the clinical record for Resident #19. 7. Consolidated physician orders dated [DATE] signed by the nurse practitioner indicated Resident #22 was [AGE] years old and admitted [DATE] with [DIAGNOSES REDACTED]. There was no order for [MEDICAL TREATMENT] other than what was sent from the discharging hospital. A MDS dated [DATE] indicated Resident #22 was totally dependent on staff for ADLs and was incontinent of bowel and bladder. The MDS indicated the resident received [MEDICAL TREATMENT]. An undated care plan indicated Resident #22 received [MEDICAL TREATMENT] for [MEDICAL CONDITION], interventions included: coordinate with the [MEDICAL TREATMENT] staff to ensure effective interchange of information for care and safety, have labs as ordered by physician, assess, document and report any abnormal findings to physician The [MEDICAL TREATMENT] flow sheets indicated Resident #22 began [MEDICAL TREATMENT] treatments [DATE]. The resident received treatments on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] A Progress note dated [DATE] indicated Resident #22 was transferred to the hospital due to a change in condition. The consent for [MEDICAL TREATMENT] treatment was not in the clinical record for Resident #22. 8. Physician orders dated [DATE] indicated Resident #18 was [AGE] years old and admitted [DATE] with [DIAGNOSES REDACTED]. Resident #18's orders indicated she had a feeding tube, (tube for providing nutrition), [MEDICAL CONDITION]/ventilator dependence (required mechanical support for breathing). Her orders did not include orders for [MEDICAL TREATMENT] instructions. The most recent MDS dated [DATE] indicated Resident #18 was in a vegetative state was totally dependent for all ADLs, incontinent of bowel and bladder, and received [MEDICAL TREATMENT] and ventilator support. The undated Care plan for Resident #18 indicated she was dependent on a ventilator for breathing and received [MEDICAL TREATMENT] for end stage [MEDICAL CONDITION]. The [MEDICAL TREATMENT] flow sheets indicated Resident #18 received [MEDICAL TREATMENT] in the facility on the following dates: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], 01/ ,[DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. A nursing note dated [DATE] indicated an order for [REDACTED]. The consent for [MEDICAL TREATMENT] treatment was not in the clinical record for Resident #18. 9. Unsigned consolidated physician orders dated [DATE] indicated Resident #10 was [AGE] years old and admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. There was no order for [MEDICAL TREATMENT], but included an order to "discontinue [MEDICAL TREATMENT] " per physician. The MDS dated [DATE] indicated Resident #10 had the ability to express his ideas/wants and he understood verbal content. That MDS indicated Resident #10 received [MEDICAL TREATMENT]. The nursing notes dated [DATE] and [DATE]indicated Resident #10 received [MEDICAL TREATMENT] on these days. The care plan dated [DATE] indicated Resident #10 was no longer on [MEDICAL TREATMENT]. The consent for [MEDICAL TREATMENT] treatment was not in the clinical record for Resident #10. During an interview on [DATE] at 9:25 a.m., the administrator said she started [DATE] and the program for providing [MEDICAL TREATMENT] in the facility was already in place. The administrator said she was not aware the residents who received [MEDICAL TREATMENT] did not have consent for [MEDICAL TREATMENT]. The [MEDICAL TREATMENT] Consent Policy dated [DATE] indicated " Every patient must have an informed consent for [MEDICAL TREATMENT] on their chart prior to treatment. Chronic patients with consent for treatment on their outpatient chart must re-sign for inpatient treatment ... " A list provided by the DON dated [DATE] indicated 0 residents currently received [MEDICAL TREATMENT] and 9 previously received [MEDICAL TREATMENT].

Based on interview and record review, the facility failed to ensure physician visits were provided at least once every 30 days for 2 of 9 residents reviewed for physician services. (Resident #'s 10, and 17) Resident #s 10, and 17 did not receive a physician visit every 30 days after admission. Resident # 17 died shortly after receiving [MEDICAL TREATMENT]. An Immediate Jeopardy was identified that existed from [DATE] through [DATE]. The facility identified a failure in care and services related to providing [MEDICAL TREATMENT] treatment to residents at the facility and discharged the final 3 residents to the hospital which resulted in the removal of the immediacy prior to the survey on [DATE]. The facility remained out of compliance at a pattern of actual harm due to the need to institute corrective measures for the failures that caused the Immediate Jeopardy. This failure could place 9 residents who received [MEDICAL TREATMENT] at the facility at risk for a lack of medical intervention and death. Findings included: 1. Unsigned consolidated physician orders [REDACTED]. There was no order for [MEDICAL TREATMENT], but included an order to "discontinue [MEDICAL TREATMENT] " per physician. The MDS dated [DATE] indicated Resident #10 had the ability to express his ideas/wants and he understood verbal content. That MDS indicated Resident #10 received [MEDICAL TREATMENT]. A nursing note dated [DATE] indicated Resident #10 refused [MEDICAL TREATMENT]. A nursing note dated [DATE] indicated a new order was received to discontinue [MEDICAL TREATMENT] for Resident #10. Resident #10's entire clinical record did not indicate a physician visit was made from admission on [DATE] thru [DATE]. 2. [DATE] consolidated physician orders [REDACTED]. These orders indicated Resident #13 was to receive [MEDICATION NAME] units/ml IV daily in the evenings. This treatment was to be administered along with [MEDICAL TREATMENT] treatments which were to be done on Monday, Wednesday, and Friday per the orders of the nephrologist. A respiratory note dated [DATE] at 5:30 p.m. indicated the respiratory therapist found Resident #17unresponsive in her room and her fingers were " slightly " purple. Resident #17 had a code of do not resuscitate. The note indicated the therapist from the previous shift reported Resident #17 had high pressure alarms all night but refused suctioning. The therapist recorded that Resident #17 "was anxious most of the night after completing [MEDICAL TREATMENT] that started at 10:11 p.m. and ended at 11:30 p.m." The MDS dated [DATE] and [DATE] indicated Resident #17 was dependent on 2 staff for all ADLs, was ventilator dependent, could understand others, could be understood and was on [MEDICAL TREATMENT]. An undated care plan indicated Resident #17 received [MEDICAL TREATMENT] and was at risk for complications. Interventions included, monitor fistula, graph, for signs/symptoms of redness, welling and report abnormalities to physician, coordinate with the [MEDICAL TREATMENT] staff to ensure effective interchange of information for care and safety, laboratory services as ordered by the physician, monitor special dietary regimen, dietary restrictions, fluid restrictions, and weight as ordered by the physician. The [MEDICAL TREATMENT] flow sheets dated [DATE], [DATE], and [DATE] indicated Resident #17 received [MEDICAL TREATMENT] by the [MEDICAL TREATMENT] RN. A nursing note dated [DATE] indicated Resident # 17 was pronounced dead at 6:06 p.m. The clinical record for Resident #17 did not have documentation of progress notes that indicated the physician saw her. During an interview on [DATE] at 11:42 a.m. the medical director said he was not notified when new residents that received [MEDICAL TREATMENT] were admitted . He said he discovered new residents that received [MEDICAL TREATMENT] when he or the NP visited the facility or received a call about a problem. He said he attended a meeting in [DATE] to correct this problem. He said at the meeting he told staff that all residents that received [MEDICAL TREATMENT] were to be admitted by the nephrologist who would provide physician orders [REDACTED]. The medical director said the nephrologist was responsible for physician visits for residents receiving [MEDICAL TREATMENT]. He said he was not aware of a [MEDICAL TREATMENT] policy and procedure. During an interview on [DATE] at 5:00 p.m., the nephrologist said he did not make rounds on any of the [MEDICAL TREATMENT] residents, and there were no progress notes. He said [MEDICAL TREATMENT] residents were admitted without his knowledge and the [MEDICAL TREATMENT] RN did not always communicate with him. The facility's policy on Physician Visits: Initial Medical Assessment ... dated [DATE] indicated: "The facility strives to assure residents/patients are provided with the appropriate medical care at the time it is needed and according to State, Federal, and JCAHO regulations. The resident/patient's physician visit will include, but is not limited to, the following: Face-to-face evaluation Review of total program of care Recording, signing, and dating resident/patient's progress and problems in maintaining or improving their functional status on the Progress Notes. Attending physician will complete an initial medical assessment on all residents/patients admitted to the facility. After the initial physician visit, a qualified Nurse Practitioner (NP) Clinical Nurse Specialist, or Physician's Assistant (PA) may make required visit (as permitted by State regulations). Each resident/patient [DIAGNOSES REDACTED]. Admission 1. Initiate the medical assessment, including a history and physical examination [REDACTED]. a. Exception may be made when an H&P was performed with 30 days prior to the admission. the physician will: 1) Review the H&P 2) Perform a second assessment to confirm information and findings." A list provided by the DON dated [DATE] indicated 0 residents currently received [MEDICAL TREATMENT] and 9 previously received [MEDICAL TREATMENT].

Based on observation, interview, and record review, the facility failed to implement the written policy and procedures to prohibit neglect for 9 of 9 residents reviewed for neglect. (Resident #s10, 15, 16, 17, 18, 19, 20, 21 and 22) Resident #s10, 15, 16, 17, 18, 19, 20, 21 and 22 received [MEDICAL TREATMENT] at the facility from a [MEDICAL TREATMENT] contracted RN. The facility did not have a license to provide [MEDICAL TREATMENT] and a criminal history check was not completed for the [MEDICAL TREATMENT] RN. Resident #s 10, 15, 16, 17, 18, 19, 20, 21 and 22 did not have informed consent or orders for [MEDICAL TREATMENT]. Resident #s 15, 16, 17, 18, 19, 20, 21 and 22 were not seen by a [MEDICAL TREATMENT] physician. The administrator, DON, and [MEDICAL TREATMENT] RN were made aware of recalled [MEDICAL TREATMENT] products, the [MEDICAL TREATMENT] RN continued to use the recalled products. Resident #s 15, 16 and 17 received recalled [MEDICAL TREATMENT] products. Nursing staff was not trained on providing care to a resident that received [MEDICAL TREATMENT] at the facility. Resident #s 15, 16, and 17 died shortly after receiving [MEDICAL TREATMENT]. Resident #s 18, 19, 20, 21, and 22 were hospitalized after receiving [MEDICAL TREATMENT]. An Immediate Jeopardy was identified that existed from [DATE] through [DATE]. The facility identified a failure in care and services related to providing [MEDICAL TREATMENT] treatment to residents at the facility and discharged the final 3 residents to the hospital which resulted in the removal of the immediacy prior to the survey on [DATE]. The facility remained out of compliance at a pattern of actual harm due to the need to institute corrective measures for the failures that caused the Immediate Jeopardy. This failure could place 9 residents who received [MEDICAL TREATMENT] treatment at the facility at risk for a lack of medical intervention and death. Findings included: The Prevention and Reporting of Resident Abuse dated [DATE] indicated " All potential employees will be screened for a history of abuse, neglect, or mistreatment of [REDACTED]. 1. Attempting to obtain information from previous employers and/or current employers when dates of hire are confirmed. 2. Contacting appropriate licensing boards and registries for information. 3. Obtaining a criminal history check" and ... " The Director of Nursing or Administrator will identify and intervene in situations in which abuse, neglect or misappropriation of resident property is more likely to occur, including an analysis of: ... 4. The identification and care planning of high risk residents, such as ...those that require heavy nursing care. " The policy defined neglect as the " ...willful deprivation by the caregiver of goods or services, which are necessary for the maintenance of physical or mental of another individual. " An Agreement for Renal Replacement Services ([MEDICAL TREATMENT]) signed [DATE] by the owner and the [MEDICAL TREATMENT] RN indicated the facility would provide acute [MEDICAL TREATMENT] treatments for those patients (residents) of the facility as requested by a physician in good standing on the facility's medical staff and duly credentialed by facility. (4. A) Normal operating hours for the services are 8 a.m. to 5 p.m., Monday through Saturday. The [MEDICAL TREATMENT] Consent Policy dated [DATE] indicated " Every patient must have an informed consent for [MEDICAL TREATMENT] on their chart prior to treatment. Chronic patients with consent for treatment on their outpatient chart must resign for inpatient treatment ..... " A policy and procedure for admission orders admission orders [REDACTED]. If the attending physician or their alternate cannot be reached, the facility shall contact the Medical Director for receipt of temporary orders until the attending physician can be contacted for confirmation or revision of orders." The facility's policy on Physician Visits: Initial Medical Assessment ... dated [DATE] indicated: "The facility strives to assure residents/patients are provided with the appropriate medical care at the time it is needed and according to State, Federal, and JCAHO regulations. The resident/patient's physician visit will include, but is not limited to, the following: Face-to-face evaluation Review of total program of care Recording, signing, and dating resident/patient's progress and problems in maintaining or improving their functional status on the Progress Notes. Attending physician will complete an initial medical assessment on all residents/patients admitted to the facility. After the initial physician visit, a qualified Nurse Practitioner (NP) Clinical Nurse Specialist, or Physician's Assistant (PA) may make required visit (as permitted by State regulations). Each resident/patient [DIAGNOSES REDACTED]. Admission 1. Initiate the medical assessment, including a history and physical examination [REDACTED]. a. Exception may be made when an H&P was performed with 30 days prior to the admission. the physician will: 1) Review the H&P 2) Perform a second assessment to confirm information and findings." During an interview on [DATE] at 11:42 a.m. the medical director said he was not notified when new residents who received [MEDICAL TREATMENT] were admitted . He said he discovered new residents who received [MEDICAL TREATMENT] when he or the NP visited the facility or received a call about a problem. He said he attended a meeting in [DATE] to correct this problem. He said at the meeting he told staff that all residents that received [MEDICAL TREATMENT] were to be admitted by the nephrologist who would provide physician orders for the residents' [MEDICAL TREATMENT] care. The medical director said the nephrologist was responsible for physician visits for residents receiving [MEDICAL TREATMENT]. He said he was not aware of a [MEDICAL TREATMENT] policy and procedure. During an interview on [DATE] at 1:15 p.m., the former interim DON, RN P, said staff had not been in-serviced on protocols for [MEDICAL TREATMENT] or received any [MEDICAL TREATMENT] training prior to the admission of residents who received [MEDICAL TREATMENT]. She said in October/[DATE] a meeting was held with the medical director, all administrative staff, and the [MEDICAL TREATMENT] RN. RN P said the need for [MEDICAL TREATMENT] protocols were discussed, because there were no signed standing physician orders, no consent for [MEDICAL TREATMENT] treatment at the facility and no order for [MEDICAL TREATMENT] treatment. RN P said the medical director said [MEDICAL TREATMENT] residents were being admitted without his knowledge. RN P said a plan was developed that consisted of developing protocols for residents that received [MEDICAL TREATMENT] and any future [MEDICAL TREATMENT] residents needed to be admitted by the nephrologist. RN P said after the meeting they received the nephrologist contact number, the [MEDICAL TREATMENT] RN phone number and a "few protocols." During an interview on [DATE] at 2:50 p.m., the [MEDICAL TREATMENT] RN said he reviewed laboratory reports prior to [MEDICAL TREATMENT]; he said the nephrologist made rounds with him on the weekends, signed orders and wrote progress notes on the residents that received [MEDICAL TREATMENT]. During an interview on [DATE] at 5:00 p.m., the nephrologist said he did not make rounds on any of the [MEDICAL TREATMENT] residents, and there were no progress notes. He said [MEDICAL TREATMENT] residents were admitted without his knowledge and the [MEDICAL TREATMENT] RN did not always communicate with him. The nephrologist said when they first started [MEDICAL TREATMENT] at the facility; he was told by the [MEDICAL TREATMENT] RN that another nephrologist was giving orders for residents' [MEDICAL TREATMENT] care. The nephrologist said the [MEDICAL TREATMENT] RN did not always communicate important information to him. The nephrologist said he signed some standing orders on [DATE] but there was a period of time before the facility had any standing physician orders for [MEDICAL TREATMENT] residents. He said he did not like the original standing orders and had recently made some changes to them. . During an interview on [DATE] at 7:45 a.m., the previous DON said she voiced her concerns regarding the [MEDICAL TREATMENT] residents several times to the administrator and the facility owner. The residents did not have orders for [MEDICAL TREATMENT] and the nephrologist never came as scheduled. She said the nephrologist would schedule a visit to come to the facility but never showed up. The previous DON said the owner and the administrator told her everything was " ok " and not to worry about the [MEDICAL TREATMENT] orders or physician visits. During an interview on [DATE] at 11:00 a.m., the administrator said the day ([DATE]) she started at the facility a QA meeting was held regarding [MEDICAL TREATMENT] care. She said she thought everything had been corrected and was not aware there continued to be issues. The administrator said she had not followed up on [MEDICAL TREATMENT] care to ensure concerns had been resolved. During an interview on [DATE] at 10:30 a.m., the staffing nurse said she had never seen the nephrologist in the facility to see the residents that received [MEDICAL TREATMENT]. She said the nurses were voicing concerns regarding no orders for the [MEDICAL TREATMENT] residents and no physician visits to for the residents. She said staff had complained to the administrator and the DON on several occasions. During an interview on [DATE] at 3:30 p.m., LVN W said she never saw the nephrologist make a visit to see the [MEDICAL TREATMENT] residents. LVN W said residents received [MEDICAL TREATMENT] late in the evening hours by one RN, and she was told to notify him of any problems with the residents. She said she voiced her concerns to the administrator that there were no orders for [MEDICAL TREATMENT] for the residents that received [MEDICAL TREATMENT], but she was told everything was " ok " . During an interview on [DATE] at 10:15 a.m., LVN Q said the nurses were concerned about [MEDICAL TREATMENT] assessments (pre and post) because they had no physician orders and no nephrologist progress notes. LVN Q said they also had concerns with clogged catheters. She said the [MEDICAL TREATMENT] RN provided [MEDICAL TREATMENT] for a resident (not known which one) for only 30 minutes on Monday, the catheter would become clogged and the [MEDICAL TREATMENT] RN did not complete the procedure. During an interview on [DATE] at 4:10 p.m., LVN 0 said she had never seen signed physician orders, laboratory services, or physician progress notes [REDACTED]. During an interview on [DATE] at 4:40 p.m., LVN T said when the facility began admitting [MEDICAL TREATMENT] residents, many of the nurses did not feel comfortable caring for them. LVN T said she had not received any training or in-services at the facility for caring for [MEDICAL TREATMENT] patients. She said the residents receiving [MEDICAL TREATMENT] did not have physician orders for [MEDICAL TREATMENT] treatment, consents for [MEDICAL TREATMENT] treatment or laboratory services ordered by the nephrologist. LVN T said the [MEDICAL TREATMENT] RN never consulted with the nephrologist when the [MEDICAL TREATMENT] RN was in the facility. LVN T said Resident #15 was alert and oriented, and wanted to get strong enough to "get up and go home". During an interview on [DATE] at 1:30 p.m., the DON said she started at the facility in [DATE] and in-serviced staff in [DATE] about pre and post [MEDICAL TREATMENT] assessment. The DON said the failures with the residents who received [MEDICAL TREATMENT] were a result of the lack of communication with the [MEDICAL TREATMENT] RN. The DON said the residents that received [MEDICAL TREATMENT] did not have signed physician orders for [MEDICAL TREATMENT] and the nephrologist did not assess the residents. The DON said she followed up on orders for one [MEDICAL TREATMENT] resident but did not check all of the residents ' records for physician orders for [MEDICAL TREATMENT]. The inservice records for [DATE] through [DATE] indicated: *[DATE] [MEDICAL TREATMENT] - attendees included administrative staff, the medical director, the RN that provided [MEDICAL TREATMENT] and facility owner. The focus was on quality and continuity of care for [MEDICAL TREATMENT] residents. *[DATE] indicated pre and post flow sheet. Nurses caring for [MEDICAL TREATMENT] residents attended this meeting. *[DATE] critical care vent and [MEDICAL TREATMENT] patients. All staff attended this meeting (nurses and CNAs). The website <http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm 0.htm accessed [DATE]> indicated " (UPDATED [DATE]) FDA issued a Class I Recall notice for Fresenius Medical Care North America [MEDICATION NAME] Liquid Acid Concentrate and [MEDICATION NAME] GranuFlo (powder) Acid Concentrate. Inappropriate prescription of these products can lead to a high serum [MEDICATION NAME] level in patients undergoing [MEDICAL TREATMENT]. This may contribute to metabolic alkalosis, which is a significant risk factor associated with low blood pressure, hypokalemia, hypoxemia, hypercapnia and cardiac arrhythmia, which, if not appropriately treated, may culminate in cardiopulmonary arrest. This product may cause serious adverse health consequences, including death. " Delivery notices dated [DATE] and [DATE] indicated recalled [MEDICATION NAME] [DATE] and [DATE] were delivered to the facility. During an interview on [DATE] at 9:40 a.m. LVN R said she was not in-serviced or trained regarding [MEDICAL TREATMENT]. She said she did not receive instructions from the [MEDICAL TREATMENT] RN. LVN R said there were news reports regarding recalled [MEDICAL TREATMENT] products that were causing deaths in residents. She said she obtained a copy of the name of the recalled products and witnessed these products being used in for [MEDICAL TREATMENT] treatments for Resident #s 15, 16, and 17. LVN R said all three of these residents experienced [MEDICAL CONDITION] in the facility. LVN R said she discussed this with the administrator and the DON and provided written information on the recalled [MEDICAL TREATMENT] products after the death of Resident #15. She said after notifying the administration the products continued to be used. During an interview on [DATE] at 1:15 p.m., the former interim DON, RN P, said she, LVN CC, LVN Q, the DON and the administrator observed recalled [MEDICAL TREATMENT] products in the storage room. RN P said the DON stated, "We'll have to get these out of here." During an interview on [DATE] at 2:50 p.m., the [MEDICAL TREATMENT] RN said he had continued to use [MEDICATION NAME] ([DATE] and [DATE]) concentrate during [MEDICAL TREATMENT] for the residents despite his knowledge that the product had been recalled by the FDA. The [MEDICAL TREATMENT] RN said the recall was a lot of media hype. During an interview on [DATE] at 10:15 a.m., LVN Q said she was aware of the recalled [MEDICAL TREATMENT] products. LVN Q said she, the RN and the administrator looked at the [MEDICAL TREATMENT] products and the administrator said she would talk to the [MEDICAL TREATMENT] RN about the products. LVN Q said she emailed the [MEDICAL TREATMENT] RN about the recalled [MEDICAL TREATMENT] product and she never heard back from him. 1. Physician orders dated [DATE] indicated Resident #15 was [AGE] years old and admitted [DATE], with [DIAGNOSES REDACTED]. No [MEDICAL TREATMENT] orders were noted on the chart. During an interview on [DATE] at 10:00 a.m. the SW said Resident #15 did not have orders for [MEDICAL TREATMENT] treatment in the entire clinical record. A physician progress notes [REDACTED]. The note indicated the plan was for the resident to receive a C- diff culture and obtain laboratory services per [MEDICAL TREATMENT] physician. There were no other physician progress notes [REDACTED]. The most recent MDS dated [DATE] indicated Resident #15 had clear comprehension, clear speech, and could make herself understood. Her BIMS score was "13" (score of ,[DATE] = cognitively intact.) She was totally dependent for all of her ADL care. The MDS indicated she received [MEDICAL TREATMENT], suctioning and tracheotomy care. An undated care plan indicated Resident #15 received [MEDICAL TREATMENT] due to [MEDICAL CONDITION]. Interventions included: order labs per physician, monitor for altered level of consciousness, shortness of breath, increased weight/[MEDICAL CONDITION], low blood pressure, irregular heart rhythm, muscle cramps, nausea, vomiting, headache, confusion and monitor catheter site for infection and patency. The nursing progress notes included the following for Resident #15: *[DATE] at 6:23 p.m., arrived from hospital, Quinton catheter ([MEDICAL TREATMENT] catheter) left chest, had moderate swelling to arms, legs and feet. *[DATE] at 10:51 a.m., on [MEDICAL TREATMENT] 3 times a week *[DATE] at 2:49 p.m., called NP regarding labs. She ordered [MEDICAL CONDITION] labs and stated, "Let nephrologist (kidney physician) decide what labs...when [MEDICAL TREATMENT] administered." *[DATE] at 5:47 p.m., [MEDICAL TREATMENT] being done in facility on Tuesday, Thursday and Saturday. *[DATE] at 10:20 p.m., panic potassium level 1.9 (potassium, normal value- 3XXX,[DATE].0). Called nurse practitioner. NP said get [MEDICAL TREATMENT] physician, contact numbers for [MEDICAL TREATMENT] and company name, [MEDICAL TREATMENT] progress notes, weights should be on resident's chart from now on. She ordered 40 meq of potassium chloride give one time now, draw potassium level in a.m. *[DATE] at 1:15 a.m., at the beginning of shift at 10:00 p.m., resident receiving [MEDICAL TREATMENT] at bedside with beside monitoring. Resident had 2 + [MEDICAL CONDITION] to lower extremities. Weight before [MEDICAL TREATMENT] 148.5 lbs. and post [MEDICAL TREATMENT] 142.6 *[DATE]-[DATE] receiving [MEDICAL TREATMENT] on Tuesday, Thursday and Saturday. * [DATE] at 3:17 a.m., received [MEDICAL TREATMENT] at the facility on Monday, Wednesday and Friday. Resident's blood pressure continues to be low at ,[DATE], resident placed in trendelenberg position (flat on the back with the feet higher than the head), blood pressure at ,[DATE], when her head was elevated, would drop back down. There was no documentation the physician was notified of the change of condition. * [DATE] at 9:59 a.m., [MEDICAL TREATMENT] Monday, Wednesday, and Friday, Quinton catheter intact with redness. There was no documentation the physician was notified of the change of condition. * [DATE] at 3:42 a.m., [MEDICAL TREATMENT] completed at 12 midnight. At 2:45 a.m., resident found with dried blood from mouth, down her chin and neck. Had bitten her own lip. * [DATE] at 2:33 a.m., resident unresponsive, unable to palpate blood pressure, or auscultate apical heart rate, bilateral lower extremities starting to mottle (lack of blood perfusion), CPR started at 12:15 a.m., 911 called and resident left the facility at 12:25 a.m. per emergency medical services. Resident expired A [MEDICAL TREATMENT] communication form dated [DATE] had blank spaces for the heart rate, breathing rate, or temperature for Resident #15. A pre-[MEDICAL TREATMENT] weight of 143.2 pounds and blood pressure of ,[DATE] was documented. The post [MEDICAL TREATMENT] weight was 142.5 pounds and the blood pressure was BP ,[DATE]. During an interview on [DATE] at 1:35 p.m., LVN N said the nurses documented pre and post [MEDICAL TREATMENT] vital signs (heart rate, breathing rate, temperature, and blood pressure) and weight on the [MEDICAL TREATMENT] communication sheet. She said, until recently all of the residents received [MEDICAL TREATMENT] on the night shift (10 p.m. - 6 a.m.). LVN N said she called the primary, the nephrologist and RN that provided the [MEDICAL TREATMENT] if she had concerns for [MEDICAL TREATMENT] residents. She said several residents that received [MEDICAL TREATMENT] had expired. She said Resident #15 "crashed" at the facility on the 10 p.m. to 6 a.m. shift. She said there were times she could not contact either the primary physician or the nephrologist when [MEDICAL TREATMENT] residents were not doing well. LVN N said if she did not reach a physician; she would send the resident to the hospital if their family wanted them sent. She said the residents receiving [MEDICAL TREATMENT] did not have consents, laboratory reports and signed physician standing orders. She said she requested consents, orders for laboratory services and signed physician standing orders to care for the residents receiving [MEDICAL TREATMENT] but these were not provided. During an interview on [DATE] at 9:40 a.m. LVN R said Resident #15 was the first [MEDICAL TREATMENT] resident at the facility. LVN R said she obtained a copy of the name of the recalled products and witnessed these products being used in for [MEDICAL TREATMENT] treatments for Resident #s 15, 16, and 17. LVN R said she discussed this with the administrator and the DON and provided written information on the recalled [MEDICAL TREATMENT] products after the death of Resident #15. LVN R said when Resident #15's, potassium was low the nurse practitioner was called because they could not contact the nephrologist. LVN R said the former interim DON implemented a new protocol to call the nephrologist, the [MEDICAL TREATMENT] RN and then the NP. 2. [DATE] consolidated physician orders signed by the NP indicated Resident #17 was [AGE] years old and admitted [DATE] with [DIAGNOSES REDACTED]. These orders indicated Resident #13 was to receive [MEDICATION NAME] units/ml IV daily in the evenings. This treatment was to be administered along with [MEDICAL TREATMENT] treatments which were to be done on Monday, Wednesday, and Friday per the orders of the nephrologist. A [MEDICAL TREATMENT] communication form dated [DATE], time not recorded, signed by the [MEDICAL TREATMENT] RN, indicated Resident #17 received [MEDICAL TREATMENT], but no laboratory services were drawn. No fluid removal amount was indicated on this report. The pre-[MEDICAL TREATMENT] weight was recorded as 301.6 pounds and her post-[MEDICAL TREATMENT] weight was 297 pounds, a difference of 4.6 pounds. The MDS dated [DATE] and [DATE] indicated Resident #17 was dependent on 2 staff for all ADLs, was ventilator dependent, could understand others, could be understood and was on [MEDICAL TREATMENT]. An undated care plan indicated Resident #17 received [MEDICAL TREATMENT] and was at risk for complications. Interventions included, monitor fistula, graph for signs/symptoms of redness, swelling and report abnormalities to physician, coordinate with the [MEDICAL TREATMENT] staff to ensure effective interchange of information for care and safety, laboratory services as ordered by the physician, monitor special dietary regimen, dietary restrictions, fluid restrictions, and weight as ordered by the physician. [MEDICAL TREATMENT] communication forms dated [DATE], [DATE], and [DATE] indicated Resident #17 had no labs done on those dates when [MEDICAL TREATMENT] was performed. The [MEDICAL TREATMENT] flow sheets dated [DATE], [DATE], and [DATE] indicated Resident #17 received [MEDICAL TREATMENT] from the [MEDICAL TREATMENT] RN. A respiratory note dated [DATE] at 5:30 p.m. indicated the respiratory therapist found Resident #17 unresponsive in her room and her fingers were "slightly " purple. Resident #17 had a code of do not resuscitate. The note indicated the therapist from the previous shift reported Resident #17 had high pressure alarms (indication of a mucus clog) all night but refused suctioning. The therapist recorded that Resident #17 "was anxious most of the night after completing [MEDICAL TREATMENT] that started at 10:11 p.m. and ended at 11:30 p.m." A nursing note dated [DATE] indicated Resident # 17 was pronounced dead at 6:06 p.m. The clinical record for Resident #17 did not have documentation of the following: - complete blood count, renal function panel, or [MEDICATION NAME] labs on the days she received [MEDICAL TREATMENT], -progress notes that indicated the [MEDICAL TREATMENT] physician saw her, -[MEDICAL TREATMENT] orders signed by the [MEDICAL TREATMENT] physician. 3. Unsigned consolidated physician orders dated [DATE] indicated Resident #21 was [AGE] years old and admitted [DATE] with [DIAGNOSES REDACTED]. The resident was 49. There were no orders for [MEDICAL TREATMENT] treatment, or laboratory services. A hospital emergency room note dated [DATE] at 11:00 a.m. indicated Resident #21 was transferred to the hospital from the nursing home on [DATE] to rule out bacteremia (bacteria in the blood). An admission nursing note dated [DATE] at 3:40 p.m. indicated Resident #21 was alert and oriented to person, place and time. She was nauseated and vomited a small amount. Speaking took great effort. Resident #21 was placed on ventilator support via her tracheotomy. She was incontinent of bowel and had a Foley catheter. A respiratory note dated [DATE] at 3:40 p.m. indicated Resident #21 arrived at the facility via ambulance and appeared tired and in mild respiratory distress. Her respirations were 26 oxygen saturations were ,[DATE]%. She was placed on ventilator support and her respiratory distress decreased. A [MEDICAL TREATMENT] communication form dated [DATE] and [DATE] indicated Resident #21 did not receive laboratory services on these dates when [MEDICAL TREATMENT] was performed. The [MEDICAL TREATMENT] flow sheets dated [DATE] and [DATE] indicated Resident #21 received [MEDICAL TREATMENT] by the [MEDICAL TREATMENT] technician, not the [MEDICAL TREATMENT] RN. Nursing notes dated [DATE] at 3:26 p.m. indicated at 2:30 p.m. Resident # 21 received [MEDICAL TREATMENT]. Nursing notes dated [DATE] at 4:08 p.m. indicated at 2:00 p.m. Resident # 21 received [MEDICAL TREATMENT]. The clinical record for Resident #21 did not have documentation of a consent for [MEDICAL TREATMENT] treatment, signed orders for [MEDICAL TREATMENT], orders for [MEDICAL TREATMENT] laboratory services (complete blood count, renal function panel, or [MEDICATION NAME] labs on the days she received [MEDICAL TREATMENT]), and physician progress notes [REDACTED]. 4. Consolidated physician orders dated [DATE] indicated Resident #16 was [AGE] years old and admitted [DATE] with [DIAGNOSES REDACTED]. The orders indicated Resident #16 was to have a complete blood count, renal function panel, and [MEDICATION NAME] level on the days he received [MEDICAL TREATMENT]. The orders were signed by the NP. There were no orders for [MEDICAL TREATMENT] treatment The MDS dated [DATE] indicated Resident #16 had [MEDICAL TREATMENT], could understand and could make herself understood, required assistance of 2 staff for all ADLS. A care plan dated [DATE] indicated Resident #16 would have [MEDICAL TREATMENT]. Interventions were to monitor fistula, graph for signs/symptoms of redness, swelling and report abnormalities to physician, coordinate with the [MEDICAL TREATMENT] staff to ensure effective interchange of information for my care and safety, laboratory services as ordered by the physician, monitor special dietary regimen, dietary restrictions, fluid restrictions, and weight as ordered by the physician. A nursing note dated [DATE] at 1:30 p.m. indicated Resident #16 experienced [MEDICAL CONDITION], CPR was initiated, and the resident was transported via emergency medical services to the hospital and returned to the facility on [DATE] at 8:15 p.m. A nursing note dated [DATE] indicated at 11:09 p.m. Resident #16's [MEDICAL TREATMENT] was completed with post weight the same as the pre weight. The [MEDICAL TREATMENT] RN said he "took off a little fluid but the resident's blood pressure dropped so he administered fluid." There was no indication in the clinical record the nephrologist or medical director was notified. A nursing note dated [DATE] at 5:01 a.m. indicated Resident #16 had no noted complications from [MEDICAL TREATMENT] on the previous shift. A nursing note dated [DATE] at 4:30 p.m. indicated Resident #16 was receiving [MEDICAL TREATMENT]. Nursing notes dated [DATE] at 11:40 p.m. indicated Resident #16 experienced [MEDICAL CONDITION] and CPR was initiated. Emergency medical services arrived at 11:50 p.m. and transported the resident to the hospital where he died . The [MEDICAL TREATMENT] flow sheets dated [DATE], [DATE], [DATE], and [DATE] indicated Resident #16 received [MEDICAL TREATMENT] by the [MEDICAL TREATMENT] RN. A [MEDICAL TREATMENT] communication form dated [DATE] indicated [MEDICAL TREATMENT] was initiated at 6:18 p.m. and completed 10:18 p.m. with no labs drawn for Resident #16. A [MEDICAL TREATMENT] communication form dated [DATE] indicated [MEDICAL TREATMENT] was initiated at 7:09 p.m. and completed at 11:09 p.m. for Resident #16. The pre weight and post weight were the same. This form indicated labs were drawn at the end of [MEDICAL TREATMENT] at 11:09 p.m. The clinical record did not have documentation of laboratory services. A [MEDICAL TREATMENT] communication form dated [DATE] indicated [MEDICAL TREATMENT] was initiated at 6:04 p.m. and completed 10:19 p.m. with no pre weight or post weight done for Resident #16. This form indicated admission labs were drawn. A [MEDICAL TREATMENT] communication form dated [DATE] indicated [MEDICAL TREATMENT] was initiated at 5:14 p.m. and completed at 7:29 p.m. for Resident #16 with no pre weight or post weight obtained and no labs were drawn. The clinical record for Resident #16 did not have documentation of consent for [MEDICAL TREATMENT] treatment, signed orders for [MEDICAL TREATMENT],and physician progress notes [REDACTED]. During an interview on [DATE] at 11:45 a.m., the medical director said he never visited any of the residents that received [MEDICAL TREATMENT] but his NP might have. The medical director said he was not informed when they admitted a resident that received [MEDICAL TREATMENT] until they were already admitted . 5. Unsigned consolidated physician orders dated [DATE] indicated Resident #20 was [AGE] years old and admitted [DATE] with [DIAGNOSES REDACTED]. There was no order for [MEDICAL TREATMENT] or [MEDICAL TREATMENT] laboratory services. An MDS dated [DATE] indicated Resident #20 was comatose (persistent vegetative state/no discernible consciousness), totally dependent on staff for ADLs, incontinent of bowel and bladder. The MDS indicated the resident received [MEDICAL TREATMENT]. A care plan dated [DATE] indicated Resident #20 received [MEDICAL TREATMENT] for [MEDICAL CONDITION], interventions included: coordinate with the [MEDICAL TREATMENT] staff to ensure effective interchange of information for my care and safety, have labs as ordered by physician and assess, document and report any abnormal findings to the physician. Resident #20's [MEDICAL TREATMENT] flow sheets indicated her [MEDICAL TREATMENT] treatments began [DATE] and [MEDICAL TREATMENT] treatments were performed on the following days: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], & [DATE]. The clinical record indicated Resident #20 had one laboratory report dated [DATE] although the [MEDICAL TREATMENT] communication forms indicated laboratory services were done by the [MEDICAL TREATMENT] RN on [DATE], [DATE], and [DATE]. The [MEDICAL TREATMENT] flow sheets indicated Resident #20 did not receive laboratory services on the following days: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], & [DATE]. Resident #20's [MEDICAL TREATMENT] flow sheets indicated no pre or post weights were done on the following days: -[DATE], -[DATE], -[DATE], -[DATE], -[DATE], -[DATE], and -[DATE]. A Progress note dated [DATE] indicated Resident #20 was transferred to the hospital due to a change in condition. No documentation was found in the clinical record that Resident #20 was seen a physician or th

Based on observation, interview, and record review, the facility failed to implement policies and procedures to prohibit neglect for 9 of 9 residents reviewed for neglect. (Resident #s10, 15, 16, 17, 18, 19, 20, 21 and 22) Resident #s10, 15, 16, 17, 18, 19, 20, 21 and 22 received [MEDICAL TREATMENT] at the facility from a contracted [MEDICAL TREATMENT] RN. The facility did not have a license to provide [MEDICAL TREATMENT]. Resident #s 10, 15, 16, 17, 18, 19, 20, 21 and 22 did not have informed consent and orders for [MEDICAL TREATMENT]. Resident #s 15, 16, 17, 18, 19, 20, 21 and 22 were not seen by a [MEDICAL TREATMENT] physician. The administrator, DON, and [MEDICAL TREATMENT] RN were made aware of recalled [MEDICAL TREATMENT] products, the [MEDICAL TREATMENT] RN coninued to use the recalled products for Resident #s 15, 16 and 17 received recalled [MEDICAL TREATMENT] products. Resident #s 15, 16, and 17 died shortly after receiving [MEDICAL TREATMENT]. Resident #s 18, 19, 20, 21, and 22 were hospitalized after receiving [MEDICAL TREATMENT]. An Immediate Jeopardy was identified that existed from [DATE] through [DATE]. The facility identified a failure in care and services related to providing [MEDICAL TREATMENT] treatment to residents at the facility and discharged the final 3 residents to the hospital which resulted in the removal of the immediacy prior to the survey on [DATE]. The facility remained out of compliance at a pattern of actual harm due to the need to institute corrective measures for the failures that caused the Immediate Jeopardy. This failure could place 9 residents who received [MEDICAL TREATMENT] treatment at the facility at risk for a lack of medical intervention and death. Findings included: During an interview on [DATE] at 11:42 a.m. the medical director said he was not notified when new residents who received [MEDICAL TREATMENT] were admitted . He said he discovered new residents who received [MEDICAL TREATMENT] when he or the NP visited the facility or received a call about a problem. He said he attended a meeting in [DATE] to correct this problem. He said at the meeting he told staff that all residents that received [MEDICAL TREATMENT] were to be admitted by the nephrologist who would provide physician orders for the residents' [MEDICAL TREATMENT] care. The medical director said the nephrologist was responsible for physician visits for residents receiving [MEDICAL TREATMENT]. He said he was not aware of a [MEDICAL TREATMENT] policy and procedure. During an interview on [DATE] at 1:15 p.m., the former interim DON, RN P, said staff had not been in-serviced on protocols for [MEDICAL TREATMENT] or received any [MEDICAL TREATMENT] training prior to the admission of residents who received [MEDICAL TREATMENT]. She said in October/[DATE] a meeting was held with the medical director, all administrative staff, and the [MEDICAL TREATMENT] RN. RN P said the need for [MEDICAL TREATMENT] protocols were discussed, because there were no signed standing physician orders, no consent for [MEDICAL TREATMENT] treatment at the facility and no order for [MEDICAL TREATMENT] treatment. RN P said the medical director said [MEDICAL TREATMENT] residents were being admitted without his knowledge. RN P said a plan was developed that consisted of developing protocols for residents that received [MEDICAL TREATMENT] and any future [MEDICAL TREATMENT] residents needed to be admitted by the nephrologist. RN P said after the meeting they received the nephrologist contact number, the [MEDICAL TREATMENT] RN phone number and a "few protocols." During an interview on [DATE] at 2:50 p.m., the [MEDICAL TREATMENT] RN said he reviewed laboratory reports prior to [MEDICAL TREATMENT]; he said the nephrologist made rounds with him on the weekends, signed orders and wrote progress notes on the residents that received [MEDICAL TREATMENT]. During an interview on [DATE] at 5:00 p.m., the nephrologist said he did not make rounds on any of the [MEDICAL TREATMENT] residents, and there were no progress notes. He said [MEDICAL TREATMENT] residents were admitted without his knowledge and the [MEDICAL TREATMENT] RN did not always communicate with him. The nephrologist said when they first started [MEDICAL TREATMENT] at the facility; he was told by the [MEDICAL TREATMENT] RN that another nephrologist was giving orders for residents' [MEDICAL TREATMENT] care. The nephrologist said the [MEDICAL TREATMENT] RN did not always communicate important information to him. The nephrologist said he signed some standing orders on [DATE] but there was a period of time before the facility had any standing physician orders for [MEDICAL TREATMENT] residents. He said he did not like the original standing orders and had recently made some changes to them. . During an interview on [DATE] at 7:45 a.m., the previous DON said she voiced her concerns regarding the [MEDICAL TREATMENT] residents several times to the administrator and the facility owner. The residents did not have orders for [MEDICAL TREATMENT] and the nephrologist never came as scheduled. She said the nephrologist would schedule a visit to come to the facility but never showed up. The previous DON said the owner and the administrator told her everything was " ok " and not to worry about the [MEDICAL TREATMENT] orders or physician visits. During an interview on [DATE] at 11:00 a.m., the administrator said the day ([DATE]) she started at the facility a QA meeting was held regarding [MEDICAL TREATMENT] care. She said she thought everything had been corrected and was not aware there continued to be issues. The administrator said she had not followed up on [MEDICAL TREATMENT] care to ensure concerns had been resolved. During an interview on [DATE] at 10:30 a.m., the staffing nurse said she had never seen the nephrologist in the facility to see the residents that received [MEDICAL TREATMENT]. She said the nurses were voicing concerns regarding no orders for the [MEDICAL TREATMENT] residents and no physician visits to for the residents. She said staff had complained to the administrator and the DON on several occasions. During an interview on [DATE] at 3:30 p.m., LVN W said she never saw the nephrologist make a visit to see the [MEDICAL TREATMENT] residents. LVN W said residents received [MEDICAL TREATMENT] late in the evening hours by one RN, and she was told to notify him of any problems with the residents. She said she voiced her concerns to the administrator that there were no orders for [MEDICAL TREATMENT] for the residents that received [MEDICAL TREATMENT], but she was told everything was " ok " . During an interview on [DATE] at 10:15 a.m., LVN Q said the nurses were concerned about [MEDICAL TREATMENT] assessments (pre and post) because they had no physician orders and no nephrologist progress notes. LVN Q said they also had concerns with clogged catheters. She said the [MEDICAL TREATMENT] RN provided [MEDICAL TREATMENT] for a resident (not known which one) for only 30 minutes on Monday, the catheter would become clogged and the [MEDICAL TREATMENT] RN did not complete the procedure. During an interview on [DATE] at 4:10 p.m., LVN 0 said she had never seen signed physician orders, laboratory services, or physician progress notes [REDACTED]. During an interview on [DATE] at 4:40 p.m., LVN T said when the facility began admitting [MEDICAL TREATMENT] residents, many of the nurses did not feel comfortable caring for them. LVN T said she had not received any training or in-services at the facility for caring for [MEDICAL TREATMENT] patients. She said the residents receiving [MEDICAL TREATMENT] did not have physician orders for [MEDICAL TREATMENT] treatment, consents for [MEDICAL TREATMENT] treatment or laboratory services ordered by the nephrologist. LVN T said the [MEDICAL TREATMENT] RN never consulted with the nephrologist when the [MEDICAL TREATMENT] RN was in the facility. LVN T said Resident #15 was alert and oriented, and wanted to get strong enough to "get up and go home". During an interview on [DATE] at 1:30 p.m., the DON said she started at the facility in [DATE] and in-serviced staff in [DATE] about pre and post [MEDICAL TREATMENT] assessment. The DON said the failures with the residents who received [MEDICAL TREATMENT] were a result of the lack of communication with the [MEDICAL TREATMENT] RN. The DON said the residents that received [MEDICAL TREATMENT] did not have signed physician orders for [MEDICAL TREATMENT] and the nephrologist did not assess the residents. The DON said she followed up on orders for one [MEDICAL TREATMENT] resident but did not check all of the residents ' records for physician orders for [MEDICAL TREATMENT]. The inservice records for [DATE] through [DATE] indicated: *[DATE] [MEDICAL TREATMENT] - attendees included administrative staff, the medical director, the RN that provided [MEDICAL TREATMENT] and facility owner. The focus was on quality and continuity of care for [MEDICAL TREATMENT] residents. *[DATE] indicated pre and post flow sheet. Nurses caring for [MEDICAL TREATMENT] residents attended this meeting. *[DATE] critical care vent and [MEDICAL TREATMENT] patients. All staff attended this meeting (nurses and CNAs). The website <http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm 0.htm accessed [DATE]> indicated " (UPDATED [DATE]) FDA issued a Class I Recall notice for Fresenius Medical Care North America [MEDICATION NAME] Liquid Acid Concentrate and [MEDICATION NAME] GranuFlo (powder) Acid Concentrate. Inappropriate prescription of these products can lead to a high serum [MEDICATION NAME] level in patients undergoing [MEDICAL TREATMENT]. This may contribute to metabolic alkalosis, which is a significant risk factor associated with low blood pressure, hypokalemia, hypoxemia, hypercapnia and cardiac arrhythmia, which, if not appropriately treated, may culminate in cardiopulmonary arrest. This product may cause serious adverse health consequences, including death. " Delivery notices dated [DATE] and [DATE] indicated recalled [MEDICATION NAME] [DATE] and [DATE] were delivered to the facility. During an interview on [DATE] at 9:40 a.m. LVN R said she was not in-serviced or trained regarding [MEDICAL TREATMENT]. She said she did not receive instructions from the [MEDICAL TREATMENT] RN. LVN R said there were news reports regarding recalled [MEDICAL TREATMENT] products that were causing deaths in residents. She said she obtained a copy of the name of the recalled products and witnessed these products being used in for [MEDICAL TREATMENT] treatments for Resident #s 15, 16, and 17. LVN R said all three of these residents experienced [MEDICAL CONDITION] in the facility. LVN R said she discussed this with the administrator and the DON and provided written information on the recalled [MEDICAL TREATMENT] products after the death of Resident #15. She said after notifying the administration the products continued to be used. During an interview on [DATE] at 1:15 p.m., the former interim DON, RN P, said she, LVN CC, LVN Q, the DON and the administrator observed recalled [MEDICAL TREATMENT] products in the storage room. RN P said the DON stated, "We'll have to get these out of here." During an interview on [DATE] at 2:50 p.m., the [MEDICAL TREATMENT] RN said he had continued to use [MEDICATION NAME] ([DATE] and [DATE]) concentrate during [MEDICAL TREATMENT] for the residents despite his knowledge that the product had been recalled by the FDA. The [MEDICAL TREATMENT] RN said the recall was a lot of media hype. During an interview on [DATE] at 10:15 a.m., LVN Q said she was aware of the recalled [MEDICAL TREATMENT] products. LVN Q said she, the RN and the administrator looked at the [MEDICAL TREATMENT] products and the administrator said she would talk to the [MEDICAL TREATMENT] RN about the products. LVN Q said she emailed the [MEDICAL TREATMENT] RN about the recalled [MEDICAL TREATMENT] product and she never heard back from him. 1. Physician orders dated [DATE] indicated Resident #15 was [AGE] years old and admitted [DATE], with [DIAGNOSES REDACTED]. No [MEDICAL TREATMENT] orders were noted on the chart. During an interview on [DATE] at 10:00 a.m. the SW said Resident #15 did not have orders for [MEDICAL TREATMENT] treatment in the entire clinical record. A physician progress notes [REDACTED]. The note indicated the plan was for the resident to receive a C- diff culture and obtain laboratory services per [MEDICAL TREATMENT] physician. There were no other physician progress notes [REDACTED]. The most recent MDS dated [DATE] indicated Resident #15 had clear comprehension, clear speech, and could make herself understood. Her BIMS score was "13" (score of ,[DATE] = cognitively intact.) She was totally dependent for all of her ADL care. The MDS indicated she received [MEDICAL TREATMENT], suctioning and tracheotomy care. An undated care plan indicated Resident #15 received [MEDICAL TREATMENT] due to [MEDICAL CONDITION]. Interventions included: order labs per physician, monitor for altered level of consciousness, shortness of breath, increased weight/[MEDICAL CONDITION], low blood pressure, irregular heart rhythm, muscle cramps, nausea, vomiting, headache, confusion and monitor catheter site for infection and patency. The nursing progress notes included the following for Resident #15: *[DATE] at 6:23 p.m., arrived from hospital, Quinton catheter ([MEDICAL TREATMENT] catheter) left chest, had moderate swelling to arms, legs and feet. *[DATE] at 10:51 a.m., on [MEDICAL TREATMENT] 3 times a week *[DATE] at 2:49 p.m., called NP regarding labs. She ordered [MEDICAL CONDITION] labs and stated, "Let nephrologist (kidney physician) decide what labs...when [MEDICAL TREATMENT] administered." *[DATE] at 5:47 p.m., [MEDICAL TREATMENT] being done in facility on Tuesday, Thursday and Saturday. *[DATE] at 10:20 p.m., panic potassium level 1.9 (potassium, normal value- 3XXX,[DATE].0). Called nurse practitioner. NP said get [MEDICAL TREATMENT] physician, contact numbers for [MEDICAL TREATMENT] and company name, [MEDICAL TREATMENT] progress notes, weights should be on resident's chart from now on. She ordered 40 meq of potassium chloride give one time now, draw potassium level in a.m. *[DATE] at 1:15 a.m., at the beginning of shift at 10:00 p.m., resident receiving [MEDICAL TREATMENT] at bedside with beside monitoring. Resident had 2 + [MEDICAL CONDITION] to lower extremities. Weight before [MEDICAL TREATMENT] 148.5 lbs. and post [MEDICAL TREATMENT] 142.6 *[DATE]-[DATE] receiving [MEDICAL TREATMENT] on Tuesday, Thursday and Saturday. * [DATE] at 3:17 a.m., received [MEDICAL TREATMENT] at the facility on Monday, Wednesday and Friday. Resident's blood pressure continues to be low at ,[DATE], resident placed in trendelenberg position (flat on the back with the feet higher than the head), blood pressure at ,[DATE], when her head was elevated, would drop back down. There was no documentation the physician was notified of the change of condition. * [DATE] at 9:59 a.m., [MEDICAL TREATMENT] Monday, Wednesday, and Friday, Quinton catheter intact with redness. There was no documentation the physician was notified of the change of condition. * [DATE] at 3:42 a.m., [MEDICAL TREATMENT] completed at 12 midnight. At 2:45 a.m., resident found with dried blood from mouth, down her chin and neck. Had bitten her own lip. * [DATE] at 2:33 a.m., resident unresponsive, unable to palpate blood pressure, or auscultate apical heart rate, bilateral lower extremities starting to mottle (lack of blood perfusion), CPR started at 12:15 a.m., 911 called and resident left the facility at 12:25 a.m. per emergency medical services. Resident expired A [MEDICAL TREATMENT] communication form dated [DATE] had blank spaces for the heart rate, breathing rate, or temperature for Resident #15. A pre-[MEDICAL TREATMENT] weight of 143.2 pounds and blood pressure of ,[DATE] was documented. The post [MEDICAL TREATMENT] weight was 142.5 pounds and the blood pressure was BP ,[DATE]. During an interview on [DATE] at 1:35 p.m., LVN N said the nurses documented pre and post [MEDICAL TREATMENT] vital signs (heart rate, breathing rate, temperature, and blood pressure) and weight on the [MEDICAL TREATMENT] communication sheet. She said, until recently all of the residents received [MEDICAL TREATMENT] on the night shift (10 p.m. - 6 a.m.). LVN N said she called the primary, the nephrologist and RN that provided the [MEDICAL TREATMENT] if she had concerns for [MEDICAL TREATMENT] residents. She said several residents that received [MEDICAL TREATMENT] had expired. She said Resident #15 "crashed" at the facility on the 10 p.m. to 6 a.m. shift. She said there were times she could not contact either the primary physician or the nephrologist when [MEDICAL TREATMENT] residents were not doing well. LVN N said if she did not reach a physician; she would send the resident to the hospital if their family wanted them sent. She said the residents receiving [MEDICAL TREATMENT] did not have consents, laboratory reports and signed physician standing orders. She said she requested consents, orders for laboratory services and signed physician standing orders to care for the residents receiving [MEDICAL TREATMENT] but these were not provided. During an interview on [DATE] at 9:40 a.m. LVN R said Resident #15 was the first [MEDICAL TREATMENT] resident at the facility. LVN R said she obtained a copy of the name of the recalled products and witnessed these products being used in for [MEDICAL TREATMENT] treatments for Resident #s 15, 16, and 17. LVN R said she discussed this with the administrator and the DON and provided written information on the recalled [MEDICAL TREATMENT] products after the death of Resident #15. LVN R said when Resident #15's, potassium was low the nurse practitioner was called because they could not contact the nephrologist. LVN R said the former interim DON implemented a new protocol to call the nephrologist, the [MEDICAL TREATMENT] RN and then the NP. 2. [DATE] consolidated physician orders signed by the NP indicated Resident #17 was [AGE] years old and admitted [DATE] with [DIAGNOSES REDACTED]. These orders indicated Resident #13 was to receive [MEDICATION NAME] units/ml IV daily in the evenings. This treatment was to be administered along with [MEDICAL TREATMENT] treatments which were to be done on Monday, Wednesday, and Friday per the orders of the nephrologist. A [MEDICAL TREATMENT] communication form dated [DATE], time not recorded, signed by the [MEDICAL TREATMENT] RN, indicated Resident #17 received [MEDICAL TREATMENT], but no laboratory services were drawn. No fluid removal amount was indicated on this report. The pre-[MEDICAL TREATMENT] weight was recorded as 301.6 pounds and her post-[MEDICAL TREATMENT] weight was 297 pounds, a difference of 4.6 pounds. The MDS dated [DATE] and [DATE] indicated Resident #17 was dependent on 2 staff for all ADLs, was ventilator dependent, could understand others, could be understood and was on [MEDICAL TREATMENT]. An undated care plan indicated Resident #17 received [MEDICAL TREATMENT] and was at risk for complications. Interventions included, monitor fistula, graph for signs/symptoms of redness, swelling and report abnormalities to physician, coordinate with the [MEDICAL TREATMENT] staff to ensure effective interchange of information for care and safety, laboratory services as ordered by the physician, monitor special dietary regimen, dietary restrictions, fluid restrictions, and weight as ordered by the physician. [MEDICAL TREATMENT] communication forms dated [DATE], [DATE], and [DATE] indicated Resident #17 had no labs done on those dates when [MEDICAL TREATMENT] was performed. The [MEDICAL TREATMENT] flow sheets dated [DATE], [DATE], and [DATE] indicated Resident #17 received [MEDICAL TREATMENT] from the [MEDICAL TREATMENT] RN. A respiratory note dated [DATE] at 5:30 p.m. indicated the respiratory therapist found Resident #17 unresponsive in her room and her fingers were "slightly " purple. Resident #17 had a code of do not resuscitate. The note indicated the therapist from the previous shift reported Resident #17 had high pressure alarms (indication of a mucus clog) all night but refused suctioning. The therapist recorded that Resident #17 "was anxious most of the night after completing [MEDICAL TREATMENT] that started at 10:11 p.m. and ended at 11:30 p.m." A nursing note dated [DATE] indicated Resident # 17 was pronounced dead at 6:06 p.m. The clinical record for Resident #17 did not have documentation of the following: - complete blood count, renal function panel, or [MEDICATION NAME] labs on the days she received [MEDICAL TREATMENT], -progress notes that indicated the [MEDICAL TREATMENT] physician saw her, -[MEDICAL TREATMENT] orders signed by the [MEDICAL TREATMENT] physician. 3. Unsigned consolidated physician orders dated [DATE] indicated Resident #21 was [AGE] years old and admitted [DATE] with [DIAGNOSES REDACTED]. The resident was 49. There were no orders for [MEDICAL TREATMENT] treatment, or laboratory services. A hospital emergency room note dated [DATE] at 11:00 a.m. indicated Resident #21 was transferred to the hospital from the nursing home on [DATE] to rule out bacteremia (bacteria in the blood). An admission nursing note dated [DATE] at 3:40 p.m. indicated Resident #21 was alert and oriented to person, place and time. She was nauseated and vomited a small amount. Speaking took great effort. Resident #21 was placed on ventilator support via her tracheotomy. She was incontinent of bowel and had a Foley catheter. A respiratory note dated [DATE] at 3:40 p.m. indicated Resident #21 arrived at the facility via ambulance and appeared tired and in mild respiratory distress. Her respirations were 26 oxygen saturations were ,[DATE]%. She was placed on ventilator support and her respiratory distress decreased. A [MEDICAL TREATMENT] communication form dated [DATE] and [DATE] indicated Resident #21 did not receive laboratory services on these dates when [MEDICAL TREATMENT] was performed. The [MEDICAL TREATMENT] flow sheets dated [DATE] and [DATE] indicated Resident #21 received [MEDICAL TREATMENT] by the [MEDICAL TREATMENT] technician, not the [MEDICAL TREATMENT] RN. Nursing notes dated [DATE] at 3:26 p.m. indicated at 2:30 p.m. Resident # 21 received [MEDICAL TREATMENT]. Nursing notes dated [DATE] at 4:08 p.m. indicated at 2:00 p.m. Resident # 21 received [MEDICAL TREATMENT]. The clinical record for Resident #21 did not have documentation of a consent for [MEDICAL TREATMENT] treatment, signed orders for [MEDICAL TREATMENT], orders for [MEDICAL TREATMENT] laboratory services (complete blood count, renal function panel, or [MEDICATION NAME] labs on the days she received [MEDICAL TREATMENT]), and physician progress notes [REDACTED]. 4. Consolidated physician orders dated [DATE] indicated Resident #16 was [AGE] years old and admitted [DATE] with [DIAGNOSES REDACTED]. The orders indicated Resident #16 was to have a complete blood count, renal function panel, and [MEDICATION NAME] level on the days he received [MEDICAL TREATMENT]. The orders were signed by the NP. There were no orders for [MEDICAL TREATMENT] treatment The MDS dated [DATE] indicated Resident #16 had [MEDICAL TREATMENT], could understand and could make herself understood, required assistance of 2 staff for all ADLS. A care plan dated [DATE] indicated Resident #16 would have [MEDICAL TREATMENT]. Interventions were to monitor fistula, graph for signs/symptoms of redness, swelling and report abnormalities to physician, coordinate with the [MEDICAL TREATMENT] staff to ensure effective interchange of information for my care and safety, laboratory services as ordered by the physician, monitor special dietary regimen, dietary restrictions, fluid restrictions, and weight as ordered by the physician. A nursing note dated [DATE] at 1:30 p.m. indicated Resident #16 experienced [MEDICAL CONDITION], CPR was initiated, and the resident was transported via emergency medical services to the hospital and returned to the facility on [DATE] at 8:15 p.m. A nursing note dated [DATE] indicated at 11:09 p.m. Resident #16's [MEDICAL TREATMENT] was completed with post weight the same as the pre weight. The [MEDICAL TREATMENT] RN said he "took off a little fluid but the resident's blood pressure dropped so he administered fluid." There was no indication in the clinical record the nephrologist or medical director was notified. A nursing note dated [DATE] at 5:01 a.m. indicated Resident #16 had no noted complications from [MEDICAL TREATMENT] on the previous shift. A nursing note dated [DATE] at 4:30 p.m. indicated Resident #16 was receiving [MEDICAL TREATMENT]. Nursing notes dated [DATE] at 11:40 p.m. indicated Resident #16 experienced [MEDICAL CONDITION] and CPR was initiated. Emergency medical services arrived at 11:50 p.m. and transported the resident to the hospital where he died . The [MEDICAL TREATMENT] flow sheets dated [DATE], [DATE], [DATE], and [DATE] indicated Resident #16 received [MEDICAL TREATMENT] by the [MEDICAL TREATMENT] RN. A [MEDICAL TREATMENT] communication form dated [DATE] indicated [MEDICAL TREATMENT] was initiated at 6:18 p.m. and completed 10:18 p.m. with no labs drawn for Resident #16. A [MEDICAL TREATMENT] communication form dated [DATE] indicated [MEDICAL TREATMENT] was initiated at 7:09 p.m. and completed at 11:09 p.m. for Resident #16. The pre weight and post weight were the same. This form indicated labs were drawn at the end of [MEDICAL TREATMENT] at 11:09 p.m. The clinical record did not have documentation of laboratory services. A [MEDICAL TREATMENT] communication form dated [DATE] indicated [MEDICAL TREATMENT] was initiated at 6:04 p.m. and completed 10:19 p.m. with no pre weight or post weight done for Resident #16. This form indicated admission labs were drawn. A [MEDICAL TREATMENT] communication form dated [DATE] indicated [MEDICAL TREATMENT] was initiated at 5:14 p.m. and completed at 7:29 p.m. for Resident #16 with no pre weight or post weight obtained and no labs were drawn. The clinical record for Resident #16 did not have documentation of consent for [MEDICAL TREATMENT] treatment, signed orders for [MEDICAL TREATMENT],and physician progress notes [REDACTED]. During an interview on [DATE] at 11:45 a.m., the medical director said he never visited any of the residents that received [MEDICAL TREATMENT] but his NP might have. The medical director said he was not informed when they admitted a resident that received [MEDICAL TREATMENT] until they were already admitted . 5. Unsigned consolidated physician orders dated [DATE] indicated Resident #20 was [AGE] years old and admitted [DATE] with [DIAGNOSES REDACTED]. There was no order for [MEDICAL TREATMENT] or [MEDICAL TREATMENT] laboratory services. An MDS dated [DATE] indicated Resident #20 was comatose (persistent vegetative state/no discernible consciousness), totally dependent on staff for ADLs, incontinent of bowel and bladder. The MDS indicated the resident received [MEDICAL TREATMENT]. A care plan dated [DATE] indicated Resident #20 received [MEDICAL TREATMENT] for [MEDICAL CONDITION], interventions included: coordinate with the [MEDICAL TREATMENT] staff to ensure effective interchange of information for my care and safety, have labs as ordered by physician and assess, document and report any abnormal findings to the physician. Resident #20's [MEDICAL TREATMENT] flow sheets indicated her [MEDICAL TREATMENT] treatments began [DATE] and [MEDICAL TREATMENT] treatments were performed on the following days: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], & [DATE]. The clinical record indicated Resident #20 had one laboratory report dated [DATE] although the [MEDICAL TREATMENT] communication forms indicated laboratory services were done by the [MEDICAL TREATMENT] RN on [DATE], [DATE], and [DATE]. The [MEDICAL TREATMENT] flow sheets indicated Resident #20 did not receive laboratory services on the following days: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], & [DATE]. Resident #20's [MEDICAL TREATMENT] flow sheets indicated no pre or post weights were done on the following days: -[DATE], -[DATE], -[DATE], -[DATE], -[DATE], -[DATE], and -[DATE]. A Progress note dated [DATE] indicated Resident #20 was transferred to the hospital due to a change in condition. No documentation was found in the clinical record that Resident #20 was seen a physician or that informed written consent for [MEDICAL TREATMENT] was given. 6. Consolidated physician orders dated [DATE] signed by the nurse practitioner indicated Resident #19 was [AGE] years old and admitted [DATE] with [DIAGNOSES REDACTED]. There were no physician orders for [MEDICAL TREATMENT] treatment. An MDS dated [DATE] indicated Resident #19 had modified independence in his cognitive skills. He was totally dependent on staff for ADLs, incontinent of bowel and had an indwelling urinary catheter. The MDS indicated the resident received [MEDICAL TREATMENT]. A care plan dated [DATE] indicated Resident #19 received [MEDICAL TREATMENT] for [MEDICAL CONDITION], interventions include:-coordinate with the [MEDICAL TREATMENT] staff to ensure effective interchange of information for care and safety, have labs as ordered by physician, assess, document and report any abnormal findings to physician, and monitor weight as ordered by physician. [MEDICAL TREATMENT] communication forms dated [DATE] and [DATE] indicated the [MEDICAL TREATMENT] RN drew pre and post [MEDICAL TREATMENT] laboratory services and admission laboratory services on each day. There were no signed physician orders for these laboratory services. The [MEDICAL TREATMENT] flow sheets indicated Resident #19 started [MEDICAL TREATMENT] treatment on [DATE]. The resident received treatment on [DATE] and [DATE]. His treatment on [DATE] could not be completed because " unable to get adequate blood flow from HD catheter " . A Progress note dated [DATE] indicated Resident #19 was transferred to the hospital due to a change in condition. A signed informed consent to receive [MEDICAL TREATMENT] treatment was not in the clinical record for Resident #19. 7. Consolidated physician orders dated [DATE] signed by the nurse practitioner indicated Resident #22 was [AGE] years old and admitted [DATE] with [DIAGNOSES REDACTED]. There was no order for [MEDICAL TREATMENT] other than what was sent from the discharging hospital. A MDS dated [DATE] indicated Resident #22 was totally dependent on staff for ADLs and was incontinent of bowel and bladder. The MDS indicated the resident received [MEDICAL TREATMENT]. An undated care plan indicated Resident #22 received [MEDICAL TREATMENT] for [MEDICAL CONDITION], interventions included: coordinate with the [MEDICAL TREATMENT] staff to ensure effective interchange of information for care and safety, have labs as ordered by physician, assess, document and report any abnormal findings to physician The [MEDICAL TREATMENT] flow sheets indicated Resident #22 began [MEDICAL TREATMENT] treatments [DATE]. The resident received treatments on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] The [MEDICAL TREATMENT] communication records indicated laboratory services were collected on [DATE] for Resident #22. There was no signed physician order for [REDACTED]. A Progress note dated [DATE] indicated Resident #22 was transferred to the hospital due to a change in condition. No documentation was found in the clinical record that Resident #22 was seen a physician or that informed written consent for [MEDICAL TREATMENT] was given. 8. Physician orders dated [DATE] indicated Resident #18 was [AGE] years old and admitted [DATE] with [DIAGNOSES REDACTED]. Resident #18's orders indicated she had a feeding tube, (tube for providing nutrition), tracheotomy/ventilato

Based on interview and record review the medical director failed to ensure medical care was coordinated for 9 of 9 residents reviewed for [MEDICAL TREATMENT]. (Resident #s 10, 15, 16, 17, 18, 19, 20, 21, 22) Resident #s 10, 15, 16, 17, 18, 19, 20, 21, and 22 did not have physician orders or consent for [MEDICAL TREATMENT] and the residents were not seen in the facility by the nephrologist. . Resident #s 15, 16, and 17 died shortly after receiving [MEDICAL TREATMENT]. Resident #s 18, 19, 20, 21, and 22 were hospitalized shortly after receiving [MEDICAL TREATMENT]. An Immediate Jeopardy was identified that existed from [DATE] through [DATE]. The facility identified a failure in care and services related to providing [MEDICAL TREATMENT] treatment to residents at the facility and discharged the final 3 residents to the hospital which resulted in the removal of the immediacy prior to the survey on [DATE]. The facility remained out of compliance at a pattern of actual harm due to the need to institute corrective measures for the failures that caused the Immediate Jeopardy. This failure could place 9 residents who received [MEDICAL TREATMENT] at the facility at risk for a lack of medical intervention and death. Findings included: During an interview on [DATE] at 11:42 a.m. the medical director said he was not notified when new residents that received [MEDICAL TREATMENT] were admitted . He said he discovered new residents that received [MEDICAL TREATMENT] when he or the NP visited the facility or received a call about a problem. He said he attended a meeting in [DATE] to correct this problem. He said at the meeting he told staff that all residents that received [MEDICAL TREATMENT] were to be admitted by the nephrologist who would provide physician orders for the residents ' [MEDICAL TREATMENT] care. The medical director said the nephrologist was responsible for physician visits for residents receiving [MEDICAL TREATMENT]. He said he was not aware of a [MEDICAL TREATMENT] policy and procedure. During an interview on [DATE] at 9:25 a.m., the administrator said she started [DATE] and the program for providing [MEDICAL TREATMENT] in the facility was already in place. The administrator said the medical director provided general care for all of the residents that received [MEDICAL TREATMENT] but the nephrologist that was hired by the [MEDICAL TREATMENT] RN was responsible for providing orders for [MEDICAL TREATMENT] treatment. The administrator said she was told by the [MEDICAL TREATMENT] RN that he did not need a license to perform [MEDICAL TREATMENT] in the nursing facility because he worked under the facility's license. The administrator said on [DATE] the previous DON held a meeting about [MEDICAL TREATMENT] protocols and she assumed they received physician orders. She said protocols were put in place for the residents that received [MEDICAL TREATMENT] after the meeting was held. The administrator said she was not aware the residents who received [MEDICAL TREATMENT] did not have physician orders, or orders for laboratory services. The administrator said she never met or saw the nephrologist. She said they did not have a signed contract with him because he was hired by the [MEDICAL TREATMENT] RN. An Agreement for Renal Replacement Services ([MEDICAL TREATMENT]) signed [DATE] by the owner and the [MEDICAL TREATMENT] RN indicated the facility would provide acute [MEDICAL TREATMENT] treatments for those patients (residents) of the facility as requested by a physician in good standing on the facility's medical staff and duly credentialed by facility. (4. A) Normal operating hours for the services are 8 a.m. to 5 p.m., Monday through Saturday. During an interview on [DATE] at 1:15 p.m., the former interim DON, RN P, said staff had not been in-serviced on protocols for [MEDICAL TREATMENT] or received any [MEDICAL TREATMENT] training. She said in October/[DATE] a meeting was held with the medical director, all administrative staff, and the [MEDICAL TREATMENT] RN. RN P said the need for [MEDICAL TREATMENT] protocols were discussed, because there were no signed standing physician orders, no consent for [MEDICAL TREATMENT] treatment at the facility and no order for [MEDICAL TREATMENT] treatment. RN P said the medical director said [MEDICAL TREATMENT] residents were being admitted without his knowledge. RN P said a plan was developed that consisted of developing protocols for residents that received [MEDICAL TREATMENT] and any future [MEDICAL TREATMENT] residents needed to be admitted by the nephrologist. RN P said after the meeting she said they received the nephrologist contact number, the [MEDICAL TREATMENT] RN phone number and a " few protocols " . During an interview on [DATE] at 2:50 p.m., the [MEDICAL TREATMENT] RN said said the nephrologist made rounds with him on the weekends, signed orders and wrote progress notes on the residents that received [MEDICAL TREATMENT]. During an interview on [DATE] at 5:00 p.m., the nephrologist said he did not make rounds on any of the [MEDICAL TREATMENT] residents, and there were no progress notes. He said [MEDICAL TREATMENT] residents were admitted without his knowledge and the [MEDICAL TREATMENT] RN did not always communicate with him. The nephrologist said when they first started [MEDICAL TREATMENT] at the facility; he was told by the [MEDICAL TREATMENT] RN that another nephrologist was giving orders for residents' [MEDICAL TREATMENT] care. The nephrologist said the [MEDICAL TREATMENT] RN did not always communicate important information to him. The nephrologist said he signed some standing orders on [DATE] but there was a period of time before the facility had any standing physician orders for [MEDICAL TREATMENT] residents. He said he did not like the original standing orders and had recently made some changes to them. . During an interview on [DATE] at 7:45 a.m., the previous DON said she voiced her concerns regarding the [MEDICAL TREATMENT] residents several times to the administrator and the facility owner. The residents did not have orders for [MEDICAL TREATMENT] and the nephrologist never came as scheduled. She said the nephrologist would schedule a visit to come to the facility but never showed up. The previous DON said the owner and the administrator told her everything was " ok " and not to worry about the [MEDICAL TREATMENT] orders or physician visits. During an interview on [DATE] at 11:00 a.m., the administrator said the day ([DATE]) she started at the facility a QA meeting was held regarding [MEDICAL TREATMENT] care. She said she thought everything had been corrected and was not aware there continued to be issues. The administrator said she had not followed up on [MEDICAL TREATMENT] care to ensure concerns had been resolved. During an interview on [DATE] at 10:30 a.m., the staffing nurse said she had never seen the nephrologist in the facility to see the residents that received [MEDICAL TREATMENT]. She said the nurses were voicing concerns regarding no orders for the [MEDICAL TREATMENT] residents and no physician visits to for the residents. She said staff had complained to the administrator and the DON on several occasions. During an interview on [DATE] at 3:30 p.m., LVN W said she never saw the nephrologist make a visit to see the [MEDICAL TREATMENT] residents. LVN W said residents received [MEDICAL TREATMENT] late in the evening hours by one RN, and she was told to notify him of any problems with the residents. She said she voiced her concerns to the administrator that there were no orders for [MEDICAL TREATMENT] for the residents that received [MEDICAL TREATMENT], but she was told everything was " ok " . During an interview on [DATE] at 4:10 p.m., LVN 0 said she had never seen signed physician orders, laboratory services, or physician progress notes [REDACTED]. During an interview on [DATE] at 10:15 a.m., LVN Q said the nurses were concerned about [MEDICAL TREATMENT] assessments (pre and post) because they had no physician orders and no nephrologist progress notes. LVN Q said they also had concerns with clogged catheters. She said the [MEDICAL TREATMENT] RN provided [MEDICAL TREATMENT] for a resident for 30 minutes on Monday, the catheter would become clogged and he would instill medicine to declog the catheter, but then the [MEDICAL TREATMENT] RN would not return until Wednesday to provide [MEDICAL TREATMENT] for the resident again. During an interview on [DATE] at 1:30 p.m., the DON said she started at the facility in [DATE] and in-serviced staff in [DATE] about pre and post [MEDICAL TREATMENT] assessment. The DON said the failures with the residents who received [MEDICAL TREATMENT] were a result of the lack of communication with the [MEDICAL TREATMENT] RN. The DON said the residents that received [MEDICAL TREATMENT] did not have signed physician orders for [MEDICAL TREATMENT] and the nephrologist did not assess the residents. The DON said she followed up on orders for one [MEDICAL TREATMENT] resident but did not check all of the residents ' records for physician orders for [MEDICAL TREATMENT]. 1. Physician orders dated [DATE] indicated Resident #15 was [AGE] years old and admitted [DATE], with [DIAGNOSES REDACTED]. No [MEDICAL TREATMENT] orders were noted on the chart. During an interview on [DATE] at 10:00 a.m. the SW said Resident #15 did not have orders for [MEDICAL TREATMENT] treatment in the entire clinical record. A physician progress notes [REDACTED]. The note indicated the plan was for the resident to receive a C- diff culture and obtain laboratory services per [MEDICAL TREATMENT] physician. There were no other physician progress notes [REDACTED]. The most recent MDS dated [DATE] indicated Resident #15 had clear comprehension, clear speech, and could make herself understood. Her BIMS score was "13" (score of ,[DATE] = cognitively intact.) She was totally dependent for all of her ADL care. The MDS indicated she received [MEDICAL TREATMENT], suctioning and [MEDICAL CONDITION] care. An undated care plan indicated Resident #15 received [MEDICAL TREATMENT] due to [MEDICAL CONDITION]. Interventions included: order labs per physician, monitor for altered level of consciousness, shortness of breath, increased weight/[MEDICAL CONDITION], low blood pressure, irregular heart rhythm, muscle cramps, nausea, vomiting, headache, confusion and monitor catheter site for infection and patency. The nursing progress notes included the following for Resident #15: *[DATE] at 10:51 a.m., on [MEDICAL TREATMENT] 3 times a week *[DATE] at 5:47 p.m., [MEDICAL TREATMENT] being done in facility on Tuesday, Thursday and Saturday. *[DATE] at 10:20 p.m., Panic potassium level 1.9 (potassium, normal value- 3XXX,[DATE].0). Called nurse practitioner. NP said get [MEDICAL TREATMENT] physician, contact numbers for [MEDICAL TREATMENT] and company name, [MEDICAL TREATMENT] progress notes, weights should be on resident's chart from now on. She ordered 40 meq of potassium chloride give one time now, draw potassium level in a.m. *[DATE] at 1:15 a.m., at the beginning of shift at 10:00 p.m., resident receiving [MEDICAL TREATMENT] at bedside with beside monitoring. Resident had 2 + [MEDICAL CONDITION] to lower extremities. Weight before [MEDICAL TREATMENT] 148.5 lbs. and post [MEDICAL TREATMENT] 142.6 *[DATE]-[DATE] receiving [MEDICAL TREATMENT] on Tuesday, Thursday and Saturday. *[DATE] at 3:17 a.m., received [MEDICAL TREATMENT] at the facility on Monday, Wednesday and Friday. Resident's blood pressure continues to be low at ,[DATE], resident placed in trendelenberg position (flat on the back with the feet higher than the head), blood pressure at ,[DATE], when her head was elevated, would drop back down. There was no documentation the physician was notified of the change of condition. *[DATE] at 9:59 a.m., [MEDICAL TREATMENT] Monday, Wednesday, and Friday, Quinton catheter intact with redness. There was no documentation the physician was notified of the change of condition. *[DATE] at 2:33 a.m., resident unresponsive, unable to palpate blood pressure, or auscultate apical heart rate, bilateral lower extremities starting to mottle (lack of blood perfusion), CPR started at 12:15 a.m., 911 called and resident left the facility at 12:25 a.m. per emergency medical services. Resident expired During an interview on [DATE] at 1:35 p.m., LVN N said the nurses documented pre and post vital signs (heart rate, breathing rate, temperature, and blood pressure) and weight on the [MEDICAL TREATMENT] communication sheet. She said, until recently all of the residents received [MEDICAL TREATMENT] on the night shift (10 p.m. - 6 a.m.). LVN N said she called the primary, the nephrologist and RN that provided the [MEDICAL TREATMENT] if she had concerns for [MEDICAL TREATMENT] residents. She said several residents that received [MEDICAL TREATMENT] had expired. She said Resident #15 "crashed" at the facility on the 10 p.m. to 6 a.m. shift. She said there were times she could not contact either the primary physician or the nephrologist when [MEDICAL TREATMENT] residents were not doing well. LVN N said when she did not reach a physician; she would send the resident to the hospital if their family wanted them sent. She said the residents receiving [MEDICAL TREATMENT] did not have consents, laboratory reports and signed physician standing orders. She said she requested consents, orders for laboratory services and signed physician standing orders to care for the residents receiving [MEDICAL TREATMENT] but these were not provided. During an interview on [DATE] at 4:40 p.m., LVN T said when the facility began admitting [MEDICAL TREATMENT] residents, many of the nurses did not feel comfortable caring for them. LVN T said she had not received any training or in-services at the facility for caring for [MEDICAL TREATMENT] patients. She said the residents receiving [MEDICAL TREATMENT] did not have physician orders for [MEDICAL TREATMENT] treatment, consents for [MEDICAL TREATMENT] treatment or laboratory services ordered by the nephrologist. LVN T said the [MEDICAL TREATMENT] RN never consulted with the nephrologist when the [MEDICAL TREATMENT] RN was in the facility. LVN T said Resident #15 was alert and oriented, and wanted to get strong enough to " get up and go home " . LVN T said she saw Resident #15 on [DATE] and the resident was fine; the resident was tired and wanted to rest. During an interview on [DATE] at 9:40 a.m. LVN R said Resident #15 was the first [MEDICAL TREATMENT] resident at the facility. LVN R said she was not in-serviced or trained regarding [MEDICAL TREATMENT]. She said she did not receive instructions from the [MEDICAL TREATMENT] RN. LVN R said when Resident #15's, potassium was low the nurse practitioner was called because they could not contact the nephrologist. LVN R said the former interim DON implemented a new protocol to call the nephrologist, the [MEDICAL TREATMENT] RN and then the NP. 2. [DATE] consolidated physician orders signed by the NP indicated Resident #17 was [AGE] years old and admitted [DATE] with [DIAGNOSES REDACTED]. These orders indicated Resident #13 was to receive [MEDICATION NAME] units/ml IV daily in the evenings. This treatment was to be administered along with [MEDICAL TREATMENT] treatments which were to be done on Monday, Wednesday, and Friday per the orders of the nephrologist. A respiratory note dated [DATE] at 5:30 p.m. indicated the respiratory therapist found Resident #17unresponsive in her room and her fingers were " slightly " purple. Resident #17 had a code of do not resuscitate. The note indicated the therapist from the previous shift reported Resident #17 had high pressure alarms all night but refused suctioning. The therapist recorded that Resident #17 "was anxious most of the night after completing [MEDICAL TREATMENT] that started at 10:11 p.m. and ended at 11:30 p.m." A [MEDICAL TREATMENT] communication form dated [DATE], time not recorded, signed by the [MEDICAL TREATMENT] RN, indicated Resident #17 received [MEDICAL TREATMENT], but no laboratory services were drawn. No fluid removal amount was indicated on this report. The pre-[MEDICAL TREATMENT] weight was recorded as 301.6 pounds and her post-[MEDICAL TREATMENT] weight was 297 pounds a difference of 4.6 pounds. The MDS dated [DATE] and [DATE] indicated Resident #17 was dependent on 2 staff for all ADLs, was ventilator dependent, could understand others, could be understood and was on [MEDICAL TREATMENT]. An undated care plan indicated Resident #17 received [MEDICAL TREATMENT] and was at risk for complications. Interventions included, monitor fistula, graph, for signs/symptoms of redness, welling and report abnormalities to physician, coordinate with the [MEDICAL TREATMENT] staff to ensure effective interchange of information for care and safety, laboratory services as ordered by the physician, monitor special dietary regimen, dietary restrictions, fluid restrictions, and weight as ordered by the physician. [MEDICAL TREATMENT] communication forms dated [DATE], [DATE], and [DATE] indicated Resident #17 had no labs done on those dates when [MEDICAL TREATMENT] was performed. The [MEDICAL TREATMENT] flow sheets dated [DATE], [DATE], and [DATE] indicated Resident #17 received [MEDICAL TREATMENT] by the [MEDICAL TREATMENT] RN. The clinical record for Resident #17 did not have documentation of the following: - complete blood count, renal function panel, or [MEDICATION NAME] labs on the days she received [MEDICAL TREATMENT], -progress notes that indicated the [MEDICAL TREATMENT] physician saw her, -[MEDICAL TREATMENT] orders signed by the [MEDICAL TREATMENT] physician. 3. Unsigned consolidated physician orders dated [DATE] indicated Resident #21 was [AGE] years old and admitted [DATE] with [DIAGNOSES REDACTED]. The resident was 49. There were no orders for [MEDICAL TREATMENT] treatment, or laboratory services. A hospital emergency room note dated [DATE] at 11:00 a.m. indicated Resident #21 was transferred to the hospital from the nursing home on [DATE] because she required [MEDICAL TREATMENT] and the machine at the nursing home was broken. This indicated the nursing home medical director was called on [DATE] at 12:55 p.m. and wanted Resident #21 admitted to the hospital to rule out bacteremia. An admission nursing note dated [DATE] at 3:40 p.m. indicated Resident #21 was alert and oriented to person, place and time. She was nauseated and vomited a small amount. Speaking took great effort. Resident #21 was placed on ventilator support via her [MEDICAL CONDITION]. She was incontinent of bowel and had a Foley catheter. A respiratory note dated [DATE] at 3:40 p.m. indicated Resident #21 arrived at the facility via ambulance and appeared tired and in mild respiratory distress. Her respirations were 26 oxygen saturations were ,[DATE]%. She was placed on ventilator support and her respiratory distress decreased. A [MEDICAL TREATMENT] communication form dated [DATE] and [DATE] indicated Resident #21 did not receive laboratory services on these dates when [MEDICAL TREATMENT] was performed. The [MEDICAL TREATMENT] flow sheets dated [DATE] and [DATE] indicated Resident #21 received [MEDICAL TREATMENT] by the [MEDICAL TREATMENT] technician, not the [MEDICAL TREATMENT] RN. Nursing notes dated [DATE] at 3:26 p.m. indicated at 2:30 p.m. Resident # 21 received [MEDICAL TREATMENT]. Nursing notes dated [DATE] at 4:08 p.m. indicated at 2:00 p.m. Resident # 21 received [MEDICAL TREATMENT]. The clinical record for Resident #21did not have documentation of a consent for [MEDICAL TREATMENT] treatment, signed orders for [MEDICAL TREATMENT], orders for [MEDICAL TREATMENT] laboratory services (complete blood count, renal function panel, or [MEDICATION NAME] labs on the days she received [MEDICAL TREATMENT]), and physician progress notes [REDACTED]. 4. Consolidated physician orders dated [DATE] indicated Resident #16 was [AGE] years old and admitted [DATE] with [DIAGNOSES REDACTED]. The orders indicated Resident #16 was to have a complete blood count, renal function panel, and [MEDICATION NAME] level on the days he received [MEDICAL TREATMENT]. The orders were signed by the NP. The MDS dated [DATE] indicated Resident #16 had [MEDICAL TREATMENT], could understand and could make herself understood, required assistance of 2 staff for all ADLS. A care plan dated [DATE] indicated Resident #16 would have [MEDICAL TREATMENT]. Interventions were to monitor fistula, graph, for signs/symptoms of redness, welling and report abnormalities to physician, coordinate with the [MEDICAL TREATMENT] staff to ensure effective interchange of information for my care and safety, laboratory services as ordered by the physician, monitor special dietary regimen, dietary restrictions, fluid restrictions, and weight as ordered by the physician. A nursing note dated [DATE] at 1:30 p.m. indicated Resident #16 experienced [MEDICAL CONDITION], CPR was initiated, and the resident was transported via emergency medical services to the hospital and returned to the facility on [DATE] at 8:15 p.m. A nursing note dated [DATE] indicated at 11:09 p.m. Resident #16's [MEDICAL TREATMENT] was completed with post weight the same as the pre weight. The [MEDICAL TREATMENT] RN said he "took off a little fluid but the resident's blood pressure dropped so he administered fluid." There was no indication in the clinical record the nephrologist or medical director was notified. A nursing note dated [DATE] at 5:01 a.m. indicated Resident #16 had no noted complications from [MEDICAL TREATMENT] on the previous shift. A nursing note dated [DATE] at 4:30 p.m. indicated Resident #16 was receiving [MEDICAL TREATMENT]. Nursing notes dated [DATE] at 11:40 p.m. indicated Resident #16 experienced [MEDICAL CONDITION] and CPR was initiated. Emergency medical services arrived at 11:50 p.m. and transported the resident to the hospital where he died . The [MEDICAL TREATMENT] flow sheets dated [DATE], [DATE], [DATE], and [DATE] indicated Resident #16 received [MEDICAL TREATMENT] by the [MEDICAL TREATMENT] RN. The clinical record for Resident #16 did not have documentation of a complete blood count, renal function panel, and [MEDICATION NAME] level. During an interview on [DATE] at 11:45 a.m., the medical director said he never visited any of the residents that received [MEDICAL TREATMENT] but his NP might have. The medical director said he was not informed when they admitted a resident that received [MEDICAL TREATMENT] until they were already admitted . The clinical record for Resident #16 did not have documentation of consent for [MEDICAL TREATMENT] treatment, signed orders for [MEDICAL TREATMENT], and physician progress notes [REDACTED]. 5. Unsigned consolidated physician orders dated [DATE] indicated Resident #20 was [AGE] years old and admitted [DATE] with [DIAGNOSES REDACTED]. There was no order for [MEDICAL TREATMENT] or [MEDICAL TREATMENT] labs. An MDS dated [DATE] indicated Resident #20 was comatose (persistent vegetative state/no discernible consciousness), totally dependent on staff for ADLs, incontinent of bowel and bladder. The MDS indicated the resident received [MEDICAL TREATMENT]. A care plan dated [DATE] indicated Resident #20 received [MEDICAL TREATMENT] for [MEDICAL CONDITION], interventions included: coordinate with the [MEDICAL TREATMENT] staff to ensure effective interchange of information for my care and safety, have labs as ordered by physician and assess, document and report any abnormal findings to the physician. Resident #20's [MEDICAL TREATMENT] flow sheets indicated her [MEDICAL TREATMENT] treatments began [DATE] and [MEDICAL TREATMENT] treatments were performed on the following days: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], & [DATE]. The clinical record indicated Resident #20 had one laboratory report dated [DATE] although the [MEDICAL TREATMENT] communication forms indicated laboratory services were done by the [MEDICAL TREATMENT] RN on [DATE], [DATE], and [DATE]. The [MEDICAL TREATMENT] flow sheets indicated Resident #20 did not receive laboratory services on the following days: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], & [DATE]. Resident #20's [MEDICAL TREATMENT] flow sheets indicated no pre or post weights were done on the following days: -[DATE], -[DATE], -[DATE], -[DATE], -[DATE], -[DATE], and -[DATE]. A Progress note dated [DATE] indicated Resident #20 was transferred to the hospital due to a change in condition. The clinical record did not contain a progress notes that indicated Resident #20 was seen by a physician and informed written consent for [MEDICAL TREATMENT] at the facility was obtained. 6. Consolidated physician orders dated [DATE] signed by the nurse practitioner indicated Resident #19 was [AGE] years old and admitted [DATE] with [DIAGNOSES REDACTED]. There were no physician orders for [MEDICAL TREATMENT] treatment. A History and Physical dated [DATE] indicated Resident #19 was seen by the physician [DATE]. An MDS dated [DATE] indicated Resident #19 had modified independence in his cognitive skills. He was totally dependent on staff for ADLs, incontinent of bowel and had an indwelling urinary catheter. The MDS indicated the resident received [MEDICAL TREATMENT]. A care plan dated [DATE] indicated Resident #19 received [MEDICAL TREATMENT] for [MEDICAL CONDITION], interventions include:-coordinate with the [MEDICAL TREATMENT] staff to ensure effective interchange of information for care and safety, have labs as ordered by physician, assess, document and report any abnormal findings to physician, and monitor my weight as ordered by physician. [MEDICAL TREATMENT] communication forms dated [DATE] and [DATE] indicated the [MEDICAL TREATMENT] RN drew pre and post [MEDICAL TREATMENT] laboratory services and admission laboratory services on each day. There were no signed physician orders for these laboratory services. The [MEDICAL TREATMENT] flow sheets indicated Resident #19 started [MEDICAL TREATMENT] treatment on [DATE]. The resident received treatment on [DATE] and [DATE]. His treatment on [DATE] could not be completed because " unable to get adequate blood flow from HD catheter " . A Progress note dated [DATE] indicated Resident #19 was transferred to the hospital due to a change in condition. A signed informed consent to receive [MEDICAL TREATMENT] treatment was not in the clinical record for Resident #19. 7. Consolidated physician orders dated [DATE] signed by the nurse practitioner indicated Resident #22 was [AGE] years old and admitted [DATE] with [DIAGNOSES REDACTED]. There was no order for [MEDICAL TREATMENT] other than what was sent from the discharging hospital. A MDS dated [DATE] indicated Resident #22 was totally dependent on staff for ADLs and was incontinent of bowel and bladder. The MDS indicated the resident received [MEDICAL TREATMENT]. An undated care plan indicated Resident #22 received [MEDICAL TREATMENT] for [MEDICAL CONDITION], interventions included: coordinate with the [MEDICAL TREATMENT] staff to ensure effective interchange of information for care and safety, have labs as ordered by physician, assess, document and report any abnormal findings to physician The [MEDICAL TREATMENT] flow sheets indicated Resident #22 began [MEDICAL TREATMENT] treatments [DATE]. The resident received treatments on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] The [MEDICAL TREATMENT] communication records indicated laboratory services were collected on [DATE] for Resident #22. There was no signed physician order for [REDACTED]. A Progress note dated [DATE] indicated Resident #22 was transferred to the hospital due to a change in condition. Progress notes that indicated Resident #22 was seen by a physician and informed written consent for [MEDICAL TREATMENT] was not in the clinical record. 8. Physician orders dated [DATE] indicated Resident #18 was [AGE] years old and admitted [DATE] with [DIAGNOSES REDACTED]. Resident #18's orders indicated she had a feeding tube, (tube for providing nutrition), [MEDICAL CONDITION]/ventilator dependence (required mechanical support for breathing). Her orders did not include orders for [MEDICAL TREATMENT] instructions. The most recent MDS for Resident #18 dated [DATE] indicated she was in a vegetative state, was totally dependent for all ADLs, incontinent of bowel and bladder, and received [MEDICAL TREATMENT] and ventilator support. The undated Care plan for Resident #18 indicated she was dependent on a ventilator for breathing and received [MEDICAL TREATMENT] for end stage [MEDICAL CONDITION]. The [MEDICAL TREATMENT] flow sheets indicated Resident #18 received [MEDICAL TREATMENT] in the facility on the following dates: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], 01/ ,[DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. Progress notes that indicated Resident #18 was seen by a physician since admission and informed written consent for [MEDICAL TREATMENT] treatment was not in the clinical record. 9. Unsigned consolidated physician orders dated [DATE] indicated Resident #10 was [AGE] years old and admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. There was no order for [MEDICAL TREATMENT], but included an order to "discontinue [MEDICAL TREATMENT] " per physician. The MDS dated [DATE] indicated Resident #10 was admitted on [DATE] and had the ability to express his ideas/wants and he understood verbal content. That MDS indicated Resident #10 received [MEDICAL TREATMENT]. The nursing notes dated [DATE] and [DATE]indicated Resident #10 received [MEDICAL TREATMENT] on these days. The care plan dated [DATE] indicated Resident #10 was no longer on [MEDICAL TREATMENT]. Progress notes that indicated Resident #10 was seen by a physician and informed written consent for [MEDICAL TREATMENT] was not in the clinical record. The [MEDICAL TREATMENT] Consent Policy dated [DATE] indicated " Every patient must have an informed consent for [MEDICAL TREATMENT] on their chart prior to treatment. Chronic patients with consent for treatment on their outpatient chart must resign for inpatient treatment ..... " A policy and procedure for admission orders admission orders [REDACTED]. If the attending physician or their alternate cannot be reached, the facility shall contact the Medical Director for receipt of temporary orders until the attending physician can be contacted for confirmation or revision of orders." The facility's policy on Physician Visits: Initial Medical Assessment ... dated [DATE] indicated: "The facility strives to assure residents/patients are provided with the appropriate medical care at the time it is needed and according to State, Federal, and JCAHO regulations. The resident/patient's physician visit will include, but is not limited to, the following: Face-to-face evaluation Review of total program of care Recording, signing, and dating resident/patient's progress and problems in maintaining or improving their functional status on the Progress Notes. Attending physician will complete an initial medical assessment on all residents/patients admitted to the facility. After the initial physician visit, a qualified Nurse Practitioner (NP) Clinical Nurse Specialist, or Physician's Assistant (PA) may make required visit (as permitted by State regulations). Each resident/patient [DIAGNOSES REDACTED]. Admission 1. Initiate the medical assessment, including a history and physical examination [REDACTED]. a. Exception may be made when an H&P was performed with 30 days prior to the admission. the physician will: 1) Review the H&P 2) Perform a second assessment to confirm information and findings." A list provided by the DON dated [DATE] indicated 0 residents currently received [MEDICAL TREATMENT] and 9 previously received [MEDICAL TREATMENT].

Based on interview and record review the facility failed to ensure the quality assessment and assurance committee developed and implemented a plan of action to provide a safe and effective [MEDICAL TREATMENT] for 9 of 9 residents reviewed for [MEDICAL TREATMENT] care and services. (Resident #s 10, 15, 16, 17, 18, 19, 20, 21, and 22) The quality assessment and assurance committee identified problems with physician orders, protocols, consent to receive [MEDICAL TREATMENT] at the facility and visits by the nephrologist for residents that received [MEDICAL TREATMENT]. A plan was not developed and interventions were not monitored. Resident #s 10, 15, 16, 17, 18, 19, 20, 21, and 22 did not have physician orders or consent for [MEDICAL TREATMENT] and the residents were not seen in the facility by the nephrologist. Resident #s 15, 16, and 17 died shortly after receiving [MEDICAL TREATMENT]. Resident #s 18, 19, 20, 21, and 22 were hospitalized shortly after receiving [MEDICAL TREATMENT]. An Immediate Jeopardy was identified that existed from [DATE] through [DATE]. The facility identified a failure in care and services related to providing [MEDICAL TREATMENT] treatment to residents at the facility and discharged the final 3 residents to the hospital which resulted in the removal of the immediacy prior to the survey on [DATE]. The facility remained out of compliance at a pattern of actual harm due to the need to institute corrective measures for the failures that caused the Immediate Jeopardy. This failure could place 9 residents who received [MEDICAL TREATMENT] at the facility at risk for a lack of medical intervention and death. Findings included: During an interview on [DATE] at 11:42 a.m. the medical director said he was not notified when new residents that received [MEDICAL TREATMENT] were admitted . He said he discovered new residents that received [MEDICAL TREATMENT] when he or the NP visited the facility or received a call about a problem. He said he attended a meeting in [DATE] to correct this problem. He said at the meeting he told staff that all residents that received [MEDICAL TREATMENT] were to be admitted by the nephrologist who would provide physician orders for the residents ' [MEDICAL TREATMENT] care. The medical director said the nephrologist was responsible for physician visits for residents receiving [MEDICAL TREATMENT]. He said he was not aware of a [MEDICAL TREATMENT] policy and procedure. During an interview on [DATE] at 1:15 p.m., the former interim DON, RN P, said staff had not been in-serviced on protocols or received any training regarding residents that received [MEDICAL TREATMENT]. She said in October or [DATE] a QA meeting about residents that received [MEDICAL TREATMENT] was held with the medical director, all administrative staff, and the [MEDICAL TREATMENT] RN. RN P said they discussed the problem of no protocols for resident receiving [MEDICAL TREATMENT], not having physician orders for [MEDICAL TREATMENT] or a signed consent for receiving [MEDICAL TREATMENT] at the facility. RN P said at the meeting the medical director said [MEDICAL TREATMENT] residents were being admitted without his knowledge and any future [MEDICAL TREATMENT] residents needed to be admitted by the nephrologist. RN P said after the meeting they received the nephrologist ' s contact number, the [MEDICAL TREATMENT] RN ' s phone and a few protocols. RN P said there was nothing in place to ensure the identified problems were addressed. During an interview on [DATE] at 5:00 p.m., the nephrologist said he did not make rounds on any of the [MEDICAL TREATMENT] residents, and there were no progress notes. He said [MEDICAL TREATMENT] residents were admitted without his knowledge and the [MEDICAL TREATMENT] RN did not always communicate with him. The nephrologist said when they first started [MEDICAL TREATMENT] at the facility; he was told by the [MEDICAL TREATMENT] RN that another nephrologist was giving orders for residents' [MEDICAL TREATMENT] care. The nephrologist said the [MEDICAL TREATMENT] RN did not always communicate important information to him. The nephrologist said he signed some standing orders on [DATE] but there was a period of time before the facility had any standing physician orders for [MEDICAL TREATMENT] residents. He said he did not like the original standing orders and had recently made some changes to them. During an interview on [DATE] at 7:45 a.m., the previous DON said she voiced her concerns regarding the [MEDICAL TREATMENT] residents several times to the administrator and the facility owner. The residents did not have orders for [MEDICAL TREATMENT] and the nephrologist never came as scheduled. She said the nephrologist would schedule a visit to come to the facility, but never showed up. The previous DON said the owner and the administrator told her everything was " ok " and not to worry about the [MEDICAL TREATMENT] orders or physician visits. During an interview on [DATE] at 11:00 a.m., the administrator said the day ([DATE]) she started at the facility a QA meeting was held regarding [MEDICAL TREATMENT] care. She said she thought everything was corrected and was not aware there continued to be issues. The administrator said a QA meeting was not held in [DATE] and she had not followed up on [MEDICAL TREATMENT] care to ensure concerns had been resolved. During an interview on [DATE] at 10:30 a.m., the staffing nurse said she had never seen the nephrologist in the facility to see the residents that received [MEDICAL TREATMENT]. She said the nurses were voicing concerns regarding no orders for the [MEDICAL TREATMENT] residents and no physician visits for the residents. She said staff had complained to the administrator and the DON on several occasions. During an interview on [DATE] at 3:30 p.m., LVN W said she never saw the nephrologist make a visit to see the [MEDICAL TREATMENT] residents. LVN W said residents received [MEDICAL TREATMENT] late in the evening hours by the [MEDICAL TREATMENT] RN, and she was told to notify the [MEDICAL TREATMENT] RN of any problems with the residents. She said she voiced her concerns regarding no orders for [MEDICAL TREATMENT] for the residents to the administrator, but she was told everything was " ok " . During an interview on [DATE] at 1:35 p.m., LVN N said she called the primary, the nephrologist and [MEDICAL TREATMENT] RN if she had concerns for [MEDICAL TREATMENT] residents. She said several residents that received [MEDICAL TREATMENT] had expired. She said Resident #15 "crashed" at the facility on the 10 p.m. to 6 a.m. shift. She said there were times she could not contact either the primary physician or the nephrologist when [MEDICAL TREATMENT] residents were not doing well. LVN N said when she did not reach a physician; she would send the resident to the hospital if their family wanted them sent. She said the residents receiving [MEDICAL TREATMENT] did not have consents, laboratory reports or signed physician standing orders. She said she requested consents, orders for laboratory services, and signed physician standing orders to care for the residents receiving [MEDICAL TREATMENT], but they were not provided During an interview on [DATE] at 4:10 p.m., LVN 0 said she had never seen signed physician orders, laboratory services, or physician progress notes [REDACTED]. During an interview on [DATE] at 10:15 a.m., LVN Q said the nurses were concerned about [MEDICAL TREATMENT] assessments (pre and post) because they had no physician orders and no nephrologist progress notes. LVN Q said they also had concerns with clogged catheters. She said the [MEDICAL TREATMENT] RN provided [MEDICAL TREATMENT] for a resident for 30 minutes on Monday, the catheter would become clogged and he would instill medicine to declog the catheter, but then the [MEDICAL TREATMENT] RN would not return until Wednesday to provide [MEDICAL TREATMENT] for the resident again. During an interview on [DATE] at 10:45 a.m., the ADON said the last QA meeting was on [DATE]. She said the medical director was present. The ADON said the medical director knew that the [MEDICAL TREATMENT] residents were discharged and he said he would help find placements. The ADON did not know if there had been a QA meeting [DATE]. During an interview on [DATE] at 1:30 p.m., the DON said she started at the facility in [DATE] and in-serviced staff in [DATE] about pre and post [MEDICAL TREATMENT] assessment. The DON said the failures with the residents who received [MEDICAL TREATMENT] were a result of the lack of communication with the [MEDICAL TREATMENT] RN. The DON said the residents that received [MEDICAL TREATMENT] did not have signed physician orders for [MEDICAL TREATMENT] and the nephrologist did not assess the residents. The DON said she followed up on orders for one [MEDICAL TREATMENT] resident but did not check all of the residents ' records for physician orders for [MEDICAL TREATMENT]. The Quality Assurance/Performance Improvement policy dated ,[DATE] said they, " .....strive to improve and provide quality, cost effective care by utilizing a standardized QA/Performance Improvement program. The QA program will strive to improve the facility's governance, managerial, clinical, financial and support processed through a system which will monitor, analyze, trend/evaluate and identify areas that would benefit from additional focus. " 1. 1. Physician orders dated [DATE] indicated Resident #15 was [AGE] years old and admitted [DATE], with [DIAGNOSES REDACTED]. No [MEDICAL TREATMENT] orders were noted on the chart. Nursing progress notes dated [DATE] indicated Resident #15 was found unresponsive and CPR was initiated. She later expired. 2. Consolidated physician orders dated [DATE] indicated Resident #16 was [AGE] years old and admitted [DATE] with [DIAGNOSES REDACTED]. The orders indicated Resident #16 was to have a complete blood count, renal function panel, and [MEDICATION NAME] level on the days he received [MEDICAL TREATMENT]. The orders were signed by the NP. The MDS dated [DATE] indicated Resident #16 had [MEDICAL TREATMENT], could understand and could make herself understood, required assistance of 2 staff for all ADLS. A care plan dated [DATE] indicated Resident #16 would have [MEDICAL TREATMENT]. Interventions were to monitor fistula, graph, for signs/symptoms of redness, welling and report abnormalities to physician, coordinate with the [MEDICAL TREATMENT] staff to ensure effective interchange of information for my care and safety, laboratory services as ordered by the physician, monitor special dietary regimen, dietary restrictions, fluid restrictions, and weight as ordered by the physician. Nursing notes dated [DATE] at 11:40 p.m. indicated Resident #16 experienced [MEDICAL CONDITION] and CPR was initiated. Emergency medical services arrived at 11:50 p.m. and transported the resident to the hospital where he died . The [MEDICAL TREATMENT] flow sheets dated [DATE], [DATE], [DATE], and [DATE] indicated Resident #16 received [MEDICAL TREATMENT] by the [MEDICAL TREATMENT] RN. The clinical record for Resident #16 did not have documentation of consent for [MEDICAL TREATMENT], signed orders for [MEDICAL TREATMENT], and physician progress notes [REDACTED]. 3. [DATE] consolidated physician orders signed by the NP indicated Resident #17 was [AGE] years old and admitted [DATE] with [DIAGNOSES REDACTED]. These orders indicated Resident #13 was to receive [MEDICATION NAME] units/ml IV daily in the evenings. This treatment was to be administered along with [MEDICAL TREATMENT] s which was to be done on Monday, Wednesday, and Friday per the orders of the nephrologist. A respiratory note dated [DATE] at 5:30 p.m. indicated the respiratory therapist found Resident #17unresponsive in her room and her fingers were " slightly " purple. Resident #17 had a code of do not resuscitate. The note indicated the therapist from the previous shift reported Resident #17 had high pressure alarms all night but refused suctioning. The therapist recorded that Resident #17 "was anxious most of the night after completing [MEDICAL TREATMENT] that started at 10:11 p.m. and ended at 11:30 p.m." The MDS dated [DATE] and [DATE] indicated Resident #17 was dependent on 2 staff for all ADLs, was ventilator dependent, could understand others, could be understood and was on [MEDICAL TREATMENT]. An undated care plan indicated Resident #17 received [MEDICAL TREATMENT] and was at risk for complications. Interventions included, monitor fistula, graph, for signs/symptoms of redness, welling and report abnormalities to physician, coordinate with the [MEDICAL TREATMENT] staff to ensure effective interchange of information for care and safety, laboratory services as ordered by the physician, monitor special dietary regimen, dietary restrictions, fluid restrictions, and weight as ordered by the physician. The [MEDICAL TREATMENT] flow sheets dated [DATE], [DATE], and [DATE] indicated Resident #17 received [MEDICAL TREATMENT] by the [MEDICAL TREATMENT] RN. The clinical record for Resident #17 did not have documentation of -progress notes that indicated the [MEDICAL TREATMENT] physician saw her, [MEDICAL TREATMENT] orders signed by the [MEDICAL TREATMENT] physician. Were they signed by any MD? 4. Unsigned consolidated physician orders dated [DATE] indicated Resident #21 was [AGE] years old and admitted [DATE] with [DIAGNOSES REDACTED]. The resident was 49. There were no orders for [MEDICAL TREATMENT], or laboratory services. A hospital emergency room note dated [DATE] at 11:00 a.m. indicated Resident #21 was transferred to the hospital from the nursing home on [DATE] because she required [MEDICAL TREATMENT] and the machine at the nursing home was broken. This indicated the nursing home medical director was called on [DATE] at 12:55 p.m. and wanted Resident #21 admitted to the hospital to rule out bacteremia. The [MEDICAL TREATMENT] flow sheets dated [DATE] and [DATE] indicated Resident #21 received [MEDICAL TREATMENT] by the [MEDICAL TREATMENT] technician, not the [MEDICAL TREATMENT] RN. Nursing notes dated [DATE] at 3:26 p.m. indicated at 2:30 p.m. Resident # 21 received [MEDICAL TREATMENT]. Nursing notes dated [DATE] at 4:08 p.m. indicated at 2:00 p.m. Resident # 21 received [MEDICAL TREATMENT]. The clinical record for Resident #21did not have documentation of consent for [MEDICAL TREATMENT], signed orders for [MEDICAL TREATMENT], and physician progress notes [REDACTED]. 5. Physician orders dated [DATE] indicated Resident #18 was [AGE] years old and admitted [DATE] with [DIAGNOSES REDACTED]. Resident #18's orders indicated she had a feeding tube, (tube for providing nutrition), [MEDICAL CONDITION]/ventilator dependence (required mechanical support for breathing). Her orders did not include orders for [MEDICAL TREATMENT] instructions. The most recent MDS for Resident #18 dated [DATE] indicated she was in a vegetative state, was totally dependent for all ADLs, incontinent of bowel and bladder, and received [MEDICAL TREATMENT] and ventilator support. The undated Care plan for Resident #18 indicated she was dependent on a ventilator for breathing and received [MEDICAL TREATMENT] for end stage [MEDICAL CONDITION]. The [MEDICAL TREATMENT] flow sheets indicated Resident #18 received [MEDICAL TREATMENT] in the facility on the following dates: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], 01/ ,[DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. Progress notes that indicated Resident #18 was seen by a physician since admission and informed written consent for [MEDICAL TREATMENT] was not in the clinical record. 6. Unsigned consolidated physician orders dated [DATE] indicated Resident #10 was [AGE] years old and admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. There was no order for [MEDICAL TREATMENT], but included an order to "discontinue [MEDICAL TREATMENT] " per physician. The MDS dated [DATE] indicated Resident #10 was admitted on [DATE] and had the ability to express his ideas/wants and he understood verbal content. That MDS indicated Resident #10 received [MEDICAL TREATMENT]. The nursing notes dated [DATE] and [DATE]indicated Resident #10 received [MEDICAL TREATMENT] on these days. The care plan dated [DATE] indicated Resident #10 was no longer on [MEDICAL TREATMENT]. Progress notes that indicated Resident #10 was seen by a physician and informed written consent for [MEDICAL TREATMENT] was not in the clinical record. 7. Unsigned consolidated physician orders dated [DATE] indicated Resident #20 was [AGE] years old and admitted [DATE] with [DIAGNOSES REDACTED]. There was no order for [MEDICAL TREATMENT] or [MEDICAL TREATMENT] labs. An MDS dated [DATE] indicated Resident #20 was comatose (persistent vegetative state/no discernible consciousness), totally dependent on staff for ADLs, incontinent of bowel and bladder. The MDS indicated the resident received [MEDICAL TREATMENT]. A care plan dated [DATE] indicated Resident #20 received [MEDICAL TREATMENT] for [MEDICAL CONDITION], interventions included: coordinate with the [MEDICAL TREATMENT] staff to ensure effective interchange of information for my care and safety, have labs as ordered by physician and assess, document and report any abnormal findings to the physician. Resident #20's [MEDICAL TREATMENT] flow sheets indicated her [MEDICAL TREATMENT] s began [DATE] and [MEDICAL TREATMENT] was performed on the following days: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], & [DATE]. A nursing note dated [DATE] indicated Resident #20 was transferred to the hospital due to a change in condition. The clinical record did not contain a progress notes that indicated Resident #20 was seen by a physician and informed written consent for [MEDICAL TREATMENT] at the facility was obtained. 8. Consolidated physician orders dated [DATE] signed by the nurse practitioner indicated Resident #19 was [AGE] years old and admitted [DATE] with [DIAGNOSES REDACTED]. There were no physician orders for [MEDICAL TREATMENT]. A History and Physical dated [DATE] indicated Resident #19 was seen by the physician [DATE]. An MDS dated [DATE] indicated Resident #19 had modified independence in his cognitive skills. He was totally dependent on staff for ADLs, incontinent of bowel and had an indwelling urinary catheter. The MDS indicated the resident received [MEDICAL TREATMENT]. A care plan dated [DATE] indicated Resident #19 received [MEDICAL TREATMENT] for [MEDICAL CONDITION], interventions include:-coordinate with the [MEDICAL TREATMENT] staff to ensure effective interchange of information for care and safety, have labs as ordered by physician, assess, document and report any abnormal findings to physician, and monitor my weight as ordered by physician. The [MEDICAL TREATMENT] flow sheets indicated Resident #19 started [MEDICAL TREATMENT] on [DATE]. The resident received [MEDICAL TREATMENT] on [DATE] and [DATE]. His [MEDICAL TREATMENT] on [DATE] could not be completed because " unable to get adequate blood flow from HD catheter " . A nursing note dated [DATE] indicated Resident #19 was transferred to the hospital due to a change in condition. A signed informed consent to receive [MEDICAL TREATMENT] was not in the clinical record for Resident #19. 9. Consolidated physician orders dated [DATE] signed by the nurse practitioner indicated Resident #22 was [AGE] years old and admitted [DATE] with [DIAGNOSES REDACTED]. There was no order for [MEDICAL TREATMENT] other than what was sent from the discharging hospital. A MDS dated [DATE] indicated Resident #22 was totally dependent on staff for ADLs and was incontinent of bowel and bladder. The MDS indicated the resident received [MEDICAL TREATMENT]. An undated care plan indicated Resident #22 received [MEDICAL TREATMENT] for [MEDICAL CONDITION], interventions included: coordinate with the [MEDICAL TREATMENT] staff to ensure effective interchange of information for care and safety, have labs as ordered by physician, assess, document and report any abnormal findings to physician The [MEDICAL TREATMENT] flow sheets indicated Resident #22 began [MEDICAL TREATMENT] s [DATE]. The resident received s on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] Progress notes that indicated Resident #22 was seen by a physician and informed written consent for [MEDICAL TREATMENT] was not in the clinical record. The [MEDICAL TREATMENT] Consent Policy dated [DATE] indicated " Every patient must have an informed consent for [MEDICAL TREATMENT] on their chart prior to treatment. Chronic patients with consent for treatment on their outpatient chart must resign for inpatient ..... " A policy and procedure for admission orders admission orders [REDACTED]. If the attending physician or their alternate can not be reached, the facility shall contact the Medical Director for receipt of temporary orders until the attending physician can be contacted for confirmation or revision of orders." A list provided by the DON dated [DATE] indicated 0 residents currently received [MEDICAL TREATMENT] and 9 previously received [MEDICAL TREATMENT].

Based on observation, interview, and record review, the facility failed to complete accurate wound assessments, provide appropriate treatment and pressure relieving surfaces, and reposition to prevent development and worsening of pressure ulcers for 4 of 6 residents reviewed for pressure ulcers. (Resident #s 3, 4, 7, and10) Resident #10 was admitted without pressure ulcers and developed 5 avoidable facility-acquired pressure ulcers. Resident #10 had two Stage II pressure ulcers on his coccyx area, one unstageable pressure ulcer on the bottom of his scrotum, one Stage II pressure ulcer on the front side of his scrotum, and one unstageable pressure ulcer on the middle of his back. The facility did not provide assessment, repositioning, or pressure relief per the treatment plan of care. Resident #7 was admitted without pressure ulcers and developed 5 avoidable facility-acquired pressure ulcers. Resident #7 had Stage II pressure ulcers on his coccyx area, left inner ankle, right inner knee and right upper hip. The resident had pressure ulcers on his left lateral foot. The facility failed to perform accurate assessments, provide treatment as ordered, provide pressure relieving devices at all times, and implement dietary interventions. Resident # 3 had a pressure ulcer to the left great toe and LVN J failed to provide the treatment as ordered on [DATE]. Resident #4 had two Stage II pressures ulcers. Staff failed to assess and notify the physician timely for a treatment order on one of the pressure ulcers when the pressure ulcer developed. The facility failed to have policies and procedures addressing pressure ulcers. These failures contributed to the development of new pressure ulcers and the worsening of existing pressure ulcers for Resident #s10, 3, 4 and 7. Immediate Jeopardy An Immediate Jeopardy situation was identified on 8/10/12. The Immediate Jeopardy was removed on 8/10/12. The facility remained out of compliance at a pattern of actual harm due to the facility's need to evaluate the effectiveness of the corrective systems. Theses failures could place 9 residents with pressure ulcers at risk for developing new pressure ulcers and decline in existing pressures ulcers. Findings included: 1. Physician orders [REDACTED]. He was admitted [DATE] with [DIAGNOSES REDACTED]. A physician telephone order dated 8/5/12 indicated Resident #10 should receive [MEDICATION NAME] to the reddened scrotal area each shift and as needed. Consolidated physician orders [REDACTED]. -Multivitamin one by mouth every two days. -Vitamin C 500 mg one by mouth twice a day. -Magic cup (Nutritional supplement) with lunch and supper -House supplement (Nutritional supplement) twice a day. The most recent MDS assessment dated [DATE] indicated Resident #10 was dependent on staff for all of his needs and was unable to make his needs known, but could sometimes understand. He was totally dependent on staff with bed mobility and toilet use, and was incontinent of bowel and bladder. This assessment indicated Resident #2 was at risk for developing pressure ulcers, but had no pressure ulcers at the time of the assessment. laboratory results dated [DATE] indicated Resident #10 had a low [MEDICATION NAME] (a test that measures the amout of protein) of 3.2 (reference range 3.4 - 4.8) and a low total protein of 5.5 (reference range 6.3 - 8.4). A dietary assessment dated [DATE] indicated Resident #10 did not have pressure ulcers. There was a recommendation to add an appetite stimulant for 30 days, continue with supplements as ordered, and add Vitamin C twice a day. A Braden scale assessment dated [DATE] indicated Resident #10 was at moderate risk for skin breakdown. A treatment care plan dated 07/10/12 indicated staff were to provide Resident #10 with hourly position changes while the resident was seated in a reclining chair or bed. Resident #10 was to be positioned properly with the use of pressure-reducing or pressure relieving devices (e.g. pillows, gel or foam cushions, alternating pressure mattress, air-fluidized bed, etc) if indicated. The care plan indicated his skin over boney prominences was to be assessed, and the soft tissue was to be assessed for reddish-brown color, warmth, firmness, induration, drainage or foul odor. Resident #10's skin assessment sheet dated 8/2/12 indicated the following: A surgical wound to the right hip measured 0.1 cm x 0.1 cm x 0.1 cm. The wound was cleaned with normal saline, patted dry, and a dry dressing was applied. There was no documentation of any pressure ulcers. During an observation and interview on 8/9/12 at 4:05 p.m. ADON/LVN G removed the covers from Resident #10 and upon seeing 5 pressure ulcers said she was unaware Resident #10 had pressure ulcers. She said the treatment nurse performed skin assessments weekly. Resident #10 did not have a pressure reduction surface on his bed. During an interview on 08/09/12 at 4:25 p.m. the treatment nurse said she was unaware of any of the pressure ulcers on Resident #10's scrotum, coccyx, or back. She said the last full skin assessment she did was on 8/2/12. During an interview on 8/9/12 at 5:00 p.m., the treatment nurse said she last assessed Resident #10's skin on 8/2/12 and she said she knew his scrotum was red, but she was unaware of the darkened area. The treatment nurse said he sat in his Geri-chair a lot. The treatment sheets dated August 2012 indicated Resident #10 received [MEDICATION NAME] to the buttocks each shift and as needed. During an observation on 8/9/12 at 5:00 p.m. the treatment nurse, measured Resident #10's pressure ulcers. The pressures ulcers were assessed as: -Coccyx (site A) 1.0 cm x 0.8 cm x 0.1 cm, open with a red wound bed. The surrounding tissue was red. -Coccyx (site B) 0.8 cm x 0.7 cm x 0.1 cm, open pressure ulcer with a red wound bed. The surrounding tissue was red. -Scrotum (site A) 1.5 cm x 0.7 cm x 0.1cm, red open pressure ulcer with surrounding area of reddened skin. -Scrotum (site B) 2.0 cm x 1.8 cm x 0.1 cm the wound bed was brownish/black with yellow tissue adhered to the wound bed. The surrounding tissue was red. -Back ([MEDICATION NAME]/Lumbar area) 1.5 cm x 2.5 cm x 0.1 cm open pressure ulcer with 50% of yellow tissue to wound bed. Wound margins intact. During an interview on 8/9/12 at 5:10 p.m. CNA B said she noticed Resident #10's scrotum being red on 8/8/12 and she told LVN E. CNA B said she did not notice any other skin problems. During an interview on 8/9/12 at 5:20 p.m. CNA V said she provided care for Resident #10 about two weeks ago and his scrotum had a red area on the bottom of it, but she did not tell anyone. During an interview on 8/9/12 at 5:33 p.m. LVN W said she looked at Resident #10's scrotum on 8/8/12 and it was red, but appeared to be getting better. She said she was unaware of any new skin issues. During an interview on 8/9/12 at 5:45 p.m. CNA T said she bathed Resident #10 on 8/8/12 and she did not notice any skin problems. She said she was not sure if she washed his scrotum. She said she did not separate his buttocks and wash between them and she did not wash his back. CNA T said she should have washed Resident #10 better. During an observation on 8/10/12 at 10:08 a.m. Resident #10 was lying on a non pressure reduction scoop mattress. The facility had not provided him with a pressure reduction surface for his bed. During an interview on 8/10/12 at 11:15 LVN E said the treatment nurse was responsible for the daily application of [MEDICATION NAME] ointment to Resident #10. She said CNAs can apply as needed after incontinent care. During an interview on 8/10/12 at 11:20 a.m. CNA L said she noticed a blackish/red ulcer to the bottom of Resident #10's scrotum on 8/5/12. She said she reported it to LVN E. She said she did not notice any ulcers to his coccyx or back. She said she did apply [MEDICATION NAME] to his buttocks on 8/5/12. During an interview on 8/10/12 at 11:35 a.m. CNA M said she provided incontinent care for Resident #10 on 8/9/12. She said she noticed a dark red spot on the bottom of his scrotum and she applied [MEDICATION NAME] ointment to it. She said she never told a nurse. She said she did not notice any skin problems to his coccyx or back. During an interview on 8/10/12 at 11:45 a.m. LVN E said she was notified by CNA R that Resident #10 had a spot on his scrotum. She said the resident had a red area with darkness to the middle of his scrotum approximately 3.0 cm x 3.0 cm. She said she told LVN G about it and was told to keep putting the [MEDICATION NAME] on it. During an interview on 8/10/12 at 12:55 p.m. LVN G said Resident #10 should be a high risk for pressure ulcers. She said his Braden score which indicated he was at moderate risk was incorrect. She said LVN E reported to her that Resident #10's scrotum had a dark red spot on it, but was not open. She said she told LVN E to continue putting [MEDICATION NAME] on his scrotum. LVN G said she did not personally assess his scrotum. 2. Physician orders [REDACTED]. The admission MDS assessment dated [DATE] indicated Resident #7 was totally dependent on staff for personal hygiene and bed mobility. He had limited range of motion in his arms and legs. Resident #7 was always incontinent of bowel/bladder, received an enteral tube feeding, and had no pressure ulcers. He was deemed at risk for pressure ulcer development. The most recent MDS assessment dated [DATE] indicated Resident #7 had no pressure ulcers and was deemed at risk for pressure ulcer development. A pressure ulcer care plan dated 07/02/12 indicated staff were to: -perform treatments per order and if no improvement in 2 weeks report to the physician, -monitor areas for increase breakdown, sign and symptoms of infection, and report to the physician. -Encourage dietary/fluid intake within dietary limits. Keep physician and responsible party informed of the resident's progress and -assess for possible reasons for skin concerns, report findings to physician Laboratory reports dated 07/01/12 indicated Resident #7 had a low [MEDICATION NAME] level of 1.7 with normal ranges being (3.4-4.8). A Braden scale assessment dated [DATE] indicated Resident #7 was at high risk for skin breakdown. A dietary assessment dated [DATE] indicated the resident was on Pro Stat 30cc twice a day. A recommendation was made to increase the Prostat to 45 cc twice a day for additional protein. The July 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A profile sheet dated 08/01/12 indicated Resident #7 had hospital stays from 04/01-12/12 and 06/29/12-07/02/12. During an observation on 07/30/12 at 10:45 a.m., Resident #7 was in bed with a tube feeding of [MEDICATION NAME] infusing at 71 cc per hour. Resident #7 was contracted in a fetal position, sheet between his knees and a foam boot to his left foot. The left lateral foot was observed with three pressure ulcers. Two of the pressure ulcers were red in the middle with a light brown periphery and the other a pink center with a hard light callous on the periphery. During an observation and interview on 07/31/12 starting at 9:22 a.m., Resident #7 was observed with the following pressure ulcers: *Right trochanter The wound bed was covered with a thick yellow substance. The tissue underneath was black. LVN J measured the pressure ulcer as being 12.7 x 10.5 cm with 8.5 x 8.0 cm of eschar. LVN J failed to clean the bed of the pressure ulcer and was getting ready to place a clean Calcium alginate dressing on the pressure ulcer. After surveyor intervention the nurse took a Q-tip and picked the thick yellow substance off the pressure ulcer. LVN J said "thank you, I thought that was eschar. It was the Calcium alginate." The pressure ulcer was cleaned with normal saline, covered with Calcium alginate and an ABD pad. Physician orders [REDACTED]. *Right elbow: The wound bed was covered with yellow tissue. LVN J measured the pressure ulcer as being 2.0 x 2.5 <0.1 cm with 0.5 x 1.7cm of slough. LVN J said "this is a Stage II and that is slough on the wound bed. " *Left trochanter: The wound bed was covered with black eschar. LVN J measured the pressure ulcer as being 6.0 x 9.3 cm with 5.0 x 5.9 x <0.1 cm of eschar. *Coccyx: The wound had black eschar, yellow slough and skin to perimeter was red. LVN J measured the coccyx was being 5.4 x 7.0 cm and inner wound bed of eschar as 3.0 x 4.0 x <0.1 cm. *Right upper hip: The wound bed had dark brown and black eschar. LVN J measured the ulcer as being 3.2 x 3.0 cm with 1.0 x 2.0 x < 0.1 cm (eschar). LVN J touched the wound bed and said it was hard. *Left inner ankle: The wound bed was dark red with a small amount of white tissue. LVN J measured the pressure ulcer as 2.5 x 2.0 cm with inner wound bed measuring 0.7 x 0.7 c <0.1 cm. *Right inner knee was closed and brown in color. LVN J measured the pressure ulcer as being 1.2 cm x 1.5 cm and the inner wound bed as 0.5cm x 0.7 cm. *Left lateral foot, LVN J measured the pressure ulcers as being 1.3 cm x 2.2 cm, 1.0 cm x 0.9 cm and 1.3 cm x 1.0 cm. LVN J said the pressure ulcers on the resident's left lateral foot were new. She said she measured the ulcers last night and was waiting on treatment orders from the physician about the pressure ulcers. She said the pressure ulcers were not there when she did treatments on Friday (07/27/12). LVN J said the new pressure ulcers were Stage I. During an interview on 07/31/12 at 10:14 a.m., LVN J said she had not done anything about the ulcer on the lateral foot of Resident #7 yet. She was just keeping them clean and dry. The physician and family were notified about 9:00 p.m. last night of the new pressure ulcers. She had not gotten a chance to see if the physician had responded to the notification about the ulcers. LVN J said she sent a fax and called the office, but it was after hours. Unless it is an emergency they make notification by fax. During an interview on 07/31/12 at 11:10 a.m., LVN J said she had not seen anything back yet from the physician regarding Resident #7. The following nursing notes indicated Resident #7 had pressure ulcers on the right trochanter, left trochanter and right elbow. This was not reflected on the 07/03/12 MDS assessment. *Right and Left trochanter 05/15/12, continue treatment to right and left trochanter, right great toe and coccyx areas. Resident tends to scoot and squirm in bed causing friction to boney areas 06/07/12 treatments continued to the bilateral trochanters, right trochanter with redness and warmth noted to peri-wound, continues with slough to wound bed. Improvement noted to the left trochanter wound. . 06/19/12 left trochanter appears to be improving and no drainage noted. 06/28/12 new order received to transfer to hospital for surgical debridement of right trochanter wound. *Right elbow 06/22/12 treatment nurses observed two new areas of breakdown: both areas located on the right antecubital area (elbow), measures 1.5cmx 2.4cm and 0.6cm x 0.3cm. *Coccyx 07/10/12 during morning skin assessment treatment nurse observed 3.0 x 2.5 cm area to the coccyx. *Left inner ankle 07/20/12 during daily wound treatment, treatment nurse observed a new open area to the left inner ankle. *Right inner knee and right upper hip 07/25/12 during wound care treatment nurse observed several new areas of breakdown on the right inner knee and right upper hip. Weekly pressure ulcer report dated 07/26/12 indicated the following: *06/04/12 (admitted with) Right trochanter- Unstageable, 11.5 cm x 10.8 cm x <2.3cm, 7.3 cm x 8.0 with necrotic tissue. *06/20/12 (admitted with) Left trochanter- Unstageable, 8.7 cm x 10 cm x <0.1 cm with 7.0 cm x 4.5 cm of necrotic tissue. *06/22/12 (admitted with) Right elbow- Stage II, 3.5 cm x 4.0 cm x < 0.1cm x 1.5 cm x 2.0 cm without necrotic tissue. *07/10/12 (acquired in-house) Coccyx- Stage II- 4.5cm x 4.0 cm and redness 8.0 cm x 5.7cm x <0.1cm without necrotic tissue. *07/20/12 (acquired in-house) Left inner ankle- Stage II, 1.5 cm x 1.9 cm x < 0.1cm without necrotic tissue. *07/25/12 (acquired in-house) Right inner knee - Stage II, 2.0 cm x 2.0 cm x <0.1cm without necrotic tissue. Right upper hip- Stage II, 3.6 cm x 2.8 cm x <0.1cm without necrotic tissue. The 07/26/12 skin assessment indicated the right trochanter, left trochanter, and right elbow pressure ulcers were present on admission. Resident #7 had no discharges during the timeframe the pressure ulcers developed. The skin assessment sheet was inaccurate on where the pressure ulcers were acquired. The July 2012 daily pressure ulcer documentation sheet for Resident #7 indicated there was no necrotic tissue on the left trochanter. The July 2012 weekly skin assessment tool indicated Resident #7 had necrotic tissue on the left trochanter. The July 2012 push tool (a pressure ulcer tool that measures healing) for Resident #7 indicated there was no necrotic tissue on the left trochanter. www.medlineuniversity.com/A useful tool for monitoring the change of a pressure ulcer over time is the Pressure Ulcer Scale for Healing (PUSH) Tool,developed by the National Pressure Ulcer Advisory Panel(NPUAP). accessed 8/22/12 The July 2012 daily pressure ulcer documentation sheet Resident #7 indicated there was no necrotic tissue on the right trochanter. The July 2012 weekly assessment tool and push tool Resident #7 indicated there was necrotic tissue. During an interview on 07/31/12 at 5:27 p.m. LVN J said the left inner ankle pressure ulcer developed in house. She said the resident received the pressure ulcers from his disease process of failure to thrive. He had been put on hospice. The resident was admitted with the ulcers on the left trochanter, right trochanter, and elbow. The coccyx ulcer did have pink tissue and she knew that for sure. She did not know when the ulcer developed the eschar. During an interview with the DON on 08/01/12 at 8:35 a.m., she said she knew there was a problem with skin. She had done training with LVN J, but was not sure if it was documented. During an interview on 08/01/12 at 9:03 a.m., NP R said most of the time the nurses called her about Resident #7's pressure ulcer. The NP said she had about 250- 300 residents and could not remember details about the pressure ulcer. She normally left notes in the chart on her residents' charts. During an interview on 08/01/12 at 9:24 a.m., CNA O indicated sometimes the staff used pillows and sometimes sheets were used between Resident #7's knees or legs. The reason given was because the resident would rub his legs together. During an interview on 08/01/12 at 1:10 p.m., the DON said the dietitian came in and exited with her before leaving and gave her the recommendations. The recommendations were faxed to the doctor and the nurses wrote the order. They try to follow through on recommendations within 72 hours. The DON said the recommendation was not put in the computer. Progress notes printed from the computer on 08/01/12 indicated the dietary assessment recommendation was put in the computer on 07/07/12. 3. Physician orders [REDACTED]. The orders indicated Resident #4 should receive topical treatment twice a day, on her coccyx and staff should clean the open area with normal saline, pat dry, apply collagen, cover with dry dressing, and change daily and as needed if soiled or displaced. The most recent MDS dated [DATE] indicated Resident #4 was independent with bed mobility and required extensive assistance from staff for toilet use. The MDS indicated Resident #4 was at risk for developing pressure ulcers and did not have a pressure ulcer during the assessment period. A weekly skin documentation form dated 7/30/12 indicated Resident #4 received calcium alginate to the wound on her coccyx. A Cinically Unavoidable Pressure Sore form dated 7/30/12 indicated Resident #4 had a Stage 2 pressure ulcers on her A coccyx that developed on 6/6/12 and a Stage 2 pressure ulcer on her B coccyx that developed on 7/30/12. Listed interventions in place prior to development included turn every 2 hours, use of a draw sheet, a pressure reducing mattress and offloading boney prominences. The form indicated Resident #4 had a Braden Scale Score of 14 and had 14.5% weight loss in the past 90 days. During an observation on 07/30/12 at 10:58 a.m., Resident #4 was observed with two open pressures ulcers to the sacral-coccyxgeal area. The pressure ulcers were not covered with a dressing. The tissue of the wound beds were pink and white in color. During an observation on 7/30/12 at 11:29 a.m., CNA B and Q provided incontinent care for Resident #4 after an incontinent episode and failed to thoroughly cleanse the skin on the buttocks. During an interview on 07/30/12 at 11:29 a.m., LVN J said she did not know when the dressing had come off the pressure ulcers. CNA Q said when she came in at 5:50 a.m. this morning (7/30/12) the dressings were off and she had forgotten to tell the charge nurse. During an observation on 07/30/12 at 11:49 a.m., LVN J cleansed the pressures ulcers with normal saline, covered them with Collagen (dressing) and then covered with a foam dressing. The pressure ulcers were measured during the treatment as being: Site A as 0.7 x 1.7 x <0.1 cm Site B as 1.5 x 1.5cm x less than 0.1 cm During an interview on 07/30/12 at 12:12 p.m., LVN J said Site B was a new pressure ulcer. She performed a treatment on Resident #4 on Friday (07/27/12) and site B was not there. LVN J said she would call the doctor for a treatment on the pressure ulcer. LVN J said "normally the doctor leaves" it up to her discretion on what treatment to use. During an interview on 7/30/12 at 1:00 p.m. LVN J said she provided care for Resident #4 during the previous weekend. She said there were 2 wounds on the resident's coccyx and she put collagen on both wounds. She said she attempted to dress both wounds but because they were in the crease of the buttocks the dressings would not stay on. LVN J said she worked the weekend of July 21st and 22nd and saw both wounds on those days as well. She said the most recent wound was about 2 cm with broken skin and the 2nd layer of tissue was visible. She said she had not received any reports from CNAs regarding Resident #4's wounds. During an interview on 07/30/12 at 12:19 p.m., CNA Q said she worked the weekend (07/28/12 and 07/29/12) during the 6 a.m.-2 p.m. shift. She saw the two pressure ulcers then. She said on both days when she first started her shift the ulcers were not dressed and she informed LVN K. 4. The physician orders [REDACTED]. The most recent MDS dated [DATE] indicated Resident #3 was unable to make his needs known and required total assistance from staff for all ADLs. Resident #3 had an indwelling catheter. Resident #3 had a stage 2 and stage 4 pressure ulcer upon admission. The most recent care plan dated 6/3/12 indicated Resident #3 received wound care to his left great toe and his left trochanter. The physician orders [REDACTED]. The treatment consisted of clean nail bed with normal saline, pat dry, apply calcium alginate, and apply dry dressing daily and as needed. During an observation on 7/31/12 at 11:25 a.m. the treatment nurse applied Triple Antibiotic Ointment to Resident #3's left great toe during wound care. During an interview on 7/31/12 at 5:00 p.m. the treatment nurse indicated she had performed the wrong treatment on Resident #3. She said she looked at the wrong orders and calcium alginate should have been applied to Resident #3's left great toe instead of Triple Antibiotic Ointment. The treatment nurse corrected the treatment. During an interview on 8/1/12 at 7:01 a.m. the DON was unable to provide an active policy/procedure for skin care and assessments. The DON said she had been unable to find any active skin policies or procedures and to her knowledge there were none in place. The Clinical Practice Guidelines from the Agency for Healthcare for Healthcare Research and Quality #15 pages 12-13 indicated the following: "Stage I: Nonblanchable [DIAGNOSES REDACTED] of intact skin, the heralding lesion of skin ulceration." "Stage II: Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. " "Stage III: Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The presents clinically as a deep crater with or without undermining of adjacent tissue. " "Stage IV: Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g. tendon, joint capsule). Undermining and sinus tracts also may be associated with Stage IV pressure ulcer " "When eschar is present, a pressure ulcer cannot be accurately staged until the eshcar is removed" Page 25 "Assessment is the starting point in preparing to treat or manage an individual with a pressure ulcer." "Assess the pressure ulcer initially for location, stage (NPUAP 1989), size, sinus tracts, undermining, tunneling, exudate, necrotic tissue, and the presence or absence of granulation tissue and [MEDICATION NAME]. " Page 37 "Use positioning devices such as pillows or foam to prevent direct contact between bony prominences (such as knees or ankles). " Page 29 "A review of literature suggests that a pressure ulcer can be a grave indicator of [MEDICAL CONDITION]. Breslow, Hallfrisch, Guy, et. al. (1993) found that high-protein diets with increased caloric contents may enhance pressure ulcer healing in malnourished nursing home patients." According to the Clinical Practice guideline #15, treatment of [REDACTED]. The state of the wound is correlated with the severity of nutritional deficits, particularly low protein intake or a below-normal serum [MEDICATION NAME]. " Immediate Jeopardy The administrator and DON were notified on 08/10/12 at 1:10 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal (POR) was accepted on 8/10/12 at 4:08 p.m. and included: -On 8/10/12 Resident #10 was provided a pressure reduction surface for his bed. -On 8/10/12 all residents identified as having risk factors for pressure ulcers were assessed for appropriate pressure-relieving surfaces and ordered immediately if required. -On 8/9/12 the treatment nurse and administrative nursing staff completed facility-wide skin assessments on all residents. Any new identified skin issues were addressed, family/physician notified, and orders obtained for treatment if required. -On 8/9/12 The DON provided an in-service to all nurses and CNAs on all shifts regarding proper notification of all skin issues daily. The DON will be notified daily of any new skin issue. -On 8/9/12 the current treatment nurse was removed from her duties and will receive training on assessment and treatment of [REDACTED]. During an interview on 8/10/12 at 6:00 p.m. the DON said she was currently working on guidelines but did not have a system in place for monitoring and tracking pressure ulcers. The surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: Resident #10 was observed on a pressure reduction surface (alternating air mattress) in his bed on 8/10/12 at 4:15 p.m. Five CNAs were interviewed and said they had received in-service training and if skin problems were identified they would document on the ADT sheet and notify the charge nurse and if the problem continued they would notify the DON. Four nurses were interviewed and related they had received in-service training and they were to review and sign off on the ADT at the end of every shift. If new problems were noted they would address and notify the physician and family. The DON said she would be monitoring and training the care provided by the treatment nurse and CNAs. Incontinent care was observed and no problems were noted. The new pressure ulcer guidelines were reviewed and contained the required guidelines and information in wound prevention and treatment, nutritional assessment and management, Braden assessments, and wound staging. On 8/10/12 at 6:45 p.m., the administrator and DON were informed the IJ was removed; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to evaluate the effectiveness of the corrective systems. The CMS 672 dated 07/30/12 indicated there were 9 residents with pressure ulcers.